Severe acute respiratory syndrome (SARS) in elders

Abstract

The prevailing myths that elders afflicted with SARS are invisibly infectious and inevitably fatal have generated much fear and stress among elders, the public, medical professionals and health care workers. To unveil the myths surrounding SARS in Elders, the Hong Kong Geriatrics Society has formed a Special Interest Group on SARS in Elders to share the clinical experiences and findings on SARS in Elders. Whereas elders aged over 65 constitute 11.7% of the Hong Kong population in 2003, elderly SARS account for 18.5% (150/1700) of SARS of all ages during the SARS epidemics in 2003. Princess Margaret Hospital admitted 150 of the 300 elderly SARS managed in public hospitals in Hong Kong. The risks of contracting SARS during the SARS epidemics in Hong Kong for the general population, elderly SARS (aged over 65) and residents of nursing homes are 0.026%, 0.041% and 0.109% respectively; the risk for males being higher than females for elderly SARS. The diagnosis of SARS in old age cannot be based solely on the WHO criteria for SARS, but requires a high index of suspicion, knowledge of the geriatric presentations of infections in old age, sensitivity to a frail elder with change in physical and functional state, alertness to any contact history of SARS, and an updated knowledge of the current prevalence of SARS in the locality. As these geriatric presentations are non-specific, it is important both to avoid under-diagnosis and over-diagnosis of SARS. Two-third (100 out of 105) of elderly patients (aged 65 or above) referred for suspected SARS has alternative diagnosis, compared with 1/3 in younger patients. Elders with SARS often have an apparently lengthened incubation period of 14 to 21 days because of delayed detection of onset and inexact day of contact due to multiple exposures. This has important clinical implications on diagnosis, contact tracing, duration of surveillance, as well as infection control measures during high risk nursing and personal care for these frail elders. Elders are more vulnerable to the adverse drug reactions of ribavirin and high dose steroid commonly used to treat SARS, especially nosocomial infection (47%). The benefit to risk ratio of any given intervention can be quite different in frail elders with significant co-morbidities when compared to younger adults or fit elders. So, an individualized approach is required in treating an elder with SARS. The high mortality rates (50-75%) reported in elders with SARS can be attributed to late presentation, delayed diagnosis, comorbid conditions, and complications from treatment . The myth surrounding SARS in elders is a timely reminder that the appropriate care of hospitalized elderly patients calls for special attitude, knowledge and skills, in particular a diagnostic and holistic approach in the face of complexity, a therapeutic approach balancing risks and benefits, and a rehabilitative and palliative approach towards frailty. Prevention of SARS depends on breaking the chain from exposure to infection, and thus both prevention of exposure and early detection of SARS in elders are important in minimizing spread. As 72% of SARS cases in residents of aged homes are hospital acquired5, unnecessary and inappropriate hospitalizations should be avoided, and their medical needs met by community and out-reach care as far as possible. Careful surveillance for possible SARS among recently discharged elders in aged homes should also be made when SARS is prevalent in that locality. Undiagnosed SARS can result in outbreak among health care workers and patients within hospital and aged homes1, 3, 4, and this may lead to further outbreaks in community. An example of similar outbreak involving unrecognized tuberculosis in a nursing home in the United States has been revealed by molecular and epidemiological links11. Thus, SARS in elders should be treated with respect. The HKGS advocates the need to approach elders in the era of SARS with appropriate attitude, knowledge and skills. Input from geriatricians is important in combating SARS in elders, whether in acute, rehabilitation or community settings. Alternatives to Hospital Care Hospital care has its own limitations when applied to frail elderly patients: iatrogenesis from excessive interventions, heroic measures and polypharmacy; adverse environment and the disruption of social contact/support; and the susceptibility to hospital acquired infections more evidenced by the SARS crisis. Geriatric Day Hospital, Community Geriatrics Assessment Service (CGAS), and Telemedicine Geriatrics Consultation have all emerged as effective alternatives to hospital care during the SARS crisis. Such services, when targeted to appropriate elderly patients, play important roles complementary to hospital care. Residential Care for frail elders Many frail elderly persons with multiple medical problems are cared in aged homes of varying quality and standard. The Kowloon West Cluster (KWC) shares 32.5% of the aged home places of the whole of Hong Kong. Of the 21489 aged home places in the KWC, 48.4% (10403 places) fall within the catchment area of the CGAS of PMH. As 72% of SARS cases in residents of aged homes are hospital acquired, unnecessary and inappropriate hospitalizations should be avoided, and their medical needs met by community and out-reach care as far as possible. The Visiting Medical Officer (VMO)-CGAS SARS project was thus introduced by the Government in May 2003, and this will be further enhanced in the coming VMO-CGAS collaboration scheme in mid-October 2003 with the organisation of a Certificate Course in Community Geriatrics for VMOs to improve their knowledge and skills in caring elders in the community. Infection Control and Surveillance Because of their dependence on close personal and nursing care, frail elders are prone to exposure to droplet spread of infections. It is therefore important to promote on the awareness and compliance of health care workers and aged home staff in maintaining proper hygiene (esp. hand washing) and taking precautions in nursing procedures to prevent infection, such as changing feeding tubes, urinary catheter, and napkins, and in sputum suction. Outbreak of infectious illnesses within aged homes can have disastrous consequences. Prevention therefore requires alertness to clustering of any illnesses in space and time for residents, staff, visitors and outreach workers of a particular aged home. This will mean education and training for aged home staff, as well as close collaboration and communication among aged home staff, visiting medical officers, out-reach community geriatricians, community nurses, acute and rehabilitation hospital staff, and microbiologists. Realizing the need for close and timely communication and collaboration among concerned parties for effective infection surveillance, geriatricians of Hospital Authority have been liaising with the Department of Health and Social Welfare Department to work out an infection surveillance system for implementation in aged home setting.