Consider the following hypothetical scenario from the experiences of an emergency medicine physician: An 84-year-old man is transferred to the emergency department (ED) from a skilled nursing facility (SNF) following three days of mild shortness of breath and non-productive cough. His past medical history includes mild dementia, COPD on home oxygen (4 liters per minute), and atrial fibrillation on anticoagulation and hypertension. The emergency medicine providers have no advanced care directives from the patient’s SNF. On arrival, the patient is awake and alert with a slight increase in work of breathing. The patient’s triage vital signs show a slightly elevated temperature, respiratory rate and heart rate which together with oxygen readings are consistent with a likely respiratory infection; blood pressure of 115/80 is within the range considered normal. His pulmonary exam demonstrates bilateral wheezing. In the Spring of 2020, the above patient commonly presents to the emergency department (ED) where a concern for COVID-19 is at the top of the list of possible problems.
Similar to the patient in this scenario, older adults with these complaints present considerable challenges to emergency medicine providers (EMP) compared to their younger counterparts.
- The first, and perhaps most obvious, is that older adults with multiple co-morbidities have the highest mortality rate with COVID-19. For this reason, the suspicion needs to be high for coronavirus, however, classic and more common disease processes such as COPD exacerbations, coronary artery disease, bacterial infections and metabolic derangements need to be concomitantly considered.
- The second challenge is that many of these patients can present more subtly than younger adults. Older adults are less likely to mount a classic fever, and those with cognitive or sensory deficits may not be able to communicate their symptomatology as clearly. Fortunately, the nation’s ED have developed fairly low threshold screening protocols to ensure maximum sensitivity in identifying older adults with potential COVID-19.
- A third, true challenge that has developed in emergency medicine revolves around airway management. Currently, professional society recommendations and many hospital policies call for limited or no use of non-invasive ventilation (such as BiPap) due to the risk for aerosolization of viral particles. For this reason, early endotracheal intubation has been the practice in many COVID-19 patients. The patient in the above story, in pre-COVID-19 times, would clearly have been a candidate for non-invasive ventilation such as BiPap or even continuing to observe on a small increase in home oxygen requirements. In current day, intubation is likely to be considered much, much earlier to prevent rapid decompensation. However, EMPs recognize that patients such as this, who are intubated, have significant morbidity and mortality, simply associated with the procedure and ICU course it will bring even, or perhaps especially, if the problem is not COVID-19 infection. Moreover, invasive and aggressive interventions such as those associated with ICU level care can be further complicated by these patient’s underlying co-morbidities, potential cognitive impairment and frequent polypharmacy. Hence, EMPs really struggle with the decision to intubate frail older adults, more so than ever, in the COVID-19 era.
- Finally, allocation of resources must be considered with such a widespread pandemic. More widespread and rapid testing of frail older adults including in the ED, as well as obtaining early prognostic markers, may be of greater benefit to this population compared to younger patients. However, given the severity of the disease in the older adult population, scarcity of some life-saving resource shortages would likely disproportionally impact older adults seen in the ED. Although workgroups and policies are being discussed and developed regarding resource allocation, this area remains uncharted territory.
The presence of frailty is elevated in older adults in the ED (See Clinical Topics: Emergency Medicine). Having a framework or understanding of a patient’s frailty could help EMP as they face these novel challenges in the COVID-19 era. For example, a frailty alert developed in the outpatient setting or based on rapid ER screening may help triage frail older adults appropriately, guide treatment decision, plan resource needs sooner and ultimately have the potential to improve the care provided to these patients during these unprecedented times. Innovative approaches are needed in order to better care for these vulnerable older ED patients.
May 29, 2020