KL N K ÇALIfiMA/RESEARCH ARTICLE Akad Geriatri 2013; 5: 117-126 Gelifl Tarihi/Received: 09/01/2013 - Kabul Edilifl Tarihi/Accepted: 26/06/2013 Clinical and Demographic Characteristics of Patients Aged 65 Years and Older Admitted to Emergency Department Acil Servise Baflvuran 65 Yafl Üstü Hastalar n Klinik ve Demografik Özellikleri Mehmet Üstünda, brahim Tunç, Murat Orak, Ayhan Özhasenekler, Hasan Mansur Durgun, Cahfer Gülo lu Department of Emergency Medicine, Faculty of Medicine, Dicle University, Diyarbakir, Turkey Dicle Üniversitesi T p Fakültesi, Acil T p Anabilim Dal, Diyarbak r, Türkiye ABSTRACT Introduction: In this study, we aimed to determine the clinical and socio-demographic characteristics of patients aged 65 years and older admitted to emergency department. Materials and Methods: In this study, emergency department admissions of patients aged 65 years and older between September 2007 and September 2011 were retrieved from digital database and patient files were obtained from the archive to retrospectively assess. Patient data were recorded on previously prepared standard study forms. Results: During this four-year period admitted to the emergency department among 128.155 patients 12.888 (10.05%) were 65 years and older. Among 1719 admissions data of which were retrieved, 903 (52.5%) were male and 816 (47.5%) were female, the mean age was 74.66±6.68 years and mortality rate was 11.5%. While mean age and ratio of widowhood in female patients were higher, ratio of married and had a higher education level in male patients were higher. The most common presenting symptom to emergency department was dyspnea (27.9%); mortality rate among those presenting with altered consciousness and out of vehicle traffic accident was higher. 41.2% of the patients were treatment and managed at emergency department. During the study period 213 patients admitted emergency department more than once. Those admitting emergency department repeatedly had a lower mean age, a higher educational level; they were also more commonly residing at the city center. Conclusion: To better care for the elderly patients, hospitals should employ educated staff and be equipped with necessary equipment to meet the specific demands of elderly people at emergency department, the entrance door of the hospitals. Key Words: Emergency department, elderly patient, repeated admission, mortality. Yaz flma Adresi/Address for Correspondence Doç. Dr. Mehmet Üstünda Dicle Üniversitesi T p Fakültesi, Acil T p Anabilim Dal, Diyarbak r/türkiye e-posta: drustundag@yahoo.com 117
Clinical and Demographic Characteristics of Patients Aged 65 Years and Older Admitted to Emergency Department ÖZET Girifl: Çal flmam zda acil servise baflvuran 65 yafl ve üstü hastalar n klinik ve sosyodemografik özelliklerinin belirlenmesi amaçland. Materyal ve Metod: Çal flmada Eylül 2007 ile Eylül 2011 tarihleri aras ndaki 65 yafl ve üstü hastalar n acil servis baflvurular bilgisayar kay tlar ndan tespit edildi ve bu hastalar n dosyalar arflivimizden bulunarak geriye dönük olarak incelendi. Hasta verileri daha önceden haz rlanan standart çal flma formlar na kaydedildi. Bulgular: Acil servisimize bu dört y ll k süre zarf nda baflvuran 128.155 hastan n 12.888 (%10.05)'i 65 yafl ve üstü hastalara aitti. Standart çal flma formundaki tüm verilere ulafl labilen 1719 baflvurunun 903 (%52.5) ü erkek, 816 (%47.5) s kad n, yafl ortalamas ; 74.66±6.68 ve mortalite oran %11.5 idi. Kad n hastalarda yafl ortalamas ve dul olma oran daha yüksek iken erkek hastalarda evli ve e itimli olma oran daha yüksekti. Acil servise en s k baflvuru nedeni nefes darl (%27.9) iken fluur de- iflikli i ve araç d fl trafik kazas nedeniyle baflvuran hastalarda mortalite oran daha yüksekti. Hastalar m z n %41.2'sinin takip ve tedavisi acil klini inde yap ld. Çal flma periyodu boyunca 213 hasta acil servise iki ve daha fazla baflvuru yapm flt. Mükerrer baflvuru yapanlarda bir kez baflvuranlara göre yafl ortalamas daha düflük, e itim seviyesi daha yüksek ve il merkezinde yaflama oran daha yüksek idi. Sonuç: Yafll hastalara