COVID-19 in the Elderly-A Glimpse of Optimism

Received: 30-Dec-2020 Accepted Date: Feb 11, 2021 ; Published: 18-Feb-2021

Case History

This 92-year-old lady, who resides in a care home, had a plethora of comorbidities, including Alzheimer’s dementia, Non-Hodgkin’s Lymphoma, Supra-Ventricular Tachycardia, Chronic Kidney Disease, recurrent cellulitis, Osteoarthritis with a history of bladder cancer, and lung abscess. She was on immune-suppressants for her Lymphoma. However, she was able to mobilize, communicate, and was mostly independent.

With the beginning of the pandemic, all the care home residents had been flagged as high risk, and the shielding was advised. The care home tried to isolate and care for patients in their rooms and stopped visits from families and friends to minimize the risk of exposure. Unfortunately, those measures only helped in delaying the outbreak, not preventing it; mainly due to the size of the care home, which had more than 75 residents, and a large number of staff needed. Moreover, around 90% of the residents suffered from dementia and it proved exceedingly difficult to care for some of them in their rooms.

Around mid-April, this lady developed symptoms of chesty cough with no fever or shortness of breath. Her observations were normal apart from her oxygen saturation which was 94%. She was started on Amoxicillin for a possible chest infection and was swabbed for the COVID-19 virus. Four days later, she started spiking temperatures of more than 39°C and was subsequently changed to Co-Amoxiclav as an antibiotic cover for COVID-19 infection, as per local guidelines.

This lady continued to deteriorate with reduced oral intake, persistent fever, and spending most of the time in bed. Her chest showed bilateral crackles and oxygen saturation was 88%-91% but dropped to 86% on minimum exertion. The clinical picture, and having few confirmed cases at the care home, made the diagnosis of COVID-19 pneumonia highly likely.

Initially, it was decided to admit her to the hospital considering she was for full active treatment. However, upon further discussions involving the patient and her family, it was decided that she would rather stay at the care home, in her familiar environment, looked after by her friendly carers. Her management was limited to community-based treatment and the End of Life (EOL) pathway was started. At that time, her swab results confirmed a COVID-19 infection.

After more than three weeks of the illness and two courses of antibiotics, she was still spiking temperatures with low oxygen saturation and was commenced on doxycycline. She was reviewed again, via video consultation, a few days later. She was sat on the chair, looked comfortable, with no obvious dyspnoea, although oxygen saturation was still 93%. She was talking and smiling on occasion. She also had better oral intake and improved urine output. She continued to improve slowly and steadily and a few weeks later, she was almost back to her baseline functional level and ready to restart her lymphoma treatment.

Discussion

On the 31^st of December 2019, a case of atypical pneumonia was reported to the WHO country office in China. Following that, events escalated at an unprecedented rate. Only one month later, the WHO declared an international emergency and declared it as a pandemic on the 11^th of March 2020 [1].

In the UK, the first case was confirmed on the 29^th of January; by May 14^th there were around 230,000 confirmed cases [2].

Most of the published guidance and decision aiding tools suggested screening patients for fever, cough, and shortness of breath [3]. It also highlighted that elderly patient were at higher risk to get the infection, getting seriously ill, and dying from the illness. This increased risk was attributed to the physiological changes of aging on top of multiple underlying comorbidities. Those physiological changes also meant elderly patients were unlikely to have the classical presenting symptoms [4-6]. Therefore, a lower threshold is required to be able to diagnose the disease, predict and manage its progression in the elderly.

Over 2 months, this 92-year-old lady had gone through ups and downs, including initiating the EOL pathway. Throughout this journey, she was isolated in her room, deprived of the essential social contact, except the occasional video chat with her family, which helped her get a smile back. The impact of the social isolation on her mental health and her will to fight was a major obstacle in this journey. In the face of all those challenges and against all odds she eventually turned the corner. She had put up an impressive fight and achieved full recovery.

Conclusion

The COVID-19 virus has affected the lives of the whole planet, infected millions, and killed hundreds of thousands. It has disrupted families and communities and significantly damaged the economy. We have heard quite a few stories of young healthy individuals struggling to fight off the virus. The media was full of stories of the brave NHS heroes who lost their lives while helping others battle the virus. Amidst this picture of doom and gloom, and under on-going lockdown policies, I believe this story gives us a glimpse of optimism and reminds us that there is always hope.

Declerations

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

1. World Health Organization. "Coronavirus Disease (COVID-19)-Events as they happen." 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen
2. Gov.Uk Coronavirus (COVID-19) in the UK. https://coronavirus.data.gov.uk/?_ga=2.168797091.360000489.1589466373-1315879453.1589466373
3. Greenhalgh, Trisha, Gerald Choon Huat Koh, and Josip Car. "Covid-19: A remote assessment in primary care." BMJ, 2020, p. 368.
4. Jung, Yu Jin, et al. "Atypical clinical presentation of geriatric syndrome in elderly patients with pneumonia or coronary artery disease." Annals of Geriatric Medicine and Research, Vol. 21, No. 4, 2017, pp. 158-63.
5. D'Adamo, Heather, Thomas Yoshikawa, and Joseph G. Ouslander. "Coronavirus disease 2019 in geriatrics and long‐term care: The ABCDs of COVID‐19." Journal of the American Geriatrics Society, Vol. 68, No. 5, 2020, pp. 912-17.
6. Covid, Atypical. "Presentations in older people-the need for continued vigilance." British Geriatrics Society, 2020. https://www.bgs.org.uk/blog/atypical-covid-19-presentations-in-older-people-%E2%80%93-the-need-for-continued-vigilance