|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2017 | Volume
: 15
| Issue : 3 | Page : 227-230 |
|
Profile of geriatric patients presenting to the emergency department
Kundavaram Paul Prabhakar Abhilash, Moses Amos Kirubairaj, Saurabh Ramesh Sahare
Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Web Publication | 7-Aug-2017 |
Correspondence Address:
Kundavaram Paul Prabhakar Abhilash
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_22_17
Background: In both developed and developing countries, the proportion of people over 60 years of age is growing faster than any other age group as a result of longer life expectancy due to improved health care. As a result, emergency department (ED) visits are on the rise. Materials and Methods: This retrospective observational study was conducted in the ED of a large tertiary level hospital between September 2014 and December 2014. All patients >65 years presenting to the ED were included in the analysis. Results: During the study period, 1090 geriatric patients comprised 13.9% of the ED admissions. The mean age of the patients was 74.2 ± 20.32 years. There was a male predominance (65.4%). The most common presenting complaints were breathing difficulty (28%), fever (21.6%), vomiting (14%), chest pain (11.5%), abdominal pain (11.5%), trauma (11%), giddiness (10.4%), and altered sensorium (10%). The distribution of the most common organ systems involved are as follows: Cardiovascular system (18.7%), respiratory system (15.8%), trauma (13.9%), genitourinary system (13.8%), neurological system (12.3%), skin and soft tissue infections (6%), and others (25.1%). Among the respiratory conditions, acute exacerbation of asthma/chronic obstructive pulmonary disease was the most common (61.2%), followed by pneumonia (28.9). More than half (51.5%) were discharged from ED, 47.5% (518 patients) were admitted to the hospital, and 0.91% (10 patients) expired in the ED. A further 64 patients expired during the hospital stay. The overall inhospital mortality among the geriatric emergencies was 6.8% (79/1090). The mean length of hospital stay was 8.06 days. Conclusion: The admission profile among this geriatric population showed that cardiorespiratory conditions are the most common emergencies, followed by trauma. ED of India should be aware of this demographic profile and be prepared to handle these emergencies efficiently.
Keywords: Emergencies, emergency department, geriatric, profile
How to cite this article:
Abhilash KP, Kirubairaj MA, Sahare SR. Profile of geriatric patients presenting to the emergency department. Curr Med Issues 2017;15:227-30 |
| Introduction | |  |
Geriatric health and diseases are influenced by the process of aging.[1],[2] Age is a recognized constitutional risk factor for many medical conditions, especially noncommunicable diseases.[2] This might be due to biophysiological changes characterized by progressive constriction of the homeostatic reserves of each organ system and a decline in the ability to adapt to physical, physiological, and psychosocial challenges. Older patients are likely to have multiple comorbidities or chronic illnesses with impaired physical and cognitive function and are likely to have lesser social support. Geriatric patients are therefore at a higher risk of morbidity and mortality when they present with emergencies.[3] This poses a management challenge to the emergency department (ED) physicians. As the number of people over the age of 65 years is increasing in both the developed and developing countries, the number of ED visits is also bound to increase.[3] In the West, geriatric age group represents more than 13% of the population, and nearly, 15% of the ED visits are made by the elderly, and these patients were more likely to have serious injury or illness, consume more ED resources, and require surgery or admission.[4] As per the 1991 census of India, the geriatric population was 57 million. There has been a steep increase in the number of elderly persons between 1991 and 2001, and according to projections, the number is likely to soar to 327 million by 2050.[5],[6],[7] According to the 2011 census, the geriatric population comprised 8.2% of the total population.[8] Availability of better health care facilities and decreasing mortality rate probably contributed to this demographic change, thus acquiring India the label of “an ageing nation.” ED across India need to be prepared to handle this change in the demography, and hence, it is important to know the patient profile of geriatric emergencies. However, literature from India on this subject is scant. Hence, we conducted this study to describe the profile of geriatric emergencies in a large tertiary care hospital of South India.
| Materials and Methods | | |
This retrospective observational study was conducted in Christian Medical College, Vellore, a 2700-bed tertiary care hospital in Tamil Nadu, South India, between January 1, 2012, and March 31, 2012. The ED is a 45 bedded emergency with a triage-based priority system which receives an average of 190–240 patients a day. All adult patients more than 65 years of age who presented to our ED during the study period were screened through the hospital electronic database. Data of the patients was obtained from the electronic hospital records. Details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: demographics, presenting complaints, ED diagnosis, and outcome from the hospital. All patients had routine blood investigations and relevant radiological tests based on the initial evaluation. After initial stabilization by the ED team, the patients were handed over to the respective departments for further management or were discharged from the ED if stable. The final diagnosis was noted and was classified based on the predominant organ system involvement.
