Emergency medicine in the extreme geriatric era: A retrospective analysis of patients aged in their mid 90s and older in the emergency department

Polypharmacy and risk of fractures in older adults: A systematic review

BACKGROUND

Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association.

METHODS

We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, abstracts, and full texts, then performed data extraction and quality assessment.

RESULTS

Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose-response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high.

CONCLUSIONS

Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.

Complications Arising from Dental Trauma Incurred from Falls Involving Geriatric Patients: A Case Report

Elderly patients have a high incidence of falls that result in facial injuries. Many cases present with dental crown fractures and soft-tissue lacerations. The initial diagnosis is especially important in this type of dental trauma, since an initial error can result in the failure to establish the correct treatment from the very beginning, worsening the prognosis, which, in the worst case, can compromise the teeth affected by the trauma. Case report: We present the case of a patient, a 79-year-old woman, who suffered an accidental fall. The patient was examined by a dentist in the emergency room. She was diagnosed with a simple crown fracture of the right upper central incisor and right upper lateral incisor without any pulpal involvement and with laceration of the lower lip. Months later, she had an episode of inflammation in the lower lip, and she developed edema and pain. An X-ray of the lower lip revealed a radiopaque mass compatible with a fragment of dental tissue due to the inclusion of remnants of the dental tissue resulting from the previous accident fall. Conclusions: The population of geriatric patients is steadily increasing in our society, and a higher frequency of falls has been observed in this age group, affecting the maxillofacial region, with consequent dental trauma on many occasions. Therefore, as professionals, we must pay special attention to the prevention and treatment of this problem, insisting on the importance of routine investigation in the emergency visit for dental trauma, which includes a meticulous examination of the soft tissues accompanied by a radiographic examination, when the inclusion of foreign bodies is suspected.

Implementing a multidisciplinary rapid geriatric observation unit for non-critical older patients referred to hospital: observational study on real-world data

BACKGROUND

Geriatric rapid observation units may represent an alternative to hospitalization in older patients with non-critical acute illness.

AIMS

To describe the characteristics and outcomes of patients admitted to a geriatric observation unit called URGe (Unità Geriatrica Rapida), implemented in an Italian hospital and characterized by multidisciplinary medical staff with geriatric expertise, fast-track access to diagnostic resources, regular use of point-of-care ultrasound and predicted length of stay (LOS) < 72 h.

METHODS

The medical records of patients admitted to URGe during a 3-month period (452 subjects, 247 F and 205 M, median age 82 years, IQR 77-87) were retrospectively examined. The primary study endpoint was transferral from URGe to regular wards. Baseline covariates included demographics, comprehensive geriatric assessment, acute illnesses, comorbidities, vital signs and routine laboratory tests.

RESULTS

Despite elevated burden of multimorbidity (median number of chronic diseases 4, IQR 2-5) and frailty (median Rockwood Clinical Frailty Scale score 4, IQR 3-6), only 137 patients (30.3%) required transferral from URGe to regular wards. The main factors positively associated with this outcome were Rockwood score, fever, cancer and red cell distribution width (P < 0.05 on multivariate logistic regression model). The rate of complications (mortality, delirium, and falls) during URGe stay was low (0.5%, 7% and 2%, respectively). Overall duration of hospital stay was lower than that of a group of historical controls matched by age, sex, main diagnosis, multimorbidity and frailty.

CONCLUSIONS

The URGe model of acute geriatric care is feasible, safe and has the potential of reducing unnecessary hospitalizations of older patients.

Clinical Presentations of Adolescents Aged 16-18 Years in the Adult Emergency Department

BACKGROUND

In many large hospitals in Switzerland, adolescents 16 years and older are treated in adult emergency departments (ED). There have been few publications about this specific patient population, especially in Switzerland. This study aims to provide an overview of emergency presentations of adolescents between 16-18 years of age when compared to adults and focuses on their principle complaints.

METHODS

We conducted a single-centre, retrospective, cross-sectional study of all patients aged 16 years and older presenting to the adult ED at the University Hospital (Inselspital) in Bern, Switzerland, from 2013 to 2017. This analysis gives an overview of emergency presentations of adolescents between 16-18 years of age in this time period and compares their consultation characteristics to those of adult patients.

