INTRODUCTION

Ramadan is the month of fasting when Muslims deliberately avoid the consumption of food, water and oral or intravenous medications from dawn until sunset. Furthermore, nutritional habits, which are already diverse worldwide, become even more diverse among Muslim populations in Ramadan.1,2 As fasting in Ramadan is a separate entity from real starvation, biochemical and physiological parameters during fasting are different than those observed in usual starvation. Moreover, life rhythm, sleep order, eating habits and sleep time are all altered in Ramadan.3 Such changes in lifestyle may particularly affect patients with chronic disorders or conditions that may be exacerbated by fasting-induced dehydration.2 The effects of 1-month starvation and fluid restriction have been examined in normal healthy individuals as well as in various potentially sensitive groups residing in a variety of countries.4 It has been reported that they induced metabolic changes, a lesser rate of fasting-related health effects, a reduced medication compliance, increased nervousness, sleep deprivation, weakness and headache.4

It is important to understand the effects of Ramadan on clinical disorders and emergency department (ED) admissions to appreciate the working conditions of emergency physicians and managers.2 Research reports focusing on the incidence and presenting features of various disorders in Ramadan are inadequate to accurately evaluate ED presentations during Ramadan.3 Studies examining ED presentations in Ramadan have produced conflicting data about the incidence of various disorders in Ramadan. While a number of studies have reported that some conditions become more common in Ramadan, some others have reported unchanged incidence for such disorders.2,3 Moreover, a study showed that the incidence of traffic accidents was increased with a parallel increase in the rates of ED admissions and injuries in Ramadan.4

No study has yet investigated the clinical outcomes of patients aged 65 years or older in Ramadan and the following month. Our study was designed to determine whether Ramadan, where lifestyles are altered, influences ED visits, clinical features and outcomes of patients aged 65 years or older, irrespective of the fasting status.

METHODS

We retrospectively reviewed data from the ‘Nucleus Medical Information System’ database of patients aged 65 years or older who presented to the ED in Ramadan (16 May 2018–14 June 2018) and the following month (15 June 2018–14 July 2018) in 2018. Patients younger than 65 years of age, those with missing medical data and those who did not present in Ramadan or the following month were excluded from the study.

Patients’ age, gender, presenting symptom, time of presentation, type of presentation, comorbid conditions, trauma type (if presentation was due to trauma), laboratory and radiological studies done, consultations requested from other departments, final diagnosis according to ICD-10 coding system, ED outcome and length of stay in the ED were recorded on pre-prepared data forms.

The presenting complaints were arranged by adding common patient complaints to the classification used in the ED clinical practice model developed by Hockberger et al.5

Our study was approved by Mersin University Rectorate Clinical Research Ethics Committee (dated 17 October 2018; no. 2018/416).

Statistical analysis

Continuous variables were tested for normality using Shapiro– Wilk test. Student’s t-test was used to test the differences between the mean ages of both sexes, as well as to test the intergroup differences in the length of ED stay. Descriptive statistics were reported as mean and standard deviation. Categorical variables were compared using Pearson’s chi-square and likelihood ratio chi-square tests. Their descriptive statistics were expressed as number and percentage. A value of p<0.05 was considered statistically significant. Data analysis was performed using MedCalc®17.9.7 software package.

RESULTS

Two months before Ramadan, the number of patients >65 years old was 2523 in total (1293 presentations between 16 March 2018 and 15 April 2018 and 1230 presentations between 16 April 2018 and 15 May 2018). Two months after Ramadan, the number of patients >65 years old was 2603 (1363 presentations between 15 June 2018 and 14 July 2018 and 1240 presentations between 15 July 2018 and 14 August 2018). There were 1152 ED presentations of patients aged 65 years or older in Ramadan and 1363 presentations in the following month. A total of 1947 patients meeting the inclusion criteria were studied, of which 958 presented in Ramadan and 989 in the following month. Their mean (SD) age was 74.8 (7.2) years. The mean (SD) age of those presenting in Ramadan was 74.68 (7.12) years, and of those presenting in the following month was 74.98 (7.24) years (p=0.57). The mean (SD) age of women and men was 75.1 (7.3) and 74.5 (7.0) years, respectively (p=0.04).

