An analysis of the literature revealed that, 12–24% of ED admissions are made by elderly patients. This rate is higher in socioeconomically developed countries where life expectancy is higher [5, 8, 9, 11]. The proportion of longlivers among elderly patients presenting to the ED also varies between societies. In a study conducted in Switzerland, the percentage of longlivers among elderly patients presenting to the ED was 24%, in a study conducted in Italy it was 19%; and in a study conducted in the UK, it was approximately 30% [3, 6, 12]. In a study conducted in Australia, it was shown that 7.6% of the population aged 65 years and over consisted of people aged 90 years and over. In a study conducted in Turkey, 10% of the patients who admitted to the ED were aged 65 years and older and 7.2% of these patients were aged 85 years and older [13]. The rate of approximately 15% of ED patients aged 65 years and over in our study is higher than that in the other study conducted in Turkey and is compatible with the literature. The percentage of longlivers in elderly patients, which was 3.9% in our study, is lower than that in studies conducted in Western countries. In the other study conducted in Turkey, it was thought that the percentage of longlivers was greater than that found in our study because longlivers were defined as patients aged 85 years and older. The difference from the studies conducted in European countries can be attributed to the fact that the life expectancy in these societies is grater than that in Turkey due to their high socioeconomic status.
In ED patients aged 65 years and older, the female sex ratio has been shown to be between 50–52%. In longlivers, the female sex ratio increases up to 60–68% [2, 6, 12, 14]. In our study, the female sex ratio of 60% in the longlivers group was similar to that in the literature. The high female sex ratio in the longlivers group may be explained by the fact that life expectancy is greater in women than in men. The fact that harmful habits such as tobacco, alcohol or substance use are more common in men, that men are more exposed to trauma as a result of occupational reasons, wars or accidents, and that diseases which are the main cause of death are more common in men may explain the shorter life expectancy of men compared to women [15].
The fact that the relatives of longlivers are generally elderly people is a factor that makes it difficult for them to access health services. It is very difficult for longlivers who are bedridden due to stroke or dementia to be transported to outpatient clinics or emergency services by means of their relatives. In previous studies, it was observed that 60–70% of longlivers were transported to the ED by ambulance [6, 16]. In our study, the rate of admission by ambulance was 77.6% (n = 552). The high rate of admission by ambulance may be explained by the easy access to ambulance services in Turkey and the fact that ambulance requests made through the 112 emergency call lines almost always responded positively. Although easy access to ambulances and emergency health services is often abused, it cannot be ignored that it improves the quality of life of groups such as longlivers who need continuous support. Establishing vehicles other than general ambulances that provide access to health services only for longliver patients will prevent unnecessary occupation of ambulances. Examination and treatment areas, in other words, geriatric EDs, which will be established for elderly patients outside the emergency departments and will provide 24-hour service, will prevent frequent ED applications, especially by longlivers, and will prevent ED crowding.
In our study, longlivers were mostly admitted during outhours. The reason for this may be that longlivers are too old to apply to the hospital on their own and their relatives cannot accompany them in the inhours because they have to work. The fact that there was no difference between the shift groups in terms of hospitalization or mortality rates suggests that the admission times were determined according to the availability of relatives rather than the clinical conditions of the patients.
One of the main reasons that elderly patients are difficult to manage and complicated patients are in the ED because of the presence of multiple comorbid diseases. Studies conducted with patients aged 65 years and older admitted to the ED have shown that 87–97% of these patients have a comorbid disease [14, 17]. Cardiovascular diseases, dementia and COPD are the most common comorbid diseases in longlivers [3]. In our study, hypertension, cardiovascular disease and dementia were found to be the most common comorbid diseases in longlivers. Our study supports the findings in the literature, with a comorbidity rate of 91%. The incidence of hypertension increases with age. While hypertension is observed in approximately 29% of adults in the United States of America (USA), this rate increases to 65% at the age of 60 years and older [18]. Hypertension is one of the leading risk factors for cardiovascular diseases [19, 20]. The increase in hypertensive years with advancing age may explain the frequency of cardiovascular diseases in longlivers. Hypertension is also a risk factor for the development of dementia [20]. Improving blood pressure control in longlivers is important for improving quality of life and reducing the development of comorbid diseases.
The incidence of dementia is gradually increasing in society, and its importance as a public health problem is becoming visible. It is thought that 7.7 million people are diagnosed with dementia annually worldwide [20]. According to World Health Organization (WHO) data, there were 35.6 million dementia patients worldwide in 2010, and this number is expected to triple by 2050 [21]. Alzheimer's disease, dementia with Lewy bodies and dementia due to Parkinson's disease, which are the most common causes of dementia, are common diseases of advanced age, especially in longlivers [21, 22]. The increase in life expectancy indicates that the burden of dementia on healthcare systems will increase in the coming years. It is important to identify the factors that cause the development of dementia and reduce its effects, but we will encounter many more dementia patients in the coming years than today. Starting to organize centers where the care and treatment of dementia patients can be carried out together today has the potential to prevent possible crises in the health system in the future.
According to the literature on ED diagnoses in longlivers, heart failure, trauma, pneumonia and various infections constitute the main diagnoses [2, 5, 13, 16]. In our study, the most common diagnosis was musculoskeletal injuries due to falls. Longlivers are prone to falls because of their reduced physical capacity. Because of the high incidence of dementia, longlivers may not be able to avoid behaviours that may cause falls and may not be able to protect themselves. People who take care of longlivers should be cautious about the risk of falls and should not leave the patient alone as much as possible in actions such as walking, climbing up and down stairs. In toilets and bathrooms, which are places where falls frequently occur, it will be useful to create devices that longlivers can move by holding on. Another precaution that can be taken is to keep the toilets and bathrooms used by longlivers dry and clean to prevent slipping and falling. Upper respiratory tract infections and pneumonias were also the most common diagnoses in our study. It is important for longlivers whose immune system is not as strong as that of young people to use masks that cover the mouth and nose when entering crowded areas, and people who are known to have respiratory tract infections should not be in the same environment as longlivers as possible to protect against infectious diseases. Exacerbations of chronic diseases such as COLD or heart failure were also common diagnoses in our study. Failure of longlivers to take their prescribed medication for these diseases as recommended will lead to worsening of the symptoms of these diseases. It is important that those caring for longlivers check that patients are taking their medication regularly and at the appropriate dose.
In studies in which ED admissions of elderly patients were analysed, 0.6%-4% of patients in the longlivers age group were reported to die in the ED [3, 6, 12, 16]. The 30-day mortality of longlivers after ED presentation was shown to be 8% in one study [16]. In our study, the 48-hour mortality rate of the longlivers after ED admission was 1.4%, which was similar to the in-ED mortality rates reported in previous studies. Advanced age is known to be a risk factor for mortality alone [10]. In our study, the fact that the 48-hour, 30-day and 180-day mortality rates of the longlivers group were greater than those of the relatively young elderly may be explained in this way. İmportantly, longlivers who are observed to have a high mortality rate should be evaluated in detail at ED admission, prolonged waiting times that may cause them to leave without being evaluated by a physician should be avoided, and the treatments to be recommended at the end of the evaluation should be explained in detail to the patient and the people who provide care.