over the past 10 years an increasing proportion of elderly people , especially those with dementia , had recourse to the department of emergency and acceptance ( dea ) : the elderly , in respect to young and adult people , on average , have more urgent requests , stay longer in the department ( both for diagnosis and for therapy ) , use more resources and staff time . despite a great number of tests and procedures , diagnoses tend to be less accurate : this condition is explained by the atypical presentation of many diseases , the clinical and pharmacological comorbidity , which tend to complicate the presentation , the diagnosis , and the treatment of acute or chronic disease . in addition , older people often belong to the dea for diseases that require intensive care : a study carried out for 5 years in 352 hospitals in the usa and england , it was found that the percentage of admission in polyfunctional intensive therapy ( pit ) of patients over 65 years is very high ( above 50% ) . in the total group of patients belonging to the dea , the subsequent admission to the pit was mainly for medical conditions ( 53% in england , 63% in usa ) , and less for acute surgical diseases ( 48 vesus 41% , resp . ) . the data shows that elderly patients who belong to the dea , and among these also patients suffer from dementia , are presented to the hospital for somatic diseases or acute and severe surgical procedures that require often intensive treatment . it should be noted , moreover , a different intensively diagnostic / therapeutic attitude between different countries : usa pit hospitalization of elderly patients from the dea has increased , especially for acute somatic diseases . this reflects in part the difference in prevalence in the elderly population , and probably represents a different attitude in the decisions of hospitalization of elderly patients between the two countries . a study conducted in italy showed that 21% of people who belong to the dea are over 65 years . the percentage of those who are hospitalized increased with age : it goes from 11% of those under 65 years , to 56% of the over nineties . the majority of patients hospitalized in medical departments from dea is over sixty - five ( 60% ) , but represents only 25% in surgical wards . among all patients hospitalized and then hospitalized for the dea , the sick elderly patient who suffers from dementia that reaches the dea , therefore , is often hospitalized because of the seriousness of his condition requires acute somatic hospital treatment . moreover , because of the greater disease severity , the duration of hospital stay in patients over eighty years is longer than the hospital stay of younger females ( 7.9 versus 5.8 , resp . an increase in patients , over 85 years , who belong to the dea : 71% versus 65% of the general population . more than 80% are suffering from dementia , of which 30% suffer from severe dementia , and 20% from the moderate form of disease ( patients followed at home by a caregiver ) .   another interesting fact that emerges from the study is the cause of hospitalization : 43% of the patients are evaluated for acute somatic pathology , and 33% for chronic heart failure . the percentage increases for each age group ; over-85-year group always ( including the dementia for 80% ) that have the highest percentage ( 41% ) of hospitalization for acute somatic illness . the recent studies paint a scene so disturbing : a high number of elderly patients and , among these , a high percentage of people with dementia , belong to a structure for acute , historically more prepared to manage acuities in young and adult . the future scenario must necessarily change , since the number of patients with these characteristics tends to increase over time . among the possible explanations for this phenomenon , apart from the increase in the average age of the population and worsening of chronic somatic illnesses and comorbidity ( especially in people with dementia ) in general , it increases the vision of the dea as a replacement more quickly and technological than the caregivers , and the lack of an adequate social / assistance support at home . the majority of patients with dementia pertains to the dea for an acute somatic or surgical illness , or a chronic heart failure . the diseases that most often drive the elderly to apply for an urgent evaluation are cardiovascular diseases ( angina , heart failure , arrhythmias , and syncope ) or respiratory diseases ( acute exacerbation of chronic bronchitis , bronchial asthma , and pneumonia ) , in addition , cancer ( cancer of the lung , breast , and large bowel ) , and neurological diseases ( acute cerebrovascular disease , altered state of consciousness ) . among surgical emergencies , the most common diagnosis is related to trauma and fractures , caused mainly by falling to the ground . other diseases that result in the arrival at the dea are clinical emergencies that require different level of intervention : sometimes less technological and more clinical ( dehydration , urinary tract infections , intestinal subileus , delirium , behavioral disturbances , and subsequent guidance of therapeutic prescription ) others more specific to the setting of care ( acute respiratory failure from respiratory infection , acute myocardial infarction , and sepsis ) . finally , in some cases , the patient with dementia