MDS Alert

Elderly people may present differently; know what to look for.

Statistically, the disease COVID-19 and its complications, caused by the novel coronavirus SARS-CoV-2, kill more older people than young people. Long-term care facilities are uniquely vulnerable, so make sure your staff know which symptoms to look for.

The media generally shares the Centers for Disease Control and Prevention (CDC)’s guidance to look out for fever, dry cough, and shortness of breath as the main symptoms of COVID-19. But older folks may present differently if infected — and the timeline in which the disease plays out may be different, too.

Note Changes Over Time

“Now for many, symptoms run their course in about a week and then start getting better. But in others, things can get worse, leading to severe shortness of breath, pneumonia, and something called acute respiratory distress syndrome, known as ARDS, where the lungs fill with fluid,” says Brendan Jackson, MD, MPH, CDR, medical epidemiologist from the COVID-19 response clinical team at the Centers for Disease Control & Prevention (CDC) in Atlanta, in a Clinician Outreach and Communication Activity call focused on COVID-19 updates for long-term care facilities.

“Not everyone with COVID-19 will have a fever. We all know that older adults, especially those with severe medical conditions, don’t always display typical responses to infection. So, that said, the early symptoms of COVID-19 in these patients may be a little bit vague. Things like confusion, or just general malaise and not feeling well,” Jackson says. Monitor residents’ temperatures and note even slight increases in temperature that might not qualify as a fever.

“We want clinicians to know that people may not develop shortness of breath until they’ve already been sick for several days. We’ve seen this on numerous occasions … even into their second week of illness. In one report in China, the average patient wasn’t hospitalized until day seven of their illness. And sometimes people may be fairly stable for about a week and more quickly develop respiratory failure. So be on the lookout for that,” he adds.

Another important thing to note: Use caution with intravenous fluids, Jackson says. If affected residents have respiratory distress and are already prone to volume overload or pulmonary edema, that extra IV fluid may end up in their lungs, worsening their breathing.

Also be careful about secondary infections. Jackson says that infection on top of COVID-19 is not common, per se, but bacterial or fungal infections can happen, and so can drug-resistant infections.

In SNFs, consider adding pulse oximetry and heart rate to the regular vital sign checks, if your facility doesn’t do this already, Jackson says.

Make Prevention a Priority by Limiting Entrance

Surveyors are looking to ensure facilities are preparing adequately for COVID-19 by boning up their infection control and prevention procedures, after finding deficiencies in a Kirkland, Washington, facility that may have allowed COVID-19 to flourish.

“Both residents and older visitors have had mortality rates substantially higher than the general population, making infection prevention and control all the more important. Second, when it comes to signs and symptoms, please educate your staff on what those signs and symptoms are and their critical role in protecting residents,” Jackson says.

One important aspect of prevention? Limiting the entrance of visitors and even staff into your facility.

“We’ve discovered clusters of symptomatic residents at not just one facility, but at multiple facilities in the same geographic area. And during those investigations [we] have identified ill healthcare personnel as being among the earliest identified cases of COVID-19 in facilities. We’ve also seen visitors of long-term care facilities developing COVID-19 and have seen movement of both ill healthcare personnel who may work at more than one facility, and residents being associated with outbreaks,” says Lieutenant Commander Kara Jacobs Slifka, MD, MPH, a member of the U.S. Public Health Service and a medical officer from the COVID-19 Response Clinical Team, in the call.

If you aren’t already fighting COVID-19 in your facility, don’t let your guard down; take action now. CDC guidance and state and local governments have led to many facilities banning visitors entirely, but make sure you evaluate staff and services, too.

“The first step may be to create a list of staff, visiting consultants, volunteers, and any other services that enter your facility. This will look different for every facility. But what you may consider doing is engaging each of those different services and providers in order to create a plan for how you may limit or even stop visits. Consider looking at the services provided and creating a list of services that absolutely must continue for the necessary medical care of your residents, those that may be delayed, or those that may be stopped, even temporarily,” Jacobs Slifka says.

“Ultimately, the decision about which personnel should be restricted will need to be determined locally, at the facility level,” she adds.

David R. Wright, director of quality, safety & oversight group at CMS, had released guidance earlier in March for facilities to establish social distancing practice for residents within the facility as well, including canceling activities and dining room meals.

Don’t forget that part of your preparations should include establishing a chain of communication with staff, if you don’t have one already, so you can rapidly disseminate any messages, she says.

Staff should also be allowed — and encouraged — to stay home when sick, Jacobs Slifka says. “Staff should regularly monitor themselves, even when they’re not working, for fever or symptoms of respiratory infection. And when staff come to work at the start of their shift, they should have their temperature taken, along with symptom screening. Ill staff who are identified throughout the workday should immediately stop what they’re doing, put on a face mask, notify the facility, and go home.”

Check out this CDC checklist for other means of preparation: www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf.