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| CASE REPORT |
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| Year : 2020 | Volume
: 16
| Issue : 3 | Page : 133-135 |
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Fall in elderly during COVID-19 pandemic: A case report and review
R Magesh1, Phani Krishna Machiraju2, Neetu Mariam Alex2
1 Department of Geriatrics, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Internal Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| Date of Submission | 02-Sep-2020 |
| Date of Decision | 15-Sep-2020 |
| Date of Acceptance | 25-Sep-2020 |
| Date of Web Publication | 23-Feb-2021 |
Correspondence Address:
Dr. Phani Krishna Machiraju
Department of Internal Medicine, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jiag.jiag_5_20
Coronavirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 primarily affects the lung resulting in acute lung injury, which may progress to acute respiratory distress syndrome and rarely multiorgan dysfunction syndrome. Elderly are the worst affected among all age groups. Falls are one of the most common problems faced by the elderly. Since the outbreak of this pandemic, most hospital resources have been redirected to the care of COVID-19 patients, resulting in the postponement of many orthopedic elective surgeries. In this case report, we discussed managing a traumatic fall in the elderly who tested positive for COVID-19.
Keywords: Coronavirus, coronavirus disease-19, elderly, fall, severe acute respiratory syndrome coronavirus 2
How to cite this article:
Magesh R, Machiraju PK, Alex NM. Fall in elderly during COVID-19 pandemic: A case report and review. J Indian Acad Geriatr 2020;16:133-5 |
How to cite this URL:
Magesh R, Machiraju PK, Alex NM. Fall in elderly during COVID-19 pandemic: A case report and review. J Indian Acad Geriatr [serial online] 2020 [cited 2023 Mar 21];16:133-5. Available from: http://www.jiag.com/text.asp?2020/16/3/133/309989 |
| Background | |  |
Coronavirus disease-19 (COVID-19) caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) primarily affects the lung resulting in acute lung injury, which may progress to acute respiratory distress syndrome and rarely multiorgan dysfunction syndrome. Elderly are the worst affected among all age groups. This may be attributed to underlying comorbidities and frailty.
Test, trace, isolate, and strict quarantine measures are being implemented worldwide to contain the spread of infection. Studies have shown that social isolation and loneliness in the elderly is associated with an increased risk of fall.[1] Falls are the leading cause of injury with more than one-third of the elderly aged above 65 reporting falls each year.
Since the outbreak of this pandemic, most hospital resources are redirected to the care of COVID-19 patients, resulting in the postponement of many elective surgeries. In the setting of COVID-19, knowledge about injury characteristics in the elderly and guidelines for the management of these injuries are more critical than ever before. In this report, we share our experience of handling an elective surgery for intertrochanteric fracture of the femur, resulting from a fall in the elderly during the COVID time.
| Case Report | | |
An 80-year-old gentleman, known to have hypertension, asthma, obesity, and obstructive sleep apnea, presented to us on June 4, 2020, with an alleged history of fall from his bed while trying to get up in the morning. He sustained an injury to his right hip following the fall. He denied other injuries, ENT bleed, seizure, vomiting, loss of consciousness, fever, cough, and urinary or bowel symptoms.
On arrival, he was hemodynamically stable with the pulse rate of 84/min, respiratory rate of 24/min, SpO2 of 98% on room air, temperature of 98.6°F, and blood pressure of 120/80 mm Hg. Systemic examination was unremarkable. Local examination revealed tenderness over right trochanter with painful restricted range of movements in the right hip. Right lower limb was externally rotated with limb shortening. All peripheral pulses were palpable. X-ray of the right femur was notable for displaced fracture of the right proximal femur. Chest X-ray showed minimal bilateral infiltrates.
Baseline laboratories showed mild anemia (Hb: 11.3 g/dl), elevated total counts (22,690/mm3), and hypocalcaemia (7.9 mg/dl). Blood sugar (random: 129 mg/dl), renal function tests (urea: 24 mg/dl, creatinine: 1.2 mg/dl), and electrocardiogram were normal. As per hospital protocol, he was tested preoperatively for COVID-19 by RT-PCR on June 5, 2020, and it turned out to be positive. Computed tomographic scan chest done on day 2 of admission revealed mild emphysematous bilateral lung fields and mild cardiomegaly. An echocardiogram done showed left ventricular hypertrophy and normal left ventricular function (LVEF of 60%).
Inflammatory markers were elevated (CRP: 94.1, IL-6: 182.3). We had a detailed discussion with family, orthopedic team, and infectious team to weigh risk versus benefit over prioritizing COVID-19 treatment over surgical intervention and decided to withhold surgery for the time being. He was started on low molecular weight heparin (clexane 60 mg subcutaneous OD). Repeat COVID-19 tested on June 18, 2020, was positive. Blood and urine cultures were negative. Infectious disease team cleared him for surgery. However, the surgeon was apprehensive in view of the patient being still the positive and associated risk of transmission to his team. He continued to be positive for COVID-19 by RT-PCR done on July 1, 2020, and July 10, 2020.
After due consideration to patient safety and postoperative outcome, he was taken up for right open proximal femoral nailing under general anesthesia on July 13, 2020. Peri- and post-operative periods were uneventful. He was made to walk on postoperative day 1 with walker support. Vitamin D level was low and he was started on supplements. Serum inflammatory markers were normal at the time of discharge. He was discharged in a hemodynamically stable condition on 48th day of admission.
| Discussion | | |
Falls are one of the most common problems faced by the elderly. In India, about 14%–53% of people above 60 years of age experience fall each year.[2] A fall may result in traumatic complications resulting in increased hospitalizations or nontraumatic complications, such as fear of fall. Older adults aged ≥85 years are at 10–15 times increased risk of fracture.
Negative consequences of social isolation during a pandemic are lack of Vitamin D, depression, cognitive decline, loneliness, reduced physical activity levels, and increased body mass, further increasing the risk of falls in older people.[3] Our patient was an 80-year-old gentleman with morbid obesity and low serum calcium levels, contributing to the traumatic complication of fall.
These accidental events will increase the consumption of already scarce medical resources and increase the risk of COVID-19 transmission in hospital settings. A study by Zhu et al. has revealed that 70–74 years is the most involved age group, with an increased prevalence of hip fracture,[4] as in our case. The increased prevalence of hip fractures during a pandemic may be due to fatigue and weakness due to COVID-19 disease.
Hence, COVID-19 infection needs to be ruled out in an elderly patient presenting with a fragile hip fracture, in the current scenario.[5] There were no consensus guidelines regarding lower limb fragility fracture management, especially if patients positive for COVID-19, and very sparse literature was available.
A systematic review and a meta-analysis on the impact of surgery timing in elderly hip fractures have shown that early surgery is associated with 20% reduction in 1-year mortality and reduced incidence of perioperative complications.[6] However, the availability of appropriate surgical capacity with a competent staff is difficult during these pandemic times. Studies have shown that healthcare workers are at increased risk of contracting COVID-19. In the resource-limited country like ours, reduction of risk to staff and sustainable staffing model is prerequisite.
Minimal data was available regarding the safety of surgery and the impact of COVID-19 on postoperative recovery of the patients. An international multicenter cohort study has shown that half of the patients with perioperative SARS-CoV-2 infection had postoperative pulmonary complications and higher mortality rates, especially in men aged 70 years and above.[7] Obese people are at greater risk for severe illness.[8]
Contrary to this, another study in Northern Italy has shown improvement in respiratory symptoms in those patients who underwent surgery.[9] However, only 16 patients were part of this study which is a significant limitation.
Risk of COVID-19 infection may not be 100% excluded. Hence, patients should agree to undergo surgery accepting the risk of diseases and need for additional preoperative screening. European Society for Sports Traumatology, Knee Surgery and Arthroscopy recommends to postpone surgery in the confirmed case until he/she recovers completely and to repeat RT-PCR and CT chest 48–72 h before surgery. If a patient had recovered from COVID-19, the adequate immune response should be validated by a serological test.[10]
The nonoperative therapeutic approach may be considered for nonobligatory fractures till we tide over the peak of this pandemic,[11] especially in the elderly with multiple comorbidities. Studies before pandemic did not show any significant differences between operative and nonoperative treatment of nonobligatory fractures such as proximal humerus fracture.[13]
However, for obligatory fractures (as in our patient), the surgical approach is recommended. British Orthopaedic Association guidelines recommend considering hip and femoral fractures as an urgent surgical priority.[12] Early surgery for proximal fracture of the femur may help in early mobilization and improvement in respiratory physiology. However, patients with severe hypoxia, organ dysfunction, and critical illness may not be considered for surgery until he/she improves.[9] It should be performed in a negative pressure operating room with full personal protective equipment if surgery is planned.
| Conclusion | | |
We need to be highly flexible in patient and treatment selection during these pandemic times. The general condition of the patients, comorbidities, severity of COVID-19, risk of surgery, risk of in-hospital transmission to healthcare personnel and other patients, and phase of a pandemic should all be given due consideration while planning for surgery. This pandemic may provide us with an opportunity to explore newer management methods for different types of fracture and observe the outcome.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Petersen N, König HH, Hajek A. The link between falls, social isolation and loneliness: A systematic review. Arch Gerontol Geriatr 2020;88:104020.  |
| 2. | Dsouza SA, Rajashekar B, Dsouza HS, Kumar KB. Falls in Indian older adults: A barrier to active ageing. Asian J Gerontol Geriatr 2014;9:33-40. |
| 3. | Pelicioni PH, Lord SR. COVID-19 will severely impact older people's lives, and in many more ways than you think! Braz J Phys Ther 2020;24:293-4. |
| 4. | Zhu Y, Chen W, Xin X, Yin Y, Hu J, Lv H, et al. Epidemiologic characteristics of traumatic fractures in elderly patients during the outbreak of coronavirus disease 2019 in China. Int Orthop 2020;44:1565-70. |
| 5. | Shariyate MJ, Kachooei AR. Association of new coronavirus disease with fragility hip and lower limb fractures in elderly patients. Arch Bone Jt Surg 2020;8:297-301. |
| 6. | Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: A systematic review and meta-analysis. Sci Rep 2018;8:13933. |
| 7. | COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020;396:27-38. |
| 8. | Garg S, Kim L, Whitaker M, O'Halloran A, Cummings C, Holstein R, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019-COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:458-64. |
| 9. | Catellani F, Coscione A, D'Ambrosi R, Usai L, Roscitano C, Fiorentino G. Treatment of proximal femoral fragility fractures in patients with COVID-19 during the SARS-CoV-2 outbreak in Northern Italy. J Bone Joint Surg Am 2020;102:e58. |
| 10. | Mouton C, Hirschmann MT, Ollivier M, Seil R, Menetrey J. COVID-19-ESSKA guidelines and recommendations for resuming elective surgery. J Exp Orthop 2020;7:28. |
| 11. | Iyengar K, Vaish A, Vaishya R. Revisiting conservative orthopaedic management of fractures during COVID-19 pandemic. J Clin Orthop Trauma 2020;11:718-20. |
| 12. | |
| 13. | Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J 2017;99-B: 383-92. |
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