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COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
391
than 6feet may still be a concern when exposures occur indoors over a long period
of time. Correct use of PPE, use of source control by the infected individual, and
vaccination status should all be considered when evaluating such an exposure.
CDC guidance for healthcare worker exposures and PPE usage, can be found at:
https://www.cdc.gov/coronavirus/2019- ncov/hcp/guidance- risk- assesmenthcp.html.
Patient Assessment andManagement
A rapid and targeted evaluation is required for residents “suspected” with
COVID-19 infection. In addition to managing respiratory and non-respiratory
symptoms, there needs to be a heightened awareness of comorbidities and their
impact on resident prognosis. Comorbidities that can worsen a resident’s condition include HTN, heart failure, respiratory disease, diabetes, renal failure, and
cancer. Cognitive impairment, pre-COVID mental status, and the presence of
frailty also affect prognosis and outcome. Practitioners with expertise in geriatric
medicine can assess and provide inclusive care to manage a residents’ multidimensional health status, functional ability, caregiver involvement, and social
support.
Resident evaluation and clinical assessment may be performed on site when permissible, or by telehealth with nursing staff facilitating the visit. Important factors
to consider when a evaluating a resident with “suspected” COVID-19 include:
• Level of alertness, confusion, delirium, or coma.
• Respiratory effort and oxygen saturation.
• Fever.
• Hemodynamic stability (heart rate, blood pressure).
• Blood glucose level (regardless of prior diagnosis of diabetes).
• Baseline laboratory tests (CBC with differential, CMP, CRP).
• Intake of food and uids—assess hydration status.
• Functional status and level of dependency (consider use of Clinical Frailty Scale).
Clinicians should be aware that 40% of COVID-19-positive patients can have no
signs or symptoms, and 30% present atypically (in a recent study of 400 residents
across four long-term care facilities). Frail individuals also have a higher risk of
hospitalization and mortality [4]. In a French study of 480 residents in metropolitan
nursing homes, male gender, age >85years, diabetes, dyspnea, thermal dysregulation (hypo or hyperthermia), altered level of consciousness, and falls were associated with increased risk of COVID-19-related mortality [5]. Other studies also cite
dementia and other neuropsychological conditions, urinary and bowel incontinence,
chronic kidney disease, cardiovascular disease, prior pneumonia or respiratory disease, malnutrition and dehydration, as well as functional dependency as risk factors
392
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N. Pandya et al.
for increased mortality. Also associated with increased mortality in residents are the
need for supplemental oxygen, O2 desaturation despite O2 supplementation, bilateral lung inltrates, elevated C reactive protein (CRP) and/or, interleukin-6 (IL-6),
a reduced lymphocyte count, low GFR, hemoconcentration, hypernatremia, and
reduced serum albumin [6].
Management ofCOVID-19 Infection
Management of residents with COVID-19 requires good symptom control and supportive care. Pharmacotherapeutic intervention is essential. Since there are no specic guidelines for managing residents with COVID-19in nursing and assisted
living, the recommendations reviewed in Table2 represent a consensus of professional society guidelines as well as those from the CDC.It is important to acknowledge that many facilities have been able to successfully manage COVID-19 “in
house” and avoid resident hospitalization and to provide appropriate palliative care
in those residents near end of life. The current pharmacological managment recommendations for non-hospitalized patients are summarized in Table3.
