Abstract
Aim
We evaluated the relation between general status on arrival and prognosis in patients aged 90 years and older who were admitted to our department through the emergency room, with the aim of assisting the development of a treatment policy for elderly people.
Methods
We retrospectively analyzed patients aged 90 years and older who were admitted to our department from January 2006 to September 2013. Patients were divided into two groups, patients who were discharged from our hospital or transferred to another hospital, and patients who died in our hospital. Comparisons of the patients' general status and the results of blood examinations were carried out between the two groups. Independent parameters to predict prognosis were also evaluated.
Results
Fifty‐eight patients were enrolled in this study. The mean age was 93.2 ± 3.4 years (range, 90–106 years). Forty‐five patients (77.6%) were discharged from our hospital (group A), and 13 patients (22.4%) died (group B). The percentage of patients with the inability to walk independently was significantly higher in group B. Mean arterial pressure, Glasgow Coma Scale (GCS), PaO2/FiO2 ratio, and serum albumin level on arrival were significantly better in group A. Multivariate logistic regression analysis indicated that the inability to walk independently (odds ratio, 22.4; 95% confidence interval, 4.4–113.1; P < 0.0001) and GCS (odds ratio, 7.0; 95% confidence interval, 1.8–27.7; P = 0.003) were the parameters to predict prognosis.
Conclusion
The inability to walk independently and GCS (consciousness status) are the most sensitive predictors of prognosis in emergency patients aged 90 years and older.
Keywords: Aged, coma, consciousness, emergencies, prognosis
Introduction
The population of developed countries such as France, Germany, Italy, UK, USA, Canada, and Japan are aging as a result of low fertility, low immigration, and increased longevity.1 Japan has currently the most advanced aging population, and the proportion aged 65 years and older is estimated to increase from 23.0% in 2010 to 29.1% in 2020, and 31.6% in 2030 based upon median death and birth rates.2 Although the total population has decreased since 2008 in Japan,2 there will be a gradual increase in demand for emergency ambulances due to the aging population and lower birthrate.3 Additionally, emergency ambulance dispatches to elderly people have recently increased with the aging of the Japanese people. The 2011 annual report from the Fire and Disaster Management Agency in Japan showed that emergency ambulance dispatches to people aged 65 years or older accounted for 2,692,581 (52%) of all 5,178,862 cases.4
Geriatric medicine, which treats elderly people with differing characteristics to those of young people, is an essential medical field, however, there are no established guidelines regarding the use of invasive procedures and/or treatment modalities to elderly people. In addition, emergency room (ER) physicians experience many cases where sufficient informed consents regarding the occurrence of sudden aggravation are not given to patients themselves and/or their family. Particularly, we ER physicians are troubled with the current treatment policy for elderly people aged 90 years or older, which entrusts their treatment decisions to the judgment of the on‐site doctor.
In this study, we evaluated the relation between general status on arrival and prognosis in patients aged 90 years and older who were admitted to our department through the ER, to assist in developing treatment policy for elderly people.
Patients and Methods
This study was approved by the Medical Ethical Committee of Gunma University Hospital (Maebashi, Japan). Written consent was obtained from all patients or their appointed representatives.
Our emergency department accepts patients with every status, ranging from mild to severe. We undertake primary care, and patients are referred to specialists if necessary. Patients are admitted to our department and, as attending physicians, we make a diagnosis, decide the admission, and can initiate treatment. We retrospectively analyzed patients aged 90 years and older admitted to our department of emergency medicine through the hospital's ER from January 2006 to September 2013. Patients with end‐stage malignancy or with cardiopulmonary arrest were excluded from this study. We retrospectively reviewed the medical records of all patients and obtained necessary information. Patients were divided into two groups, those who were discharged from our hospital or transferred to another hospital, and those who died in our hospital. Comparisons regarding underlying diseases, mean age, male/female ratio, the percentage of patients with the inability to walk independently, and those with gastrostomy on admission were carried out between the two groups. The general status of each patient, such as mean arterial pressure (MAP), Glasgow Coma Scale (GCS), and PaO2/FiO2 (P/F) ratio on arrival, was also compared. Additionally, results of blood examinations (levels of lactate in arterial blood, hemoglobin, white blood cells, platelets, total protein, albumin, total bilirubin, and creatinine measured on arrival) were compared between the two groups. Based on those comparisons, the independent parameters to predict prognosis in emergent patients aged 90 years old and older were evaluated.
Statistical analysis
Data are presented as the mean ± standard deviation. The Mann–Whitney U‐test or χ2‐test (with Yates' correction if necessary) was used to compare variables between the two groups, and the independent variables were selected. A multivariate logistic regression model was used to detect independent parameters to predict the prognosis in emergent patients aged 90 years or older. The odds ratios (OR) and 95% confidence intervals (CI) were also calculated. Statistical analyses were carried out using IBM spss Statistics 20 (IBM Software Group, Chicago, IL, USA). A P‐value of less than 0.05 was interpreted to be statistically significant.
