What is the plan of care for an elderly patient with a viral illness presenting with fever, cough, and congestion, including medication and doses?

Plan of Care for Elderly Patients with Viral Illness Presenting with Fever, Cough, and Congestion

For elderly patients with viral illness presenting with fever, cough, and congestion, treatment should focus on symptomatic relief with acetaminophen for fever, dextromethorphan for cough, adequate hydration, rest, and monitoring for complications, with consideration of antiviral therapy if influenza is suspected within 48 hours of symptom onset. 1

Assessment and Monitoring

• Fever in elderly patients should be defined as: (1) A single oral temperature ≥100°F (37.8°C); or (2) repeated oral temperatures ≥99°F (37.2°C) or rectal temperatures ≥99.5°F (37.5°C); or (3) an increase in temperature of ≥2°F (≥1.1°C) over the baseline temperature 1
• Monitor for decline in functional status, including new or increasing confusion, incontinence, falling, deteriorating mobility, reduced food intake, or failure to cooperate with staff, which may indicate infection in elderly patients 1
• Vital signs including temperature, respiratory rate, pulse, blood pressure, mental status, and oxygen saturation should be monitored at least twice daily 1
• Consider hospital admission if the patient has two or more of the following unstable clinical factors: temperature >37.8°C, heart rate >100/min, respiratory rate >24/min, systolic blood pressure <90 mmHg, oxygen saturation <90%, inability to maintain oral intake, or abnormal mental status 1

Medication Management

Antipyretics/Analgesics

• Acetaminophen 650 mg every 8 hours (2 caplets) with water, not exceeding 6 caplets (3,000 mg) in 24 hours 2
• Avoid crushing, chewing, or splitting acetaminophen tablets 2

Antitussives

• For patients 12 years and older: Dextromethorphan 10 mL every 12 hours, not exceeding 20 mL in 24 hours 3
• Use only the dosing cup provided with the medication 3

Antivirals (if influenza suspected)

• Consider oseltamivir 75 mg every 12 hours for five days if:
  • Symptoms have been present for two days or less
  • Patient has fever (>38°C) 1
• Reduce oseltamivir dose by 50% (75 mg once daily) if creatinine clearance is less than 30 ml/minute 1
• Elderly patients who cannot mount an adequate febrile response may still be eligible for antiviral treatment despite lack of documented fever 1
• Hospitalized elderly patients who are severely ill may benefit from antiviral treatment even if started more than 48 hours from symptom onset 1

Antibiotics

• Previously well elderly adults with viral illness without pneumonia do not routinely require antibiotics 1
• Consider antibiotics in elderly patients who:
  • Develop worsening symptoms (recrudescent fever or increasing dyspnoea) 1
  • Are at high risk of complications or secondary infection and present with lower respiratory features 1
• When antibiotics are indicated, preferred oral options include:
  • Co-amoxiclav or a tetracycline 1
  • Alternative options: clarithromycin (or erythromycin) or a fluoroquinolone active against Streptococcus pneumoniae and Staphylococcus aureus 1

Supportive Care

• Ensure adequate hydration and nutritional support, especially in severe or prolonged illness 1
• Provide supplemental oxygen therapy if oxygen saturation falls below 90% 1
• Encourage rest and limited activity until symptoms improve 1
• Monitor for cardiac complications and volume depletion 1

Special Considerations for Elderly Patients

• Recognize that elderly patients may present atypically with infection, often without classic symptoms 4
• Be aware that fever may be absent in 20-30% of elderly patients with serious infections 4
• Viral respiratory infections in elderly can cause significant morbidity and mortality similar to non-pandemic influenza 5
• Respiratory syncytial virus (RSV) and other respiratory viruses should be considered in elderly patients with respiratory symptoms 1, 5
• Attack rates of viral respiratory infections in nursing homes are approximately 5-10% per year with significant rates of pneumonia (10-20%) and death (2-5%) 5

Follow-up Care

• Consider follow-up clinical review for all patients who suffered significant complications or who had significant worsening of their underlying disease 1
• Provide patients with information about their illness, medications, and follow-up arrangements 1
• Arrange the follow-up plan with the patient and their primary care provider 1