daha iyi bak m verebilmek için hastanelerin girifl kap s olan acil servislerin yafll hastalar ve bunlar n kendine özgü gereksinimlerini karfl layabilecek e itimli personel ve gerekli donan ma sahip olmalar gereklidir. Anahtar Kelimeler: Acil servis, yafll hasta, mükerrer baflvuru, mortalite. INTRODUCTION Ratio of the elderly population to total population has been gradually increasing both in the world and Turkey. It has been estimated that this number will be doubled by the next two decades and Turkey will host the most crowded elderly population of Europe in 2050 (1). The increase in the elderly population as a consequence of the ever increasing mean life expectancy in humans indicates that it is important to deal with problems of the elderly people and identify common issues of aging in terms of healthcare services. It has been reported that use of emergency department is more common among elderly population compared to normal population (2). It has been also reported that aged population admit emergency departments more frequently and with more complex problems, require a more intense care, are subjected to more radiologic and laboratory examinations, stay for longer periods at emergency department, and are more commonly admitted to regular wards and intensive care units compared to other age groups (3-5). Elderly people present to our hospital s emergency department for many different causes. The aim of our study was to identify clinical and sociodemographic characteristics of patients aged 65 years and older admitted to emergency department. MATERIALS and METHODS Data of 12.888 admissions over age of 65 treated at Dicle University Hospital Emergency Department between September 2007 and September 2011 were retrospectively assessed. Total number of admissions for 4 years equaled 128.155. Patient data were recorded on previously prepared standard study forms. Study forms included the following information: age, sex, repeated emergency department admission, marital status, number of children if present, mode and hour of admission, admitted complaint, observation unit, admission clinic and diagnosis, duration of hospital stay, discharge status, survival status, presence of chronic diseases, drugs used, laboratory results, prostheses and devices used, literacy status, residency status (City Center, County, Village), and housing status. Out of 12.888 admissions, 1719 admissions, data in the standard study forms of which could be retrieved, were included. Of these, 1166 admissions were of one-time-admission. On the other hand, 553 forms belonged to patients who admitted emergency department more than once. The number of patients with more than one admission was 213. All patients were evaluated at emergency department. Their diagnosis and treatment were done according to standard guidelines. Age, sex, marital status, educational status, number of children, place of residence, housing status, his- 118 Akad Geriatri 2013; 5: 117-126
Acil Servise Baflvuran 65 Yafl Üstü Hastalar n Klinik ve Demografik Özellikleri torical characteristics, prostheses, devices, and drugs used were assessed in terms of repeated or single admission. The patients were classified into two survivor and dead groups. Clinical and sociodemographic characteristics considered to be effective on mortality, duration of hospital stay and admission clinic were assessed. Univariate analyses were performed using chi-square test for categorical variables and Student s t test for continuous variables. Mean values were calculated as mean ± SD (Standard Deviation). p< 0.05 was considered statistically significant. RESULTS Among 1719 admissions included in the study, 903 (52.5%) were male and 816 (47.5%) were female. The mean age was 74.66 ± 6.68 (65-107) years. The mean age of women was 75.20 ± 7.14 (65-107) years and it was 74.18 ± 6.20 (65-102) years in men, with the mean age of women being significantly higher than men (p= 0.002). Widowhood was significantly prevalent in women compared to men whereas being married was more common among men than women (p< 