It is indeed a time of drastic change.
The novel coronavirus SARS-CoV2 that causes COVID-19 has reordered our lives in unimaginable ways. In medicine, it has made health care workers rethink most of their treatment protocols, incorporating COVID-19 and its risks into their management of patients. Most of what we know biologically and physiologically about treatment and management of palliative, hospice, and end-of-life cases have also been impacted.
In this article, I will enumerate the possible complicating factors that may affect the care of elderly patients with COVID-19, particularly those with advanced chronic illness. I will present 5 Points in this acronym for you to remember it easily:
1. Blood clotting
Clots in the brain and other organs have been reported in a number of patients with COVID-19. These were confirmed with imaging studies such as Cranial Tomographic scan (CT-scan) or Magnetic Resonance Imaging (MRI). These clots may or may not have associated respiratory symptoms. Blood platelet counts may also be deranged, just like in Dengue fever.
The danger with clots lie in their potential to cause circulatory obstruction. This may manifest as stroke symptoms or discoloration of hands and feet. Some doctors may prescribe medication to prevent these from happening.
Elderly patients with a previous history of blood clots resulting in stroke or those with clotting disorders affecting the arms and legs may especially be vulnerable to this complication.
2. Seizures or convulsions
If the brain is affected by the virus, there is the potential to develop seizures and alterations in mental status. This may also be due to the infectious process itself that causes elevated body temperature leading to disorientation and hallucination.
If the patient was already diagnosed with seizure disorder before COVID-19 became a pandemic, the condition may be further aggravated. Signs of impending seizure may include changes in sensorium, headache, irritability, changes in speech, or confusion.
An elderly patient who was prescribed with medications to prevent seizures may not necessarily need to stop taking these drugs if ever infection hits. However, there might be a need to adjust the medications in case the infection triggers the underlying disease.
3. Altered smell and taste
Smell and taste is altered in most upper respiratory tract infections. However, patients with COVID-19 do not usually develop nasal congestion. In COVID patients, research shows that taste dysfunction is more common. This is said to be a distinguishing characteristic.
Impairment of taste and smell is likely due to the virus targeting the nasal and oral passages. Most of the receptors that it targets (called ACE2 receptors) are located in these areas. Binding of SARS-COv2 inhibits the function of the sensory receptors, affecting taste and smell.
However, an interesting finding in a study from Wuhan notes that only 5% of their patients suffered from smell and taste dysfunction. This compares to around over 30 to just below 90 percent of Europeans. The difference could be due to genetics, as there is genetic variation among races with regards to the ACE2 receptor which is targeted by the virus.
As most palliative care patients already have poor appetite, further reduction in the desire to eat may result in more nutritional problems when they get infected with COVID-19.
4. Cardiovascular Disease and Obesity
A higher body mass index is associated with more severe COVID-19. This means that obesity itself is a risk factor for developing COVID-19. Related to this are diseases such as diabetes and hypertension leading to stroke. Thus, patients with these conditions must be cautious to avoid infection.
5. Behavioral Changes
The common life-threatening complications of pulmonary embolism, acute respiratory distress, myocardial infarction or heart attack, encephalitis, renal failure, paralysis, and coma may stem from any of a combination of these 4 risk factors. The sad part is, in the coming years, we may see a wave of patients with psychiatric conditions. Depression, post-traumatic stress disorder, anxiety, insomnia, and psychosis may soon find increased numbers in the future, and may add more issues to hospice patients.
As seen in past experiences with past coronaviruses (SARS-Cov -1 and MERS-Cov), not all patients return to their normal emotional and cognitive states. It was seen in studies that poor memory and slow mental processing was common among those who survived. This was due to the long-lasting effects of the infection on brain parenchyma. Again, vascular risk factors leading to poor blood supply to the brain play a big role. This vascular supply is further compromised by viral infections.
For those who are healthy, it is good to note that regular exercise, a healthy diet, reduced stress, and good sleeping habits can improve the immune system. With these strategies, those who are exposed will stand a better chance of coping with the disease. For hospice and palliative care patients, improving their quality of life and survival would still rest on a multi-centered approach to care. And when they do get infected with the virus, a compassionate health care environment may greatly improve survival rates and boost the immune system for better outcomes.