To the Editor,
The Thrace region (TR21 statistical region) is undergoing a demographic shift that warrants targeted, system-level redesign of emergency care. According to Turkish Statistical Institute Elderly Statistics 2024, while Türkiye elderly population is 10.6%, Edirne (17.2%) and Kırklareli (16.3%) are among the fastest-aging provinces nationally1. In parallel, Tekirdağ—despite a relatively lower elderly proportion (10.2%)—recorded the country’s highest net internal migration in 2023 (+22,674)2. This creates a distinct service-delivery paradox: aging rural populations and high-volume, migrant-receiving industrial centers converge within the same regional emergency care ecosystem. As an emergency physician practicing in the Thrace region, I observe daily how this dual pressure increases admission demand, prolongs emergency department (ED) stays, and amplifies risk in frail older adults.
The Clinical Reality
Geriatric emergency medicine extends well beyond atypical presentations. Regional data underscore a predictable yet high-stakes clinical profile. In a regional cohort, falls accounted for 10.9% of geriatric ED presentations and may conceal clinically significant injuries, particularly when initial findings are subtle3. Delirium—reported in 10.6% of older ED patients—was an independent predictor of mortality at both 6 months [hazard ratio (HR) 4.5] and 5 years (HR 3.4)3. The so-called “3D” syndromes (delirium, dementia, depression) further complicate assessment; depression and dementia were reported in 35.1% and 45.6% of presentations, respectively3.
The Boarding Crisis
Boarding—prolonged ED stays after an admission decision—is a major threat for older adults. A multicenter French prospective cohort study demonstrated that older patients who spent overnight in the ED had increased in-hospital mortality (adjusted risk ratio 1.39 overall), rising to 1.81 among patients requiring assistance with activities of daily living4. A systematic review likewise reported that prolonged boarding of frail individuals in the ED is associated with adverse outcomes and increased mortality risk5. Prolonged ED stretcher stays also contribute to hospital-acquired infections, pressure injuries, sleep disruption, delirium amplification, and accelerated functional decline.
Evidence-based Solutions
Structured geriatric ED models aligned with the American College of Emergency Physicians’ Geriatric Emergency Department Accreditation framework have been associated with reduced ED length of stay without increasing short-term return visits6. In Türkiye, a patient- and caregiver-perspective survey also supports the need for dedicated geriatric emergency services7. In addition, a geriatric ED innovation program has been associated with lower Medicare expenditures, supporting the health-economic rationale for such models8. However, a nationwide survey from Türkiye suggests that adherence to geriatric ED guideline recommendations remains very low, underscoring the implementation gap9. For Thrace, a regional geriatric emergency network could be implemented with three measurable objectives: (1) Clinical Frailty scale screening at triage; (2) confusion assessment method-based delirium pathways; (3) boarding escalation thresholds triggering expedited admission or transfer.
CONCLUSION
Thrace’s demographic transition is already reshaping emergency care delivery. Boarding of older adults should be regarded as a patient safety risk rather than a system delay. Designating Thrace as a pilot region for geriatric ED implementation may reduce preventable harm and improve outcomes in this rapidly aging population.