0.001). Educational status was significantly better in men compared to women. Sociodemographic characteristics of our patients are presented in Table 1. One hundred and ninety seven (11.5%) patients died. Sociodemographic characteristics of surviving and dead patients are presented in Table 2. Seven hundred thirty two (42.6%) patients admitted to hospital on their own while 987 (57.4%) were brought by an ambulance. Assessment of the admission symptoms revealed that the most common 5 presenting symptoms were, in descending order, dyspnea (27.9%), abdominal pain (15.3%), chest pain (13.0%), altered consciousness (9.9%) and other internal complaints (23.6%). Mortality rates were significantly hig- Table 1. Sociodemographic characteristics of the patients Sociodemographic characteristics Male (n= 903) Female (n= 816) Total (n= 1719) p Age (years; Mean ± SD) 74.18 ± 6.20 75.20 ± 7.14 74.66 ± 6.68 0.002 Marital status Married 726 503 1229 < 0.001 Single - 2 2 0.225 Widow 177 311 488 < 0.001 Educational status lliterate 366 707 1073 < 0.001 Literate 220 58 278 < 0.001 Primary 255 47 302 < 0.001 High school 58 4 62 < 0.001 College 4 0 4 0.126 Place of residence City center 570 566 1136 0.007 County 194 134 328 0.008 Village 139 116 255 0.498 Housing status Own house, with spouse 236 184 420 0.092 Own house, with spouse and children 464 271 735 < 0.001 Child (ren) s house 161 262 423 0.001 Alone 14 33 47 0.002 House of relatives 27 64 91 < 0.001 Nursing home - 1 1 0.475 Hospital stay (days; Mean ± SD) 5.30 ± 7.14 4.97 ± 6.45 5.14 ± 6.82 0.317 Akad Geriatri 2013; 5: 117-126 119
Clinical and Demographic Characteristics of Patients Aged 65 Years and Older Admitted to Emergency Department Table 2. Sociodemographic characteristics of surviving and dead patients Sociodemographic characteristics Dead (n= 197) Survivor (n= 1522) p Gender Male 114 789 0.112 Female 83 733 Age (years; Mean ± SD) 75.49 ± 6.79 74.55 ± 6.66 0.069 Marital status Married 126 1104 0.015 Single - 2 1.000 Widow 71 416 0.012 Educational status lliterate 116 957 0.275 Literate 28 250 0.473 Primary 46 256 0.028 High school 7 55 1.000 College - 4 1.000 Place of residence City center 128 1008 0.749 County 40 288 0.631 Village 29 226 1.000 Housing status Own house, with spouse 37 383 0.053 Own house, with spouse and children 79 656 0.445 Child (ren) s house 61 362 0.035 Alone 6 41 0.815 House of relatives 13 78 0.396 Nursing home - 1 1.000 Hospital stay (days; Mean ± SD; range) 6.17 ± 10.54 (0-83) 5.01 ± 6.17 (0-82) 0.132 her among those admissions with altered consciousness and out of vehicle traffic accidents. Admission symptoms among patients admitting to emergency departments were detailed in Table 3. Comorbidities in our patients included hypertension in 50.1%, coronary artery disease in 37.5%, previous operation in 34%, diabetes in 29.2%, and COPD in 22.9%. Comparison of surviving and dying patients revealed that CVS and COPD were significantly different among groups (p<0.001 and p=0.024, respectively). Forty one point two percent of our patients were managed at emergency department followed by cardiology (14.4%), gastroenterology (8%), chest diseases (7.4%), general surgery (5.4%). Mortality rates by clinics were as follows: 47.5% for intensive care unit, 45.5% for neurosurgery, 29.7% for neurology, and 19.6% for general surgery. For emergency department where the majority of the patients were managed the mortality rate was 7.6%. Patient characteristics in terms of comorbid diseases, habits and followed clinics are given in Table 4. During the study period, 213 patients admitted to emergency department twice or more (minimum: 2, maximum: 7). Repeated admitters were younger, had a higher educational background, and were living more commonly at city centers. Assessment of patients with single and repeated admission in regard of comorbid diseases and habits demonstrated that chronic renal failure, COPD, coronary artery disease, chronic liver disease, diabetes mellitus, hypertension, history 120 Akad Geriatri 2013; 5: 117-126
