What are the recommended management strategies for Covid-19 in the geriatric population?

COVID-19 Management in the Geriatric Population

Vaccination is the cornerstone of COVID-19 management in older adults (≥65 years), and all currently approved COVID-19 vaccines are safe and effective in this population despite lower antibody responses, as they remain highly effective at preventing mortality. 1

Risk Stratification and Vulnerability Assessment

Geriatric patients face substantially elevated mortality risk from COVID-19, with case fatality rates reaching 9.3% in those over 80 years compared to <0.2% in those under 60. 1 This heightened vulnerability stems from multiple factors:

• Frailty assessment is critical: Frailty independently predicts COVID-19 mortality regardless of age or acute infection status, and is associated with longer hospital stays and increased need for home-care support post-discharge. 1
• Comorbidity burden: Cardiovascular disease, hypertension, diabetes mellitus, chronic kidney disease, and chronic pulmonary disease significantly increase severe disease risk. 2, 3
• Immunosenescence: Depressed immunity and lower organ function contribute to both increased susceptibility and dampened vaccine responses. 1, 2

Medication Management Principles

For elderly COVID-19 patients, reduce polypharmacy appropriately, adjust drug doses according to organ function and drug interactions, and actively prevent adverse events. 1

Dose Adjustments

• Patients 60-80 years should receive 3/4 to 4/5 of standard adult doses 1
• Patients over 80 years should receive 1/2 of standard adult doses 1
• Review all medication prescriptions to minimize drug interactions, particularly with experimental COVID-19 therapies 1, 4

Multidisciplinary Medication Review

Facilitate collaboration among community workers, physicians, nurses, pharmacists, physiotherapists, occupational therapists, and mental health providers to address multimorbidity and hypofunction problems. 1

Clinical Monitoring and Complication Prevention

For severe COVID-19 in elderly patients, focus on supportive and symptomatic treatment while closely monitoring for secondary infections and disseminated intravascular coagulation. 1

Key Monitoring Parameters

• Neutrophil ratio: Significantly elevated in elderly patients, indicating higher susceptibility to secondary bacterial infections 1
• D-dimer levels: Markedly elevated, suggesting increased risk of disseminated intravascular coagulation requiring close coagulation monitoring 1
• Respiratory pathogen surveillance: Actively perform monitoring and implement targeted anti-infective treatment promptly 1
• Nutritional status: Peripheral blood albumin and prealbumin are significantly lower in elderly patients, with increased prevalence of anorexia 1

Atypical Presentations in Older Adults

Screening policies must include atypical presentations with or without classical COVID-19 symptoms, as elderly patients frequently present without typical fever, cough, or dyspnea. 5, 4

Common atypical manifestations include:

• Delirium and acute confusion 6
• Falls and functional decline 6
• Anorexia and reduced oral intake 1
• Generalized weakness without respiratory symptoms 5

Geriatric Care Team Integration

Incorporate geriatric care teams in the management of older COVID-19 patients to address geriatric syndromes and optimize outcomes. 1, 6

This multidisciplinary approach should address:

• Delirium prevention and management 6
• Sarcopenia and functional decline 6
• Fall risk assessment 6
• Goals of care discussions and code status determination early in the disease course 1

Infection Prevention in Long-Term Care Facilities

For elderly residents in nursing homes and long-term care facilities, who face increased risk of acquiring and transmitting COVID-19:

• Implement telehealth consultations to reduce exposure while maintaining care continuity 1
• Balance isolation requirements against the need for companionship, particularly for those nearing end of life 1
• Address social isolation through technology-facilitated visits, outdoor activities at distance, and creative solutions like virtual reality for family connections 1
• Monitor for behavioral changes: Social isolation may worsen dementia symptoms, cause depression, and lead to physical inactivity 1

Psychosocial Considerations

Address the profound impact of isolation and loneliness, which have led to physical inactivity and depression in elderly patients during the pandemic. 1

• Maintain regular check-ins with family members 1
• Facilitate technology use for social engagement, providing additional support as needed 1
• Recognize and validate anticipatory grief in patients and families 1
• Provide bereavement preparation information related to COVID-19 1

Vaccination Strategy

Despite concerns about weaker antibody responses in the elderly:

• All approved COVID-19 vaccines remain effective at preventing mortality in geriatric populations 1
• Prioritize vaccination for those with multiple comorbidities, including chronic hypertension, cardiac disease, diabetes, obesity, and immunodeficiency 1
• Individuals with frailty show dampened antibody responses but still benefit from vaccination 1
• Vaccination trials should specifically consider and include frailty assessment 1

Common Pitfalls to Avoid

• Do not use standard adult dosing without adjustment for age and organ function 1
• Do not rely solely on typical COVID-19 symptoms for diagnosis in elderly patients 5, 4
• Do not overlook drug interactions between COVID-19 therapies and existing medications 1, 4
• Do not implement strict isolation without considering the detrimental effects on cognitive function and mental health 1
• Do not assume vaccine ineffectiveness based on lower antibody titers; mortality benefit persists 1