Women constituted 53.9% of patients presenting in Ramadan and 52.7% of patients presenting in the following month. Patients presenting to the ED on their own were 66.9% in Ramadan and 66.3% of those in the following month (p=0.79). Patients who presented in Ramadan most commonly (23.8%) presented between 20:00 and 23:59 hours and those who presented in the following month most commonly (24%) presented between 08:00 and 11:59 (p=0.26; Table I).

TABLE I. Characteristics of patients presenting in Ramadan and in the following month

Characteristic Ramadan (n=958) n(%) Month after Ramadan (n=989), n(%) p value Gender Women 516 (53.9) 521 (52.7) 0.60 Men 442 (46.1) 468 (47.3) Time of presentation 08:00–11:59 198 (20.7) 237 (24.0) 0.26 12:00–15:59 205 (21.4) 199 (20.1) 16:00–19:59 181 (18.9) 209 (21.1) 20:00–23:59 228 (23.8) 209 (21.1) 00:00–03:59 78 (8.1) 75 (7.6) 04:00–07:59 68 (7.1) 60 (6.1) Type of presentation Ambulance 317 (33.1) 333 (33.7) 0.79 By own means 641 (66.9) 656 (66.3) Presenting complaint/system involvement Gastrointestinal 190 (19.8) 201 (20.3) <0.001 Pulmonary 128 (13.4) 124 (12.5) Trauma 110 (11.5) 99 (10.0) Central nervous 91 (9.5) 166 (16.8) Cardiovascular 69 (7.2) 66 (6.7) Musculoskeletal 62 (6.5) 63 (6.4) Weakness 52 (5.4) 48 (4.9) Fever 36 (3.8) 47 (4.8) Genitourinary 36 (3.8) 39 (3.9) Head and neck 22 (2.3) 14 (1.4) Dermatological 17 (1.8) 16 (1.6) Poor overall medical status 11 (1.1) 16 (1.6) Endocrinological 8 (0.8) 8 (0.8) Assault by pets or wild animals 7 (0.7) 5 (0.5) Haematological and oncological 2 (0.2) 3 (0.3) Cardiac arrest 2 (0.2) 2 (0.2) Psychological 1 (0.1) 5 (0.5) Toxicological 0 (0) 0 (0) Non-specific 116 (12.1) 67 (6.8) Chronic disorders Hypertension 501 (52.3) 537 (54.3) 0.38 Diabetes 321 (33.5) 334 (33.8) 0 . 9 Coronary artery disease 262 (27.3) 290 (29.3) 0.33 Malignancy 133 (13.9) 127 (12.8) 0 . 5 Congestive heart failure 131 (13.6) 109 (11.0) 0.08 Chronic obstructive pulmonary disease (asthma) 91 (9.5) 115 (11.6) 0.13 Cerebrovascular accident 76 (7.9) 74 (7.5) 0.71 Renal failure 62 (6.5) 55 (5.6) 0.4 Alzheimer disease 40 (4.2) 57 (5.0) 0.11 Parkinson disease 18 (1.9) 20 (2.0) 0.82 Hepatic diseases/cirrhosis 5 (0.5) 9 (0.9) 0.31 Other disorders 138 (14.4) 110 (11.1) 0.03

Among patients who presented in Ramadan, 90% (n=862) had a chronic disease, while 86.7% (n=857) of those who presented in the following month had a chronic disease (p=0.02) and the difference was not significant (Table I); 9.5% of the patients who presented in Ramadan and 16.8% of those who presented in the following month had presented with complaints related to the central nervous system (CNS) (p<0.0001). Also 12.1% of patients who presented in Ramadan and 6.8% of those that presented in the following month presented with non-specific complaints (p=0.0002). No significant difference was found between the two groups with regard to other parameters of complaints (Table I).

A history of trauma was more common (present in 11.5%) in patients who presented in Ramadan compared to those who presented in the following month (10%; p=0.29). The two groups did not show a significant difference of type of trauma (p=0.13); therefore, no paired group comparison was made on a categorical basis. An analysis of trauma types in patients with a trauma history showed that 67.3% of patients who presented in Ramadan and 61.6% of patients who presented in the following month presented after falls from the same height (Table II).

