Admission of Elderly in Emergency Units: Causes and Problems

Ageing is a normal, yet very complex process. As the body ages, the function of each system of body becomes impaired eventually giving rise to various health problems. This makes them frequent users of emergency units. Aminzadeh et al., has reported that older adults use emergency services at a higher rate, their visits have a greater level of urgency and they have longer stays in the emergency department. Even the elderly experience higher rates of adverse health outcomes after their discharge from hospital [1].

Informed consent was obtained from each subject after explaining the objectives, activities and duration of their involvement. They were assured of maintaining their confidentiality.
Statistical analysis: Data was analyzed using SPSS 16.0 version. Descriptive statistics was employed to analyze the data. Table 1 depicts socio demographic data of the subjects. Maximum subjects (62.3%) were in the age group of 60 -69 years, followed by 24.3% in the age group of 70-79 years and only 1.7% was above 90 years of age. More than half (63.3%) were male subjects and belonged to urban area (55%), 38% were living alone. Half of the subjects were completely dependent for financial support on their care givers. Table 2 depicts clinical diagnosis of the subjects in all the emergency units on the basis of different body systems. In medicine unit more patients (27%) were admitted with problems of cardiovascular system, in surgery unit problems of gastrointestinal system were predominately more, however in trauma unit more patients were with musculoskeletal problems. Table 3 depicts the organizational problems of the subjects/ caregivers in emergency. It indicates that about half (41.3%) of these subjects were not able to sleep properly. Problems regarding sitting arrangement for the attendants, insufficient beds for patients and overcrowding etc., were reported by majority of the subjects. Maximum were staying in the waiting hall followed by rain shelters (tents outside the institute) and shrine.

Discussion
This world is seeing a tremendous rise in elderly population. According to WHO, globally elderly population is growing faster than any age group. In 2010, about 600 million people were 60 years or older, by 2025 figure is expected to reach 1.2 billion people and in 2050 it is likely to be around 1.9 billion. In developing countries the proportion of elderly will increase from 7% to 12% by 2025 [6]. India is the second most popular country in the world. It has 76.6 million people at or over the age of 60, which constitute above 7.7% of total population [7].
The elderly population is one of the most vulnerable and neglected section of society. So this section needs more care, attention to improve their quality of life. Over the period of time, the elderly people become more susceptible to disease and disability. They often have limited regenerative abilities and are more prone to disease, various symptoms, and sickness than younger adults. Often they suffer from many health problems requiring emergency management. From health perspective it is more important to recognize the emergency health problems and health needs of elderly and to take steps to promote emergency health facilities.
The present study was undertaken with the objective to determine the causes of emergency admission among elderly and to enumerate problem faced by the elderly and their caregivers in various emergency units i.e. medicine, surgery and trauma.
As per planned methodology the subject were selected through purposive sampling technique. 300 subjects were enrolled with 100 from each unit. Data was collected from the subjects and caregivers by using an interview schedule. More than half of subjects (62.3%) were in the age group of 60-69 yrs, 63.3% subjects were male, 78% were married and 18.7% were widow/widower. Around one third were still working. More number of males using emergency unit has been reported by Stori et al., in their study [8]. Generally it has been seen that the males live longer than females. It is obvious that health problems will also be more in males. And generally also it has been seen that the males are comparatively better looked after than the females.
It is the accepted fact that with advancing age, the functioning of all the body system gets impaired. There is loss of tissue, overall strength, cognitive and motor function. They become more prone to fractures and disabilities. In present study out of 100 patients in trauma unit, 63% had various types of injuries due to fall or road side accidents. Similar results have been reported by Kara et al in their study [5].
Likelihood of developing health problems and chronic health problems increases as the body ages. The First National Sample Survey (NSS) conducted during the second half of 1980s, focused on the elderly had indicated that 45% of the elderly suffered from some chronic illness like pain in the joints and cough. Other diseases noted in the NSS survey included blood pressure, heart disease, urinary problems and diabetes [9]. In present study it was revealed that in 45% subjects from medicine unit, 21% from surgery unit and 28% from trauma unit have hypertension as a co-morbidity.
In the current study, 17% subjects from surgical emergency unit had gastrointestinal system related symptom at the time of admission like nausea, vomiting, abdominal distention, pain abdomen etc. It could be explained by the fact that in most of the elderly cases, it is usually observed that they start behaving like children. They do not realize what they should be eating. So, they may not digest whatever they eat and land up with acute GI problems. Our findings of having more admission of the subjects with GI problems has been supported by a study conducted on elderly patients in emergency department Geneva, Switzerland, that abdominal complaint was the main complaint in 3% to 13% of emergency department visits in older patient.
In the present study it was found that 61% subjects were not working. In Indian settings, in majority of the states, the age of superannuation is 60 years, though it is 58 yrs and even 65 yrs in certain other states. So, after retirement from the job, the elderly become dependent on their caregivers, more so, if there is no pension. In the current study, 50% of the subjects were completely dependent and 20% were partially dependent on their caregivers, though 30% were independently managing their financial aspects.
PGIMER Chandigarh is a tertiary care hospital. There has been unprecedented rise in the number of patients every year from all over North India. More number of patients and attendant needs more space and proper sitting arrangements. The findings of the present study revealed that most of the subjects (80%) had problem related to sitting arrangement for their relatives.
Another common problem which was faced by 60% the patients/ caregivers was regarding the location of labs etc. and being not oriented to the hospital. They verbalized that there should be more staff appointed who can guide them, so that their precious time can be saved. To overcome this problem, in fact, more signboards in regional languages showing the way to various locations inside the hospital should be displayed.
These are a need to develop strategies to make the emergency department more senior friendly. We need to develop model of care in emergency for the older people customized to the Indian population. The previous models for the elderly care have mixed results. One study has reported that early geriatric assessment provided by a nurse specialist had no effect on admission rates, length of stay, or functional decline [10]. However, in another study, a nurse dedicated specifically to discharge planning for older adults reduced the proportion of unscheduled emergency return visits and facilitated the transition from emergency back home and into the community [11].
So, proportional to the increase in elderly population in future, the emergency admission of this vulnerable segment is also likely to increase. Thus, we need to develop certain policies to provide quality care to the elderly patients as well as their caregivers. In a qualitative study [12] carried out on 527 registered nurses from 49 US hospitals, five central themes were emerged from the analysis. These represented a lack of older person hospital environment fit in the emergency department. These themes were respect for the older adults and their care givers, correct and best procedures and treatment, time and staff to do things right, transitions, and a safe and enabling environment. The nurses offered solutions to address lack of fit, including modifications to the social climate, policies and procedures, care systems and processes, and physical design. So, the problems identified and the solutions offered by nurses could be helpful in planning strategies for the care of elderly people in emergency.