Acil Servise Baflvuran 65 Yafl Üstü Hastalar n Klinik ve Demografik Özellikleri Table 3. Admission symptoms of the patients Symptom Survivor (n= 1522) Dead (n= 197) Total (n= 1719) p Chest pain 206 17 223 0.055 Abdominal pain 242 21 263 0.058 Nausea-vomiting 92 6 98 0.102 Diarrhea 21-21 0.159 Constipation 20 4 24 0.345 Difficulty in urinating 25 1 26 0.351 Dysuria 17-17 0.246 Flank pain 26-26 0.064 Stroke 12 1 13 1.000 Altered consciousness 100 70 170 < 0.001 Dyspnea 417 62 479 0.238 Fever 39 2 41 0.222 Hematemesis 51 7 58 0.834 Melena 54 5 59 0.676 Hematochesia 6-6 1.000 Epistaxis 19-19 0.155 Rash 6-6 1.000 Leg edema 19 2 21 1.000 Generalized edema 5-5 1.000 Drug intoxication 1-1 1.000 In-vehicle traffic accident 9-9 0.609 Out of vehicle traffic accident 10 5 15 0.022 Sharp object wound 2-2 1.000 Burn 4-4 1.000 Assault 1-1 1.000 Simple fall 63 2 65 0.027 Fall from a height 10-10 0.616 Foreign material in the eye 6-6 1.000 Other 360 45 405 0.859 of previous operation, and presence of malignancy were significantly more common in those with repeated admission. Sociodemographic characteristics of patients admitting once and more than once are given in Table 5. DISCUSSION It is known that geriatric population applies to emergency departments more commonly than normal population and they more frequently need intensive care unit care (2,6,7,8). Therefore, emergency de- Akad Geriatri 2013; 5: 117-126 121
Clinical and Demographic Characteristics of Patients Aged 65 Years and Older Admitted to Emergency Department Table 4. Comorbid diseases, habits and followed clinics of our patients Comorbid diseases and habits Survivor (n= 1522) Dead (n= 197) Total (n= 1719) p Chronic renal failure 286 47 333 0.103 COPD 335 58 393 0.024 CVS 121 33 154 < 0.001 Coronary artery disease 564 81 645 0.274 Chronic hepatic failure 114 9 123 0.144 Diabetes mellitus 442 60 502 0.678 Hypertension 768 93 861 0.406 Previous operation 536 49 585 0.004 Malignancy 192 34 226 0.073 Smoking 220 35 255 0.241 Alcohol 7-7 1.000 Followed clinics Emergency department 653 54 707 < 0.001 Chest diseases 107 21 128 0.082 Neurosurgery 6 5 11 0.005 General surgery 74 18 92 0.018 Chest surgery 5-5 1.000 Intensive care unit 31 28 59 < 0.001 Gastroenterology 129 8 137 0.035 Nephrology 61 3 64 0.107 Infectious diseases 31 2 33 0.577 Neurology 52 22 74 < 0.001 Hematology 22 3 25 0.760 Endocrinology 28-28 0.066 Cardiology 219 26 245 0.745 Orthopedics 54 1 55 0.016 Cardiovascular surgery 11 1 12 1.000 Reanimation 3 2 5 0.103 Urology 18-18 0.253 Ear, nose and throat 4-4 1.000 Dermatology 2-2 1.000 Physiotherapy 2-2 1.000 Plastic surgery 2-2 1.000 Oncology 8 3 11 0.122 CVS: Cerebrovascular stroke; COPD: Chronic obstructive pulmonary disease. 122 Akad Geriatri 2013; 5: 117-126
Acil Servise Baflvuran 65 Yafl Üstü Hastalar n Klinik ve Demografik Özellikleri Table 5. Sociodemographic characteristics of patients admitting once and more than once Sociodemographic characteristics One-time presenters (n= 1166) Repeated presenters (n= 213) p Gender Male 590 117 0.264 Female 576 96 Age (years; Mean ± SD) 75.01 ± 6.92 73.90 ± 6.24 0.029 Marital status Married 804 161 0.061 Single 2-1.000 Widow 360 52 0.062 Educational status lliterate 739 127 0.316 Literate 162 44 0.016 Primary 225 33 0.214 High school 36 9 0.400 College 4-1.000 Place of residence City center 716 166 < 0.001 County 233 31 0.072 Village 216 16 < 0.001 Housing status Own house, with spouse 262 58 0.184 Own house, with spouse and children 516 89 0.548 Child (ren) s house 267 60 0.097 Alone 45 1 0.006 House of relatives 75 5 0.016 Nursing home 1-1.000 Outcome Survivor 993 189 0.201 Dead 173 24 Hospital stay (days; Mean ± SD) 5.02 ± 6.53 13.72 ± 13.91 < 0.001 Comorbid diseases and habits Chronic renal failure 161 59 < 0.001 COPD 227 63 0.001 CVS 96 14 0.492 Coronary artery disease 342 117 < 0.001 Chronic liver disease 46 21 0.001 Diabetes mellitus 292 80 < 0.001 Hypertension 503 131 < 0.001 Previous operation 336 91 < 0.001 Malignancy 120 42 < 0.001 Smoking 164 32 0.749 Alcohol 5 1 1.000 COPD: Chronic obstructive pulmonary disease, CSV: Cerebrovascular stroke.
