RESUMEN
Abstract Background The COVID-19 pandemic has swept across the world, causing a staggering number of deaths, particularly among older individuals. The most common symptoms of COVID-19 are fever, dry cough, and shortness of breath, but delirium has been reported in older adults, including those with preexisting neurodegenerative disorders. Some research has suggested that the role of neuropsychiatric sequelae in COVID-19, especially delirium, has been underreported and that the lack of fever and respiratory distress in this population may exacerbate underdiagnosis and subsequent mortality. Here, we discuss the variable course of COVID-19 by detailing the course of illness in two individuals who are age 90+ with mild COVID-19. Method We conducted chart reviews and telephone interviews in two patients who were age 90+. Case 1 had an outpatient follow-up visit via teleconferencing. Due to COVID-19 protocols, in-person research assessments were not completed. Both were on hospice due to underlying terminal medical conditions. Result Both cases are age 90+ patients with dementia who receive hospice care for multiple underlying medical comorbidities. Case 1 presented at home with a low-grade temperature that was below the CDC COVID-19 guidelines for fever at that time;he experienced cough, confusion, and functional decline and was admitted to a COVID-19 unit after testing positive for the disease. His workup also included a COVID-19 laboratory panel, which was mostly abnormal (including extremely elevated brain natriuretic peptide) but had normal WBC. He did not experience further deterioration, and 22 days later, after testing COVID-19 negative, he was discharged to a skilled nursing facility (SNF), followed by discharge to home 15 days later. Case 2 had metastatic carcinoma and a preexisting diagnosis of probable dementia with Lewy bodies. COVID-19 was diagnosed through all-resident screening at his SNF. He did not exhibit respiratory symptoms or fever at that time. While nursing staff reported confusion, agitation, and restlessness, these symptoms could not be differentiated from complications related to his underlying dementia. This patient was isolated within the SNF and was not hospitalized. Conclusion These two cases demonstrate the variability of symptom manifestation in COVID-19 in this high-risk population.
RESUMEN
Telemedicine technology has become essential to healthcare delivery in the COVID-19 era, but concerns remain regarding whether the intimacy and communication that is central to high-quality palliative care will be compromised by the use of this technology. We employed a business model approach to identify the need for system innovation in palliative care, and a quality improvement approach to structure the project. Products from this project included a standard operating procedure for safe use of tablet computers for inpatient palliative care consultations and family visitations; tablet procurement with installation of video telehealth software; and training and education for clinical staff and other stakeholders. We describe a case illustrating the successful use of palliative care telehealth in the care of a COVID-19-positive patient at the end of life. Successful use of video telehealth for palliative care involved overcoming inertia to the development of telehealth infrastructure and learning clinical video telehealth skills; and engaging front-line care staff and family members who were open to a trial of telehealth for communication. Information gleaned from family about the patient as a person helped bedside staff to tailor care toward aspects meaningful to the patient and family and informed best practices to incorporate intimacy into future palliative video consultations and family visit.