Precautions during Pandemic

 

Advisory for Senior citizens during COVID-19 pandemic

This is an advisory for those at increased risk of severe illness from COVID-19

This group includes those who are:

·         Age 60 and older (especially those 70 years and above)

·         Individuals with the following medical conditions

o   Chronic (long-term) respiratory disease, such as asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, post tuberculous sequelae, interstitial lung disease

o   Chronic heart disease, such as heart failure

o   Chronic kidney disease

o   Chronic liver disease, such as alcoholic, and viral hepatitis

o   Chronic neurologic conditions, such as Parkinson’s disease, stroke

o   Diabetes

For older adults who are mobile:

·         Avoid contact with someone who is displaying symptoms of coronavirus.

·         Avoid moving out of the house

·         Avoid going to park for a walk, instead, consider doing light exercise and yoga at home

·         Remain actively mobile within the house

·         Maintain hygiene by washing hand. Especially prior to having meals and after using the washroom. This can be done by washing hands with soap and water for at least 20 seconds

·         Avoid small and large gatherings at all cost

·         Avoid having visitors at home

·         Clean frequently touched objects such as spectacles

·         If living alone, one can consider depending on healthy neighbours for acquiring essentials for home

For older adults who are dependent for daily activities:

Advice to the care provider

·         Wash your hands prior to helping the older individual

·         Clean the surfaces which are frequently used. These include a walking cane, walker, wheel-chair, bedpan etc

·         Assist the older individual and help her/him in washing hands

·         If the caregiver is symptomatic, avoid contact with the older adult

·         Cover nose and mouth adequately using a tissue or cloth while coughing or sneezing

·         Avoid being completely bed-bound

·         Contact help-line if the older adult has following symptoms:

o   Fever, with or without body ache

o   New-onset, continuous cough, shortness of breath

o   Unusually poor appetite, inability to feed

o   Change in mental status, such as excessively drowsy during the day, not responding, speaking inappropriately

o   New onset of inability to recognise relative which he/she could before

For mental well-being

·         Avoid complete isolation

·         Do not confine oneself in a room

·         Communicate with relatives at home

·         Communicate with neighbours, provided physical distancing is followed, and gathering of people is avoided

·         Avoid reading or watching the news on coronavirus

 

For queries regarding medical illness use teleconsultation services

Telemedicine number: 9686985055

 

Pneumococcal vaccine

Community-acquired pneumonia (CAP) is an important cause of hospitalization and mortality in older adults. And India contributed about 23% of the global pneumonia burden. In a systematic review from India, Pneumococci (or S. pneumonia) was the predominant pathogen in CAP, amounting to 19% of the cases.

Currently, two types of pneumococcal vaccines are available, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23). These vaccines have been shown to decrease the development of invasive pneumococcal disease in this age group.

Let us look at the recommendation of theses vaccines in older adults:

For adults 65 years or older who do not have an immunocompromising condition and want to receive PPSV23 only:

·         Take one dose of PPSV23.

·         Anyone who has received doses of PPSV23 before the age of 65 should receive one final dose of the vaccine at age 65 or older.

For adults 65 years or older who do not have an immunocompromising condition and want to receive PCV13 and PPSV23:

·         Take one dose of PCV13 first, then take one dose of PPSV23 at least one year later.

·         If you have already received PPSV23, take a dose of PCV13 at least one year later.

·         If you have taken a dose of PPSV23 before the age of 65, take one more dose of the vaccine at 65 or older.

Geriatric Medicine

 

Immunization of Senior citizens

 

Immunizations are not just for children. The protection provided by some childhood vaccines can wear off over time, making older adults at risk for vaccine-preventable disease. Older adults are especially vulnerable to infectious diseases because of immunosenescence (decreasing immunity due to age) and comorbid conditions such as diabetes, chronic kidney disease, liver disease, heart failure and chronic respiratory illnesses.

