ED physicians encounter more and more geriatric patients as life expectancy increases in the developed world. Those patients present with distinctive features, including increased frailty, multiple morbidities, functional and cognitive impairment, and a high medication burden, rendering them more complex to evaluate and treat. “Generalized weakness” or "nonspecific" complaints are frequent causes for their referral to the ED. In this work, we addressed this important issue by studying the older adult characteristics and outcomes in a tertiary hospital ED setting.
While no significant difference was found for demographic, clinical, and laboratory variables between the weakness and non-weakness groups for patients who were discharged from the ED, for patients who were admitted, functional level differed significantly. Patients admitted due to weakness were more likely to be functionally dependent than patients admitted for other diagnoses. This observation links “weakness”, a poorly defined diagnosis with reduced functionality. Though not evaluated in the current study, frailty and cognitive decline are correlated with the level of dependency18–20. Frail patients might present with subtle and less “typical” features of various medical diagnoses. Cognitively impaired patients may experience difficulties communicating their specific symptoms.
An important observation in this work is the finding of an increased risk for mortality during and following hospitalization of older adults admitted to the ED for "weakness". Several explanations may be given to this observation. As indicated earlier (Table 1), functional level differed significantly for admitted patients. Patients admitted due to weakness tend to be more dependent in their daily activities. This may provide a partial explanation to the increased mortality rate of this group, as functional level was previously linked with risk of all-cause mortailty21,22. An additional possible explanation may be the erroneous perception that, lacking a specific diagnosis, these patients’ condition is better than it really is. This approach may lead to slower performance of diagnostic procedures and less extensive investigation for the etiology of their weakness, thus perhaps resulting in delayed treatment and increased risk of complications.
Infections were the main specific etiology for the “weakness” group admissions to the ED (24%). This finding can be explained by blunted and atypical inflammatory responses to infections of older adults9,10. A less expected result was the high proportion of patients hospitalized for weakness who were discharged from the hospital without a clear diagnosis of the condition that was responsible for the acute state which leads to their admission (22%). Another unexpected finding was that social issues, such as neglect and loneliness, were the basic etiology to the final diagnosis of "weakness" in less than 1%. We had expected that “weakness” or vague symptoms of malaise or apathy might be expressions of loneliness or neglect, but our findings did not support our expectations.
This work has several limitations that bear mention in addition to its retrospective design. One is that the older patients who were not referred to the on-call geriatrician at the ED were not included in the study. This may confer a selection bias by excluding the patients with severe or life-threatening medical issues for which they were rapidly admitted and transferred to medical wards. This bias may have contributed to the finding of more serious prognoses of the “weakness” patients compared to those of the “non-weakness” patients. Another limitation is that the final diagnosis at discharge from hospitalization is chosen from a “discharge diagnoses” list. This list might be inaccurate because of an inherent difficulty to specify a single clear-cut cause for an older, fragile patient’s acute deterioration (e.g., identifying specific diagnosis for an infectious event, identifying one factor responsible for the delirious state of a patient).