Medical demographics in sub-Saharan Africa: Does the proportion of elderly patients in accident and emergency units mirror life expectancy trends?

Abstract

Dear Editor, We read with great interest the article titled “Patterns and Outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria.”[1] In this observational report by Ogunmola and Olamoyegun, the authors note that due to a lower life expectancy in the developing world, elderly patients make up a relatively lower proportion of those treated in accident and emergency (A and E) systems compared to other regions of the world.[1] While this is an important and accurate observation, the authors of this letter would like to point out that a previously unnoticed demographic trend has emerged recently, and it may significantly affect the delivery of A and E services in sub-Saharan Africa. A review of demographic patterns in published studies describing various A and E populations from Sub-Saharan Africa (inclusive of the study by Ogunmola and Olamoyegun) reveals a notable increase in the overall proportion of elderly patients over time, from a low of 1.7% in 1990 to the 27% reported in 2014 [Figure 1].[1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24] While these data are derived from relatively heterogeneous sources (e.g., different geographic locations, facility acuity levels, population characteristics, and definitions of elderly), it is clear that there is a trend of increasing age among patients seeking A and E care in sub-Saharan Africa over time. Although this trend is not surprising given the increasing life expectancy in the region during the past few decades [Figure 2], this demographic change is likely to present significant challenges to the delivery of A and E care in sub-Saharan Africa without adequate preparation. Figure 1 Graphical representation of the increasing proportion of patients defined as elderly (Y-axis) in the literature reports from sub-Saharan Africa, based on accident and emergency literature between 1990 and 2014 (X-axis). Individual reports are each represented by “X,“ with the dashed heavy black line showing the third-degree polynomial model of the overall composite trend Figure 2 Long-term trend in life expectancy at birth in sub-Saharan Africa. Between 1960 and 2010, the average life expectancy increased from approximately 40 years to nearly 55 years Source: http://www.openpop.org Aging is a global concern, with more than 500 million adults aged 65 and older worldwide, and this older adult population grows by approximately 870,000 each month.[25] With continued shifts within the global population structure, healthcare systems around the world are already seeing increasing numbers of older patients and must be prepared to face a host of high-intensity health issues prevalent in the elderly population including coexisting cognitive disorders, multiple comorbidities, and polypharmacy.[26 27 28 29] When considering the emergency care of acutely ill or injured elderly patients with the added complexity of preexisting, sometimes poorly controlled chronic diseases, a significant expenditure of resources will be required to provide adequate medical care in a sustainable manner.[30] Regions such as sub-Saharan Africa, which are already operating at the limits of their resources, will need to develop and embrace healthcare innovation and multidisciplinary team approaches as part of the general strategy to better serve the fast-growing geriatric population segment.[31 32 33 34 35] Facing acute workforce shortages, both primary care providers and specialists may need to flex beyond their primary areas of expertise to provide comprehensive care to those in need.[36] To accomplish these goals, significant educational efforts will be required to ensure proper patient and provider awareness of key issues at hand including topics such as preventive health, medication safety, and drug–drug interactions.[37 38 39] Identifying patterns of healthcare utilization specific to the geriatric population could be key in developing such targeted preventive and primary care coordination. Health systems in sub-Saharan Africa will need to effectively manage increasing proportion of patients with chronic diseases (diabetes, congestive heart failure, mental health issues, chronic kidney, and pulmonary diseases).[40 41 42] Consequently, underdeveloped specialty areas such as critical care, medical/surgical subspecialties, geriatric care, and palliative services will inevitably come into focus.[43 44 45] Additional resources may be needed to partially alleviate healthcare provider shortages. At the same time, creative, nontraditional solutions, such as telemedicine and other similar initiatives, may be critical in this domain.[46 47 48] Adequate and timely access to health care is important in reducing excess A and E utilization and improving health outcomes.[49 50] Trauma care in sub-Saharan Africa will continue to evolve. Regionalization of trauma systems will likely be necessary to provide injured patients with optimal care, especially for those presenting with severe injuries in the setting of preexisting medical conditions.[51] This process will require the development of sustainable, cost-effective multidisciplinary approaches that incorporate high-quality geriatric and critical care capabilities, as well as reliable access to emergency medical and surgical services.[52 53] Emergency and trauma providers accustomed to treating younger patients will need to make an important transition in both acute awareness and knowledge application regarding both general and specialty geriatric care including specifically targeted postgraduate, graduate, and medical education efforts.[54 55 56] Finally, Ogunmola and Olamoyegun suggest that the elderly may be disproportionately affected by medical emergencies (e.g., the ≥60-year-old segment constitutes approximately 5% of total sub-Saharan population, yet the authors report a 27% representation of elderly in their manuscript).[1 57] In comparison, persons aged 65 or older in the United States represented 11% of the total population in 2009–2010, however, comprised only 15% of emergency room visits.[58] Given this observation, we must emphasize the importance of well-functioning and adequately funded public health surveillance services that are capable of monitoring demographic changes, critical health outcomes (including mortality rates), incidence and prevalence of diseases, injury statistics, health care-related complications, resource utilization, and life expectancy within a community. The global elderly population is growing, with continued increases in this demographic segment across the developing world.[59 60] Leaders of sub-Saharan Africa, in conjunction with the international community, must prepare to face the challenges associated with this demographic megatrend. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.