Advances in medicine have generated a longevity revolution marked by longer lives, changed mortality expectations and new challenges for the healthcare systems globally. By 2050, the global population aged ≥60 years is projected to reach 2.1 billion.1 Average global life expectancy at birth is estimated to rise to around 77.4 years in 2054.2 In sync with the global trends, India is undergoing a rapid demographic transition with the elderly population projected to rise to 319 million by 2050, growing at an annual rate of approximately 3% 3 and with women accounting for 58% of the elderly population and the overall dependency ratio of 62 dependents per 100 working-age individuals.3,4 This elderly population is a vulnerable group for both communicable as well as non-communicable diseases. They face unique challenges with cognitive problems, rising disabilities, multiple comorbidities, inadequate geriatric infrastructure and urban-rural divide in access to medical services. Multi-morbidity state is a common scenario in geriatric health needs, which not only complicates the management, course of illness and outcomes, but also strains the healthcare infrastructure and resource.5,6,7 The  problem in developing countries is more complex in view of inadequate infrastructure, insufficient social security provisions, little health insurance coverage and low literacy and awareness levels. Cultural upbringing that dictates chronological age is a criterion for seeking active medical attention and the assumption that most of the symptoms in the elderly are a part of the usual ageing process, leads to unnecessary delay, adverse outcomes and underutilisation of available healthcare facilities.8,9,10

This observational study included 1000 elderly patients (>60 years) who, over a duration of one year, sought medical attention in the emergency section of the Department of Medicine, Government Medical College, Jammu, a tertiary care hospital. The study was commenced after due permission from the Institutional Ethics Committee, GMC, Jammu and the data was collected after an informed consent was signed by either the study participants or their authorised representatives. The patient demographics, common presenting complaints, comorbidities, disease patterns were studied. In addition to a detailed history and examination, all routine haematological, biochemical and microbiological investigations were carried out and documented. Radiological investigations like CT scan and MRI and specific systemic investigations like CSF study, UGI/LGI endoscopies, fibroscan, 2D Echo were carried out on a case to case basis. The ED triage outcomes including discharge with advice for treatment on outpatient basis or admission to ICU / HDU/ Wards were documented. The clinical outcomes of these patients, be it immediate discharge from ED or discharge after hospital stay or death were observed and also the effect of delay in seeking medical care on these outcomes. The collected data was entered in MS Excel and analysed using SPSS. Continuous variables were presented as mean (standard deviation) while categorical and nominal variables were presented as percentages. A p value of <0.05 was considered as statistically significant.

A total of 1000 elderly patients (> 60 years) attending the ED over a period of one year were included in the study after taking due informed consent. Majority of the patients were in the age group of 65-70 years (53.1%) followed by those in 70-80 years group (31.5%).  The mean age of the study cohort was 72.80±7.04 years with a male to female ratio of 0.8:1.  In our study, 47.5% of the patients presented to ED within 24 hours (<24hrs) of symptom onset, 42.5% presented between 1-5 days and 10% presented after 5 days (>5 days) from the symptom onset. While 88% of our patients presented with multiple symptoms to ED, only

12% reported with a solitary symptom. The most common symptom was shortness of breath (37%) followed by fever (23.5%), giddiness (18%) and nausea/vomiting (17.5%). Other presenting symptoms were generalised malaise (13.5%), focal neurological deficits (12.8%), chest pain (10.7%) and altered sensorium(10.5%). The most common etiological causes observed were respiratory (19.5%) followed by infection related (17.6%), cardiovascular (17.4%), neurological (14.4%), gastrointestinal (13.5%) and others (Metabolic (9.8%), renal (6.5%) and neoplastic (1.3%)).  In this study, 90.1% of our patients required hospital admission (ICU or HDU or Ward) and 9.9% patients were managed on an outpatient basis. The admitted patient cohort demonstrated a mortality of 7.8% (table 2).