The Universal Immunization Programme (UIP) by the Ministry of Health and Family Welfare, Government of India was one of the world's largest health programmes. It provides several vaccines to infants, children and pregnant women, though older adults and adults with chronic illness (mentioned above) are not included. With the implementation of the COVID-19 vaccine, we have seen policymakers' focus has shifted towards this vulnerable population. We hope that older adults will also be included under the Universal Immunisation Programme. Below is the list of vaccines recommended by the Centers for Disease Control and Prevention (CDC) for older adults in 2021.

Recommended Adult Immunization Schedule 2021

Vaccine	50-64 years	≥65 years
Influenza inactivated (IIV) or Influenza recombinant (RIV4)	1 dose annually
Tetanus, diphtheria, pertussis	1 dose Td/Tdap for wound management Td or Tdap booster every 10 years
Measles, mumps, rubella	1 or 2 doses depending on the indication
Varicella (VAR)	2 doses
Zoster recombinant (RVZ)	2 doses
Pneumococcal conjugate (PCV 13)	1 dose
Pneumococcal polysaccharide (PPSV23)	1 or 2 doses depending on the indication
Hepatitis B (Hep B)	3 doses
Meningococcal	1 or 2 doses depending on the indication
Haemophilus influenzae type B	1 or 3 doses depending on the indication

Geriatric Medicine in India

 Like many other developing countries, India did not realise the impact of population ageing till the 1970s. The need for geriatric medicine as a separate speciality was not appreciated, and it had a late beginning. In 1978, the outpatient service in geriatric medicine was started in Madras Medical College and Hospital, Chennai was started. The inpatient service was established in 1988, and the postgraduate program in geriatric medicine was formed in 1996, under the aegis of Dr MGR Medical University of Tamil Nadu. The National Policy on Older Persons (NPOP) (1999) mandated the establishment of geriatric medicine in all medical colleges. Responding to NPOP, the Medical Council of India developed the postgraduate training curriculum in geriatric medicine in 1999. Madras Medical College was the first medical college to establish postgraduate training in India. In 2004, a Postgraduate diploma in geriatric medicine was launched by the Indira Gandhi National Open University, Delhi, to equip the primary doctor with knowledge and skill in geriatrics and deal with older people's unique problems. After the initial enthusiasm, the program lost its importance due to a lack of hands-on training facilities and non-recognition by licensing authorities. Subsequently, Amrita Institute of Medical Science in Kochi, Kerala, Christian Medical College, Vellore, Tamil Nadu and Mahatma Gandhi Mission Medical College, New Mumbai, All India Institute of Medical Sciences, New Delhi have started a postgraduate (MD) training programme in geriatric medicine.

There is limited exposure to old-age care in the undergraduate medical curriculum and nearly non-existent in nursing and paraprofessional training. To address these issues, the Government of India launched an intensive training programme with sponsorship from the World Health Organization (WHO). The programme was managed by the All India Institute of Medical Sciences, New Delhi and reached 100 medical colleges between 1998 and 2001. More than 200 primary care physicians were trained in workshops conducted in medical colleges across the country. This initiative, with focused operational inputs from WHO, led to creating a critical mass of teachers and specialists trained in old age care and the evidence base required for more significant initiative. The National Programme for Health Care of the Elderly (NPHCE) was launched in 2010 by the Ministry of Health and Family Welfare, Government of India. The programme has a two-pronged strategy: capacity building through PG training in medical colleges and expansion of service from district hospitals to the peripheral most dispensary.

During the 12^th five year plan, it was proposed that 12 medical colleges would be added for setting up Regional Geriatric Centres. The Position paper by the Indian Academy of Geriatric's states that we need 27,600 geriatricians for a 138 crore population(1). Assuming that all the RGC'c become fully functional with adequate staff, we would still have only 120 geriatricians, far below the minimum requirement. The key measures enumerated to develop the health workforce included:

·         Training primary care physicians and internists

·         Mid-career training of family physicians and general practitioners

·         Mandatory addition of geriatric medicine in the medical curriculum

·         Incentives for institutes to implement geriatric medicine postgraduation programmes

·         Making geriatric medicine a mandatory department for medical colleges

Through these measures, we can aspire to achieve the goal of healthy ageing and health for all in India.

