COVID 19 and Older AdultsLuna Ragsdale, MD, MPHChief, Emergency DepartmentDurham VA Health Care SystemDecember 3, 2020

Risks for Older Adults

85 years and older •13 fold higher risk of hospitalization

•630-fold higher risk of death

World Data

• In China, case fatality rate for >80 years was 21.9% compared to 1.4% in patient of all ages with no underlying conditions

• In Italy, where 23% of the population is over 65 years-89% of COVID-19 deaths are over 70 years old -31% between 70-79-58% are over 80 years old

It’s not all bad news…

103-year-old Zhang Guangfen was admitted to Wuhan’s Liyuan Hospital March 1st and has completely recovered

Most common symptoms

Fever

Cough

Sputum

Nonspecific Symptoms

Without fever or cough Fatigue Myalgias Nausea and

vomiting

Atypical Symptoms

Delirium

Low-grade fever

Abdominal pain

What is a fever?

IDSA recommends modified fever definition for older patients:

• Oral temperature over 100 F (37.8 C)

• TWO oral temperatures over 99 F (37.2C)

• Elevation of 2 F (1 C) from baseline body temp

Why are older adults affected more?

Immunosenscence Inflammaging Decreased clearing

Perrotta F, Corbi G, Mazzeo G, et al. COVID-19 and the elderly: insights into pathogenesis and clinical decision-making [published correction appears in Aging Clin Exp Res. 2020 Sep;32(9):1909]. Aging Clin Exp Res. 2020;32(8):1599-1608. doi:10.1007/s40520-020-01631-y

• An 86-year-old man is transferred from a skilled nursing facility (SNF) with two-day history of cough and progressive shortness of breath.

• PMH is significant for COPD, atrial fibrillation, and dementia (non-ambulatory, oriented to person and place, two-person assist for ADLs.)

• EMS informs that there are “dozens” of people with URI symptoms at the facility.• Your ED is holding ICU patients for an average of 20 hours. • Supplemental History: There are no cases of COVID-19 in your county. There are three in an adjacent county. The patient’s

daughter is in route to the ED. His POLST form states “DNR; apply all other measures.” • Evaluation: Awake, alert, moderately increased respiratory effort. Temp 100 F (tympanic), RR 27, Pox 87% RA, HR 108, BP 102/62.

Fair air movement, diffuse wheezes. He frequently removes the facemask placed by EMS. • • Do standard COPD interventions change with circulating COVID-19? Should he be intubated if his respiratory status deteriorates? • • Should the “dozens” of other patients from the facility come to the ED? • • If his status improves, or his daughter requests, can the SNF accept him back without a negative COVID-19 test? •

Levels of Care

Independent Living

Assisted Living

Skilled Nursing

COVID 19 and Nursing Homes

45% of all COVID deaths from long-term care facilities

Assisted Living

May only have one licensed practical nurse for entire facility

Less therapeutic and diagnostic capabilities

Nursing Homes

• Combo of long-term care patients and shorter term skilled nursing/rehab

• Have medical and nursing oversight

• Most have diagnostic and therapeutic capabilities

• Xray (mobile)• IV fluids/medications• Labs (mobile)

Nursing Home Staffing

• Federal law requires Medicare and Medicaid certified nursing homes to have :

• A registered nurse (RN) on duty at least 8 hours a day, 7 days a week

• A licensed nurse (RN or LPN) on duty 24 hours a day

• Direct care by certified nursing assistants• 1:7-10 daytime• 1:20-25 nighttime

What Can SNFs provide?

Oxygen IV Meds Nebulized treatments

SNF placement?

On March 12, 2020, CMS waived an important restriction to nursing home and skilled nursing facility (SNF) access called the “the 3-day rule”.

Relaxation of this rule with this waiver now allows direct transfer of appropriate stable older adults to SNF from the ED.

Levels of Care

• All EDs should have plans in advance to deal with low-resource situations and emergency plans should include perspectives from ED, ICU, administration, referring facilities, palliative care, hospice, and medical ethics in order to best allocate scarce resources.

Social IsolationBaseline isolation

Little Reserve

Lack of family visitors

Lack of regular

interactions

Restrict needed

access to food and

med Health deterioration

Delirium and COVID

• Delirium is an emergency!!!

• Acute brain dysfunction

• Mortality rate of delirium-If admitted 10-26%-If develops during hospitalization 22-76%

Mccusker J et al. Arch Intern Med. 2002; 162(4):457-63Am J Psychiatry. 1999; 156(5 Suppl):1-20

Components of Delirium

ACUTE change from baseline

“Mom is not usually like this”

Components of Delirium

INATTENTION

ALTERED LEVEL OF AWARENESS

DISORGANIZED THINKING

AND

OR

What triggers

delirium

• Systemic illness• Fever• Hypoxemia/hypercarbia• Pain• Dehydration• Constipation• Medications

Delirium Types

Hypoactive• Sleepy• “Pleasantly Confused”

Hyperactive• Agitation• Anxiety

Mixed

Who is at Risk?

• Sensory Impairment (Vision and Hearing)

• 65+ age• Nursing Home Resident• h/o dementia• Serious infections

COVID factors

• NO VISITORS – strict visitor policies

• PPE

• Isolation/Immobility

Identify and Treat

• Missed in 75% of cases in the ED and inpatient settings

• Reversible causes• Immobility• Dehydration• Hypoxia• Pain• Constipation/urinary retention• Nausea• Psychoactive medications

http://eddelirium.org/delirium-assessment/assessment-overview/

PREVENTION IS BEST MANAGEMENT

• Mobilize the patient

• Personal contact with orientation

• Ensure physiological needs are met

-Food/drink-Warmth-Bowel and bladder emptying

Create friendlier environment

• Dimming or turning off the lights

• Minimizing auditory stimulation

• Minimizing tethers

• Having family members and familiar objects from home at the patient’s bedside

• Antipsychotic medications last resort

Delirium Management - TADA

TolerateTolerate seemingly

dangerous behaviors

1

AnticipateAnticipate what the patient might do and proactively avoid inciting agents that may cause or exacerbate

agitation

2

Don’t AgitateGolden rule of this

approach

3

COVID 19 –Resource Rationing

ED is not an optimal environment for decision making regarding resource rationing

• Lack of critical data

• Lack of time

• Barriers for effective communication

Importance of Advanced Care Planning

Proactively identifies who does not want aggressive,

invasive interventions

Clearly documented in easily accessible location

Transfers from LTCF

• Communication is a problem

Forward Triaging

Prior to the ED evaluationHPI, PMH, baseline mental and

functional status, goals of care, current hospital resources, and nursing home treatment (and

isolation) capacity

After ED evaluationRisks, benefits, and alternatives to

construct a disposition and communicate with family members

Key Points

Older patients can present atypically

Delirium can be a symptom

Best way to manage delirium is prevention

Plan ahead

Communication is key