Statistical methods
Statistical analysis was performed using SPSS software for Windows (SPSS Inc., Released 2007, version 16.0. Chicago, IL, USA). Continuous variables are presented as mean (standard deviation). Categorical and nominal variables are presented as percentages. This study was approved by the Institutional Review Board. Patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.
| Results | | |
During the study period, a total of 11,175 patients presented to the ED. Geriatric patients comprised 13.9% (1554/11,175) of the total ED visits. However, 454 charts had either incomplete documentation or were missing and were excluded from analysis. The final cohort contained 1090 patients [Figure 1]. The mean age of the patients was 74.2 ± 20.32 years. There was a male predominance (65.4%). The presenting complaints to the ED are shown in [Table 1]. The most common presenting complaints were breathing difficulty (28%), fever (21.6%), vomiting (14%), chest pain (11.5%), abdominal pain (11.5%), trauma including falls (11%), giddiness (10.4%), and altered sensorium (10%). After initial evaluation in the ED and further evaluation in the ward for inpatients, the final diagnosis was determined based on the predominant organ involved. The distribution of the most common organ systems involved are as follows: cardiovascular system (18.7%), respiratory system (15.8%), trauma (13.9%), genitourinary system (13.8%), neurological system (12.3%), skin and soft tissue infections (6%), and others (25.1%). Others (25.1%) included abdomen or liver involvement, fever with no localization, and nonspecific symptoms. Among the respiratory conditions, acute exacerbation of asthma/chronic obstructive pulmonary disease (COPD) was the most common (61.2%), followed by pneumonia (28.9) [Table 2]. Acute coronary syndromes (ST-segment elevation myocardial infarction [STEMI]/non-STEMI [NSTEMI]/unstable angina) comprised 41.1% of the cardiovascular conditions [Table 2]. Details of gastrointestinal/hepatic, genitourinary system, and skin and soft tissue infections are shown in [Table 3]. | Table 1: Presenting complaints for the emergency department visit (n=1090)
Click here to view |
 | Table 3: Diagnosis of the genitourinary, gastrointestinal conditions, and skin/soft tissue infections
Click here to view |
More than half (51.5%) were discharged from ED, 47.5% (518 patients) were admitted in the hospital, and 0.91% (10 patients) expired in the ED. A further 64 patients expired during the hospital stay. The overall inhospital mortality among the geriatric emergencies was 6.8% (79/1090). The mean length of hospital stay was 8.06 days.
| Discussion | | |
The phenomenon of population aging is becoming a major concern for the ED of all hospitals in both developing and developed countries. Our study shows that the geriatric age group makes up a significant number of ED visits. It is a simple descriptive study that sheds light on the common presenting complaints and the diagnosis of the ED visits.
Our study showed acute onset breathlessness to be the most common presenting complaint to the ED. Acute dyspnea in the elderly is often the consequence of multiple overlapping disorders, such as pneumonia, acute heart failure, COPD, anemia, hypertension, and ischemic heart disease. ED physicians must be trained well to recognize and manage acute dyspnea of uncertain cause and varying goals of care because of the associated comorbidities and decreased functional status. Infrastructure for invasive and noninvasive ventilation is limited to tertiary care hospitals and private corporate hospitals and is out of reach of the majority of the rural geriatric population. These two forms of ventilatory support, though unavailable in most parts of the country, play a crucial role in early resuscitation for patients with acute dyspnea in the ED.
In our study, half the cardiovascular disease emergencies were acute coronary syndromes (STEMI/NSTEMI/unstable angina). With increasing number of comorbidities with age and age itself being a risk factor for coronary artery disease, it is not surprising to have myocardial ischemia/infarction as the leading cardiovascular emergency in the elderly.
There are many socioeconomic challenges faced by the elderly population of India. Currently, most of the geriatric outpatient services are available only at a few tertiary care hospitals in India. However, 75% of the elderly reside in rural areas, and it is essential that geriatric health care services be made a part of the primary health care services.[5],[6],[8] Specialized training of doctors in geriatric medicine needs to improve and increase on a large scale to meet the health demands of the second most populous country in the world. In addition to that, peripheral health workers and community health volunteers should receive special training to identify early and refer elderly patients for timely and proper treatment.