Table 2 General management and supportive care
Clinical problem Management Notes
Fever, headache,
myalgias
Cough Antitussives Avoid preparations containing codeine
Dyspnea Prone position may be
Dehydration Oral or intravenous uids if
Weakness Early mobilization
Nutrition Feeding assistance
Identify goals of
care
Polypharmacy Discontinue unnecessary
Sources: Centers for Medicare and Medicaid Services; Infectious Disease Society of America
Acetaminophen Daily dose not to exceed 3g
Incentive spirometry
helpful
Supplemental oxygen to
maintain saturation above
92%
necessary
Physical therapy
Reduce isolation when
possible
Nutritional supplements
Initiate early discussions
with patients and care
partners
supplements and treatments
Stop sliding scale insulin
Breathing exercises to reduce anxiety in
severe dyspnea
Regular monitoring of vital signs and
electrolyte and renal function
Formal advance care planning helpful;
consider using structured tool for planning
and communication
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
Table 3 Pharmacologic management: recommendations for non-hospitalized patients [7–9]
Therapeutic agent Suggested dose Caveats
For patients at high risk of progressing to severe disease
Nirmatrelvir/
ritonavir (Paxlovid)
Remdesivir 200mg IV on day 1, followed by 100mg
Alternative agents for patients at high risk of progressing to severe disease
Bebtolivamab 175mg as single IV injection in 30s Observe patient for ≥1h
Molnupiravir 800mg PO BID × 5days, ≤5days from
Other potential agents
Dexamethasone 6mg PO daily for duration of use of
Sources: CMS, IDSA
300mg nirmatrelvir/100 ritonavir Q 12h
× 5days, ≤5days from onset of
symptoms
150mg nirmatrelvir/100 ritonavir Q 12h
× 5days, ≤5days from onset of
symptoms
IV Q D on day 2 and 3
onset of symptoms
oxygen IF discharged from ED with
new or increased need for
supplemental oxygen
If eGFR >60mL/min
If eGFR ≤60 and ≥30mL/min
Not recommended if eGFR
<30mL/min
Evaluate concurrent
medications for drug–drug
interactions
≤7Days from onset of
symptoms
Expected to be active against
Omicron variant
If IV therapies are feasible in
the facility
Monitor patient during
infusion and 1h afterwards
≤7Days from onset of
symptoms
Use only if nirmatrelvir/
ritonavir (Paxlovid) are not
available
Not to exceed 10days, monitor
for adverse effects
Continue corticosteroids if
used for prior indication
Equivalent doses are 40mg
prednisone or 32mg
methylprednisolone
393
Medications Not Recommended, or Only intheContext
ofaClinical Trial
Since the advent of the COVID-19 pandemic, many medications have been administered with varying published results. However, in the light of the current state of
knowledge and results from an increasing number of larger studies, the use of the
following medications is not recommended: ivermectin, famotidine, colchicine, and
pre- and post-exposure prophylaxis with hydroxychloroquine and azithromycin.
The following medications are only recommended in the context of a clinical trial:
inhaled corticosteroids, and uvoxamine.
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N. Pandya et al.
Long-Term Consequences ofCOVID-19 Infection
Post-acute COVID-19 is dened as the presence of symptoms present 3 weeks
after initial disease presentation, and chronic COVID-19 as symptoms occurring
beyond 12 weeks. In a telephone survey conducted by the Center for Disease
Control (CDC), 47% of older adults with three or more chronic conditions reported
that they had not returned to their usual state of health 14–21days after a positive
test [10]. Negative mental health outcomes have been noted in patients during the
COVID-19 pandemic. These include delirium, depression, and behavioral problems. Strategies to mitigate these outcomes have included virtual visits, and
increased volunteer and staff engagement of residents. After recovery from acute
COVID-19 infection, patients may experience long-term effects: severe symptoms
and end-organ dysfunction, altered cognition, and loss of physical function.
Comorbidities may also increase in severity as usual care of conditions such as
COPD and heart failure may have been disrupted. All these factors require close
monitoring and prudent adjustment of treatments. Long-term effects observed in
residents who have been aficted with COVID-19 include:
• Fatigue.
• Weight loss.
• Dyspnea.
• Oxygen dependence (associated with pulmonary brosis, and interstitial
prominence).
• Encephalopathy (white matter changes, hypometabolism, acute or sub-acute
infarcts on neuroimaging) [11].
• Increase incidence of heart failure.
• Impaired circulation in the feet.
• Headache, vertigo, impaired smell, and taste.
• Myopathy.
• Peripheral neuropathy.
• Decline in function (may lead to wheelchair or bedbound status).
• Post-traumatic stress (especially in those with respiratory symptoms).
• Depression or anxiety (especially in those with respiratory symptoms).
Long COVID-19
Persistent cluster of symptoms post-acute COVID-19 can occur up to 15months or
longer, termed “Long COVID-19.” These include “brain fog” (cognitive decit,
memory loss, difculty with concentration), headaches, dizziness, tingling, blurred
vision, tinnitus, and chronic fatigue. This condition may be related to the presence
of increased level of autoantibodies, the presence of EBV DNA in blood, viral fragments of SARS-CoV-2 RNA in the blood, and Type 2 diabetes. Cardiopulmonary
symptoms are common with persisting dyspnea, partially due to reduced lung
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
395
diffusion capacity. Patients who have had more severe disease are more likely to
develop long COVID-19.
Summary
The COVID-19 pandemic has precipitated a crisis in post-acute and long-term care
that has challenged staff and practitioners (indeed all health care workers) to rethink
and restructure the physical and people environment in the provision of care to
short-stay and long-term residents of nursing, assisted living and independent living
facilities. As COVID-19 shifts from a pandemic phase to an endemic phase, infection prevention and control will continue to be essential to reduce exposure risk to
facility residents and staff. This will require an impetus to ensure residents have
received up-to-date immunizations for the pneumococcal vaccine, annual inuenza
vaccination, and ongoing COVID-19 vaccination as new variant and booster vaccines are developed in order to maintain effective antibody titer levels to COVID-19.