Results
From January 2006 to September 2013, 1,928 patients were admitted to our department, of which 66 patients were aged 90 years or older (3.4%). There were two patients with end‐stage cancer (pharyngeal carcinoma in one, and colon carcinoma in another), and six patients with cardiopulmonary arrest. Therefore, those eight patients were excluded from this study.
The mean age and male/female ratio in the remaining 58 patients (3.0%) were 93.2 ± 3.4 years (range, 90–106 years) and 20/38, respectively. There were no maintenance dialysis patients among those 58 patients. Forty‐five patients (77.6%) were discharged from our hospital to home or transferred to other hospitals (group A), and 13 patients (22.4%) unfortunately died in our hospital (group B).
The patients' background diseases are shown in Table 1. There were no significant differences in the underlying diseases between the two groups.
Table 1.
Background diseases in Japanese patients aged ≥90 years admitted to an emergency medicine department (n = 58)
| Group A | Group B | P‐value | |
|---|---|---|---|
| Gastrointestinal bleeding | 9 | 2 | 0.9779 |
| Traumatic brain injury | 6 | 2 | 0.7890 |
| Aspiration pneumonia | 4 | 3 | 0.3682 |
| Pneumonia | 4 | 2 | 0.8725 |
| Acute gastroenteritis | 3 | 0 | 0.8064 |
| Acute poisoning | 3 | 0 | 0.8064 |
| Dehydration | 2 | 1 | 0.8064 |
| Accidental hypothermia | 2 | 0 | 0.9289 |
| Cholecystitis | 2 | 0 | 0.9289 |
| Heatstroke | 1 | 1 | 0.9289 |
| Congestive heart failure | 1 | 1 | 0.9289 |
| Bronchial asthma | 1 | 0 | 0.5046 |
| Hypoglycemia | 1 | 0 | 0.5046 |
| Influenza | 1 | 0 | 0.5046 |
| Inhalation injury | 1 | 0 | 0.5046 |
| Liver abscess | 1 | 0 | 0.5046 |
| Phlegmon in lower limb | 1 | 0 | 0.5046 |
| Transient ischemic attacks | 1 | 0 | 0.5046 |
| Urinary tract infection | 1 | 0 | 0.5046 |
| Multiple trauma | 0 | 1 | 0.5046 |
| Total | 45 | 13 |
Group A, patients who were discharged from our hospital or transferred to another hospital; Group B, patients who died in our hospital.
The comparison in characteristics between the two groups are shown in Table 2. There were no significant differences in the mean age, male/female ratio, or the presence of gastrostomy between the two groups. However, the percentage of patients with the inability to walk independently was significantly higher in group B than in group A.
Table 2.
Clinical characteristics of Japanese patients aged ≥90 years admitted to an emergency medicine department (n = 58)
| Group A (n = 45) | Group B (n = 13) | P‐value | |
|---|---|---|---|
| Mean age (years) | 93.1 ± 3.1 | 93.7 ± 4.4 | 0.6597 |
| Male/female | 16/29 | 5/10 | 0.7085 |
| Inability to walk independently | 3 (6.7%) | 8 (61.5%) | <0.0001 |
| Gastrostomy | 0 (0%) | 1 (7.7%) | 0.5046 |
Group A, patients who were discharged from our hospital or transferred to another hospital; Group B, patients who died in our hospital. Bold P‐value indicates significance.
Table 3 shows the comparisons in general condition and laboratory data on arrival between the two groups. There were no significant differences in lactate level in arterial blood, hemoglobin, white blood cells, platelets, total protein, total bilirubin, or creatinine measured on arrival between the two groups. However, MAP, GCS, P/F ratio, and serum albumin levels on arrival were significantly better in group A than in group B.
Table 3.
Objective measurements and laboratory data in Japanese patients aged ≥90 years admitted to an emergency medicine department (n = 58)
| Group A | Group B | P‐value | |
|---|---|---|---|
| MAP (mmHg) | 99.4 ± 20.3 | 78.3 ± 21.5 | 0.0111 |
| GCS | 12.8 ± 3.0 | 7.8 ± 3.8 | 0.0005 |
| P/F ratio (mmHg) | 337.0 ± 142.7 | 180.6 ± 97.8 | 0.0006 |
| Lactate (mg/dL) | 25.0 ± 21.9 | 34.1 ± 26.1 | 0.3388 |
| Hb (g/dL) | 11.2 ± 2.0 | 11.7 ± 2.4 | 0.4703 |
| WBC (/mm3) | 8,433 ± 3827 | 11,338 ± 5,023 | 0.0713 |
| Platelet (×104/mm3) | 16.7 ± 5.5 | 18.3 ± 6.9 | 0.4480 |
| Serum total protein (g/dL) | 6.5 ± 0.8 | 6.1 ± 0.9 | 0.2028 |
| Serum albumin (g/dL) | 3.4 ± 0.5 | 2.9 ± 0.6 | 0.0291 |
| Serum total bilirubin (mg/dL) | 0.9 ± 0.5 | 0.9 ± 0.4 | 0.7861 |
| Serum creatinine (mg/dL) | 1.0 ± 0.6 | 1.6 ± 1.3 | 0.1582 |
Group A, patients who were discharged from our hospital or transferred to another hospital; Group B, patients who died in our hospital. GCS, Glasgow Coma Scale; Hb, hemoglobin; MAP, mean arterial pressure; P/F ratio, PaO2/FiO2; WBC, white blood cell count. Bold P‐values indicate significance.