Studies from the West have shown that the elderly have a higher ED use, are more likely to be brought by ambulances, and have a higher admission rate.[9],[10],[11] Older age has also been shown to be associated with increased length of ED stay, higher resource use, higher rates of missed diagnosis, higher ED revisit rate, and medication errors than younger severity matched controls.[4],[10],[11],[12],[13] Even in India, the old-age dependency ratio climbed from 10.9% in 1961 to 14.2% in 2011, for India as a whole. For females and males, the value of the ratio was 14.9% and 13.6% in 2011.[8] Many of the elderly live in old age homes or stay alone at home and tend to ignore their health with lesser family support. With the increasing trend of nuclear families in the society and with fewer children in the family, the care of older persons with their reduced mobility and debilitating disabilities is getting increasingly difficult. Hence, they are prone to rapid deterioration of their health resulting in ED visits.
As the proportion of the elderly increases, there exists a need to redesign ED protocols and physical layout. Most ED in India are not “elderly-friendly” with cramped waiting areas, inadequate wheelchair facilities, and toilets not designed for wheelchair-bound patients. Health care policy makers need to look into these aspects of care in the ED across the country to make them be prepared to handle the ever increasing load of the elderly with standard protocols and adequate infrastructure.
The retrospective nature of our study was a major limitation. Many charts were missing or had incomplete documentation and hence could not be analyzed. Another limitation is driven by the fact that this study was conducted in a large tertiary care hospital, and hence, the patient population may be biased by patient selection and referral pattern.
The admission profile among this geriatric population showed that cardiorespiratory conditions are the most common emergencies, followed by trauma. ED of India should be aware of this demographic profile and be prepared to handle these emergencies efficiently. Due to the scarcity of data on geriatric emergencies from India, prospective follow-up studies are essential to truly understand the magnitude of the problem among the elderly.
Financial support and sponsorship
Nil.
Conflicts of interets
There are no conflicts of interest.
| References | | |
| 1. | Mobbs C. Biology of aging. In: Beers MH, Berkow R, editors. The Merck Manual of Geriatrics. 3 rd ed. New Jersey (USA): Merck and Co Inc., White House Station; 2001. p. 25.  |
| 2. | Kennedy RD, Caird FI. Physiology of aging of the heart. Cardiovasc Clin 1981;12:1-8. |
| 3. | Dickinson ET, Verdile VP, Kostyun CT, Salluzzo RF. Geriatric use of emergency medical services. Ann Emerg Med 1996;27:199-203. |
| 4. | Strange GR, Chen EH. Use of emergency departments by elder patients: A five-year follow-up study. Acad Emerg Med 1998;5:1157-62. |
| 5. | Elderly in India: Profile and Programs; 2016. Available from: http://www.mospi.gov.in [Last accessed on 2017 Mar 08]. |
| 6. | Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8. [ PUBMED] [Full text] |
| 7. | Irudaya Rajan S. Demography of ageing. In: Dey AB, editor. Ageing in India, Situational Analysis and Planning for the Future. New Delhi: Rakmo Press; 2003. |
| 8. | |
| 9. | Aminzadeh F, Dalziel WB. Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 2002;39:238-47. |
| 10. | Lowenstein SR, Crescenzi CA, Kern DC, Steel K. Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-35. |
| 11. | Lowthian JA, Cameron PA, Stoelwinder JU, Curtis A, Currell A, Cooke MW, et al. Increasing utilisation of emergency ambulances. Aust Health Rev 2011;35:63-9. |
| 12. | Caplan GA, Brown A, Croker WD, Doolan J. Risk of admission within 4 weeks of discharge of elderly patients from the emergency department – The DEED study. Discharge of elderly from emergency department. Age Ageing 1998;27:697-702. |
| 13. | Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, et al. Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med 1999;6:1232-42. |
[Figure 1]
[Table 1], [Table 2], [Table 3]
| This article has been cited by | | 1 |
Severe or not so severe? The gravity of geriatric trauma |
|
| KundavaramPaul Prabhakar Abhilash,Sharon Pradeeptha,Andrea Cris,Darpanarayan Hazra,Anmol Jindal,Jagadesha Selvan | | Journal of Family Medicine and Primary Care. 2021; 10(7): 2614 | | [Pubmed] | [DOI] | | | 2 |
Clinical profile, outcomes and predictors of mortality in elderly patients admitted to the emergency medicine intensive care unit of a teaching hospital – A single-center registry |
|
| William Wilson, Prithvishree Ravindra, UdaykumarJ Khasage, JeffreyPradeep Raj, Vinayak Jain, Bijoyini Bose, Sreenidhi Kosuri | | Journal of Family Medicine and Primary Care. 2021; 10(10): 3791 | | [Pubmed] | [DOI] | | | 3 |
Profile and outcome of patients with ground-level falls |
|
| Salma Kaiser,Myla Yacob,KundavaramPaul Prabhakar Abhilash | | Journal of Family Medicine and Primary Care. 2020; 9(2): 614 | | [Pubmed] | [DOI] | |
|
 |
|
|
|
Search Pubmed for