THE COMPLEX PUZZLE OF MANAGING THE ELDERLY BURN PATIENT:

Transcription

1 THE COMPLEX PUZZLE OF MANAGING THE ELDERLY BURN PATIENT: BURN LOCATION IS IRRELEVANT TO RISK FOR DYSPHAGIA AND ITS COMPLICATIONS IN PATIENTS OVER 75 YEARS Nicola Clayton 1,2,3, Caroline Nicholls 2,4, Karen Blazquez 1,2, Peter Maitz 2, Andrea Issler-Fisher 2 1 Speech Pathology Department, Concord Hospital, NSW Australia 2 Burns Unit, Concord Hospital, NSW Australia 3 School of Health & Rehabilitation Sciences, The University of Queensland, QLD Australia 4 Nutrition & Dietetics Department, Concord Hospital, NSW Australia

2 STUDY BACKGROUND Management of the elderly burn patient is complex Advanced age associated with increased risk for morbidity and mortality 1 Dysphagia prevalence in aged population: 23% in living community older persons (>70 years) 2 34% following hip fracture surgery 3 84% with advanced dementia 4

3 STUDY BACKGROUND Dysphagia can be significant and protracted following severe burn injury 5-14 Predictive factors for dysphagia have been identified & validated: Head & neck burns Inhalation injury >18% TBSA burn ICU admission Intubation & mechanical ventilation Escharotomy

4 STUDY BACKGROUND (CONT.) Current prevalence of dysphagia % of all adult burn admissions all ages 15 BUT Is the prevalence rate and predictive factors for dysphagia different in burn patients >75 years of age?

5 STUDY AIM 1. Determine the prevalence rate of dysphagia 2. Identify a set of risk factors for dysphagia for patients over the age of 75 years admitted for treatment of burn injury

6 METHODOLOGY Swallowing assessment routinely provided for all burn patients 75 years admitted for treatment at CRGH Study conducted over 4 year period: July June 2017 Inclusion criteria Patients 75 years Admitted to Burns Unit at CRGH Burn injury to any location Exclusion criteria Patients whose swallow function was not assessed on admission due to poor prognosis for survival

7 OUTCOME MEASURES Retrospective chart review conducted: Demographic & Burn data Age Gender Swallowing & Nutrition data Functional Oral Intake Scale Days NBM % TBSA burnt Days on modified diet Location & mechanism of burn Past medical history Premorbid cognition Length of Stay (LOS) In-hospital complications Number of surgeries requiring GA Residential status (admission & discharge) Days of enteral feeding Malnutrition Screening Tool Subjective Global Assessment

8 RESULTS Demographic & Burn Data: n=66: 35 male, 31 female Range Mean Age years 82 years % TBSA burn 1-31% 7.17% Surgical procedures requiring GA 0 4 surgeries <1 surgery Length of stay 2 80 days 23 days

9 RESULTS (CONT.) Burn data

10 RESULTS (CONT.) In-hospital complications

11 RESULTS (CONT.) Living status pre-admission & on discharge

12 RESULTS (CONT.) Swallowing Data FOIS outcomes for dysphagic cohort

13 RESULTS (CONT.) Swallowing Data Time points of most severe dysphagia (FOIS = 1)

14 RESULTS (CONT.) Swallowing Data Time points of no dysphagia (FOIS = 7)

15 RESULTS (CONT.) Swallowing Data Swallow function at discharge

16 RESULTS (CONT.) Impact of dysphagia Prevalence of dysphagia = 46.97% Patients with dysphagia were significantly associated with: Higher %TBSA burns (p<0.001) Pre-morbid cognitive impairment (p<0.05) Need for mechanical ventilation (p<0.001) Increased LOS (p<0.001) Increased in-hospital complications (p<0.001) Increased days of enteral feeding (p<0.001) Mortality (p<0.005)

17 RESULTS (CONT.) Impact of dysphagia There was no significant association identified for patients with dysphagia and: Age (between years) Gender Burn mechanism Burn location Number of surgeries requiring GA Need for surgery requiring GA

18 RESULTS (CONT.) Nutritional Data MST outcomes: Overall % assessed as at risk for malnutrition on screening Dysphagic cohort 51.7% assessed as at risk for malnutrition on screening Significant relationship between risk for malnutrition on screening for those patients who developed dysphagia (p<0.001) SGA outcomes: Overall 39.5% patients malnourished 76.5% of those malnourished were dysphagic But no statistical significant relationship

19 Numbers, graphs and tables tell us a lot, but Visual footage shows us so much more!

20 VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS) Instrumental swallowing assessment (also known as Modified Barium Swallow) Swallowing function is visualised using videofluoroscopy Food and fluid (mixed with barium sulphate) is administered Compensatory & therapeutic strategies trialled

21 NORMAL ANATOMY ON VFSS Nasal cavity Tongue Base of Tongue Valleculae Hyoid bone Vocal folds Trachea Soft palate Posterior pharyngeal wall Epiglottis Piriform fossae Cricopharyngeus

22 VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS) NORMAL

23 OSWALD: 96 YEAR OLD MALE WITH 12% TBSA BURN 2 O SCALD

24 DISCUSSION Prevalence of dysphagia is higher in burn patients >75 years Dysphagia is associated with: Increased LOS Duration of enteral feeding In-hospital complications including mortality Risk factors for dysphagia in this population include: % TBSA burn Need for mechanical ventilation Pre-morbid cognitive impairment

25 LIMITATIONS Retrospective chart review Not every patient received an instrumental assessment of swallowing function potential under-estimate of dysphagia

26 CONCLUSION Prevalence of dysphagia is high in elderly burn population Vigilant referral and management of dysphagia is essential

27 REFERENCES 1. Lundgren et al., JBCR Ortega et al., J Am Med Dir Assoc Love et al., Age Aging Rofes et al., Eur Respir J Clayton & Kennedy, Dysphagia 2007a 6. Clayton et al., Burns Clayton et al., Burns Cheung et al., IJSLP Edelman et al., JBCR DuBose et al., JBCR Rumbach et al., JBCR 2009a 12. Rumbach et al., Dysphagia 2012a 13. Rumbach et al., JBCR 2012b 14. Ward et al., JBCR Rumbach et al., JBCR 2011a 16. Rumbach et al., Burns 2014

28 ACKNOWLEDGEMENTS Lumenis conference sponsorship Anne Darton (NSW SBIS) database interrogation