If another COVID-19 pandemic occurs that limits access to in-hospital care, it may
require that staff and practitioners at nursing facilities provide hospital-level care.
Readiness to meet such a challenge will be vital.
The future for post-acute and long-term care holds promise for better resident
care, and better management of COVID-19 infection, better drugs, better COVID-19
vaccines, and better trained HCWs, staff, and practices as health care in facilities is
“re-imagined.”
Pearls for the Practitioners
• COVID-19 has transitioned from an epidemic to a pandemic and currently to an
endemic phase (as of fall 2022).
• COVID-19 Omicron variant and subvariants are more infectious than the initial
original/previous variants (Alpha, Beta and Delta) seen in 2020 and 2021.
• Persons are 65% less likely to die from the Omicron variant but are at increased
risk to develop Long COVID.
• Be cognizant of the similarities and differences in the presentation signs and
symptoms and clinical course of COVID-19, inuenza, and the common cold.
• Be aware of the changing CDC recommendations for LTC facilities (testing,
monitoring, isolation, cohorting, and visitation).
• CDC recommendations for infection control program pertains to all practitioners
and clinicians; to understand and follow… isolation, and return to work policies
applies to you!
• Follow the requirement to notify the local Health Department upon a “suspected”
or “conrmed” COVID-19 outbreak at the nursing or assisted living facility.
• Practice thorough patient evaluation upon diagnosis and ongoing during active
infection and during convalescence.
• Apply geriatric principles of care, knowledge and skills in geriatric syndromes
that often coexist with COVID-19in older adults.
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N. Pandya et al.
• Keep informed of current and new pharmacotherapy including availability of
convalescent plasma therapy and infusion of monoclinal antibodies.
• Support vaccination programs of residents, resident families, staff and
practitioners.
• Assess all residents (COVID-19 and non-COVID-19) for the presence and need
for mental health care.
• Acquire experience in the use of telemedicine with residents, staff, and care plan
and family meetings.
• Recognize Long COVID-19/chronic COVID-19 signs/symptoms.
• Be alert as to the risk of a cytokine storm and coagulopathy (DVT, pulmonary
emboli) with COVID-19.
References
1. Gaur S, Pandya N, Dumyati G, etal. A structured tool for communication and care planning in
the era of the COVID-19 pandemic. J Am Med Dir Assoc. 2020;21(7):943–7.
2. The National Imperative to Improve Nursing Home Quality. The National Academies of sciences, engineering, and medicine. Washington, DC: The National Academies Press; 2022.
3. Abbasi J. COVID-19 crisis advances efforts to reimagine nursing homes.
JAMA. 2021;326(16):1568.
4. Covino M, Russo A, Salini S, etal. Frailty assessment in the emergency department for risk
stratication of COVID-19 patients aged ≥80 years. J Am Med Dir Assoc. 2021;22(9):1845–52.
5. Couderc A, Correard F, Hamidou Z, etal. Factors associated with COVID-19 hospitalizations
and deaths in French nursing homes. J Am Med Dir Assoc. 2021;22(8):1581–7.
6. Dyer AH, Fallon A, Noonan C, etal. Managing the impact of COVID-19in nursing homes and
long-term care facilities: an update. J Am Med Dir Assoc. 2022;23(9):1590–602.
7. Nonhospitalized patients: general management | COVID-19 treatment guidelines (nih.gov).
8. Nonhospitalized adults: therapeutic management | COVID-19 treatment guidelines (nih.gov).
9. https://www.idsociety.org/practice- guideline/covid- 19- guideline- treatment- and- management/.
10. Del Rio C, Collins LF, Malani P. Managing the impact of COVID-19 in nursing homes
and long-term care facilities: an update. Long-term health consequences of COVID-19.
JAMA. 2020;324(17):1723–4. https://doi.org/10.1001/jama.2020.19719.
11. Manca R, De Marco M, Ince PG, Venneri A.Heterogeneity in regional damage detected by
neuroimaging and neuropathological studies in older adults with COVID-19: a cognitiveneuroscience systematic review to inform the long-term impact of the virus on neurocognitive
trajectories. Front Aging Neurosci. 2021;13:646908.
Further Reading
Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious
Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP).
Centers for Medicare and Medicaid Services (CMS). Nursing Home COVID-19 Public File.
https://data.cms.gov/covid-19/covid-19-nursing-home-data. Accessed 10 May 2022.
Centers for Medicare and Medicaid Services (CMS). The impact of COVID-19 on Medicare ben-
eciaries in nursing homes. 2021.