is sent to the dea for clinical problems related to an incorrect home management : oversedation from psychopharmacological treatment , side effects from medications ( iatrogenic hypotension , hypoglycemia jatrogena ) . a careful medical and medication history is the necessary instrument ( low - tech , but related to the practice of good clinical practice ) that would lead to the diagnosis and solution of the problem . it should also be considered that there is a different prevalence of somatic diseases in different stages of alzheimer 's disease and other dementias . those that are usually associated with mild to moderate dementia are the tumours , diabetes , gastrointestinal disease , while those associated with severe dementia are pneumonia and other infectious diseases , stroke , malnutrition , hip fractures , bed sores . , dementia complicates the management of chronic diseases , compromising the ability of patients to detect the presence of an incipient fault , to measure the severity of the disease , to accurately report symptoms , and to follow closely the prescriptions . a difficult problem in clinical management and in supporting people with dementia is the impairment in the ability to report somatic symptoms : this ability seems directly related to insight of disease , different from person to person . patients with dementia generally tend to subreport symptoms of organic disease , and therefore may be at increased risk of somatic disease : a result could be that many potentially treatable medical conditions are overlooked . furthermore , the clinical manifestations of somatic diseases may be atypical in patients with dementia , the onset of acute illness or exacerbation of persistent disease may occur , rather than with classic signs and symptoms , with confusion : hyperkinetic or hypokinetic delirium , the second even more difficult to detect and interpret . finally , somatic diseases may occur with sudden onset of behavioral problems , or a modification if in their background : usually there is an increase in frequency and severity of bpsd ( behavioural and psichological symptoms of dementia ) , such as agitation , insomnia , busy , deliria , or hallucinations . a study showed that there is a clear difference between painful somatic symptoms reported spontaneously by the person with dementia , compared to those required by an observer . considering both the symptoms reported spontaneously and those evoked after request , patients with mci and very mild complained significantly more symptoms than cognitively intact patients . the number of painful symptoms changed in patients suffering from dementia of varying severity ( from very mild to severe ) : a greater severity of cognitive impairment corresponded to a lower number of somatic symptoms reported . since the diagnostic orientation in medicine is mainly based on reported symptoms , it is possible that many diseases , potentially treatable , may not be diagnosed in the person with cognitive impairment . this condition is central in the clinical treatment of organic disease in patients with dementia , because the nonresponse ( and the consequent failure to treat ) of somatic disease significantly affects both somatic health and evolution of cognition and functional status . the assessment of somatic diseases in the course of dementia is a phase of the multidimensional assessment , which often suffers from the problems associated with comorbidity , or that is , entirely neglected . one of the targets of care of patients with dementia is in fact the prevention of complications ( infection , malnutrition , incontinence , or delirium ) which result in an increased risk of hospitalization and increased mortality in short and medium term . a careful management of possible comorbidity could therefore slow the functional decline and limit the complications . in patients with dementia , even in the early stages of the disease , medical history should be collected or at least confirmed by the principal caregiver or by a person who knows the personal history . the doctor involved in the evaluation of the patient should be able to detect the presence of signs and somatic symptoms in the acute phase . the risk that you may incur , then , rather than an overestimation of pain in patients with dementia is the underestimation of the symptom in older cognitively compromised patients . the question is to understand how it is possible to detect somatic symptoms in patients who have communication problems and memory disturbances . it is evident that , while for chronic symptoms we must rely on memory and observation of the caregiver , for the detection of acute pain you can take advantage of signs that may accompany the symptoms and be directly observed . firstly , a sudden change in cognitive status of a patient is always an alarm bell . when family members report a rapid deterioration , or an unusual confusion , the possibility that the patient has pain should always be investigated . we must observe the gestures and movements , asking the patient to report the discomfort . the same process must be implemented when the patient experiences a sudden agitation , insomnia , or when they show unusual apathy and drowsiness . determining the amount of pain is much more difficult . the correct attitude is to try any way because of the pain and to treat both the disease and the symptom . the risk of a too conservative practice is to leave the most compromised patients  those who can not communicate their pain in any way in addition to symptom assessment , the assessment of somatic health of the patient with dementia is based on the concepts already defined by the multidimensional geriatric assessment associated with the clinical evaluation of the patient . in the person with dementia , the examination is of particular importance in order to capture significant signs , that are the indicator of an underlying organic disease not reported or underestimated by the patient and the family . similarly , given the difficulty of communication of the patient , the clinical signs should be carefully considered : the difficulty breathing or tachypnea is a sign of an underlying respiratory or cardiac disease , regardless of the reported symptom ( dyspnea ) . finally , incorrect posture could be due to side effects of a prolonged neuroleptic treatment , and antalgic attitudes give an indication related to the districts affected by pain . furthermore , the presentation of somatic or acute surgical diseases can be atypical , for example , pneumonia rarely occurs with fever , chest pain , and cough , but simply with a catastrophic effect on functional status , an event that represents the most significant clinical manifestation . in front of nonspecific and atypical symptoms and signs of acute somatic illness ( lethargy , delirium , and rapid functional decline ) , it is important that the evaluation of patients with dementia , which refers to the dea , is the most complete and accurate . in dea the beats are tight , and there is often a need to evaluate many patients quickly , with the risk of neglecting the details : for this reason it is possible that the atypical signs of the diseases of the patient with dementia are neglected , resulting in delay on diagnosis and treatment of disease . it is therefore necessary , with complex patients , to retrieve that good clinical practice that researches all possible causes , starting with a thorough medical history . events interpreted as normal for adults are not normal for the elderly suffering from dementia the recent onset of fever , decreased hydration , push to try different pathologies with a patient who does not communicate and which shows only a drowsiness . still , the drug history is important , especially if we think that many drugs ( e.g. , oral hypoglycemic agents , antihypertensives , neuroleptics ) may cause side effects , especially when administered by persons not prepared by the clinical point of view ( family members ) . the assessment of vital signs , finally , is essential for a better understanding of the patient 's general condition : the determination of blood pressure , heart frequency , oxygen saturation ( or blood gas ) , body temperature , and glycemia . on the basis of the geriatric history and the clinical evaluation , it becomes easier to guide implementation of blood chemistry and instrumental analysis in dea while avoiding unnecessary and expensive tests , both in terms of patient suffering ( execution time , discomfort for the patient and their families ) that in economical terms . the evaluation of the patient with dementia which refers to the dea , therefore , requires more attention than the adult , as it needs a specific and careful approach , which considers every possible cause of somatic or surgical illness to achieve a good diagnostic orientation , a prerequisite for the selection of the correct treatment regimen . when patients with dementia belong to the dea for somatic problems or the exacerbation of cognitive or behavioral disorders , the key problem is to understand the real necessity and usefulness of hospitalization ; that is , if the issue in which the patient with dementia is presented to the dea is solved in the same emergency room , or if it becomes necessary hospitalization for diagnosis and treatment . in fact , in some cases nonspecific symptoms ( confusion , agitation , anxiety , or , conversely , apathy , and drowsiness ) may represent the onset of an acute somatic disease ( lung infection , acute heart failure , acute myocardial infarction , and fractures ) , which requires correct hospitalization . in this case , the diagnostic , clinical and instrumental capacity of the staff of the dea would lead to a disease orientation that should be treated in a hospital . sometimes , on the contrary , from the evaluation of the dea , medical conditions requiring hospitalization emerge : it is often the patient 's family that led him to the dea , frightened by a series of nonspecific symptoms that can not be understoond ( conduct disorder , bone and joint pains , abdominal pain from chronic constipation , and dyspepsia ) . the minor clinical problems can be addressed directly in the dea , for which the patient can be treated on site ( pain therapy , oral antibiotics , and enema evacuees ) and be returned to their home , or in nursing homes of origin . this attitude has a twofold advantage : firstly it solves the problem directly to the patient and his family members , reducing the discomfort and inconvenience of a hospitalization . on the other hand , it allows the patient to return to their place of residence , thus avoiding the risk of delirium , which is high for the hospitalized patient with dementia . certain negative