Acknowledgement:

An extract from a chapter titled "Evolution of Geriatric Medicine in India" by Dr A B Dey

 

References

1.       Rao AR, Mathur A, Dey A B. Health workforce development for geriatric services in India. J Indian Acad Geriatr 2020;16:176-9

Frailty

 Ageing is associated with a gradual decline in physical functioning. However, the rate of decrease varies, and hence ageing is not always coupled with frailty. Frailty is defined as an ageing-related physiological decline syndrome characterized by significant vulnerability to adverse health outcomes. Multiple protective and risk factors influence frailty during the life course, and these factors have complex interactions among one another. Older frail people experience a dramatic decline in physical and mental functions and have poorer outcomes after apparently minor stressors such as mild physical disorders and anxiety.

 

Frail adults are at increased risk of adverse health outcomes, including falls, fractures, disability, dementia, low quality of life, increased cost of care, hospitalization and premature death. Several studies have shown that the health care costs of frail individuals are several-fold higher than non-frail adults. The prevalence of frailty among 65 years and older adults ranged from 4% to 59% in different communities. Advanced age is a significant risk factor for frailty, with one-fourth of those aged 80 and above being frail. The prevalence is even higher in those with renal disease, heart failure, Alzheimer's disease, cancer etc.

How to identify a frail individual

Various tools are available, but there is no one gold standard method. Fried criteria define frailty as the presence of three out of five phenotypic criteria: low grip strength, low energy, slowed walking speed, low physical activity and/or unintentional weight loss. A pre-frail stage, in which one or two criteria are present, identifies people at high risk of progressing to frailty.

 

A risk index by counting the number of deficits accumulated over time termed as Frailty index (FI), developed by Rockwood and Mitnitski, is available. FI is a more sensitive predictor of adverse health outcomes. Other scales include frailty/vigor assessment, clinical frailty scale, brief frailty instrument, vulnerable elders survey (VES-13) etc. These tools have their advantages and disadvantages. Few are easy to use, not time-consuming, sensitive, and can be used in an OPD setting or community, whereas others require special tools, are complicated and time-consuming.

Why identify Frail individuals

It is understood that the treatment outcomes depend not on the chronological age but the biological age of the individual. By identifying frail individuals, the treatment goals can be set accordingly, including treatment (medical, surgical etc.), the intention of therapy (curative, palliative etc.). Also, by understanding the impact of frailty on treatment outcomes, the patient and their family members can make a better, informed decision.

 

 

CGA Part IV: Functional status

 

Functional Status

Intrinsic capacity (IC) is the combination of all the physical and mental capabilities of an individual. Functional ability is dependent on the IC (of the person himself/herself), the environment (external things which help improve function, Eg: spectacles, hearing aid, walker, wheelchair etc.) and the interactions between the two. This model proposed by the World Health Organization can modify how clinical practice is currently conducted, shifting from disease-centred towards function-centred paradigms.  

Measurement of functional status is an essential part of the evaluation of an older person. A person's capability to perform functional tasks can be considered as a comprehensive measure of the overall impact of age-related impairment and health conditions. Functional status is a powerful prognostic factor and an essential indicator of the quality of life.

Many tools have been proposed and used to assess functional status in older adults, some are objective measures, and others are self-reported. Self-report measures are based on questionnaires asking how people function in their environment to evaluate their ability to remain independent. Using the self-report tool, functional status can be assessed at different levels: basic activities of daily living (BADL), instrumental activities of daily living (IADL) and advanced activities of daily living (AADL). The latter is seldom used in routine clinical practice.

Basic activities of daily living (BADL)

Basic activities of daily living include fundamental skills typically needed to manage basic physical needs. They have the following categories:

·         Ambulation: the extent of a persons ability to move from one position to another and walk independently.

·         Feeding: the ability of a person to feed oneself.

·         Dressing: the ability to select appropriate clothes and to put the clothes on.