TABLE II. Distribution of patients with trauma presenting to the emergency department in Ramadan and in the following month

Trauma Ramadan (n=110), n(%) Month after Ramadan (n=99), n(%) p value Fall from same height 74 (67.3) 61 (61.6) 0.125 Fall from height 10 (9.1) 4 (4.0) Out-of-vehicle traffic accident 7 (6.4) 12 (12.1) Battery 3 (2.7) 1 (1.0) In-vehicle traffic accident 2 (1.8) 1 (1.0) Cuts 2 (1.8) 8 (8.1) Gunshot wound 0 (0) 0 (0) Burn 0 (0) 1 (1.0) Others 12 (10.9) 11 (11.1)

Cardiac enzymes were more commonly ordered for patients who presented in Ramadan (p=0.04). However, the two groups were similar in terms of other laboratory studies. Scintigraphy was requested for only 3 patients who presented in Ramadan and for none of those that presented in the following month (p=0.04). Other radiological studies were ordered at similar rates in both groups (Table III).

TABLE III. Investigations ordered for patients presenting to the emergency department in Ramadan and in the following month

Investigation Ramadan (n=958), n (%) The following month after Ramadan (n=989), n(%) p value Laboratory study Haemogram 737 (99.9) 769 (99.6) 0.625 Biochemistry 734 (99.5) 769 (99.6) 0.720 Cardiac enzyme 485 (65.7) 468 (60.6) 0.040 Urinalysis 215 (22.4) 253 (25.6) 0.105 Blood gas analysis 195 (20.4) 214 (21.6) 0.487 Coagulation profile 87 (11.8) 74 (9.6) 0.166 Drug level 15 (1.6) 19 (1.9) 0.550 Blood type 14 (1.5) 12 (1.2) 0.634 Ethanol 10 (1.0) 5 (0.5) 0.174 Imaging Chest X-ray 395 (41.2) 376 (38.0) 0.147 Brain CT 159 (16.6) 169 (17.1) 0.722 Diffusion MR 95 (9.9) 106 (10.7) 0.561 Plain film of limb 89 (9.3) 73 (7.4) 0.127 Upright plain abdominal film 81 (8.5) 95 (9.6) 0.376 Thorax CT 66 (6.9) 68 (6.9) 0.990 Abdominal CT 51 (5.3) 62 (6.3) 0.372 Ultrasonography 31 (3.2) 29 (2.9) 0.698 Doppler ultrasonography 7 (0.7) 2 (0.2) 0.086 Pelvic plain film 8 (0.8) 13 (1.3) 0.306 CT of limb 5 (0.5) 6 (0.6) 0.803 Scintigraphy 3 (0.3) 0 (0) 0.039 Cerebral MR 3 (0.3) 1 (0.1) 0.291 Vertebral plain film 3 (0.3) 2 (0.2) 0.628 Spinal MR 2 (0.2) 2 (0.2) 0.975

Consultation from another department was requested for 39% of patients who presented in Ramadan and for 37.9% of those who presented in the following month (p=0.6). A greater number of consultations was requested from neurology, and gynaecology and obstetrics departments for patients who presented in Ramadan (p=0.01 and p=0.04, respectively; Table IV).

TABLE IV. Distribution of patients presenting to the emergency department in Ramadan and in the following month by consulted department