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
Goldberg EM, Southerland LT, Meltzer AC, etal. Age-related differences in symptoms in older
emergency department patients with COVID-19: prevalence and outcomes in a multicenter
cohort. J Am Geriatr Soc. 2022;70:1918.
Health and Human Services Ofce of Inspector General. An estimated 91% of nursing home staff
nationwide received the required COVID-19 vaccine doses, and an estimated 56% of staff
nationwide received a booster dose. Report No. A-09-22-02003. 2022.
Lian J, Jin X, Hao S, etal. Analysis of epidemiological and clinical features in older patients with
coronavirus disease 2019 (COVID-19) outside Wuhan. Clin Infect Dis. 2020;71:740.
National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases.
Interim infection prevention and control recommendations to prevent SARS-CoV-2 spread in
nursing homes: nursing homes and long-term care facilities. 2022.
Saket S, Hashmi AZ.COVID-19in older adults. Cleve Clin J Med. 2021;2021:ccc080. https://doi.
org/10.3949/ccjm.88a.ccc080.
Theme Issue: Re-imagining Long-Term Care. J Am Med Dir Assoc. 2022; 23(2). Topics include
articles on reimagining medical care, nancing and payment, family involvement, nutrition
care, post diagnostic care in dementia and nursing home design and COVID-19.
Vrillon A, Hourregue C, Azuar J, et al. COVID-19in older adults: a series of 76 patients aged
85 years and older with COVID-19. J Am Geriatr Soc. 2020;68:2735.
397
Index
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A
Abuse, 298
Accountable Care Organizations
(ACOs), 47, 170
Active euthanasia, 306
Acute change in condition
acute onset of fever, 174
asymptomatic bacteruria, 174–176
behavioral problems, 173, 174
chest pain, 172
CHF, 172
dehydration, 173
in mental status, 171, 172
pneumonia, 176–178
UTI, 174–176
Acute/chronic immune activation (ACI), 111
Acute kidney injury (AKI)
age-related changes, 157
causes, 158–159
denition, 158
ADEs, see Adverse drug events
Adult Protective Services, 298, 299, 302
Advance care planning (ACP), 314
Adverse drug events (ADEs), 87
AGS, see American Geriatrics Society (AGS)
Alzheimer’s disease, 265, 271
American Academy of Physician
Assistants, 98
American Association of Nurse
Practitioners, 98
American Geriatrics Society (AGS), 354, 358
American Health Care Association and
National Center for Assisted Living
(AHCA/NCAL), 49
American Heart Association, 360
American Medical Association, 306
American Medical Association’s Committee
on Aging, 82–83
American Medical Directors Association, see
Society for Post-Acute and
Long-Term Care Medicine
Analgesics, 358
Anemia
ACI, 111
blood loss, 111
causes, 109–111
CKD, 110
clinical outcomes, 107
denition and prevalence, 108
physiologic impairments, 107
signs and symptoms, 108
treatment, 111, 112
Annual Wellness Visits (AWV), 337
Anorexia/cachexia, 204, 205
Antibiotic stewardship, 354
Antihypertensive therapy, 359
Antipsychotic medication, 353, 354
Appetite stimulants, 236, 237
Assisted living (AL)
AHCA/NCAL, 49
CEAL, 49
community characteristics, 37, 38
COVID-19, 42, 43
denition, 37
disaster preparedness, 42, 43
nancing, 41
history, 36, 37
medical care
clinical direction, 47, 48
clinical guidelines, 50
© The Editor(s) (if applicable) and The Author(s), under exclusive license to
Springer Nature Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5
399
400
Index
Assisted living (AL) (cont.)