Multivariate logistic regression analysis indicated that the inability to walk independently (OR, 22.4; 95% CI, 4.4–113.1; P ≤ 0.0001) and GCS (OR, 7.0; 95% CI, 1.8–27.7; P = 0.003) were the parameters to predict prognosis in emergent patients aged 90 years old and older.
Discussion
One of the most significant demographic changes in the past 100 years is the gradual increase in the elderly population rate,5 a worldwide problem that is not an exception in Japan. A large increase in the number of elderly people subsequently leads to the need and cost of healthcare services. The number of emergency ambulance dispatches to elderly people also increases, including those to extremely elderly patients aged 90 years and older. There were 104 patients aged 90 years and older who were transferred to our ER by ambulance in 2012, accounting for 3.4% of all emergency ambulance arrivals at our hospital.
In this study, the mortality of admitted patients aged 90 years and older was 22.4%, and the residual 77.6% of patients were discharged from our hospital or transferred to other hospitals. We predicted a higher mortality compared with the real value before we carried out this analysis, however, it is difficult to judge whether the mortality rate was satisfactory or poor because there are few reports for comparison. Yildiz and coworkers reported a mortality rate of 6.4% in elderly (age ≥65 years; mean age, 73.14 years) trauma patients,5 and Gambier et al. showed a mortality rate of 5.2% in elderly (age ≥75 years; mean age, 85.64 years) patients admitted to their internal medicine department.6 In contrast, Stippler et al. reported that only 24% of patients aged over 90 years presenting with chronic subdural hematoma returned home.7
Significant differences were not found between the two groups regarding underlying diseases. However, the percentage of patients with the inability to walk independently was significantly higher in group B than in group A, and the inability to walk independently was one of the parameters to predict prognosis in emergent patients aged 90 years old and older based on multivariate logistic regression analysis. Population‐based longitudinal studies in elderly people have shown an association between poor lower‐extremity function and disability, hospitalization, and survival in subjects with ages ranging from 65 to more than 80 years.8, 9 Studenski et al.10 recently reported a significant association between gait speed and survival in elderly people with a mean age of 73.5 (standard deviation, 5.9) years. Taekema et al.11 insisted that walking is one of the most important activities that people perform on a daily basis, and inability to accomplish a walking test was a marker of adverse outcome. Our results were consistent with those previous studies.
There were significant differences in MAP, GCS, P/F ratio, and serum albumin levels between the two groups. In addition, multivariate logistic regression analysis indicated that GCS was one of the parameters to predict prognosis in emergent patients aged 90 years and older. Mean arterial pressure is associated with hemodynamic status, the P/F ratio indicates respiratory status, GCS reflects consciousness status, and albumin is related to nutritional status. Hypoxia based on heart and/or respiratory failure influences the consciousness status, especially in elderly people. The changes in consciousness status such as confusion, memory deficit, and sleepiness were recognized as the initial presentation of heart failure in elderly patients, especially those aged over 80 years.12 Additionally, syncope was seen in elderly patients with pulmonary embolism,13, 14 and the greater incidence of syncope in older patients was basically due to their reduced cardiopulmonary reserve and pulmonary obstruction, or the increased prevalence of concurrent heart and lung diseases with advanced age.13 Taking those into consideration, it is supposed that the consciousness status is the most sensitive parameter reflecting the general status of elderly patients.
Limitations
This is a retrospective study, and the number of patients was not large. Evaluation of patient data including body mass index could not be done because we could not collect enough information regarding patients' height and weight. Only the evaluation of each patient's condition on arrival and after treatment at our hospital was included in this study; patients' conditions and prognoses after they were transferred to other hospitals were not examined. A further prospective study with a lengthened investigation period is necessary.
Conclusion
Prognostic factors in emergency patients aged 90 years and older were evaluated. The inability to walk independently and GCS (consciousness status) are the most sensitive predictors in emergency patients aged 90 years and older. A good prognosis could not be expected in elderly emergency patients with the inability to walk independently and/or a low GCS.
Conflict of Interest
None.
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