Department consulted Ramadan (n=374), n(%) Month after Ramadan (n=375), n(%) p value Cardiology 107 (28.6) 85 (22.7) 0.063 Neurology 59 (15.8) 87 (23.2) 0.010 Chest diseases 58 (15.5) 55 (14.7) 0.748 Infectious diseases 46 (12.3 43 (11.5) 0.725 Orthopaedics 41 (11.0) 30 (8.0) 0.166 Nephrology 38 (10.2) 54 (14.4) 0.077 Gastroenterology 33 (8.8) 22 (5.9) 0.121 General surgery 31 (8.3) 33 (8.8) 0.802 Haematology 18 (4.8) 16 (4.3) 0.720 Oncology 16 (4.3) 15 (4.0) 0.848 Neurosurgery 15 (4.0) 21 (5.6) 0.309 Otorhinolaryngology 10 (2.7) 8 (2.1) 0.629 Anaesthesia 6 (1.6) 4 (1.1) 0.520 Cardiovascular surgery 6 (1.6) 5 (1.3) 0.758 Ophthalmology 5 (1.3) 12 (3.2) 0.087 Thoracic surgery 5 (1.3) 5 (1.3) 0.997 Urology 4 (1.1) 9 (2.4) 0.163 Endocrinology 3 (0.8) 8 (2.1) 0.130 Plastic surgery 2 (0.5) 4 (1.1) 0.414 Psychiatry 1 (0.3) 3 (0.8) 0.306 Dermatology 1 (0.3) 0 (0) 0.238 Obstetrics and gynaecology 0 (0) 3 (0.8) 0.041

Diagnoses related to the cardiovascular system (CVS) were more commonly made in Ramadan (p=0.037), while diagnoses related to CNS, otorhinolaryngology and oncology were made more commonly in the following month (p=0.0005, p=0.024 and p=0.003, respectively; Table V).

TABLE V. Diagnosis and outcome of patients presenting to the emergency department in Ramadan and in the following month

Diagnosis/outcome Ramadan (n=958), n(%) Month after Ramadan (n=989), n(%) p value Diagnosis Gastrointestinal 162 (16.9) 159 (16.1) <0.0001 Pulmonary 117 (12.2) 103 (10.4) Cardiovascular 100 (10.4) 75 (7.6) Trauma 98 (10.2) 91 (9.2) Central nervous system-related 83 (8.7) 136 (13.8) Musculoskeletal 59 (6.2) 65 (6.6) Endocrinological-metabolic 48 (5.0) 55 (5.6) Urogenital system 44 (4.6) 51 (5.2) Non-specific symptoms 41 (4.3) 32 (3.2) Otorhinolaryngological 39 (4.1) 64 (6.5) Infectious 28 (2.9) 30 (3.0) Dermatological 20 (2.1) 17 (1.7) Haematological 18 (1.9) 20 (2.0) Mental and behavioural problems 8 (0.8) 10 (1.0) Prophylaxis and needle rabies vaccination 8 (0.8) 3 (0.3) Oncological 7 (0.7) 25 (2.5) Ophthalmological 5 (0.5) 12 (1.2) Dog, scorpion, snake bites 3 (0.3) 5 (0.5) Intoxication 1 (0.1) 1 (0.1) Mastoid 0 (0) 0 (0) Non-specific 69 (7.2) 35 (3.5) Outcome Discharge 686 (71.6) 740 (74.8) 0.36 Admission 230 (24.0) 218 (22.0) Refusal of treatment 36 (3.8) 26 (2.6) Left against medical advice 4 (0.4) 2 (0.2) Deceased 2 (0.2) 3 (0.3)

The two study groups did not differ significantly with respect to the emergency department outcomes (p=0.36); thus, no paired comparison was made on a categorical basis (Table V). Among patients who were admitted to hospital in Ramadan, 56.1% (n=129) were admitted to a regular ward and 43.9% (n=101) to the intensive care unit; among those who presented in the following month, 58.7% (n=128) were admitted to a regular ward and 41.9% (n=90) to the intensive care unit.

The mean (SD) length of stay in the ED was 220.8 (209.1) minutes among patients who presented in Ramadan and 243.2 (260.2) minutes among those who presented in the following month (p=0.04).

DISCUSSION

Patient populations visiting ED may show variations by the size of regional population, school holidays, sudden influx of visitors to towns or certain time periods such as Ramadan.6 We studied 1947 patients aged 65 years or older to ascertain their demographic and clinical properties and the effects of Ramadan on these features. It has been reported that the proportion of women among the elderly population is greater7 although different proportions of women have been reported by studies in Ramadan and the following month.2,3,8,9 Our study revealed that 53.9% of patients who presented in Ramadan and 52.7% of those who presented in the following month were women.

