The spread of COVID-19 in nursing homes, residential care and assisted living has gained incredible attention in the past few weeks for very good reasons.  Residents living in nursing homes or residential care use common dining and activity spaces and, in many cases, also share sleeping rooms.  Staff providing care in these organizations often work in multiple different facilities and overall staffing is significantly lower than available in hospitals, which increases the risk for transmission of COVID-19.  Staff in nursing homes and assisted living have a much more personal relationship with the residents, because they care for them for months or years versus the hours or days that patients are cared for in hospitals.

The decision to initiate CPR has become more difficult.  We know that CPR substantially increases the risk of aerosolized SARS-CoV-2 and its transmission to health care workers (HCW) in the area of CPR.  For this reason, AMDA and other societies have given guidance on ways to reduce the risk, but these added risk reducing measures may delay initiation of CPR.  

SNFs are now required to report patients under investigation for COVID-19 (PUIs) and actual COVID 19 cases among their residents and HCWs (Health Care Workers).  The report is updated every working day (https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/SNFsCOVID_19.aspx ) and indicates that over 20% of our SNFs have one or more cases associated with their facility.  

The World Health Organization has recognized what experts in geriatrics and long term care medicine have known for over two months.  Unfettered COVID-19 infections are devastating to nursing homes and assisted living facilities.  Reports are finally coming out that more than half of the reported deaths have occurred in senior congregate living settings.  It is quite likely that the number of deaths is still far underreported.  Only when the epidemiologists review all of the deaths across the U.S. and the world during this pandemic will we have the true answer.  The sad truth is that the experts in our field already know the answer.  We’re just waiting for corroboration.

The Wall Street Journal reported on April 11 that over 2100 skilled nursing and assisted living facilities in 37 states had been infected with SARS-COV2 with over 2,000 deaths occurring. In Sonoma County, we have developed 2 workgroups for coordinating, disseminating, and implementing best possible practice ideas.  One workgroup consists of Leadership from Public Health (PHD), skilled nursing facilities (SNFs), Hospitals, and Foundations. The other has leaders from the assisted living (AL), residential care facilities for the elderly (RCFE), and Senior Living Communities.  In the latter group, we were relieved to learn that our county just developed a contract with Sonoma State University to house up to 580 seniors with stable COVID disease so they can be quarantined outside their home facility, reducing the risk of COVID transmission within this high risk population. 

On February 29th, the first case of COVID-19 was announced, occurring in Washington state in the Kirkland nursing home.  Geriatricians around the country immediately knew what this meant. CALTCM went into action and had our first webinar on March 9.  It’s six weeks later and we’d like to give everyone direction. For anyone who has not watched our webinars, we will redirect you to the most important, in the order that they should be watched.  Keep in mind, if you’re already far along the curve, some of this might seem remedial. We can assure you, it’s not.   

Note: This article was prepared by Mr. Horowitz and Dr. Ferrini with special thanks to Dr. Robert Gibson PhD JD, Psychologist, for his input. 

Our country now has the distinction of having the most COVID cases in the world.  Our response as a nation is a stress test that has exposed our lack of a coordinated system of health care in this country.  In my community, there remains a shortage of naso-pharyngeal swabs, a public expectation of easy access to testing (County Public Health Department can do 100-120 tests per day), and many facilities still don’t have real-time access to adequate PPE.  Because of the lack of PPE and nasopharyngeal swabs, testing in some facilities for influenza/RSV/Other viruses is not being done. There appears to be an over-reliance on quarantine of residents with respiratory illness as well as shelter-in-place strategy to keep their facilities COVID-naïve.

Nursing homes are always “putting out fires.”  That excuse is often used to avoid addressing critical issues.  There’s a reason that the federal Requirements of Participation recognize the need to have a person in a nursing home tasked with infection control. That person is designated as the Infection Preventionist, or IP.  Who normally does that job?  It might be an RN or an LVN.  It is often the Director of Staff Development, or DSD.  Infection control is usually one task among many for the person typically designated to be the IP.  How does that work? Is it enough?

At CALTCM, we are very concerned for the welfare of our very vulnerable post-acute and long-term care (PALTC) residents, families, and staff.  Because the world in our lifetime has not experienced such a rapidly moving and serious pandemic, CALTCM presented a Webinar on the COVID-19 coronavirus last Monday which was well attended (over 900 registrants) and is currently available to the public at no charge (for a limited time only) with additional resources on the CALTCM COVID-19 webpage.  Since that time, more important tools and information have become available.  The CDC now has posters and handouts on COVID-19 available on their web page in multiple languages that could be used for staff and visitor education.

