Article, Geriatrics

Weakness and fatigue in older ED patients in the United States

a b s t r a c t

Background: The objectives of this study are to estimate the prevalence of weakness and fatigue visits in older emergency department (ED) patients, to compare demographics and resource use in these patients with those without these complaints, and to determine their ED diagnoses and disposition.

Methods: We performed a cross-sectional cohort analysis of ED visits in patients aged older than 65 years from the 2003 to 2007 National Hospital Ambulatory Medical Care Surveys. Weakness and fatigue visits had a reason for visit code of generalized weakness (1020.0) or tiredness and exhaustion (1015.0); the comparison cohort lacked these codes. Descriptive data are presented as totals, means, and proportions with 95% confidence intervals (CIs). Comparisons between cohorts used ?² for proportions and the adjusted Wald test for means.

Results: There were an estimated 575 million ED visits, those aged 65 years and older made 14.7% (95% CI, 14.2-15.3) of visits. Overall, 6.0% (95% CI, 5.6-6.4) of these visits had weakness and fatigue; this was the fifth most common primary reason for visit. Weakness and fatigue visits increased with age. Weakness and fatigue visits had longer ED lengths of stay (300 vs 249 minutes, P b .001), more diagnostic tests (7.7 vs 5.0, P b .001), procedures (5.7 vs 4.7, P b .001), and hospital admissions (55% vs 35%, P b .001). The most common primary diagnoses for the weakness and fatigue cohort were “other malaise and fatigue,” pneumonia, and urinary tract infection.

Conclusion: Weakness and fatigue are common in older ED patients. These patients undergo more tests and procedures, and most are admitted.

Introduction

As the population ages, emergency department (ED) visits by older patients are projected to increase substantially [1]. Emergency physicians find this patient population more complex and difficult to manage, and older ED patients undergo more diagnostic testing, have longer ED lengths of stay, and have higher rates of admission [1]. One reason for this may be the altered presentation of disease in older patients, who are more likely to present with nonspecific complaints. One recent study found that patients presenting with Nonspecific complaints tended to be older and were likely to have

serious medical diagnoses [2].

In practice, we find generalized weakness and fatigue to be complex and difficult nonspecific complaints. It has been demon- strated that older patients often present to the ED with functional decline, and these visits are frequently prompted by weakness [3].

* Corresponding author. 525 E Market St, Akron, OH 44304. Tel.: +1 330 375 7530;

fax: +1 330 375 7564.

E-mail address: [email protected] (M.C. Bhalla).

Preliminary evaluation of the reasons for visits reported by older ED patients using the National Hospital Ambulatory Medical Care Survey found that the fifth most common reason was weakness and fatigue [1,4].

Our objectives were to estimate the prevalence of weakness and fatigue as reasons for visits in older ED patients, to compare demographics and resource use in these patients to those without these complaints, and to determine the ED diagnoses and disposition of patients complaining of weakness and fatigue.

Methods

Study design

This study is an analysis of 5 years of ED visits from the NHAMCS (2003-2007). There is a delay between NHAMCS data collection and the availability to download the data. At the time of analysis, only data to 2007 were available. The hospital’s institutional review board determined that the study did not constitute human subjects research as defined in Code of Federal Regulations.

http://dx.doi.org/10.1016/j.ajem.2014.08.027

1396 M.C. Bhalla et al. / American Journal of Emergency Medicine 32 (2014) 1395-1398

Table 1

Differences in patient characteristics in the weakness and fatigue cohort and the comparison cohort

				Weakness and fatigue	Comparison	P
Weakness and fatigue	Comparison	P		(95% CI)	(95% CI)

Table 3

Differences in procedures in the weakness and fatigue cohort and the comparison cohort

Patient characteristics

(95% CI)