clinician’s role, 45
communication and care
coordination, 46, 47
guiding families and colleagues, 55
healthcare directives, 53
health promotion, disease prevention
and wellness services, 53
high-risk medications and medical
problems, 53
in-service training, 52
marketing, 51
Medical Director hiring, 54–55
medication management, 43, 44
models of care, 45
person-centered care, 54
QAPI, 56
time management guidelines, 50, 51
transfer/communication forms, 52, 53
workgroup, 56
resident characteristics, 38, 39
residents’ rights, 39–41
staff training, 42
Assisted Living Communities (ALCs), 36–38
Assisted living facility (ALF), 24
Attending physicians, 78, 82, 88
curriculum and certication
programs for, 78
functions, 78, 79
C
Cardiopulmonary resuscitation (CPR), 305
Care Plan Oversight (CPO), 31, 32
Centers for Medicare and Medicaid Services
(CMS), 5, 244, 258, 259
Centers for Medicare and Medicaid Services
State Operations Manual, 299
Center to Advance Palliative Care
(CAPC), 197
Certied Nurses Aid (CNA), 257
Cervical cancer, 192
Choosing Wisely®, medical management,
361, 365–366
Chronic obstructive pulmonary
disease (COPD)
acute exacerbation, 126, 127
diagnosis, 123, 124
identication, 122
management, 124–126
Clinical nurse specialists (CNS), 94
long-term care, 95
mental illness training, 95
Clinical Video Telehealth (CVT), 73
Clostridioides difcile infections (CDI)
clinical features, 156
management, 156, 157
morbidity and mortality, 155
risk factors, 155, 156
Cockcroft–Gault Equation, 345
Cognitive impairment, 246
Colon cancer, 192
Communication and care coordination
ACOs, 47
care transitions, 46
technology, 46
Community Living Centers (CLCs), 73
Confusion Assessment Method (CAM),
276, 277
Congestive heart failure (CHF), 172
Constipation, 207, 208
Cornell Scale for Depression in Dementia
(CSDD), 283
COVID-19, 7, 8, 265, 267, 273, 279, 287,
300, 337
assisted living, 42, 43
clinical presentation, 385, 386
demographics, 384, 385
ICP, 387, 388
long COVID-19, 394
management, 392, 393
medications, 393
patient assessment, 391, 392
patient visitation, 388, 389
post-acute COVID-19, 394
quarantine, 387
return to work criteria
workers exposed to conrmed
COVID-19, 391
workers infected with
COVID-19, 390
standard precautions, 389
symptoms, 386, 387
vaccination, 189
VBC, 15–20
viral testing, 389
COX-2 selective inhibitors, 358
Creutzfeldt–Jakob disease, 266
Cultural differences, 323
CYP2D6 gene, 362
CYP-P450 enzymes, 363
D
DEA, see Drug Enforcement Agency
Delirium, 208, 209
assessment, 276–278
clinical evaluation, 263, 264
Index
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401
clinical features, 263, 264
covid-19 pandemic, 279
denition, 275
identication, 276
PA/LTC, 275
pathophysiology, 275
prevention, 278
risk factors, 276
treatment, 278, 279
Dementia
challenging behavior, 272
clinical evaluation, 263, 264
clinical features, 263, 264
cognitive impairment
evaluation, 269, 270
medication management, 274
denition, 265
diagnosis, 267, 268
differential diagnosis, 265–267
pharmacologic treatment, 271
prognosis, 270
screening, 268
treatment, 272–274
Dementia of Alzheimer’s Type (DAT),
265, 271
Department of Veterans Affairs (VA)
CLCs, 73
community nursing facilities, 73
CVT, 73
end of life care, 74
HBPC, 72, 73
Homemaker Home Health Aide
program, 73
Hospital in Home, 72
telehealth, 73
Depression/anxiety, 211, 212, 378
clinical evaluation, 263, 264
clinical features, 263, 264
vs. dementia, 281
diagnosis, 282, 283
prevalence, 279
screening tools, 283–285
symptoms and risk factors, 280, 281
treatment, 285–287
Diabetes
challenges, 128, 129
complications, 127, 128
management, 130
medications, 129
treatment selection, 131, 132
type 1, 130
Diabetic medication, 355
Diabetic wounds, 249
Diagnosis Related Groups (DRGs), 1
Dietary Approaches to Stop Hypertension
(DASH), 359
Documentation and coding
history, 329
medical decision-making, 330
nursing facilities
assisted living facilities, 338, 339
consultations, 334
group practice, 335
home visits, 339
hospice care, 334, 335
“incident to” services, 336, 337
medicare, 338
multi-site same day visits, 335
NPP, 337, 338
split/shared visits, 335
patient visit, 328, 329
physical examination, 329
skilled nursing and non-skilled nursing
facility visits, 331–334
visit time, 330
Do Not Resuscitate (DNR), 305
Drive to Deprescribe (D2D), 352
Drug Enforcement Agency (DEA), 96, 97
Durable power of attorney, 302
Duty, 307
Dysphagia, 190
Dyspnea, 205, 206, 219
E
End-of-life care, 121
Ethical and legal issues
abuse, 298
autonomy, 294
benecence, 294
capacity evaluation, 303–305
denition, 293
end-of-life issues, 305, 306
exploitation, 299
delity, 295
justice, 295
law, 294
liability, 307, 308
mental capacity and competence,
300–303
neglect, 298
non-malecence, 295
paternalism, 295
racial disparity, 299, 300
research, 306
resident rights, 296–298
surrogate decision-making, 300–303
Excess readmission ratio (ERR), 165
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