A Silent Assassin

COVID-19 can be a silent assassin when it comes to frail older adults.  The Washington nursing home which became ground zero for the virus in the United States, "had patients who, within an hour's time, show no symptoms to going to acute symptoms and being transferred to the hospital...die relatively quickly under those circumstances."  There's been talk in the last day of the possibility of using some old fashioned medications, hydroxychloroquine and azithromycin, to treat COVID-19.  That would be great if it works.  As a geriatrician, the first question that I pose is, does it work in older adults the same way it works in younger adults?  Granted, if it works in younger adults, that would be fantastic.  My concern, however, is that the presentation of the illness in older adults appears to be quite varied, and also can kill quickly.  

A silent assassin attacks quickly and you don't see it coming.  This is one of the presentations of COVID-19 infection in frail older adults.  What was seen in the Washington nursing home was probably not an aberration. In fact, when we finally have time to look back at this pandemic, I expect to see a sudden rise in mortality for unknown reasons in the two to three weeks prior to outbreaks in assisted living facilities and nursing homes.  This creates treatment challenges.  

Geriatricians are used to the fact that older adults may present differently than younger people when it comes to many illnesses.  Infections are not unique for this, where older adults might not demonstrate a fever in the face of blood borne bacterial infections.  I've already heard a report of an assisted living resident who went to the emergency room for falls, was sent back, only to return a couple of days later with clinical signs of COVID-19.  If there was ever a time to not only mobilize geriatricians, but utilize our knowledge and expertise in the fight against COVID-19, that time is now.  

For frail older adults in particular, COVID-19 can be a silent assassin.  As we look at possible treatment methodologies, this must be taken into account.  We can not be complacent if we manage to find successful treatments soon.  There might be a tendency to relax, loosen quarantines and physical distancing recommendations.  Haste in this regard could lead to more deaths among frail older adults, who will fall before we even know that they have the infection.  While, to most, COVID-19 infection seems easy to diagnose, to the most vulnerable, and those are the ones dying from this disease, we might not see it coming quickly enough to effectively treat.