SEVERE ACUTE RESPIRATORY SYNDROME (SARS) IN ELDERS (2003)

To the Editor: In the era of severe acute respiratory syndrome (SARS), there has been much concern about the atypical features of SARS in elders, which has been described as “invisible SARS” and implicated as sources of outbreaks. To further research and unmask the prevailing myths surrounding SARS in elders, the Hong Kong Geriatrics Society (HKGS) formed a Special Interest Group (SIG) on SARS in Elders in April 2003. The HKGS released a press release on SARS in elders on April 25, 2003, to alert the public and our peers to some of the atypical presentations of SARS in old age.1 An interhospital geriatric meeting on SARS in elders was held on May 30, 2003, to share and discuss the clinical experiences and findings on SARS in elders among geriatricians and a clinical microbiologist (Sheng B, PMHSARS Study Group, personal communication).2–8 Based on this meeting, the HKGS issued a position statement on SARS in elders on June 10, 2003,9 which is summarized as follows. The World Health Organization criteria for SARS have their limitations when applied to frail older adults, who tend to present with geriatric syndromes:1,3,7 falls, confusion, incontinence, and poor feeding. Instead of a fever of more than 38°C, a fever pattern8 may be observed. SARS may not necessarily present with respiratory symptoms but may be associated with gastrointestinal symptoms such as diarrhea, nausea, or vomiting, which, in frail elderly persons, may mimic fecal incontinence1 and poor feeding. The frequent occurrence of multiple pathologies (e.g., aspiration pneumonia) in old age may mask the diagnosis of SARS.3,4 Because these geriatric presentations are nonspecific, it is important to avoid under- or overdiagnosis7 of SARS. A retrospective study showed that two-thirds (100 out of 150) of elderly patients (≥65) referred for suspected SARS had alternative diagnosis, compared with one-third of younger patients (Sheng B, PMHSARS Study Group, personal communication). Because the presentations of SARS in the elderly can be nonspecific, a positive contact history may be the first important clue leading to a diagnosis of SARS in an older adult with unexplained illness.4,7 Thus, a diagnosis of SARS in old age requires a high index of suspicion, knowledge of the geriatric presentations of infections in old age, awareness of the age-assessment changes in physical and functional state, alertness to any contact history of SARS, and an updated knowledge of the current prevalence of SARS in the locality. Elders with SARS often have an apparently lengthened incubation period of 14 to 21 days3,4 because of delayed detection of onset and inexact day of contact because of multiple exposures. This has important clinical implications for diagnosis, contact tracing, duration of surveillance, and infection control measures during high-risk nursing and personal care for these frail older persons. This long incubation period also calls for an adequate period of careful observation of hospitalized elderly at risk of SARS; when such patients are moved to a different setting (e.g., acute hospital to rehabilitation hospital or hospital to aged home), close communication between the staff about SARS contact is essential. The elderly are more vulnerable to the adverse drug reactions3,4 of ribavirin and high-dose corticosteroid commonly used to treat SARS, especially nosocomial infection (47%).4 The benefit-to-risk ratio of any given intervention can be quite different in frail elders with significant comorbidities than in younger adults or healthy older adults. So, an individualized approach is required in treating an elder with SARS. The high mortality rates (50–75%) reported in elderly persons with SARS can be attributed to late presentation, delayed diagnosis, comorbid conditions, and complications from treatment.3,4,7 For frail moribund elderly with SARS, attending to the palliative needs of the elder and his family can be challenging when there are barriers imposed by infection control. Prevention of SARS depends on breaking the chain from exposure to infection, and thus prevention of exposure and early detection of SARS in elders are important in minimizing spread. Because 72% of SARS cases in residents of nursing homes are hospital acquired,5 unnecessary and inappropriate hospitalizations should be avoided and residents' medical needs met by community and outreach care as far as possible. Careful surveillance for possible SARS in recently discharged elders in nursing homes should also be made when SARS is prevalent in that locality. Undiagnosed SARS can result in outbreaks in healthcare workers and patients within hospital and nursing homes,1,3,4 which may lead to further outbreaks in the community. An example of a similar outbreak involving unrecognized tuberculosis in a nursing home in the United States has been revealed by molecular and epidemiological links.10 Thus, SARS in elders should be treated with respect. The HKGS advocates the need to approach elders in the era of SARS with appropriate attitude, knowledge, and skills. Input from geriatricians is important in combating SARS in elders, whether in acute, rehabilitation, or community settings.