conditions must be , however , remember : even today , too often , the patient suffering from dementia is an uncomfortable patient . when the patient arrives at the dea , the doctor knows that , most likely , he will tract a number of problems that characterize a complex patient . often the risk is to reduce the attention , to make a superficial assessment , assuming a series of chronic pathologies , and therefore not worthy of consideration . superficiality and carelessness , unfortunately , do not allow an overall assessment of the patient , with the risk of failing the expectations of the patient and family members , or to neglect the real problem of the patient ( e.g. , to deal with the agitated patient with sedatives without thinking about the cause that could be pneumonia ) . finally , particular attention should be paid to the environment : the dea is often a noisy , crowded place , where all patients are understandably suffering from an illness , seeking an answer quickly , not including delays or procedures , also because few medics find the time to stop and explain it . stress related to pain , noise , and unfamiliar environment are reflected even more heavily on the patient suffering from dementia , who find themselves in a  tower of babel  where just few stop talk to them , trying to understand their problems and to cheer them up . little attention is given to their needs , including physiological ones : if they have to wait in the dea for several hours before the visit , it is difficult for them to ask for help , as they suffer from dementia , they do not pay attention to their needs : hydration , using the bathroom , eating , and caring for their somatic pain . the risk is to accentuate the symptoms , including behavioural ones , and arrive at the time of the visit with a patient even more confusing and therefore , in our eyes , even more incomprehensible . the future of the dea , if it is to become efficient and effective , is to specialize in these patients , who will increasingly need quick and competent responses . a large number of people who come to the dea suffer from a severe form of dementia : 12% of patients who are admitted to medical ward from the emergency department suffer from severe dementia , so it is possible to envisage a double rate if we include patients with dementia in mild to moderate impairment . the hospital and the staff of the dea , in general , are not prepared to deal with the continuing ( and increasing gradually over time ) requirement of care by people with dementia , regardless of its severity . in fact , with increasing age , it increases the clinical complexity of patients that belong to the hospital . it is necessary that the staff of the dea is prepared ( and not just on the field ) to the assessment and planning of the elderly patient with dementia : how to recognize cognitive , sensory deficits , to identify the patient 's functional status and social resources at home are fundamental factors that drive both the diagnostic orientation and treatment choices ( hospital care versus at home care ) . the risk you take is to use the outdated disease - oriented method that does not help the understanding of geriatric pathologies . as noted in a recent study , most physicians working in the dea in the usa reported higher levels of anxiety as a result of the large number of elderly patients who belong to the hospital , and their inability to cope with the complexity of the patient . the low level of experience , and the lack of specific training in geriatric medicine for acute care and in relation to the elderly and their families , are factors contributing to increased stress for staff . the future scenario should include a plan to improve the quality of care , through a specific theoretical and practical training for all personnel working in an emergency ward : the objective is to train skilled professionals to handle the urgency of the young and adult , but also specialized in the treatment of acute diseases of the elderly patients with dementia .
the hospitalization of the elderly with acute illness is one of the most discussed in the organization of health services , it is not yet clear whether the hospital is really the best response to the needs of the elderly , especially those with cognitive impairment . despite evidence of possible adverse effects of hospitalization ( immobilization , acute confusional state resulting in sedation , risk of falls , intestinal sub - ileus ) , 
 there has been an increasing use of the hospital , particularly to specialist services . 
 regardless of the benefits from the shelter ( instrumental diagnosis and prompt treatment of acute somatic disease ) , in people with dementia it needs to identify the characteristics of the person ( cognitive impairment , functional status , somatic comorbidity , social and familial status ) , the personal needs and , therefore , diagnostic and therapeutic targets which must be assumed for that sick person during hospitalization . to this end 
 , it is fundamental the role of assessment and diagnostic orientation that takes place in the department of emergency and acceptance ( dea ) , which mainly receives patients at the hospital . even before the hospital recovery it is therefore essential to check how many elderly patients with cognitive impairment that belong to the dea , and what are their needs .