The challenges of working with older people with COVID-19
Prof Rowan H Harwood is a geriatrician and Professor of Palliative and End-of-Life Care at the University of Nottingham. Amongst wide clinical and research interests he has particular expertise in delirium and dementia. He is Editor of Age and Ageing.
The value and fascination of working with older people is versatility and variety. Almost uniquely amongst medical specialties, geriatric medicine is broader not narrower than its parent discipline. We are acute physicians, and experts in chronic disease management, disability and rehabilitation, co-morbid mental health problems, decision-making, transitions and end-of-life care. We work in multi-professional teams, across sectors and with families. We see how older people recover, how they cope and how they die. In this respect, dealing with COVID-19 seems both different and the same.
Initial reports emphasised pyrexia and cough. Experience rapidly showed that older people could present in atypical or non-specific ways. Delirium, fatigue, falls, anorexia, dehydration, diarrhoea, ‘silent hypoxia’, and without necessarily having a raised temperature. These presentations featured relatively little in published case series, but were quickly identified by geriatricians, who are well used to complexity. The bewildering spectrum in severity and time course is disconcerting, from asymptomatic and mild cases to hypoxia, delirium and death, as are the numbers and ubiquity, the relative youth of some we are seeing, and the mimics and influence of co-morbidity. We have yet to seriously consider the needs of those recovering, and how we help them regain function, cognition and mental health.
A more-or-less unified health service has been a strength, in terms of co-ordination, and re-direction of available resource, but working in a system with a history of relentless focus on efficiency, elimination of slack, with a utilitarian ethic has also led to controversy. Most agree the unacceptability of chronological age as a basis for treatment decisions and a measure of frailty is certainly more informative than age per se; by definition, we would expect problems relating to COVID-19 to be greater for those who live with frailty. Tools, such as the Clinical Frailty Scale, have been pushed to their limits – the CFS is a disability scale; it describes levels of function, which relates to, but is not the same as, frailty. Hence there is controversy about applying it to younger physically or intellectually disabled people. To my knowledge the CFS, and hastily-concocted ITU eligibility scores based on it, have not been validated in predicting ITU outcomes. At the same time, we must protect vulnerable people from unpleasant interventions from which they have little or no chance of benefit, and must use limited resources both equitably and for maximum health gain. Palliative medicine routinely uses the notion of avoiding ‘treatment burden’; more than ever we must recognise that treatments come with varied costs. The defence against abuse of these tools and arbitrary decision-making is our broad-based training, and sound professional judgement.
Many aspects of our usual practice are challenged. A few years ago, I was involved with an inter-professional communication skills training programme for people with dementia, called VOICE. We worked with actors who were experienced patient simulators. When we de-briefed them they commented how much trainees touched them. It makes sense, but was almost sub-conscious. We are also learning how dependent older people are on seeing our faces, and our lips move, when we communicate, impossible when wearing a mask. All this is swept away and lends new challenges.
Family inclusion has been an article of faith for geriatricians, especially when managing people living with delirium and dementia. The necessity for taking ‘lockdown’ seriously in a pandemic should go without saying, but it has been particularly hard on vulnerable older people, and those who are dying. Many have graciously accepted telephone conversations instead, and video-calling has come of age.
Care homes are rarely appreciated for the work they do, and the first response of the healthcare system in the face of COVID-19 was adversarial. In the name of speedy discharge to empty valuable hospital beds, care homes were denied a say on who they took back or took in, and patients and families were denied choice on where they went. Many homes instituted fairly extreme isolation practices, excluding families and visitors. Personal protective equipment was absent or in short supply. With staff and new arrivals exposed and vulnerable, it was surely only a matter of time before care homes saw outbreaks, and in view of the universal frailty of their residents, severe mortality. The BGS has published helpful guidelines on managing COVID-19 in care homes.
Age and Ageing has received many submission on COVID-19. We select what we publish on the basis of importance, novelty, quality of design and interest to geriatricians, and have maintained these standards. Time and circumstances have made it hard to undertake rigorous research on COVID-19 amongst older people, and we applaud those who have tried. We urge support for, and inclusion of, older people in the NIHR Recovery and other drug-treatment trials, and the principles underlying research published by the BGS.