RESULTS

Data of a total of 203,817 patients who presented to our adult ED between 2013 and 2017 were analysed. Adolescents account for 2.5% of all emergency presentations. The number of ED presentations in the reviewed time period rose for adults (+2368, 95% CI: 1695, 3041, p = 0.002 consultations more per year; +25% comparing 2013 with 2017), while adolescent presentations did not significantly increase (p = 0.420). In comparison to adult patients, adolescents presented significantly more often during the night (39.1% vs. 31.5%, p < 0.001), as walk-ins (54.2% vs. 44.9%, p < 0.001), or with less highly acute complaints at triage (21% vs. 31%, p < 0.001). They were more likely to be discharged (70.8% vs. 52.2%, p < 0.001). We found a significant association between the two age groups and principle complaints. In comparison to adults, trauma and psychiatric problems were significantly more common among adolescents.

CONCLUSIONS

Our data showed that complaints in adolescent patients under 18 years of age significantly differ from those in older patients. The artificial age cut-off therefore puts this vulnerable population at risk of receiving inadequate diagnostic testing and treatment adapted only for adults. Additional studies are needed on the reasons adolescents and young adults seek ED care, as this could lead to improvements in the care processes for this vulnerable population.

Falls in ED patients: do elderly patients on direct oral anticoagulants bleed less than those on vitamin K antagonists?

Background

Falls from standing are common in the elderly and are associated with a significant risk of bleeding. We have compared the proportional incidence of bleeding complications in patients on either direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA).

Methods

Our retrospective cohort study compared elderly patients (≥65 years) on DOAC or VKA oral anticoagulation who presented at the study site – a Swiss university emergency department (ED) – between 01.06.2012 and 01.07.2017 after a fall. The outcomes were the proportional incidence of any bleeding complication and its components (e.g. intracranial haemorrhage), as well as procedural and clinical parameters (length of hospital stay, admission to intensive care unit, in-hospital-mortality). Uni- and multivariable analyses were used to compare the studied outcomes.

Results

In total, 1447 anticoagulated patients were included – on either VKA (n = 1021) or DOAC (n = 426). There were relatively more bleeding complications in the VKA group (n = 237, 23.2%) than in the DOAC group (n = 69, 16.2%, p = 0.003). The difference persisted in multivariable analysis with 0.7-fold (95% CI: 0.5–0.9, p = 0.014) lower odds for patients under DOAC than under VKA for presenting with any bleeding complications, and 0.6-fold (95% 0.4–0.9, p = 0.013) lower odds for presenting with intracranial haemorrhage. There were no significant differences in the other studied outcomes.

Conclusions

Among elderly, anticoagulated patients who had fallen from standing, those under DOACs had a lower proportional incidence of bleeding complications in general and an even lower incidence of intracranial haemorrhage than in patients under VKAs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00866-6.

Changing trends in epidemiology and management of facial trauma in a Swiss geriatric population

OBJECTIVE

To assess the prevalence and surgical treatment of facial fractures in a Swiss population aged 65 and over.

BACKGROUND

The knowledge of the characteristics of geriatric trauma may help to prevent injuries and better allocate clinical resources for the management of multimorbid patients.

MATERIAL AND METHODS

This study retrospectively evaluated a cohort of 181 patients who presented at the Bern University Hospital in Switzerland from May 2012 to September 2016. Data on age, gender, aetiology and type of trauma, treatment and complications, co-morbidities and associated injuries were obtained.

RESULTS

Women were most frequently affected (55.2%). Mean age was 80 years. Zygomatic complex fractures were the most frequent type of fractures (37%), followed by isolated orbital fractures (27.6%). Falls were the most common cause of trauma (76.1%). Thirty-five per cent of all patients were taking anticoagulation or platelet aggregation medication. Hospitalisation was required in 88.4%, whereby 92.3% of the patients underwent surgical treatment. Surgery had to be performed immediately in three cases to treat compression of the optic nerve. Median hospital length of stay was 4 days, with 68% of patients returning to a domestic environment and 32% being transferred to another institution for further treatment.

CONCLUSION

The most common cause of facial injuries is a fall while standing in a domestic environment. Midface fractures were the most common type of fractures.