In a study by Al Assaad et al., which investigated ED presentations before, during and after Ramadan, the mean (SD) age of patients who presented in Ramadan was 53.88 (22.58) years, and of those who presented in the other 2 months was 54.21 (21.88) years, with no significant difference between both groups.2 In another study, the mean (SD) age was 59.91 (14.60) years in Ramadan and 62.11 (14.61) years in the following month.3 In our study, the mean age of patients was higher as we included patients who were 65 years or older.

In the literature, regardless of age group, it was reported that more patients were seen during the daytime shift in all months except during Ramadan when more patients were seen during the night shift.6,10 In line with the literature, we too found that patients frequently presented to the ED at the evening in Ramadan and at daytime in the following month. However, we did not find a statistically significant difference.

It has been reported that one-third of elderly patients reach the ED by ambulance.11 We also found a similar number during and after Ramadan 33.1% and 33.7%, respectively.

Balhara et al. reported that patients most commonly presented with complaints concerning the gastrointestinal system (GIS) followed by those of the ear, nose and throat (ENT) and muscular complaints in Ramadan, whereas they most commonly presented with complaints of ENT followed by GIS and CNS in the following month.10 In our study, the patients most commonly presented with complaints of GIS followed by respiratory complaints in Ramadan, whereas the most common complaints in the following month were related to GIS and CNS. A higher incidence of complaints of GIS in the elderly may be attributed to reduced motility, secretion and absorption capacities of GIS and increased prevalence of peptic ulcer; atrophic gastritis and hypochlorhydria due to physiological changes. A significant increase in complaints of the CNS in the month after Ramadan may be explained by the extremely high temperatures in summer; a majority of patients had underlying cardiovascular and hypertensive comorbid conditions and thus were using multiple medications. The heat caused complaints of the CNS such as dizziness, headache and weakness.

Ageing is associated with reduced muscle mass and strength, neuronal loss and related slowed motion, delayed reaction time and imbalance.12 Such physiological and metabolic alterations may result in an increased incidence of trauma, including falls from the same height. It has been reported that falls constitute approximately three-fourths of all trauma incidents in the geriatric population, and almost the entire remaining one-fourth are caused by motor vehicle accidents and injuries.13 We found that 10.2% of our patients presented for trauma injuries, with falls being the most common aetiology, followed by motor vehicle accidents in both groups. Although there was no significant difference between the Ramadan month and the following month with respect to the number of falls, it was greater in Ramadan than the following month. A greater incidence of falls in Ramadan may be associated with reduced cognitive functions during daytime fasting, which weakens defensive reflexes.

A study by Al Assaad et al. found no significant difference between the rates of ED presentations in Ramadan and the following month among elderly people with at least one chronic disorder.2 However, we found that a higher proportion of elderly patients with chronic conditions presented during Ramadan than in the following month. This difference may be because elderly people with chronic disorders may be omitting medications during fasting. In a group of patients with a history of diabetes mellitus (DM), Elbarsha et al. reported that 60.5% of patients presenting in Ramadan had a history of hypertension (HT); 28.2% had a history of coronary artery disease (CAD) and 13% had a history of cerebrovascular accident; they also noted that the ranks of chronic conditions remained unchanged for patients who presented in the months following Ramadan.14 Another study scrutinized the prevalence of chronic conditions and found that 30.4% of patients had HT, 15.4% DM and 6.7% CAD.2 Topacoglu et al. reported that the number of ED presentations of patients with HT was significantly higher in Ramadan than in the following month.3 Perk et al., on the other hand, reported no significant difference between Ramadan and the following month with regard to ED presentations of patients with HT.15 In our study, no significant difference was observed between the two groups in terms of chronic disease.

Elderly patients presenting with atypical symptoms and underlying disorders may give rise to the need for providing more intensive care and ordering an increased number of laboratory and radiological studies. We did not come across any study that focused on orders of laboratory or radiological studies in Ramadan or the following month. Our study revealed that blood tests were ordered for 77% of the patients in Ramadan and 78.1% in the following month. We found that cardiac enzymes were ordered more commonly in Ramadan. A greater number of complaints related to CVS at admission, CVS-related diagnoses and cardiology consultations in Ramadan than that of the following month may explain a higher number of orders for cardiac enzyme studies in Ramadan. Radiological studies were ordered at similar rates in both groups except for scintigraphy.

