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COVID-19: what can we learn from our care and treatment of older people during the pandemic?

The pandemic has underlined the importance of identifying older people living with frailty, delirium and end of life care needs 

The pandemic has underlined the importance of identifying older people living with frailty, delirium and end of life care needs

  • Consultant editor Nicky Hayes recounts her experiences of being redeployed during the pandemic and some of the lessons learned
  • Survival of some older people underlines the importance of frailty assessment in relation to treatment escalation
  • Frailty is a better predictor of outcomes of COVID-19 infection in older people than simply age or co-morbidities
Picture: Shutterstock

The vulnerability of older people to COVID-19 has been evident since even before the pandemic hit the UK in March.

A review of cases in China and elsewhere found people aged over 70 were at high risk of dying

The pandemic has underlined the importance of identifying older people living with frailty, delirium and end of life care needs

  • Consultant editor Nicky Hayes recounts her experiences of being redeployed during the pandemic and some of the lessons learned
  • Survival of some older people underlines the importance of frailty assessment in relation to treatment escalation
  • Frailty is a better predictor of outcomes of COVID-19 infection in older people than simply age or co-morbidities
Picture: Shutterstock

The vulnerability of older people to COVID-19 has been evident since even before the pandemic hit the UK in March.

A review of cases in China and elsewhere found people aged over 70 were at high risk of dying if they became ill with the virus, and estimated nearly one in five people with COVID-19 aged over 80 was likely to need to go into hospital.

Data from the Office for National Statistics confirm that the highest proportion of deaths in England and Wales has been in people aged over 75.

This has had significant implications for the treatment and care of our older population in hospital throughout the pandemic.

Many NHS staff had to be rapidly redeployed from their usual roles

In March and April increasing numbers of hospital staff were themselves off sick or self-isolating due to exposure to the virus.

And for a few hectic weeks it was deemed essential that NHS staff be rapidly redeployed from their usual roles to meet the change in demand and to cover for absent colleagues.

Compassionate and effective communication

As a nurse consultant for older people at King’s College Hospital NHS Foundation Trust in London, I deliver a specialist service for older people living with frailty and Parkinson’s disease in hospitals, care homes and the community.

Redeployed, I switched to working as a nurse on an older people’s ward. An immediate challenge for me was the need to rapidly get up to date on the technology of caregiving, so I could make as efficient a contribution as possible at this busiest of times.

Picture: Tim George

The ward had changed its role too. From its usual focus on care and rehabilitation for people living with dementia, it transformed into an acute ward, with huge demand for oxygen, IV antibiotics, fluids and morphine. Delirium levels were high, with patients exhibiting both hypoactive and hyperactive symptoms.

Communicating compassionately and effectively with people with dementia and delirium when you must don and doff personal protective equipment (PPE) and communicate through the barrier of a surgical face mask and face shield is challenging.

It was quickly obvious that for these patients, the crisis of COVID-19 infection called for additional measures to support person-centred care.

With visitors mostly absent unless patients were at the end of life, technology and social media were priceless in bringing relatives and friends to the bedside.

The continued use of documents such as This is Me, a support tool for person-centred care, provided essential information about patients in their absence.

The usual course of my work takes me into care homes across our local boroughs in London, so I found it poignant to see some of the residents I knew being admitted to hospital and passing away.

Despite the high mortality risk for older people, many of our patients survived COVID-19

Office for National Statistics data show that between 17 April and 19 June 2020 there were 3,721 COVID-19-related deaths of care home residents in hospital and 11,969 deaths in care homes.

‘Many hospital emergency departments now use tools such as the Clinical Frailty Scale to identify frailty and promote access to comprehensive assessment’

These data need to be used to further inform future healthcare support for care home residents and preparedness should there be a second wave of the pandemic. Issues affecting transfers between hospitals and care homes include the need for effective communication relating to COVID-19 screening and swab results, infection control and availability of advance care planning.

Despite the high mortality risk for older people, many of our patients survived COVID-19 and were discharged, with much waving and applause as they left the ward.

Frailty is a better predictor of disease outcomes with COVID-19

Their survival demonstrates that age is not in itself a predictor of mortality in COVID-19 infection, and underlines the importance of individual frailty assessment in relation to treatment escalation.

Frailty is a better predictor of disease outcomes with COVID-19 than age or co-morbidity. Many hospital emergency departments now use tools such as the Clinical Frailty Scale (CFS) to identify people living with frailty and promote access to comprehensive assessment.

The National Institute for Health and Care Excellence’s COVID-19 Rapid Guideline: Critical Care in Adults suggests a score on the CFS of five or more may trigger discussion about treatment plans, escalation to critical care and do not attempt cardiopulmonary resuscitation decisions.

Nurses have an important role in decision-making

But a careful emphasis must still be maintained on the role and limits of scores in supporting decision-making, keeping the individual at the centre of the process.

View our frailty resource collection

As part of the multidisciplinary team, nurses have an important role in contributing to this decision-making.

Sadly, some of our frail patients did not survive COVID-19, often succumbing with a rapidity that shocked even the most experienced of us. This called for the most sensitive support for relatives and friends who could not be with them. Nine patients died on our ward of 30 in a single day.

As nurses we were fortunate to have sources of support and time to reflect on these issues, even during shifts that felt like mayhem, so that we could better care for our patients and relatives, and also look after ourselves.

There were a great number of challenges for us during this period, not least of which were the limits of the available evidence base about COVID-19 in relation to treatment and care decisions.

More choices for patients and carers over appointments

Research is needed into the effect of COVID-19 on older people living with frailty and co-morbidities in the short and longer term. This does not mean we cannot learn from our current experience, but we also need to build reliable data and a robust evidence base.

At the time of writing, the COVID-19 peak appears to have passed and I am picking up my role again, including visiting people in their own homes and care homes. Ways of working have changed, with stringent use of PPE and more choices for patients and their carers about their appointments.

Picture: iStock

For those with access to the internet I can offer a virtual review, or I can phone them, although a review in person remains the most popular option.

All sectors need to work together to support frail older people

Some people have had many weeks of enforced staying at home during which they were reluctant to contact health services or use the emergency services, sometimes with significant consequences. Contacting a woman aged 93, I learned that she had fallen at home during the peak of the crisis but had been reluctant to seek advice on her subsequent sore neck. In fact she had fractured her odontoid peg, a bone in the cervical spine, and is only now receiving the treatment she needs.

My experience caring for older people with COVID-19 has been a personal challenge but has ultimately enriched my own practice, and left me full of admiration for my NHS colleagues.

The pandemic has underlined the significance of identification of older people living with frailty, delirium and end of life care needs, the need to build the evidence base and the importance of all sectors working together to support our most frail older people.

Nicky Hayes

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