With improved healthcare service, increasing life expectancy will leads to population aging and with that, it is expected in 2030, Malaysia will become an aging country with 15% of its population above 65 years old (2). 

Malaysia is a upper middle income country and healthcare expenditure is on the rise to accommodate the improving healthcare service. It is expected to rise up to RM91.1b by 2025 (1). 

A single center study in a university hospital in Malaysia identified that ¾ of older persons intubated in the emergency department from 2015 to 2019 died during the same admission (3). Older age, cardiac arrest as indication and high APACHE score were identified as predictors of mortality.

Hence, can we continue like this especially in a resource limited country like Malaysia?

The Geriatric Emergency Medicine (GEM) Special Interest Group College of Emergency Physician Academy Medicine Malaysia, has initiated a new direction on the management of critically ill older persons. A GEM Online Forum 1/2023 on the subject was conducted on the 29th March 2023 with panelists from Singapore and local clinicians.

The panelists were Dr Colin Eng Choon Ong, a senior consultant emergency physician from Ng Teng Fong General Hospital Singapore and three other clinicians from University Malaya Medical Centre (UMMC), Prof Dr Tan Maw Pin, a senior consultant geriatrician, Prof Dr Nor’azim bin Mohd Yunos, a senior consultant anaesthetist and Dr Lam Chee Loong, a consultant palliative physician. The forum was moderated by Assoc Prof Dr Mohd Idzwan Zakaria, a senior consultant emergency physician UMMC. 

Prior to the forum proper, each panelist delivered a short 15 minute talk. Dr Colin in his talk mentioned of the existence of the Mental Capacity Act 2008 in Singapore in which in a life threatening condition, physicians are allowed to make the medical decisions in the best interest of the patient. Malaysia lacked such law and Prof Maw Pin mentioned that a similar Mental Capacity Act for Malaysia would be ready in 2024 which probably looked similar to the Mental Capacity Act 2005 in the UK.

Dr Colin mentioned that the use of Clinical Frailty Score (CFS) to assess functional state, the number of comorbidities, illness trajectory and illness severity were the medical factors influencing prognosis. Patient plans and preferences which involved existing advanced medical directive or advance care planning were the patient factors influencing prognosis. Prof Azim’s spoke about the VIP2 study identified that CFS >4, cognitive decline and activity of daily life < 4 were predictive factors to poor 30 day mortality outcome.

Dr Chee Loong stressed the importance of empathy which included spoken and body language. The forum then continued with Q&A session from the moderator and the audience. The 2 hour session then ended with the moderator informing that a new protocol on the management of critically ill older persons in the emergency department in Malaysia would come out in the near future. 

References:

1. reporter S. Malaysian health expenditure to reach MYR91.1b in 2025: Fitch Malaysia: healthcareasia; 2022 [cited 2023 20.4.2023]. Available from: https://healthcareasiamagazine.com/healthcare/news/malaysian-health-expenditure-reach-myr911b-in-2025-fitch2022.
2. MAHIDIN MU. CURRENT POPULATION ESTIMATES, MALAYSIA, 2020. DEPARTMENT OF STATISTICS MALAYSIA, 2020:3.
3. Zakaria MI, Manshor NC, Tan MP. Associated Factors of In-hospital Mortality among Intubated Older Adults in Emergency Department; a Cross-sectional Study. Archives of Academic Emergency Medicine 2023;11(1):e16-e16.