·         Personal hygiene: the ability to bathe and groom oneself and maintain dental hygiene, nail and hair care.

·         Continence: the ability to control bladder and bowel function.

·         Toileting: the ability to get to and from the toilet, using it appropriately, and cleaning oneself.

The Katz index of independence and the Barthel index is commonly used for BADL evaluation. The Katz index ranks performance in the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, two or less indicates severe functional impairment. The Barthel index assesses ten activities. The total score ranges from 0 to 100 points, with higher scores indicating better performance.

Instrumental activities of daily living (IADL)

The instrumental ADLs are those that require more complex thinking skills, including organizational skills. IADLs are those activities that allow an individual to live independently in a community. The Lawton IADL scale includes eight domains:

·         Using the telephone

·         Shopping

·         Preparing food

·         Housekeeping

·         Laundry

·         Mode of transportation

·         Responsibility for their medications

·         Ability to handle finances

The scoring should be individualized, as not everyone performs all the above eight activities. Hence a more appropriate scoring method would be first asking if the person performed an activity and has he/she stopped doing it recently.

Advanced activities of daily living (AADL)

AADL is based on intentional conducts involving the physical, mental and social functioning that allow the individual to develop multiple social roles and maintain good mental health and quality of life. It is also of interest in establishing the diagnosis of Alzheimer's disease in an earlier stage, as these activities require high cognitive functioning and are responsive to subtle changes. Common AADLs are:

·         Participating in a meeting

·         Giving advice to family

·         Reading a newspaper

·         Shopping on special occasions

·         Socializing with others

·         Taking a walk

·         Care of a grandchild

 

Objective measures of physical function might be superior to self-report tools in people who are in general healthy. The measure includes short physical performance battery (SPPB), gait speed or 400 m walking test or 6- minute walk test. This is the best strategy to detect early limitations and stratify the risk of future health outcomes in otherwise fully independent people. Learning how each ADL affects an individual to care for themselves can help determine whether a patient would need daily assistance.

With the advancement in technology, we can provide support to people with impaired ADLs. Assistive devices are external devices that are designed to assist a person in performing a particular task. With the use of appropriate devices of good-quality, it is possible to improve the quality of life by enabling a person to participate in life at home, work, and the community.

CGA Part III: Nutrition and Balance

 As part of physical health assessment, we have identified the importance of vision, hearing and multimorbidity review, and polypharmacy harm. The other essential sub-domains include nutritional status and balance.

Nutritional status

Maintaining adequate nutrition requires the contribution of physical, cognitive, psychological and social domains. These domains become impaired with advancing age and increase the risk of malnutrition. Inadequate micronutrient intake is common in older persons, as several age-related medical conditions predispose them to vitamin and mineral deficiencies. Malnutrition further predisposes them to functional decline, mobility impairment, falls, fractures etc. Nutritional deficiency is also associated with poor outcome after hospitalization for acute illness, frailty, sarcopenia (low muscle mass), poor memory (due to vitamin deficiencies) etc. Hence screening and assessment of malnutrition are a crucial part of CGA.

There are four components specific to geriatric nutritional assessment:

1.       Nutritional history performed with a nutritional health checklist.

2.       A record of a patient’s usual food intake based on 24-hour diet recall.

3.       Physical examination with particular attention to signs of inadequate nutrition

4.       Select laboratory tests.

Many nutrition screening tools are available for malnutrition identification. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends the subjective global assessment (SGA) tool. It requires the patient to record weight changes, functional capacity, dietary intake, metabolic stress, loss of subcutaneous fat, and ankle swelling. It has the advantage of simple operation, repetitiveness, and no need for any laboratory tests. Its subjective reporting makes it inaccurate.

The mini-nutritional assessment (MNA) is an elderly-specific tool and is well-validated in nutritional risk screening and nutritional status assessment. It includes nutritional assessment, subjective assessment, anthropometry and general assessment. A score of 24-30 indicates good nourishment, 17-24 indicates a risk of malnutrition and a score <17 indicates malnutrition. An even simpler version called mini-nutritional assessment short-form (MNA-SF) was developed in 2001. It has a high correlation with MNA and a useful screening tool.