Clinical and Demographic Characteristics of Patients Aged 65 Years and Older Admitted to Emergency Department partments are the entrance door of the hospitals. Furthermore, ratio of elderly population, defined as 65 years and older, gradually increases. Parallel to that increase, emergency department admissions also increase (9). The ratio of emergency department admissions to all admissions was 10.05% (12.888/128.155). This ratio was similar to other ratios ranging between 11.5-50% in other studies (10,11). The ratio of emergency department admissions is inherently affected by the country, city, localization of emergency department, and demographic features of the region. Since the worldwide life expectancy for women is longer than men, the ratio of female population is larger among older age groups. It has been suggested that this gender disproportion among older population will increasingly continue in future (12). The increased proportion of female group among elderly has led to development of a concept called feminization of senility. Feminization of senility defines an increase in female population among elderly population in addition to a state of resultant of the difficulties women experience before and during senility (13). We also found that women had a higher mean age compared to men. However, our male patients had a slightly higher number than female counterparts, albeit statistically insignificant. To our opinion, the reason of phenomenon is that men apply to a health facility for any health problem because of the men s value in the patriarchal structure of our region whereas women hesitate to apply to health facilities. A longer life lived by women means that they will live part of their remaining life alone. Thus, senility period is a more though period for women than men. Many elderly men have a spouse while majority of women have to live this period without a spouse (13). For example, two-third of elderly women aged 65 years and older are widows (14). We also found that majority of our male patients were married while the rate of widowhood was significantly higher among women. The difference between the genders in terms of marital status stems from the sociocultural structure in our region. A man whose spouse has died can easily marry another woman whereas the opposite is difficult due to social pressure. Status of women is lower than men in many countries of the world and the women are subjected to a systematic discrimination in many areas of life. A greater amount of poverty, a lower educational status, literacy rate, access to health care, a limited opportunity to work in qualified jobs, and responsibility of giving care to family members in addition to a higher likelihood of living the rest of the life alone cause women to have a worse health status and a higher rate of disability at old age (13). Consistent with the literature, our study also detected that majority of women in our study population were illiterate. This results from prevention of girls from continuing their education because of sociocultural factors. In a study by Satar et al. it has been reported that majority of elderly people presenting to emergency department reside at city centers (3). Similarly, majority of our patients consisted of those residing at city center. Due to sociocultural features and the great importance of the family concept in our region, most of our patients were living with their spouses, children, and relatives and they could easily access to healthcare facilities with the help of these people. Hence, a very low number of the patients with repeated admission among those living alone confirm this finding. In a study by Özflaker and et al. 20% of elderly patients admitted to the emergency department by ambulance (15). In our study, this rate was higher. These results show that 112 emergency services are frequently used by geriatric patients. This is because of the positive developments in health policy especially in 112 emergency services. Causes of emergency department admissions differ in the literature. In the study by Ünsal et al. hypertension, cardiac and pulmonary diseases, upper respiratory and urinary tract infections were the most common causes of admission (4). Özflaker et al., on the other hand, reported that respiratory problems, gastrointestinal disorders, cardiovascular disorders, and trauma comprise the most common admission disorders among elderly (15). Satar et al. reported stroke as the most common disease followed by, in descending order, oncologic emergencies, general body trauma, and chronic renal failure (3). In our study dyspnea was the most common presenting symptom followed by, in descending order, abdominal pain, chest pain, altered 124 Akad Geriatri 2013; 5: 117-126