Table 1: Distribution of patient outcomes with ED arrival time after symptom onset

The main causes of mortality were cardiovascular (30%), infection related (28%) and neurological events (22%). Highest mortality (20%) was seen amongst patients who reported to the hospital after 5 days of symptom onset, followed by those who reported within 1-5 days from onset (6.59%). Least mortality was observed among the inpatient group who arrived in ED within 24 hours of symptom onset. (4.84%) The relative risk of death was increased in both groups who attended ED after 1-5 days of onset as well as those who attended after 5 days as compared to those who came in within 24 hours but the ones arriving >5 days after symptom onset had a 4-fold higher risk of death compared to those arriving within 24h, and this result was statistically significant [RR: (>5 days: 4.13 (CI 2.34–7.29) → Significant] while the increase for 1–5 days was modest and not statistically significant.; [Relative risk (RR)(1-5days): 1.36 (CI 0.78–2.36) → Not significant.] The odds ratio in the both delayed presentation groups was also corroborative. [Odds ratio (OR) (>5days): 4.91 (CI 2.65–9.09)→Significant] [Odds ratio (OR)(1-5days): 1.38 (CI 0.77–2.47)→Not significant]

Table 2: Impact of Delay in hospital presentation after symptom onset on Mortality

The mean age of the subjects in the mortality group (75.2±8.1 years) was higher than the mean age of patients discharged after admission (72.17±6.2 years) which was higher than the group who were managed on outpatient basis (71.9±6.5 years). Thus mean age differed significantly across outcome groups (ANOVA, F = 6.8, p = 0.001), with patients who died being older (75.2 ± 8.1 years) compared to those discharged. Sex distribution did not differ significantly across outcomes (Chi-square, χ² = 0.65, df = 2, p = 0.72). There was a significant age vs outcome association (p ≈ 0.001) with older patients more likely to die and an insignificant sex vs outcome association (p ≈ 0.72) with male/female proportions similar across outcomes. Advanced chronological age was observed to be associated with a higher likelihood of hospital admission after ED visit as well as higher in-hospital mortality.

Table 3: Association of Patient Outcomes with Age and Sex

India is facing an increased burden of an ageing population in the presence of limited health care resources and minuscule budgetary allocations. With the elderly population expected to exceed 300 million by 2050, the added strain on the existing health facilities is inevitable. The ED visits by elderly patients have increased and due to their multi-morbidity states, their care and management is often complex and fraught with unique challenges.4,6,10

The mean age of our study population was 72.80±7.04 years with females and males comprising 55.4% and 45.6% respectively of the study group. Wilson et al. also reported similar results with mean (SD) age of the study participants as 70.23 ± 7.18 years.13 Iloh G et al., in 2012 in their study of 216 geriatric emergency patients, aged 65-98 years, observed the mean age was 72 ± 1.14 years and there was a female preponderance (56.5% F vs 43.5% M) which is in sync with our findings. 53.5 % of our patients belonged to 60-70 years age group.14 Prabhudev et al., also reported that the mean age of the admitted elderly patients in their study was 72.7 ± 6.4 years.15 Ramadevi M et al., (2016) in their study of geriatric patients reported most of the patients in the age group of 60- 65 years (45%) with a male to female ratio of 2:1.11 Reddy APK et al., (2016) in their study of 200 geriatric patients (age >60 years) observed that most patients (31%) were in the age group of 65-69 years.12 Their findings corroborate with our observations but the predominance of females was not reported by them. However, this can be explained by the fact that sex ratio among the elderly in India stands at 1,065 females per 1,000 males, with women accounting for 58% of the elderly population. Also, we have included only patients visiting the emergency department and this could be a reason for bias.16 Moreover, the life expectancy for women in India is more than that in men (70.5 years in men versus 73.6 years in women, 2023 - UN, World Population Prospects)18  

