Response Response

To the Editor,

Dr Castellote Varona states that geriatric assessment has shown to be useful in hospital emergency services and mentions his references 2 and 3; these do include patients from emergency units, but geriatric assessment is not carried out by those services. Geriatric assessment in the emergency rooms is a topic of debate^1,2 and, in any case, it is not systematically carried out by Spanish emergency units, which are known for their high patient volumes.^3,4 Although we are among those with a growing opinion of the value of proper functional assessments for the elderly in emergency rooms,^5,6 our emergency services do not currently perform a general geriatric assessment that includes in-depth examination of factors related to polypharmacy, treatment adherence, social problems, delirium, anthropometric variables, or the depressive, cognitive and functional states mentioned by the author, since the doctors in these units are bound to act depending on the time required by the patient's specific problem. Therefore, we believe that a geriatric assessment that is specifically adapted to the emergency room dynamic would help incorporate this tool in the normal treatment routine.

Furthermore, we believe that our study reflects the true (low) capacity of Spanish emergency services when it comes to quickly obtaining the nutritional parameters mentioned by Dr Castellote Varona, or the natriuretic peptide score or echographic estimation of the left ventricular ejection fraction mentioned by Dr González-Costello et al. Having this information at a later date, after admission, is not useful for making decisions about treatment and whether to admit or discharge a patient in an emergency unit. Furthermore, in hospitals that do not have a fully computerised clinical history, it may even be difficult to find out the patient's previous ejection fraction at the moment when he/ she is being treated in the emergency room. Not to mention that it may not have been measured: only 29% of our patients had a prior estimated ejection fraction, and it was increasingly uncommon in the oldest patients: 65-74 years, 38%; 75-84 years, 28%; >84 years, 22% (P<.01).

We are conscious of the fact that our model for acute heart failure (AHF) in emergency units⁷ has advantages and disadvantages when compared to other models used to obtain a prognosis for these patients,⁸ and of the fact that it contained numerous limitations which were mentioned exhaustively in the original article. However, we feel that the greatest advantage which it offers is that of being realistic and useful for doctors who treat AHF patients in our emergency rooms.