After assessing the nutritional status, it is essential to identify factors which contribute to it. These may include low vision, poor dentition (teeth), tremors in hand, painful wound in the oral cavity, difficulty in swallowing, poor dietary practices, constipation, altered taste perception due to medications, joint pain, neurological disease such as stroke, Parkinson’s disease, socioeconomic causes etc. The management should include an expert dietitian and aim to tackle the factor/factors which lead to undernutrition.

Balance

Impaired balance in older persons often manifests as falls and fall-related injuries. Around one-third of community-living older persons fall at least once per year, with many falling multiple times. Falls are among the leading causes of chronic disability in older adults, leading to fractures, soft tissue damage, brain damage, hospitalization and death. The risk of falling should be assessed by explicitly asking the patient about falls and testing balance, gait and lower extremity strength. A simple screening question to screen for falls is to ask:

·                     Have you ever had a fall in the past year

Individuals who say yes should be further asked regarding the number of falls (single episode or recurrent falls), the circumstances leading to falling (accidental slip/trip, blackout, dizziness etc.), details of the fall (usually from the patient as well as a witness of fall), complications following the fall (loss of consciousness, hip or low back pain, headache, change in sensorium) etc. We can divide the factors which lead to falls into intrinsic and extrinsic factors. Extrinsic factors include wet floor, high steps, low lighting, clutter on the floor (toys, wires), ill-fitting footwear etc. Intrinsic factors include poor vision, medications that cause low BP on standing, increased frequency of micturition (making a person prone to falls during the night), joint disease, neurological and cardiac disease, making the person prone for falls. A detailed history and physical examination help identify the cause/causes of fall in an older adult.

There are many methods and scales for balance and fall risk assessment. Balance can be assessed by asking the patient to maintain a side-by-side, semi-tandem, and full-tandem position for 10 seconds. The times up-and-go (TUG) test evaluates the capability to rise from a chair, walk three meters, turn, walk back, and sit down again on the chair. Patients who take longer time are at increased risk of fall. Also, during the test observation of how the patient walks (the stride length, step height, arm swing, turning around, stooped posture etc.) gives a clue to the cause of imbalance. A detailed evaluation, including a physiotherapist, also helps to plan management and rehabilitation.  

 

By screening older adults, we identify common, yet often missed conditions. And the corrective steps taken can improve the quality of life, adding life to years.

COVID-19 and Older adults –Your Questions and Our answers

 

Dr. Prabha Adhikari M.R.

Professor and HOD Geriatric Medicine

Yenepoya Medical College, Mangalore

Everybody knows that COVID-19 had a devastating effect on older adults (age 60 years and above). Data from the Centre for Disease Control USA, WHO and published data from China have shown that age is an independent risk factor for COVID-19  hospitalization and death. Out of 10 people who have died due to COVID -19, 8 are above 60 years. Also, older individuals have multiple comorbidities which further predispose them to hospitalizations and death. The atypical presentation and hyperimmune response also contribute to the development of complicated COVID.

As a complication, patients with COVID have suffered from a stroke, heart attacks and other life-threatening complications and succumbed. Few of these complications have occurred as a delayed complication when the standard test for COVID become negative.

Similarly, we have witnessed COVID affecting the brain, intestines, liver, kidneys and other organs in older adults. This is because they already have an organ which is weak and such organs are affected earlier. This is called a weak link system. A person with chronic kidney failure will abruptly present with worsening of the kidney disease needing dialysis. An individual with dementia or Parkinson's disease will present with worsening of their symptoms. Same is the status with liver disorder. These cases are not recognized as COVID, and they succumb to the illness as -due to kidney failure, heart failure or brain failure.

With the release of COVID-19 vaccine, the elderly have the dilemma of taking it and exposing them to side effects or not taking it and taking the risk of COVID morbidity or mortality. Here are answers to a few of their questions and dilemma.

