Covid19 in elderly

The COVID-19 outbreak which has rapidly jumped from epidemic to pandemic has affected over 2 lakh people worldwide with fatality rates being particularly high among the elderly. In this article, Dr. OP Sharma lists the risk factors responsible for infection among older people and specific instructions that doctors can give to vulnerable patients.

 

What is COVID-19?

COVID-19 is a novel coronavirus that causes upper respiratory tract infection, which may trickle down to the lower respiratory tract causing severe pneumonia, septicaemia, ARDS, and multiorgan failure.

It spreads from person-to-person through large droplets of respiratory secretions predominately from those having LRTI, via the mucous membranes within a distance of 1 metre. The virus has an incubation period of 2 to 14 days with mean incubation period of 5.2 days. The recovery time in mild cases is 2 weeks while in severe cases- 4 to 6 weeks.

Who can be suspected of having infection?

Suspect a person suffering from COVID-19 if the person has fever, weakness, breathlessness, or signs/symptoms of lower respiratory illness (cough or shortness of breath). Any person including healthcare workers who have had close contact with a lab-confirmed patient within 14 days of symptom onset or has a travel history to a corona-affected country should also come under the lens.

Concern for the elderly

While people mostly affected during swine flu in India in 2009 and 2014 were young adults, COVID-19 is mostly affecting and causing fatalities in the elderly. Fatality ranges in the age group of 50 to 59 years (1.3%), increases with age 60 to 69 years (3.6%), 70 to 79 years (8%), and in the above 80 years group (14.8%).

Elderly with advancing age become more immune deficit. There is decline in the functioning of the immune system, often referred to as immunosenescence. There is also a decrease in the synthesis of T and B lymphocytes, and there is a decreased capacity of those cells to mount a specific immune response. There is also a reduction in the functioning memory of the lymphocytes leading to failure to mount an immunological attack on invading organisms. The risk of infection increases in persons with impaired IgG synthesis, impaired phagocytosis and defective clearance of secretions.

Moreover, the incidence of comorbid conditions in the elderly is high. Polypharmacy is common and the use of steroids is rampant. Staying indoors, the lack of physical activity and smoking makes them more vulnerable for upper respiratory tract infections, which also takes a longer time to clear because of physiological decline in the functioning of trachea and bronchi.

The elderly are more prone to infections because of:

1 Physiological decline in the functioning of the respiratory system leading to decreased clearance of secretions.

2 Poor lifestyle and personal habits such as staying indoors, lack of exercise, smoking, alcohol use, poor nutrition (malnutrition including deficiency of vitamins and minerals).

3 Decline in functioning of the immune system due to immunosuppressive conditions such as HIV, congenital immunodeficiency, malignancies, bone marrow transplantation or organ transplantation, persons with functional/anatomic asplenia (sickle cell disease/splenectomy).

4 Use of therapy- alkylating agents, antimetabolites, systemic corticosteroids etc.

5 Immunocompetence but presence of comorbidities like diabetes mellitus type 2, CHF due to various causes like CAD, cardiomyopathy, uncontrolled hypertension, chronic renal failure, chronic pulmonary diseases- COPD/emphysema, bronchial asthma, bronchiectasis, hepatitis C, chronic liver disease– cirrhosis.

6 Presence of obstructive sleep apnoea (OSA) and increased susceptibility to nocturnal aspirations.

7 Higher incidence of drug resistance owing to repeated and injudicious use of antibiotics.

Preventive strategies for the elderly

Specific instructions that can help vulnerable population:

Frequent washing of hands with soap and water or use of sanitisers

Avoiding unnecessary touching of the nose, mouth and face

Avoiding handshakes

Staying away (1-metre distance) from people who are coughing and/or sneezing

Staying away from people with travel history to corona-affected countries.

Being physically active every day; regular brisk walks (with or without sticks) half hour to one hour will increase overall fitness

Doing pulmonary exercises (learned from a chest physiotherapist) to improve ventilation in the upper lung segments and in the lower segments close to the diaphragm which otherwise are prone to infections as being the favourable places for virus to grow

Avoiding public transport and minimising shopping

Drinking more liquids

Talking while maintaining a distance at least 6 feet; coronavirus can travel not just with air drops within 1.8 meters but also by kissing and having coitus

Not using alcohol as a medicament for the virus as it opens the respiratory tract as a gateway for the virus

Using facemasks which are good for protecting oneself from those coughing and sneezing

Wearing glasses instead of contact lenses, at least for the next few months

General instructions that can help patients:

Keeping comorbidities in check- diabetes mellitus type 2, CHF due to various causes like CAD, cardiomyopathy, uncontrolled hypertension, chronic renal failure, chronic pulmonary diseases – COPD/emphysema, bronchial asthma, bronchiectasis, hepatitis C, chronic liver disease – cirrhosis)

Maintaining oral hygiene by regular cleaning, brushing of teeth, cleaning of dentures etc.

Avoiding smoking and tobacco chewing

Ensuring proper nutrition which should include adequate calories, proteins, fresh fruits and vegetables; ensuring adequate intake of vitamins, mineral supplements and phytoncides-based foods such as garlic, spring onions, spinach, cabbage etc. to help with immunity

Adopting healthy sleep practices

Avoiding tea, coffee, tobacco or any other form of stimulant close to bedtime (sleep should not be enforced and alcohol should be avoided to induce sleep)

Treating nocturnal aspirations due to laxity of gastroesophageal sphincter either due to ageing, disease or drugs to prevent infections

Getting vaccinated; people with chronic diseases may be offered preventive respiratory vaccines like influenza and pneumococcal vaccines

Minimising polypharmacy

Avoiding injudicious and inappropriate use of antibiotics to prevent antimicrobial resistance

Avoiding mass gatherings and travel to COVID-19 affected countries

  

Disclaimer- The views and opinions expressed in this article are those of the author’s and do not necessarily reflect the official policy or position of M3 India.

The author Dr. O. P. Sharma is a Senior Consultant Geriatric Medicine at Indraprastha Apollo Hospitals, New Delhi

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