A recent study published in JAMA, August 2019 suggests that in a large population prior exposure to strong anticholinergic drugs is associated with the risk of dementia. Previous studies by Richardson et.al. (2018) and Gray et.al. (2015) were small case-control cohort studies while these studies suggested an association between anticholinergics and dementia the sample size were too small to draw conclusions.  The findings of this large middle-aged to elderly cohort study by Coupland, et.al. advocates for deprescribing of anticholinergic agents in middle-aged to older adults (e.g. 55 years and older) to reduce the risk of dementia. 

As high-achieving health care professionals, we pride ourselves on our ability to do it all…take call for a colleague on a holiday, I can do that! Pull a double shift, no problem! Med cart audit before survey, I’m on it! “Volunteer” to organize the holiday party, sure! We have grown used to the fact that we are in an industry that is highly stressful, and we are expected to do more with less. We have all embraced this challenge because we have a passion for this field, we believe that our patients deserve our best, and our colleagues depend upon us to deliver maximum effort, every day.

CALTCM typically holds its Annual Meeting in April, sandwiched between the Annual Meetings of the American Geriatrics Society and AMDA.  For those of us in the field of Geriatrics and Post Acute and Long Term Care, it can get kind of crazy. This year, we’re trying something different.  We’ve moved the Annual Meeting to October 8-10, 2020. This also gives us more time to promote the meeting and work on growing our membership.

By now, we have all been aware of an outbreak of respiratory illness caused by a novel coronavirus (COVID-19 ) that was initially detected in Wuhan City, Hubei Province, China. Is your facility prepared? Are you up to date on recommendations about staff, visitors and even residents who have recently returned from international travel?

In the last issue of the WAVE, I reported on the potential direct clinical value of an excellent AMDA Webinar on Sleep Disorders in Older Adults. In that Webinar Dr. Kitamura mentioned a number of factors which could aggravate restless leg syndrome (RLS).  One of those, the prescribing of SSRI’s directly applied to one of my older patients with RLS who was requesting Ativan, because her Ropinirole was no longer working.  A month prior, I had started her on Lexapro for depression and had recently advanced the dose to 10 mg daily. 

On January 27, 2020, the saga that began in 2013 with a lawsuit against the California Department of Public Health (then captioned CANHR v. Smith) finally concluded, although some details remain to be worked out.  The bottom line is that in skilled nursing facilities, the Epple/IDT process, sometimes referred to as an Ethics Committee or Bioethics Committee (even though the composition of such a committee in nursing homes is rarely as robust as it is for hospital Bioethics Committees), is able to make decisions for incapacitated, unrepresented nursing home residents—including all psychotropics and end-of-life decisions—but a non-facility-affiliated resident representative must be part of the process.  

As some of you know, 2019 ended with the closing of my Post-acute & Long-term Care practice.  In the process, I turned over the care of my patients to 3 other physicians and my 2 facility Medical Directorships to 2 of my colleagues.  Having been the Medical Director for over 33 years at my CCRC, I have had some time to reflect on this role, beyond the CMS expectations and AMDA guidelines ((https://paltc.org/product-store/amda-model-medical-director-agreement-and-supplemental-materials-medical-director).  

• Deaths: 54 since Sept. 29, 2019
• Outbreaks: 16 since Sept. 29, 2019
• Laboratory: 27.7% positive
• Outpatient Influenza-Like Illnesses*: Above expected levels
• Hospitalizations: Above expected levels

For more information from the CDC on this years Flu activity, go to: https://www.cdc.gov/flu/index.htm

I recently received a text message from a nurse at my Geriatric Clinic that informed me “Mrs. X, (90 y/o) is demanding a prescription for lorazepam (Ativan) for an intolerable flare of insomnia and anxiety”.  She had seen a clinic colleague 2 days prior, who had declined this request, but did prescribe an alternative medicine for her restless leg syndrome (RLS). Though my next day clinic schedule was already full, I texted back to add her to my schedule.  

I’ve recently seen a spate of reports of individuals whose “life has been saved” by the Apple Watch. Reading these articles generally reveals that it was actually the onset of atrial fibrillation that was detected. While that is very important and promptly addressing atrial fibrillation can allow treatment to prevent devastating strokes, I have yet to see true evidence of saving lives. Until they build in a defibrillator, I suspect most of the health benefits from this type of remote monitoring will be identification of bradycardia, atrial fibrillation and other cardiac arrhythmias. A large study on the value of arrhythmia monitoring with the watch, The Apple Heart Study, has had its rationale and design published but the results remain to be reported. Versions 4 and 5 of the Apple Watch can take a single lead EKG, but I have not seen any reports where changing morphology is used to detect hyperkalemia or QT prolongation or ischemia. There is a paper in preprint on using the Apple Watch to take standard and precordial leads, by placing it on the leg or changing the finger used to record. It remains to be seen if this rather cumbersome approach has practical utility in a busy medical practice.