1.      Should I take COVID-19 Vaccine?

If you are a fit older adult, you must take the COVID-19 vaccine.

If you have a comorbidity, you have to take it.

2.      The vaccine has side effects. I am scared. My children are not allowing me to take the vaccine.

Vaccine side effect so far has been expected reactions. About one third will experience pain at the injection site, fever, body ache. These are rarely severe enough to confine one to bed. I was the first to be vaccinated in our institution, and I was fine after the injection. Younger people did develop a fever and pain. However, these symptoms will subside with paracetamol and ice pack.

3.      What about anaphylaxis, a sudden allergic reaction?

It is a 1 in 1,00,000 reaction. All the centres are well equipped with anaphylaxis kit which contains the antidote for the same. This reaction causes difficulty in breathing and low blood pressure, but this is reversible with treatment.

After vaccination, everybody is observed for 30 minutes by the medical team as the reaction occurs within 30 minutes.

Also, the emergency team will always be ready.

4.      We heard that two health care professionals developed a heart attack and died after vaccinations in Karnataka.

They were investigated. They did not die immediately after vaccination. They died after two days, and both had confirmed heart attacks. They were not elderly.

5.      We heard that in Norway as many as 33 elderly died after vaccination.

Two lakh nursing home residents were vaccinated. They were frail, weak, dependent elderly. They were anyway too sick to live as the weekly death rate among them were at least two deaths. It so happened that they died after vaccination.

They were cleared as natural deaths by WHO

However, we will not venture and vaccinate frail elderly who are bedridden and suffering from end-stage diseases whose life is limited anyway

6.      Which vaccine is better?

We have two vaccines at the moment in India. Covishield made by Serum Institute of India with the transfer of technology from Oxford University and Astra Zeneca and Covaxin by Bharath Biotech. Both are given as two doses Intramuscularly 28 day apart.

Antibody response and side effect profile are similar

7.      How long will I get Immunity?

At the moment for six months for sure. It is predicted that immunity may last up to 6 years. We are happy if immunity lasts for one year. Studies are still ongoing

8.      If I have had COVID and if I am living, why should I take?

If you had a mild disease in the past, there is no guarantee that the next one will also be mild .mutations are occurring, and you can have any number of attacks

9.      If I had COVID when is safe to take the vaccine?

I would recommend that you had mild  COVID- you can take vaccine after 14 days after you became COVID negative which is almost a month

If you have severe COVID-19 safer to wait for three months for all the activated cytokines to settle

10.  If I am on a blood thinner, can I take vaccination?

Suppose you are on aspirin or clopidogrel or an antiplatelet drug you can take the vaccination. If you are on a drug called an anticoagulant, IM Injections can make a haematoma. Hence please consult your doctor about the safety of stopping the same

11.  I have an allergy. Can I Take the vaccination?

If you have an allergy, you are at high risk of COVID complications. However, if you had a severe allergy to any COVID Vaccination or any other vaccination, you may opt-out of vaccination

12.  Today we read that five doctors of Karnataka developed COVID after vaccination?

Vaccination will start protection only after the second dose, that too 45 days after the second dose. Although we may upload pictures in the media that I am safe, I am vaccinated, we need to be cautious. Vaccine efficacy is not 100%. In studies, it will be 70-80 per cent efficacious. In the field, it is around 60 per cent protection. All the five people were front line workers

Kindly continue to wear Mask and maintain Physical distancing although you feel good and protected after vaccination. We have prayed and hoped that we will get the vaccine soon. When the vaccine has been produced by the efforts of so many, doubting rumours are going around. All the developing countries are towards universal vaccination. We being a vast country with a huge population we have completed  3 million vaccinations and are almost completing the first phase, and the second phase is about to start. In the 3^rd phase, those above 50 will get the vaccination by February, March.

You will get a call and a message about the centre before the date of your vaccination. Do not miss this opportunity. I wish you all a Happy and safe Vaccination. Let us all be proud of the privilege of getting vaccinated at no cost.