Evidence indicates that elderly patients are at increased risk of adverse outcomes after burn injuries due to frailty. When compared with younger individuals, older patients who suffer burn injuries are at higher risk for falls, complications, rehospitalization, care dependency, and mortality. As society ages, more elderly patients are expected to be admitted to specialized burn care facilities. “Currently, we have limited insights into the specific needs and outcomes of the elderly in specialized burn care, especially regarding assessments and treatment for frailty,” says Charlotte I. Cords, MD.
Since 2012, hospitals in the Netherlands have been obligated to screen all patients aged 70 and older for frailness using the Dutch Safety Management System (DSMS) frailty screening tool. “The DSMS includes screening for delirium, risk for falls, undernourishment, and activities of daily living dependence,” Dr. Cords explains. “It enables frailty recognition during hospitalization and makes personalized treatment plans possible. An early diagnosis of frailty can ensure that frail patients with burns receive the right interventions to prevent or delay possible adverse outcomes. However, research is lacking on the feasibility and validity of the DSMS screening tool for specialized burn care.”
Many Elderly Patients Do Not Receive Frailty Screening
For a multicenter retrospective study published in the European Burn Journal, Dr. Cords and colleagues assessed the feasibility and validity of the DSMS frailty screening in specialized burn care as well as predictors for completing such screenings. Additionally, the prevalence of frailty in elderly patients was assessed. In total, 515 patients aged 70 and older who were admitted to specialized burn centers between 2012 and 2018 were included in the analysis.
According to the study results, most elderly patients were screened using the DSMS frailty screening instrument, but one-third was not screened or did not have any screening documented (Table). The DSMS was completed by just 39.6% of patients in the study and was partially completed by 23.9%. “Frailty assessment using the DSMS was feasible in patient who were less severely ill,” Dr. Cords says. The screening was most often completed in patients who were admitted to the hospital after 2015 and among those who were less severely injured.
“Our study also found that 44.0% of all screened patients had a risk of frailty in two or more domains of the DSMS,” notes Dr. Cords. “Furthermore, more than 60% scored positive on at least one domain. Several patient characteristics correlated with increased risks for frailty, including older age, more comorbidities, longer hospital length of stay, and more frequent non-home discharges.” In many cases, a positive DSMS frailty screening result was based on risks for delirium. A positive delirium risk screening was seen in 42.1% of patients, demonstrating its importance as a frailty factor.
Education Needed on Implementing Frailty Screening
According to the investigators, the relevance of frailty screening in burn care was evident by the elevated risk for frailty seen in nearly one-half of elderly patients in the study. “Our findings imply that frailty could be easily assessed in patients with less major burn injuries,” adds Dr. Cords. “However, a different instrument might be needed for older patients with more severe burns; the DSMS frailty screening tool is not feasible for these individuals. Furthermore, our study showed that the DSMS is predictive of outcomes and can be used to identify frail patients with burn injuries.”
Currently, it is unclear the extent to which preventive measures are being implemented as standard care after a positive DSMS screening in elderly patients with burn injuries. “In future research, we want to assess whether the DSMS is the best frailty assessment tool for patients treated in specialized burn care settings,” Dr. Cords says. “We’re currently conducting a prospective study that aims to assess the feasibility, reliability, and different aspects of validity for three promising frailty assessment tools: the Clinical Frailty Scale, the Groningen Frailty Indicator, and the Burn Frailty Index.” Additional studies are also needed to assess the possible relationship between frailty and mortality and other adverse outcomes, preferably using data from a large prospective study.
