The World Health Organization (WHO) estimates that by 2050, there will be more than 2 billion people over the age of 60. This indicates that the world’s population is undergoing a significant demographic change [1] [2] . Most of this aging population will live in low- and middle-income countries (LMICs), which will put even more strain on already overburdened healthcare systems [3] .

Geriatric patients have distinctive problems in emergency treatment, such as atypical disease presentations, frailty, poly pharmacy, and cognitive dysfunction, which may hinder diagnosis and delay urgent therapies [3] [4] . Current evidence indicates that older patients admitted through emergency departments face greater risks of poor outcomes, such as extended hospitalizations, critical care unit admission, and increased mortality rates in comparison to younger groups of patients. Resource-constrained environments frequently exacerbate these risk factors, restricting access to specialized geriatric and critical care services [5] [6] .

In sub-Saharan Africa, including Somalia, inadequate healthcare systems struggle due to political instability, a lack of resources, and insufficient staff. Emerging evidence indicates that older adults in African emergency departments frequently present with both non-communicable diseases (such as hypertension, stroke, and heart failure) and infectious diseases, illustrating the dual burden of disease in low- and middle-income countries [7] [8] . However, systematic data on geriatric emergency care in Somalia are still limited. It is crucial to note that there is less knowledge regarding the determinants of mortality in this vulnerable population, despite their significantly higher risk of adverse outcomes [9] [10] .

Identifying the factors that predict mortality in older emergency department patients is important for ensuring that inadequate health systems are able to detect problems, take action, and use their resources wisely. Consequently, this study is designed to identify the demographic characteristics, clinical presentations, comorbidities, and mortality predictors among elderly patients admitted to the emergency department of a tertiary care hospital in Somalia.

The study included 654 elderly patients. The average age was 72.3 years, with 71.3% of people being between 65 and 75 years old and 28.7% being between 76 and 85 years old. There was no statistically significant correlation between age and in-hospital mortality (p = 0.332). The study population was made up of 61.9% males and 38.1% females. Gender was similarly not directly predictive of mortality (p = 0.896). As shown in Table 1 .

The most common manifestations at admission were nausea and vomiting

P-Value (Level of Significance), n (numbers), % (Percentage), ICU (Intensive Care Unit), ENT (Otorhinolaryngology).

(26.8%), shortness of breath and cough (22.9%), and abdominal discomfort (18.0%). Various presenting symptoms were significantly correlated with increased mortality, including altered mental status (13.8%, p = 0.001), limb weakness (15.4%, p = 0.007), dyspnea (p = 0.010), lower limb or generalized edema (p = 0.010), urinary retention or hematuria (p = 0.002), and trauma-related injuries (p = 0.021). Conversely, symptoms including fever, headache, and diarrhea did not exhibit a statistically significant correlation with mortality. These findings are detailed in Table 2 .

Hypertension (42.5%) and diabetes mellitus (30.3%) were the most common comorbidities, followed by cardiovascular disease, neurological diseases, renal failure, and liver disease. However, none of these chronic illnesses had a significant correlation with death (p = 0.05 for all). The odds ratio (OR = 2.01) for liver disease was the highest, although it was not statistically significant (p = 0.298) as summarized in Table 3 .

These results indicate that acute clinical problems exerted a more significant influence on death outcomes compared to chronic comorbidities. Out of all the patients, 104 (15.9%) died while they were in the hospital, and 550 (84.1%) survived. A significant predictor of mortality was admission to the intensive care unit (ICU), which had a mortality rate of 13.9%, compared to 2.0% among general

P-Value (Level of Significance), n (Number), % (Percentage).

OR (Odds Ratio), P-Value (Level of Significance), n (Number), % (Percentage).

ward patients (p = 0.001). There were also variations between departments, with patients admitted through general surgery and pulmonology departments having higher death rates (p = 0.001) as recorded in Table 1 .

The majority of patients (80.4%) received medical treatment, whereas 19.6% underwent surgical treatments; however, the type of treatment was not significantly correlated with mortality (p = 0.149). Conversely, the necessity for critical interventions, including intubation, vasopressor administration, and dialysis, was significantly correlated with elevated mortality (p = 0.001 for all) as also shown in Table 1 . A disease-specific mortality analysis showed that individuals with fractures, anemia, gastroenteritis, or urological problems did not die. Patients with acute abdominal (37.9%), lung infections (32.4%), traumatic brain injury (23.3%), renal failure (20.7%), and stroke (13.0%) had the highest death rates as recorded in Table 4 .

P-Value (Level of Significance), TB (Tuberculosis), DVT (Deep Venous Thrombosis), PAD (Peripheral Artery Disease).