47.5% patients in our study presented within 24 hours of symptom onset, 42.5% between 1-5 days and 10% presented after 5 days of symptom onset. The delay in seeking care is primarily due to lack of awareness, cultural practices that chronological age is a sole determinant of need for seeking medical attention, difficult terrain and delayed referrals. Among our patients, the most common symptoms observed were shortness of breath (37%), fever (23.5%), giddiness (18%) and nausea/vomiting (17.5%). Similar findings were reported by Abhilash KPP et al in 2017 with the most common presenting complaints in their study group being breathing difficulty (28%), fever (21.6%) and vomiting (14%).19 Wilson et al. also reported breathing difficulty (29.41%) and fever (21.47%) as the most common presenting complaints thereby upholding our observations.13 Most common causes of ED visits and admissions in our study were respiratory (19.5%) followed by infectious (non-respiratory) (17.6%), cardiovascular (17.4%), neurological (14.4%), gastrointestinal (13.5%) and others (metabolic (9.8%), renal (6.5%, neoplastic (1.3%)). Similar findings were put forth in a study on Chinese Geriatric patients by Hong wei Liu, with the three most common causes of geriatric emergencies being respiratory disease (26.2%), cardiovascular disease (20.8%) and neurological disease (10.9%).20 Results akin to these were reported by a study conducted in France which highlighted that cardiopulmonary disease (31.6%) was the most common reason for emergency admissions of elderly patients in a university hospital. Our study had comparable results with the most common organ systems involved being cardiopulmonary (CVS (18.7%), respiratory system (15.8%)).14

Hypertension and T2DM are the most common comorbidities among the geriatric population presenting to ED and these findings have been upheld in different studies by Prabhudev et al., and Wilson et al. 90.1% of our elderly patients were admitted (ICU or HDU or Ward) and managed as per protocol, 9.9% were discharged from ED and managed on an outpatient basis.15 Among the admitted patients 7.8% died. In the study by Abhilash KPP et al (2017), more than half of the elderly patients seeking medical care in ED were discharged (51.5%), 47.5% were admitted in the hospital, and an overall in-hospital mortality encountered was 6.8% (79/1090).19 Their overall in-hospital mortality was comparable with that of 7.8 % in our patients. What stands out in our study is that a high mortality (20%) was seen in patients who reported to the hospital after >5 days of symptom onset followed by those who reported from 1-5 days from symptom onset (6.59%) and the least mortality (4.84%) was noted among those who presented early within 24 hours of symptom onset. There is a highly significant association between delay in ED arrival after symptom onset and mortality. Patients arriving later (>5 days after symptom onset) have substantially higher mortality compared to those arriving earlier. The patients arriving 1–5 days after symptom onset have about 35% higher risk of death compared to those arriving within 24h, however, this didn’t reach statistical significance. [RR: 1.36 (CI 0.78–2.36)] The patients arriving >5 days after symptom onset have a 4-fold higher risk of death compared to those arriving within 24h, [RR - 4.13(CI 2.34–7.29)] and this result is statistically significant. (p < 0.0001) Our findings are at par with those of Jones s et al.24

This underscores the importance of public awareness regarding disease symptoms and the significance of early medical intervention. Mortality rates among elderly patients in different studies range from 17 to 73 %.19 A statistically significant association was observed between increasing age and adverse outcome of the study participants. The mean age of the patients differed significantly across outcome groups (p = 0.001) with patients who died, being older (75.2 ± 8.1 years) compared to those who were discharged either directly from ED or after in-patient stay (71.9±6.5, 72.17±6.2 years). Sex distribution did not differ significantly across outcomes (p = 0.72) Thus, higher patient age increased the likelihood of hospitalisation and in hospital mortality increased, but no significant association was observed between gender and the final outcome.27

Early initiation of treatment and a multidisciplinary approach help to provide optimum care to the elderly visiting the ED. There is a need for public health education and awareness to deconstruct the thought that higher chronological age can put off the need and timing of seeking medical attention.25,26 Comprehensive geriatric care is the need of today so that the elderly are supported across all domains of healthcare access, financial limitations, social isolation and digital and infrastructure barriers

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