Acil Servise Baflvuran 65 Yafl Üstü Hastalar n Klinik ve Demografik Özellikleri consciousness, and general body trauma. Mortality was significantly higher among the patients presenting with altered consciousness. To our opinion, the differences in the presenting symptoms originate from the location of the study center, ease of patient access to the healthcare facility, and the differences between sociodemographic and cultural characteristics of the region. Previous studies have reported that 90% of people aged over 65 in our country have a chronic disease and 35% has 2, 23% has 3, and 15% has 4 or more diseases (16). In a study in our region including individuals aged 55 years or more Turhano lu et al. reported hypertension, osteoporosis, and osteoarthritis as the most common diseases (17). We also found that hypertension was most prevalent, with a rate of 50.1%, followed in descending order by coronary artery disease, diabetes, COPD and chronic renal failure. This order was the same for the patients who repeatedly presented during study period. As a conclusion; we detected factors and demographic data effective on mortality and repeated presentations among elderly people. In summary we detected that; Widowhood as the marital status was more prevalent among women and being married was more common among men, Our female patients had a lower literacy rate, Admissions from city center were more common, Majority of our patients were living with their spouses, children, or relatives, The most common presenting symptom at the emergency department was dyspnea, Mortality rate was high in patients presenting with altered consciousness, Majority of patients were discharged from emergency department with cure, Intensive care admissions had a higher ratio among admitted patients, The most common chronic disease was hypertension, Presence of cerebrovascular accidents in patient history increased mortality, Patients who were from city center comprised the most numbered patient group among those who repeatedly admit, repeated admissions were low in those living alone or with relatives, and high among those with comorbid diseases and chronic drug use. Elderly population also increases in our country with improved living conditions and this increase parallels to an increasing number of elderly patients admitting to emergency department. Aging-associated issues and multiple accompanying chronic diseases necessitate a different and more sophisticated patient care. To better care for the elderly patients, hospitals should employ educated staff and be equipped with necessary equipment to meet the specific demands of elderly people at emergency departments, the entrance door of the hospitals. REFERENCES 1. Çilingiro lu N, Demirel S. Yafll l k ve yafll ayr mc l. Turkish Journal of Geriatrics 2004; 7: 225-30. 2. 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. 3. Satar S, Sebe A, Avc A, Karakufl A, çme F. Yafll hasta ve acil servis. Çukurova Üniversitesi T p Fakültesi Dergisi 2004; 29: 43-50. 4. Ünsal A, Çevik AA, Metintafl S, Arslantafl D, nan OÇ. Yafll hastalar n acil servis baflvurular. Turkish J Geriatr 2003; 6: 83-8. 5. Mert E. Geriatrik hastalar n acil servis kullan m, Turkish J Geriatr 2006; 9: 70-4. 6. Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, et al. Geriatric patient emergency visits. Part I: comparison of visits by geriatric and younger patients. Ann Emerg Med 1992; 21: 802-7. 7. Baum SA, Rubenstein LZ. Old people in the emergency room: age related differences in emergency department use and care. J Am Geriatr Soc 1987;35:398. 8. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med 1992; 21: 819-24. 9. Kunt MM, Sivri B. Geriatrik aciller. Kutsal YG, Aslan D (editörler): Temel Geriatri. Ankara: Öncü Bas mevi, 2007: 193-9. 10. McLigeyo SO. The pattern of geriatric admissions in the medical wards at the Kenyatta National Hospital. East Afr Med J 1993; 70: 37-9. 11. Vanpee D, Swine C, Vandenbossche P, Gillet JB131. Epidemiological profile of geriatric patients admitted to the emergency de- Akad Geriatri 2013; 5: 117-126 125
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