Annals of Burns and Fire Disasters - vol. XI - n. 2 - June 1998

THE ELDERLY PATIENT IN A BURNS CENTRE

*Servizio di Psicologia, Centro Grandi Ustionati, Azienda Ospedaliera CTO, CRF, Marta Adelaide, Turin, ltaly
**Centro Grandi Ustionati, Turin, ltaly

SUMMARY. In the last few years the Turin Burns Centre (Italy) has seen a considerable increase in the number of elderly patients admitted. This study considers whether the management of elderly patients in an isolated ward is different from that of younger patients and, if so, in what way. The data collected indicate that the experience of elderly patients admitted to a Burns Centre is different from that of other patients, as it is often less traumatic, and their assistance requires a different approach from that provided by other protocols.

Elderly persons aged 65 yr and over now make up a large proportion of the patients admitted every year to the Turin Burns Centre. This phenomenon is steadily increasing (from 0 patients in 1985 to 52 in 1995), and it is reasonable to hypothesize that by the year 2000 there will be so many of these patients that routine treatment protocols will have to be modified.

A retrospective study was carried out of 99 patients aged 65 yr and more (57% male, 43% female) between 1990 and 1994. Of these patients 5 1 % died in hospital, and 10% after discharge. Of the survivors, 50% lived outside our city area, and it was not possible for us to obtain their personal testimony. The study was therefore carried out in 19 patients, and includes: clinical interview, semistructured questionnaire with questions based on the memory of most significant daily actions, with a comparative analysis of the results obtained by another study conducted in 59 patients (63% male) aged under 65 yr admitted to the same centre. The analysis of the data contains a personal, social and clinical section.
The data were processed using a one-dimension analysis of frequency distribution and the cluster analysis technique. We present below the most significant findings.

Typically, burn patients are aged over 65 years have a primary school education and family interests, live in a small town near a large city, have problems with organic pathologies related to their age (hypertension, cardiovascular and digestive system problems), and do not present important psychiatric pathologies related or due to the trauma, although they present feelings of anxiety or depression related to "being elderly", i.e. the difficulties arising from having to cope with separations and renunciations. The burn accident usually occurs in the home, especially because of flame, or when lighting stoves and fires or burning garden refuse, using boiling water, failing into hot bath water, or spilling hot soup. The patients do not usually remember the dynamics of the accident: there is a kind of protective amnesia covering the first period, which gives way to many years of memories of painful experiences related to the accident in general; they are convinced that the burn was accidental and they consider the sequelae tolerable and acceptable, even if 80% report severe functional and sensory disabilities, and 41% say they have not resumed their previous life because of some functional limitation. However, very soon after leaving hospital, they have accepted themselves and their new body.
Burn patients aged less than 65 yr, in contrast, have a middle-upper secondary school education, were in employment at the time of the accident, and declare that they have not accepted their body and have had problems resuming their previous life. also for aesthetic reasons.
With regard to the hospitalization of elderly patients, who in 60% of cases were admitted to other hospitals before arriving in our Burns Centre, the memory of the human welcome and the treatment received is excellent; the professional figures who left the most positive impression were the physicians and the nurses. The physiotherapists do not constitute positive reference elements, while the psychologists leave no trace in the memory at all.
This is different from the response of patients of other ages, in whom psychotherapists and physiotherapists are positive presences because of the specific role they play In patients over the age of 65 yr it is interesting that 42% report they have felt the need of stronger ties with the outside world, while 21% recall the separation from their loved ones as something necessary and 47% as a source of great sadness; however, to the question regarding what made their stay in the Burns Centre more bearable, 47% replied "the staff' (patients aged under 65 yr did not consider the staff a primary point of reference).
Patients over 65 yr continue to report a state of disorientation (26%) and disturbed sensory perception (16%), while 70% experienced a lack of space-time references and sought new forms of adaptation.
In our opinion the reason for these differences is directly related to the patients' age: for elderly patients, who cut themselves off from the external world and witness the modifications occurring in their bodies, space perception becomes narrower and time appears shorter, giving rise to an experience of altered corporality and modified spacetime relationships.
For these reasons over-65-year-olds have less need of relationships with other persons, even their near and dear ones, and their well-being is related, above all, to a "sphere of ease".
Worry and anxiety in the elderly about new environments are caused by their desire to occupy a space that does not ignore them, with persons who prevent them from entering a state of anonymity and who define a safe area for them. The entire medical team has this task of containment and affective support: for this reason, the figure of the psychologist and the physiotherapist are not important as "experts" but as elements who are part of Burn Centre's internal personnel.
Returning to the Tables,, the last finding is of orreat interest. For elderly patients, the worst memory is that of bathing (71%), which they associate (100%) with unendurable. endless pain. In contrast, for patients aged less than 65 yr, the worst memories are those of hospitalization, solitude, and the physical impossibility of communicating with their family.
It is our belief that the extremely upsetting memory of pain in elderly patients is due to the fact that in advanced age the body plays a leading role in existential suffering. This is all the more true when, in the event of real suffering, existential pain affects our corporability with indescribable pain.

Conclusions

This study draws attention to the fact that some aspects of the hospitalization and treatment of elderly burn patients cannot follow traditional methods.
Age plays an important role, also in a Burns Centre and patients react differently to their hospitalization. A serious burn is always a traumatic event that arouses deepseated fears, yet elderly patients, in an emergency situation, may have the capacity to restructure and review their personality. The fact that in their everyday life they have accustomed themselves to restricting their interpersonal contacts helps them to cope with the "exceptional" situation of isolation, if the quality of the relationship established with the Burn Centre is good.
Participation in the life of the burns ward helps the medical and nursing team to learn how to manage the needs of the patients, who feel the support and sympathy of those responsible for their care, also through the sharing of emotional experiences. A relationship constructed on the basis of professional skill together with human warmth and empathy - also manifested in the acceptance of the patients' subjective needs - increases the mutual trust of the patients and their families. The overall objective is to treat the illness
not as an irreparable break from normality experienced only as a loss of physical integrity but as a moment when a certain quality of life can still be maintained.
It is not however easy for the staff of an Intensive Therapy Unit, who live side by side with the daily risk of death, to give the patient a relational space, i.e. to notice everything the patients communicate, without being caught up by a feeling of solitude, by a sense of impotence/ omnipotence, and by the patients' own suffering. No one working in such conditions is immune to these feelings. Not even psychologists.
In order to offer medical and nursing staff the experience of a different approach, the Turin Centre is experimenting with a new interdisciplinary work model, with various professional figures who work together and present their experiences in weekly meetings that enable them to "hold together" the various aspects of the patient: medical, psychological, nursing.

RESUME. Pendant les dernières années nous avons vu au Centre des Grands Brûlés de Turin (Italie) une augmentation considérable du numéro des patients âgés hospitalisés. Cette étude a considéré si la manière d'affronter la période d'hospitalization dans un secteur d'isolement est différente de celle des patients plus jeunes. Les résultats de l'analyse indiquent que le patient âgé vit son hospitalisation dans un Centre de Brûlés en manière différente, très souvent moins traumatisante, ce qui impose une approche assistencielle différente de celle des protocoles habituels.

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