Abstract
Up to 20% of elderly patients present to the emergency department (ED) with non-specific complaints (NSC), such as "generalised weakness", the majority suffering from serious conditions requiring timely intervention. Little is known about the use and influence of diuretics and renin-angiotensin-aldosterone (RAAS) blockade on morbidity in those patients. Thehypothesis was tested that the use of diuretics and RAAS blockade could be associated with an increased incidence of serious conditions in those patients. During a 23-month period, all adult non-trauma patients with an Emergency Severity Index (ESI) of 2 or 3 were prospectively enrolled. Serious conditions were defined as potentially life-threatening conditions or conditions requiring early intervention to prevent further morbidity and mortality. Study population consisted of 633 patients with median age 82 years, median Charlson comorbidity index 2. 59% of all subjects suffered from a serious condition. 299 subjects (47.2%) used diuretics, of which 65.6% suffered from a serious condition. Combination therapy of RAAS blockade and diuretics was found in 158 subjects (24.9%), 70.3% of which suffered from a serious condition. The intake of two or more diuretics, loop diuretics and a combination therapy with diuretics and RAAS blockade were associated with an increased risk for serious condition (p = 0.036; p = 0.021; p = 0.004). Treatment with two or more diuretics, loop diuretics, or a combination therapy with RAAS blockade and diuretics are independently associated with serious condition and therefore should be recognized as "red flags" in elderly patients presenting to the ED with NSC.
Highlights
Diuretics, especially loop and thiazide diuretics as well as blockade of the renin-angiotensin-aldosterone-system (RAAS), are widely used in patients of all ages for hypertension or congestive heart failure
QUESTIONS UNDER STUDY: Up to 20% of elderly patients present to the emergency department (ED) with nonspecific complaints (NSC), such as “generalised weakness”, the majority suffering from serious conditions requiring timely intervention
The hypothesis was tested that the use of diuretics and RAAS blockade could be associated with an increased incidence of serious conditions in those patients
Summary
Especially loop and thiazide diuretics as well as blockade of the renin-angiotensin-aldosterone-system (RAAS), are widely used in patients of all ages for hypertension or congestive heart failure. The recently published AHA/ACC/ESH expert consensus recommended a thiazide-type diuretic, a calcium antagonist, RAAS blockade, or a combination of those as first line-therapy in uncomplicated elevated blood pressure of the elderly [2]. Whereas the mentioned guidelines consider RAAS blockade to be a relatively safe therapy, the use of diuretics is a known and feared risk factor related to an imbalance in electrolyte- and hydration status. Those disturbances of the elderlies’ electrolyte- and hydration homeostasis may potentially lead to severe complications, such as renal impairment and increased mortality [4,5,6] and, among many others, may often cause symptoms such as “feeling dizzy or weak”. A recent study about patients presenting to the ED with non-specific abdominal pain demonstrated, that after a twelve month follow-up period one fourth still
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