March 18, 2020
PATIENT SCENARIO 1:
The daughter of an 82-year-old community-dwelling, woman calls the ED nurse hotline regarding her mother. The patient has a past medical history of diabetes mellitus and multiple comorbid illnesses. During the past week the patient had a cough, runny nose, and a slight fever. No temperature has been taken today. Her cough has worsened over the last week. The patient has not recently traveled, however family members from Europe visited the patient three weeks ago. They were not ill. The patient’s fingerstick blood glucose has been running higher than baseline and the daughter feels that the patient globally looks a bit worse than baseline.
- Should this patient be sent to the ED?
- Should she receive COVID-19 testing?
- Are there alternative sites for her testing and treatment?
- What systems should be in place to address her care?
As of noon March 18, 2020, 7,038 cases of COVID-19 have been reported in America.1 Numbers are predicted to increase dramatically due to increases of testing. There have been 116 deaths, mostly in older adults. There are 106 patients now reported as fully recovered. Twenty-three older adult deaths were a cluster from one nursing facility in Washington state.2 Currently, 49 states have reported cases of COVID-19 infection, and President Trump has declared a National State of Emergency. Without widespread containment measures, the number of cases is projected to double every 6.4 days.3
COVID-19 differs from other viral URI’s because of virulence. The virus lives on surfaces for up to 9-days and is more contagious than influenza. There also exists no herd immunity for this novel infection, and to date no vaccine exists.4
This manuscript presents two common case scenarios to illustrate the central role of the Emergency Department (ED) in the diagnosis, acute management, and community care coordination of complex older adults in this rapidly changing situation.
What is Unique About COVID-19 & Older Adults?
Due to physiologic changes of aging, decreased immune function, and multimorbidity, older adults are at significantly increased risk from COVID-19.5 See Appendix 1 for Key Points for Patients. Older adults are more susceptible to the infection itself and are more likely to suffer from the severe form of COVID-19 disease and to have complications.
Aging may also complicate diagnosis, as older adults with respiratory viruses often present atypically. The median duration from symptom onset to death is 11.5 days in persons >70 years vs. 14 days in younger persons.6
The definition of fever may need to be altered for older adults. Please see the section on what is fever below. A careful fever evaluation is essential in older adults as based on a new report by Cao et.al.7 Cao showed rapid increases in visits, with 40% of all ED visits for fever evaluation. Based on such numbers, administrators would anticipate the depletion of personal protection equipment effecting majority of ED providers.
A recent World Health Organization report found that the case fatality rate for COVID-19 patients older than 80 years in China was 21.9%, while patients of all ages with no underlying chronic conditions had a fatality rate of only 1.4%.8 It should be considered that issues such as inadequate ED or ICU care, or lack of resources could also adversely affect mortality and that age is one of many such factors.
Mortality data emerging from Italy reveals the staggeringly high risk of this virus for older adults.6 In Italy, where 23% of the population is over 65 years, 89% of COVID-19 deaths are over 70 years old (31% between 70-79 and 58% are over 80 years old).7
On the hopeful side, 103-year-old Zhang Guangfen was admitted to Wuhan’s Liyuan Hospital March 1st and has completely recovered.
What is Fever in Older Adults?
Should we use a temperature of only 100°F to screen for disease in older adults? COVID-19 symptom screenings often use fever as an important sign of illness. Data from China inform that fever is the most common sign, with 83% of 99 inpatients with mean age 55 (15% over 70) exhibiting fever.9
However, fever may not be a sufficiently sensitive sign in older adults, as it is frequently blunted or absent even in serious infection.10 Lacking specific data from the evolving COVID-19 epidemic, influenza, another respiratory virus with significant mortality in older adults, also informs the sensitivity of fever in older adults. One ED-based study shows that only 32% of patients over 60 years with proven influenza had triage temperatures >100˚F.11 Temperature may be even less sensitive among our most frail older adults, those in senior living, who carry the highest risk from infection.
The Infectious Disease Society of America recommends modifying the definition of fever for older adults to:
- A single oral temperature over 100°F, or
- 2 oral repeated temperatures over 99°F or
- an increase in temperature of 2°F over the baseline temperature.12
|Contributors: Michael L Malone, MD, Teresita M Hogan, MD, FACEP, Adam Perry, MD, Kevin Biese, MD, Alice Bonner, PhD, RN, FAAN, Patti Pagel, RN, Kathleen T Unroe, MD, MHA
|Collaborators: West Health, The John A. Hartford Foundation, and The Institute for Healthcare Improvement