Treatment

Any procedure 73.3% (69.5-76.8) 63.9% (62.7-66.1) b.0001

ED wait time, min	50.4 (43.6-57.2)	46.3 (43.7-49.0)	.1781	Total procedures, number	5.7 (4.1-7.3)	4.7 (4.1-5.3.)	.1648
ED length of stay, min	299.6 (279.4-319.7)	249.4 (240.3-258.4)	b.0001	Intravenous fluids	62.0% (57.8-66.1)	41.8% (39.8-43.8)	b.0001
Tachycardia	21.8% (19.1-24.8)	20.3% (19.5-21.1)	.2711	Medication	69.0% (65.2-72.5)	76.7% (75.3-78.0)	b.0001
Fever	8.1% (6.6-9.9)	4.3% (4.0-4.7)	b.0001	Bladder catheterization	11.3% (9.1-13.9)	8.1% (7.4-8.9)	.0007
Hypotension	4.3% (3.4-5.5)	3.0% (2.7-3.4)	.0033
Admission	55.0% (51.5-58.3)	36.4% (33.8-36.9)	b.0001
ICU admission	3.8% (2.4-6.1)	3.51% (2.9-4.3)	.7720

Abbreviation: ICU, intensive care unit.

Selection of participants

Our study population was NHAMCS ED visits. The Center for Disease Control‘s NHAMCS collects data on a national sample of visits to US EDs. Eligible hospitals include US nongovernment run and noninstitutional general hospitals. A 4-stage probability sample is used to select the geographic area, the hospitals within each area, the emergency service areas, and the patient visits for abstraction. This allows for the generation of national estimates of the characteristics of ED visits. Data collected include demographics, the patient’s reasons for visit, diagnostic services, procedures, diagnoses, and disposition [4]. Data are collected by hospital staff members or census bureau field representa- tives during randomly assigned 4-week periods at each hospital. Data collection is monitored by NHAMCS field representatives and checked manually and by computer algorithm to ensure accuracy [4].

Our population of interest was visits by patients aged 65 years and older. We retained visits by those aged younger than 65 years in the data set to allow for accurate calculation of national estimates, but these visits were used only for the comparison of weakness and fatigue visits by age. The NHAMCS lists up to 3 reasons for visit using a standardized classification system. We defined the weakness and fatigue cohort as those visits having any listed reason for visit code of generalized weakness (1020.0) or tiredness and exhaustion (1015.0). The comparison cohort was visits without one of these codes listed.

Outcome measures

The main descriptive outcome was the prevalence of weakness and fatigue visits in the aged 65 years and older subpopulation. The prevalence was stratified by age range to determine whether an age

Table 2

Differences in diagnostic testing in the weakness and fatigue cohort and the comparison cohort

effect was present. Outcomes for the comparison between cohorts of patients aged 65 years and older with and without weakness and fatigue included patient characteristics, diagnostic testing, and procedures (Tables 1-3).

Primary data analysis

The 5 years of NHAMCS data were aggregated into a single file and analyzed with Stata IC (version 11.0; StataCorp LP, College Station, TX). National estimates were calculated with Stata survey commands, using patient weight, strata, and primary sampling unit variables. We present descriptive data as totals, means, and proportions with 95% confidence intervals (CIs). We compared cohorts using ?² for proportions and the adjusted Wald test for means. No adjustment for multiple comparisons was made. Variables with cells containing less than 30 observations produce unstable estimates and are not presented.

Results

Characteristics of study subjects

There were 181 786 visit observations for analysis during the 5 study years. This provided a national estimate of 575 million ED visits. Patients aged 65 years and older made an estimated 85 million ED visits between 2003 and 2007 and represented 14.7% (95% CI, 14.2%- 15.3%) of all ED visits.

Main results

Of those patients aged 65 years and older, 6.4% (95% CI, 5.9-6.8) were in the weakness and fatigue cohort. The prevalence of weakness and fatigue increased with age: 1% in those aged younger than 65 years, 4.6% in those aged 65 to 74 years, 6.5% in those aged 75 to 84 years, and 7.7% in those aged 85 years and older (P b .0001) (Fig. 1). Weakness and fatigue was the fifth most common primary reason for visit in older ED patients, after trauma, dyspnea, chest pain, and abdominal pain.