Most of the patients (71.4%) were in the hospital for 1 to 7 days, during which time 8.7% of all deaths occurred (p = 0.001) as shown in Table 1 . This indicates that shorter hospitalizations were substantially correlated with increased mortality, presumably due to the severity or immediate course of illness resulting in premature in-hospital death. Overall, the study indicates that acute clinical presentations, ICU admission, life-sustaining interventions, and certain severe diagnoses are strong indicators of mortality in older patients. On the other hand, age, gender, type of treatment, and chronic comorbidities like hypertension and diabetes mellitus were not independently related to death in the hospital.

In this retrospective cohort study of 654 geriatric patients hospitalized in the emergency department (ED) of a tertiary hospital in Somalia, we found an in-hospital mortality rate of 15.9%. The main indications that an individual could pass away were the severity of their acute illness and signs of physiological decline, such as changes in mental status, shortness of breath, weakness in the limbs, generalized edema, trauma-related injuries, ICU admission, and the need for life-sustaining treatments like intubation, vasopressors, and dialysis. Common chronic diseases like hypertension and diabetes mellitus did not independently predict death. These results suggest that short-term outcomes in the emergency department are mostly determined by the severity of presenting diseases rather than the preexisting chronic disease burden [11] [12] .

Our findings are consistent with previous research conducted in corresponding low- and middle-income country (LMIC) contexts, where insufficient emergency and critical care resources lead to heightened death rates among older persons [13] [14] . Age and gender did not show a significant correlation with death in our group, aligning with prior studies indicating that clinical presentation and severity are more predictive of outcomes in elderly emergency department patients than demographic characteristics [15] [16] . ICU hospitalization and the necessity for extensive life-sustaining treatments were especially strong predictors, indicating the severity of underlying organ failure and the complexity of acute presentations [17] [18] .

Analysis based on diagnosis showed that acute abdominal and lung infections, renal failure, and traumatic brain injury had the greatest death rates. On the other hand, fractures, anemia, gastroenteritis, and urological disorders had very low death rates. Likewise, surgical procedures, conducted in 20.5% of patients, did not exhibit a significant correlation with mortality, indicating that prompt surgery, when warranted, does not worsen outcomes in the older population [19] . Shorter hospital stays (1 - 7 days) were surprisingly linked to increased mortality, underscoring that early in-hospital deaths frequently stem from severe or rapidly progressive illnesses, a conclusion aligned with existing evidence on acute deterioration in older individuals [20] [21] .

This study has major implications for clinical practice in Somalia and other resource-constrained environments. Early detection of high-risk presentations—especially altered mental status, respiratory distress, trauma, and organ failure—should prompt immediate evaluation and an escalation in care, encompassing early diagnostics, oxygen therapy, and timely referral to surgery or the ICU. The incorporation of validated risk-stratification instruments, such as early warning scores or frailty assessments, may further optimize triage efficiency and resource distribution in the emergency department [22] [23] . Furthermore, the high mortality rate associated with aggressive treatments underscores the importance of structured goals-of-care discussions and shared decision-making with patients and their families, particularly when ICU resources are limited.

There are a few problems with this study. First, its retrospective, single-center design and reliance on medical records may have caused misclassification or information bias. For instance, there was no standardized way to measure frailty, and there was limited information about patients’ functional status before they became ill, the medications they used, or their do-not-resuscitate (DNR) wishes. Secondly, we could not examine long-term outcomes other than in-hospital death, such as 30-day or 90-day mortality and loss of function. Thirdly, even though we performed both bivariate and multivariate analyses, there may still be residual confounding because we did not evaluate some variables, such as frailty, baseline functional level, severity of acute illness, and time to treatment. Fourth, systemic limitations on the number of critical care beds also affected the results. There are not many ICU beds available. Only four hospitals in the area have ICUs, and only one of them has 35 ICU beds. For older persons, the number of ICU admissions each month is usually between 5 and 10. Also, there are not enough skilled ICU doctors and nurses; only one hospital has professionals who are trained to work in critical care. Cultural and social variables also affect who is admitted to the ICU. Many families would rather not send their elderly relatives to the ICU and instead care for them at home. Lastly, our hospital is a tertiary referral center, which means it probably receives more severe cases than smaller or primary care hospitals do.

Finally, our study shows that the short-term mortality rate among older people who go to the emergency department in Somalia is mostly influenced by the severity of the acute illness and the amount of organ support needed, not by the number of chronic conditions present at the same time. For older people who do not have a lot of resources, targeted interventions such as quickly identifying high-risk cases, using detection and frailty resources, expanding the emergency department and intensive care unit, and planning discussions about goals of care may improve outcomes.