Logoglu et al. reported that consultations were requested from the departments of cardiology (15.2%), internal diseases (13.7%) and chest diseases (7.4%).16 It was found that cardiology consultations were requested for 28.6%, neurology consultations for 15.8% and chest disease consultation for 15.5% of patients, who presented in Ramadan. It was also found that neurology consultations were requested for 23.2%, cardiology consultations for 22.7% and chest disease consultation for 14.7% of patients, who presented in the month after Ramadan. Our study showed that the number of consultations requested from the neurology and obstetrics and gynaecology departments was greater in the month after Ramadan. This difference may have stemmed from a significant increase in the rate of CNS-related complaints in the following month compared to that of Ramadan itself.

Many studies have mentioned different final diagnoses for elderly patients at the time of their discharge from the emergency department.17–19 Our study found that GIS-related diagnoses were most commonly made (16.9%) in Ramadan, which were followed by respiratory (12.2%) and cardiovascular diagnoses (10.4%). In the month following Ramadan, GIS diagnoses were the most common (16.1%), followed by CNS (13.8%) and respiratory (10.4%). A higher incidence of GIS complaints in the elderly may be attributed to physiological changes. During Ramadan, because people eat most of their food in the early part of the night and then in the early morning, they may be more prone to develop acute gastritis. A review of the literature shows that the most common diagnoses vary by country and region. Previous studies comparing stroke rates in Ramadan and other months have shown no significant differences.20,21 We found a significant increase in the rate of CNS-related diagnoses in the month after Ramadan. Al Suwaidi et al. reported that the proportion of patients diagnosed with decompensated heart failure was significantly lower in Ramadan than in the other months of the year.22 Several studies have indicated that the proportion of patients diagnosed with acute coronary syndrome was lower in Ramadan than in other months.8,23,24 Balhara et al. found no significant difference in CVS diagnoses during Ramadan and in the following month.10 We, on the other hand, found a higher proportion of elderly patients with CVS diagnoses in Ramadan than in the following month. During Ramadan, patients are more likely to miss their drugs compared to the non-Ramadan period. This could lead to higher complications, particularly accelerated HT, decompensated heart failure, myocardial infarction, etc. The lack of any information about the fasting status and drug use of patients constitutes a limitation of our study.

It has been reported that 12.8%–28.1% of elderly patients are admitted to hospital.11,17 We found an admission rate of 28.4% in Ramadan and 25.2% in the following month. A study by Al Assaad et al. showed that patients stayed longer in the ED in Ramadan than in other months (5.42 [14.86] hours v. 3.96 [4.29] hours; p=0.006).2 In our study, the mean length of ED stay was 220.8 (209.1) minutes in Ramadan and 243.2 (260.2) minutes in the following month. The difference in the length of stay may be explained by Ramadan in our region having coincided with the last days of spring when the climate is temperate, whereas the following month coincided with hotter days of summer when air temperature and humidity were higher, which adversely affected elderly people and prolonged their ED stay.

Limitations

The major limitations of our study were its retrospective design and the lack of any information about the fasting status and drug usage of the patients. Some of the diseases may become more prevalent immediately following Ramadan due to various reasons including effects of long fasting on various body systems. The lack of comparison with the month preceding Ramadan in terms of diseases constitutes one of the limitations of our study. On the other hand, its strengths include its being a large-study encompassing data from Ramadan and the following month, in a large number of patients.

Conclusion

Our study showed that, among patients presenting in Ramadan, the rates of chronic disorders were higher; the rate of CNS-related complaints were lower; CVS-related diagnoses were more common; diagnoses related to CNS and otorhinolaryngology were less common and the duration of ED stay was shorter. We also found that the two groups did not differ significantly with respect to mean age, gender distribution, times of presentation, type of presentation, presence of trauma, trauma types, number of orders for radiological studies and ED outcomes.