Table 1 compares the patient characteristics for those with and

Diagnostic tests

Total diagnostic tests, number	7.7 (7.3-8.1)	6.0 (5.7-6.2)	b.0001
Pulse oximetry	50.7% (45.8-55.4)	39.9% (37.0-43.0)	b.0001
Cardiac monitor	32.1% (28.8-35.6)	21.2% (19.6-22.8)	b.0001
ECG	69.3% (66.3-72.2)	43.0% (41.7-44.3)	b.0001
Chest x-ray	57.38% (51.6-63.0)	39.0% (37.1-40.9)	b.0001
MRI/CT	25.3% (20.7-30.5)	15.0% (13.8-16.4)	b.0001
Ultrasound	2.1% (1.5-2.9)	2.4% (2.2-2.7)	.4135
Urinalysis	48.2% (45.1-51.4)	26.4% (25.4-27.4)	b.0001
Urine culture	10.2% (7.8-13.4)	7.0% (6.1-8.1)	.0160
CBC	87.0% (84.5-89.1)	60.2% (58.9-61.5)	b.0001
Creatinine	51.2% (44.1-58.3)	35.1% (31.9-38.4)	b.0001
Electrolytes	52.1% (47.5-56.7)	35.1% (32.6-37.7)	b.0001
Glucose	55.2% (50.0-60.3)	35.8% (33.4-38.3)	b.0001

Weakness and fatigue (95% CI)

Comparison P

(95% CI)

without weakness and fatigue. Those with weakness and fatigue had a

10.00%

7.70%

6.50%

4.60%

2.10%

1.70%

0.60%

9.00%

8.00%

7.00%

6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00%

Abbreviations: ECG, electrocardiogram; MRI/CT, magnetic resonance imaging/computed tomography; CBC, complete blood cell count.

<45 45-64 65-74 75-84 85+ total

Fig. 1. Percentage of patients with weakness and fatigue as ED visit reason by age.

M.C. Bhalla et al. / American Journal of Emergency Medicine 32 (2014) 1395-1398 1397

longer ED length of stay and a higher admission rate but similar ED wait time and intensive care unit admission rate. Fever was almost twice as likely in patients with weakness and fatigue compared with those without, and hypotension was more common.

There were significantly more total diagnostic tests during visits by patients with weakness and fatigue and a higher rate of nearly all individual diagnostic tests except ultrasound (Table 2). Older patients with weakness and fatigue more often received intravenous fluids, were more likely to have had at least 1 procedure, and were less likely to receive medications (Table 3).

The most common final diagnosis by International Classification of Diseases, Ninth Revision code for the weakness and fatigue cohort was “other malaise and fatigue” in 29%. Other common diagnoses were pneumonia, unspecified (14%); urinary tract infection, unspecified (13%); syncope and collapse (11%); congestive heart failure, unspec- ified (7%); Volume depletion (7%); fever and other physiologic disturbance (5%); anemia, unspecified (5%); dehydration (5%); and hemorrhage of the gastrointestinal tract (4%) (Fig. 2).

Discussion

Practicing emergency physicians recognize that generalized weak- ness and fatigue are common complaints in older ED patients. Our finding that it is the fifth most common reason for visit in older adult ED patients affirms this. In addition, patients with weakness and fatigue use more ED resources including diagnostic tests, have longer ED lengths of stay, and have higher admission rates. Given these findings, it is curious that little attention has been paid to this complaint in the emergency medicine community. We believe that this is the first study to describe weakness and fatigue in older ED patients.

Several important points are highlighted in this study. We found that, despite extensive diagnostic testing and longer ED length of stay, nearly one-third of visits for weakness and fatigue have the nonspecific “other malaise and fatigue” as the primary diagnosis. More than half of the weakness and fatigue cohort are admitted to the hospital, which is significantly more than the comparison cohort. This underscores the considerable resource use in this population but also highlights the important concern that hospital admission itself can result in functional decline in older patients [5]. Because of the relationship between muscle weakness and physical function, we expect that patients with weakness and fatigue would be at higher risk for functional decline after hospitalization [6]. Another study found that patients with generalized weakness had an increase change of admit and return within 30 days [7]. It may be that patients with generalized weakness and fatigue need to be assessed for additional rehabilitation or home health treatments [8-10].

