A 90-year-old friend of mine (Mr W) is the primary caregiver for his 89-year-old wife who has Alzheimer disease that has progressed to the late stages of the disease, hallmarked by memory loss, confusion, agitation, sundowning, and inability to recognize family members. She wandered out of the house while her husband slept and was brought to the emergency department (ED) by the police. In the ED, she was admitted and treated for dehydration and a urinary tract infection. A case manager found a placement for her in a facility with a memory care unit, but after a week’s stay on the unit, Mr W took his wife home because she was spending most of the day in bed. He decided to hire 2 experienced caregivers for her at home and I worked with him to develop a home care plan.
The comprehensive plan provided 5 to 8 hours of care each day and was successful with no further incidents until the care providers, Mr W, and his wife all developed upper respiratory infections. Mrs W was the first to develop symptoms of a dry hacking cough, loss of appetite, and fatigue. She had no fever and a rapid COVID-19 test was negative and she was treated symptomatically with over-the-counter medications. Both caregivers and Mr W developed cold symptoms a week later and all tested negative for COVID-19, respiratory syncytial virus (RSV), and influenza. Both caregivers, Mr W, and Mrs W had received the COVID-19 vaccine series and 3 booster shots as well as an annual influenza vaccine. Ten days after her first symptoms presented, Mrs W developed a low-grade temperature and a loose productive cough.
Mr W called and asked for my recommendations. Given her course and symptoms, I considered pneumonia as the top differential diagnosis. At the initial onset of symptoms, her COVID-19 test was negative and she had no fever, so I assumed that she had a cold that settled in her lungs, causing a loose, productive cough and a fever. As a fragile older person, she was not able to clear her lungs and developed pneumonia. Mr W asked if he should take her to the ED, but I advised him to call his doctor, who has a concierge practice, present the symptoms, and request an antibiotic. Going to a clinic would confuse his wife, expose her to other germs, and yield the same result as well as expose Mr W to risks.
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Mr W called his wife’s doctor and also his son, an infectious disease doctor, and they both advised him to take her to urgent care for a rapid COVID-19 test, influenza test, and chest radiography as is recommended in evidence-based guidelines. COVID-19, RSV, and influenza tests were all negative and chest radiography revealed a consolidation. Thus, after 4 hours at urgent care, she was prescribed azithromycin, the medication I had initially recommended.
Evidence-based practice guidelines dictate the protocol that the doctor followed. However, when a fragile, older patient is involved, especially one being cared for by an older caregiver, the guidelines don’t always fit. Evidence-based guidelines are like recipes, they are established based on symptoms of the general population and must be tweaked. In this case, Mrs W would have been best served by a home visit, which was not an option with the concierge service. At urgent care, given her fever and lack of fluids, she would have benefitted from IV fluids but the required evidence for that treatment is laboratory results, and diagnostics were not conducted.
Because of my years of clinical experience working with fragile older patients, I tweaked the recipe and considered the risk vs benefit of documenting pneumonia with a chest radiograph. My rationale was that influenza was unlikely, COVID-19 testing was negative, and antibiotics were the best treatment given the course of her symptoms and her age. In the end, she was treated with antibiotics, but only after she had been exposed to risks at urgent care, experienced dehydration the additional stress of leaving her home.
The oldest patients require their own set of evidence-based practice guidelines, but these guidelines do not exist. Thus, experience and common sense should guide treatment.
Margaret Ackerman, DNP, APRN, is an associate professor in the Adult Gerontology Nurse Practitioner program at Salem State University in Salem, Massachusetts, and a practicing provider at Feltin Community Care, a home-based practice for fragile patients.
