Saturday, July 26, 2008

The changing trend of US Emergency Department (ED) visit (More Older Age Groups to the ED) - What about in Malaysia?

A study based on the US National Hospital Ambulatory Medical Care Survey showed ED visits for patients aged 65 to 74 has increased 34% from 1993 to 2003.

The authors conclude that if these trends continue, ED visits in US for this group (65-year to 74-year-old) could nearly double from 6.4 million visits to 11.7 million visits by 2013.

Implication: As stated by Richard D. Zane in a commentary in Journal Watch, the problem with this is not just about building bigger capacity emergency departments, but also to understand complexity of cases presented among patients in this older age group.

Roberts DC et al. Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med 2008 Jun; 51:769.

How about in Malaysia?
I am not aware of anyone who have done a similar survey in Malaysia looking at the changing trend of ED visit – but if anyone knows of any, please email me.

A search of the Jabatan Perangkaan Malaysia or Department of Statistics Malaysia shows that the life expectancy has slightly increased from 2005 – 2007, but generally it is about 71 years for male and 76 years for female – and it is going to improve in the future. And so by this reasoning, the percentage of older people visiting the ED would probably increases.

Life Expectancy at birth (number of years)
2005 2006 2007
Male 71.4 71.6 71.9
Female 76.1 76.2 76.4

Department of Statistics Malaysia

Generally, when seeing an older patient, there are three principles that we have to keep in mind. It can be remembered by the mnemonic: OLD

O – odd presentations; atypical presentations are common

L – Lots of medications [polypharmacy is common]

D – deceiving/ deceivingly normal vital signs – beware that normal vital signs can be abnormal in geriatric patients

Whatever it is, managing older patients can be quite an intriguing and challenging task due to the various physiological changes listed below.

Examples of physiological changes:

The integument

Skin atrophies and decreased density of the sweat glands resulting in altered thermoregulatory, increases risk of heat-related injuries (heat exhaustion, heat stroke, etc).

On the other hand, loss of subcutaneous body fat increases risk of hypothermia.

Cardiovascular System
Reduced ability to mount and sustain an increased cardiac output in response to hemodynamic insults.

Reduced ability to accommodate filling pressure and volume changes.

This effect may be further blunted by the various drugs the patient may be taking (e.g. a beta-blocker, calcium chanel blocker)

Pulmonary function
Chronic obstruction airway diseases, restrictive lung diseases, intercostal muscle weakening and loss of elastic recoil, less sensitivity in pulmonary chemoreceptors, and changes in the peak expiratory flow rate can negatively affect the overall efficiency of ventilation.

Renal system
Loss of renal mass and functioning glomeruli results in reduced GFR, and compromised drug and toxin elimination.

GFR begins a slow and steady decline around age 40 years and a decline in renal blood flow occur in the fourth decade at a rate of about 10% per decade.

Neurological system
Poor reflex coordination precipitating a fall or trauma due to loss of neurons and nerve fibers and slower dendrite connections.

Impaired responsiveness to pain, which can result in masking a diagnosis or resulting in an underestimation of the significance of symptoms.

Musculoskeletal system
Osteoporosis resulting in impaired mobility and risk of pathological fracture.
Immune system Decreases in T- and B-cell function and thymic atrophy can increase the geriatric patient's vulnerability to infection.


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jann said...

mention about survey done in Malaysia..i'm looking for the best way to educate community for not abusing our emergency of the way that i'm thinking of is to developed questionnaire and to distribute it among the patient who come under "green" category...or any other way..need ur opinion as an expert in this field..Malaysian not really aware of function of emergency department..


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