Weakness and fatigue associated with acute illness have not been extensively researched. However, a great deal of research has been done on the overlapping geriatric syndromes of falls, sarcopenia, and frailty. [6,11-14] Falls are a common ED complaint and are associated with increased functional decline. Physical fatigue has been found to affect gait and may be a risk factor for falls [15]. Sarcopenia is the loss of skeletal muscle mass and function, which is commonly associated

with aging [6]. The initial presentation may be a decline in function or mobility difficulty [6]. Studies of patients with sarcopenia diagnosed by having low muscle mass, slow walking speed, and weak hand grip are found and increase in fall risk and mortality independent of age and comorbid conditions [16,17]. Frailty is a state of decreased homeostatic reserve resulting in an increased vulnerability to stressors [11]. Weakness and exhaustion (a synonym for fatigue) are 2 of the 5 criteria to define frailty in 1 commonly used definition [11]. Although sarcopenia and frailty are chronic geriatric syndromes, older patients with these syndromes may be at increased risk for weakness and fatigue when faced with acute illness. Recently, Quinlan et al [12] suggested that transitions in frailty states can occur with acute illness and that delirium and frailty may share common Pathophysiologic mechanisms in acute illness.

Future research into the pathophysiology of weakness and fatigue associated with acute illness can be provided direction by the findings of sarcopenia and frailty research. For example, weakness and fatigue with a specific diagnosis were most often due to infectious processes, and fever was nearly twice as likely in patients with weakness and fatigue. These findings suggest an underlying inflammatory state. Both frailty and sarcopenia have been associated with elevations in inflammatory cytokines in the absence of acute illness [13,18]. Preliminary evidence also suggests that inflammation in hospitalized patients is associated with muscle weakness [19]. The possibility that the additional inflammatory response to infection may worsen weakness in frail older adults should be explored. We postulate that other potential mechanisms for weakness associated with acute illness may include Mitochondrial dysfunction, endocrine factors, or Neuromuscular dysfunction.

The NHAMCS data set allowed us to make robust estimates of the national impact of weakness and fatigue in US EDs. However, there are a number of potential limitations. This is a secondary analysis of the NHAMCS data set and thus relies on the accuracy of data collection in the NHAMCS. However, the procedures used to ensure Data quality are extensive. We relied on the recording of weakness and fatigue as a coded reason for visit for our analysis; this may underestimate the actual number of affected patients who did not express this as a reason for visit. Because this database does not provide longitudinal data, we are unable to determine outcomes. For example, it is unknown whether patients with nonspecific diagnoses later have a specific diagnosis or whether the cause remains unknown. Future research examining a longitudinal cohort of patients with weakness and fatigue would be needed to answer these questions. Furthermore, data are based on visits not patients, so the same patient may appear more than once, although the size of the data set should limit the impact of a multiple visits by a single patient. The large size of the data set raises possibility of finding statistical significance without clinical importance. We believe, however, that nearly all the findings in Table 1 are clinically important. We chose not to adjust for multiple comparisons; given the large data set, even conservative adjustments would not substantively change the results.

In summary, our analysis of the NHAMCS data set found that

weakness and fatigue are common in older ED patients. These patients

578.9 Hemorrage of the GI tract

276.51 Dehydration

285.9 Anemia, uspecified

780.6 fever and other physiologic disturbance

276.5 Volume Depletion

428.0 CHF unspecified

780.2 syncope and collapse

599.0 UTI unspecified

486 Pneumonia unspecified

780.79 other malaise and fatigue

4.2

4.48

4.62

7.13

11.05

13.71

13.99

29.23

0 5 10 15 20 25 30

Fig. 2. International Classification of Diseases, Ninth Revision code for patients with weakness and fatigue as a chief complaint.

1398 M.C. Bhalla et al. / American Journal of Emergency Medicine 32 (2014) 1395-1398

undergo more tests and procedures, and most are admitted. Further research into the pathophysiology, management, and outcomes of weakness and fatigue is warranted.

References

AJEM