COVID-19 in older adults: clinical, psychosocial, and public health considerations

Complications of COVID-19 have been particularly severe among older adults, who are the focus of this article. Public policy goals should prioritize pandemic preparedness in nursing homes, as well as civic and local government-based support programs for community-dwelling older adults, to ensure that risk of infection is mitigated while promoting wellness during a period of stress and uncertainty.


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(12% for patients >60 years vs. 3% for patients <60 years) (8).Although 89% of patients experienced a fever (defined as a temperature greater than 99.5°F) during their hospitalization in one study, only 44% were febrile at the time of admission (9).
Though symptoms generally are more pronounced in older adults, asymptomatic or presymptomatic infections have been described in this population.During a point-prevalence survey conducted as part of an outbreak investigation at a nursing home in King County, Washington, 13 of 23 (57%) residents who tested positive were asymptomatic at the time of testing.Ten of 13 of these patients (77%) subsequently developed typical COVID-19 symptoms upon reevaluation 7 days after initial testing (11).
Common laboratory abnormalities include lymphopenia and thrombocytopenia (5).Higher rates of lymphopenia and anemia, lower albumin, and higher aspartate transaminase (AST) and C-reactive protein (CRP) are found in older adults compared with younger patients (8).Chest computed tomography (CT) is more sensitive than chest x-ray for detection of pulmonary disease.Bilateral pulmonary infiltrates that can consist of ground glass opacifications, consolidations, or both are among commonly found manifestations (10).
The incubation period for COVID-19 is typically 4-6 days, with 98% of patients developing symptoms within 11 days of exposure (12).The median time from the development of first symptoms to dyspnea was 5 days and time to hospital admission was 7 days (9).Symptomatic older adults are more likely to require ICU admission (9.6% vs. 1.4%,P < 0.001) and develop acute respiratory distress syndrome (ARDS) (16.9% vs. 5.4%, P < 0.001) compared with patients less than 60 years of age (8).Incidence of concomitant thromboembolism is high among critically ill COVID-19 patients (13).Outcomes can be devastating in the setting of sustained nursing home transmission.One Seattle area outbreak of 101 residents resulted in a CFR of 33.7% (14).This outbreak highlighted infection prevention disparities, deficiencies, and staffing challenges within a sector that cares for one of our most fragile populations.
There is no clearly established effective treatment for COVID-19 at this time.Care is predominantly supportive, including antipyretics and supplemental oxygen, as well as mechanical ventilation for those with respiratory failure.No specific therapies are recommended by the Infectious Disease Society of America outside of a clinical trial (15).Hydroxychloroquine, an oral antiparasitic agent, has been used widely with a paucity of supporting data.Ongoing promising clinical trials include those to assess remdesivir, an intravenous RNA polymerase inhibitor, and tociluzimab, an IL-6 inhibitor.Because SARS-CoV-2 binds to the angiotensin-converting enzyme 2 (ACE2) receptor, some have postulated that use of ACE inhibitors and angiotensin receptor blockers, which increase ACE2 expression, could worsen COVID-19 outcomes (16).However, there are no clinical data to support this hypothesis and concern exists regarding abrupt discontinuation, particularly among older adults at risk for cardiovascular events.The American Heart Association recommends continuing these medications in patients with COVID-19 unless advised otherwise by their physician (17).

Psychosocial considerations
With community spread increasing, health care facilities have been urged to suspend all nonessential visits.This guidance has been beneficial in delaying or reducing nosocomial spread within hospitals, assisted living facilities, and nursing homes.However, unintended consequences of social distancing have resulted in more isolation among older nursing home residents, reduced physical activity, as residents are unable to use rehabilitation gyms, and lack of friendly visitors as a way to enhance psychosocial wellbeing.Furthermore, there have been tragic instances of COVID-19 patients dying alone without their loved ones nearby.These risks can be mitigated to some extent by rapid testing of vulnerable population caregivers and having good, honest, and in-time communications with families early and often (18).
With COVID-19 spreading widely, particularly in larger metropolitan areas within the United States, overwhelming numbers of older adults with comorbidities and frailty have led to a high number of older adults requiring medical attention, including ICU care, at the same time.Several of these patients have required intubation and prolonged mechanical ventilation.This has led to a shortage of ventilators, compelling frontline clinicians to make difficult and uncomfortable choices in rationing life-sustaining care.With no definitive therapy available, providers have little to offer.In these situations, discussions with palliative care teams are critical to decide the goals of care and to communicate with families who are unable to visit their loved ones.These teams generally consist of a palliative care physician, nurse practitioner or physician assistant, social worker, and nurse case manager.These teams have been crucial in helping frontline clinicians draft management plans, decide on goals of care, and communicate with families (19).
As result of consolidation of outpatient operations and social distancing measures, healthy community-dwelling older adults are often devoid of necessary support, knowledge, and adaptive strategies to manage their day-to-day routines and are at risk of worsening their underlying comorbidities.Communicating with "well and worried" older adults using virtual lectures via senior community-based centers and learning communities, and ramping up virtual and video health visits have helped mitigate some of these concerns -albeit only for those who have access to these resources (20).

Public health and policy impact
Our health care system has evolved tremendously in the last decade -largely in response to reducing inpatient hospital stays.Innovative models such as using nursing facilities for short-stay rehabilitation, longterm acute care hospitals for patients requiring long-term ventilation, house calls, and hospital-at-home programs to allow seniors to "age-in-place," have moved health care out of the hospital walls, and helped older adults recover from acute illness and maintain their functional independence.However, this pandemic has shown glaring gaps in preparing these sectors and patients for emergencies, particularly those related to preventing infections and managing outbreaks.
Developing, adopting, and testing disaster preparedness plans, including for pandemics, in post-acute care settings including nursing homes, assisted living facilities, and long-term acute care hospitals is of paramount importance, given the wide spectrum of COVID-19 symptoms and high risk of severe outcomes in older adults.This can be particularly challenging considering the limited human and material resources dedicated to infection prevention at many facilities.Much like the rest of the country, public health and infection control infrastructure in these facilities needs to be substantially enhanced and modernized.
In general, the United States has become too reliant on single-use products, including standard personal protective equipment (PPE).With resources generally directed to acute care hospitals first, these challenges are compounded in poorly resourced facilities that care for an aging demographic.Increased use of items that can be disinfected and reused can allow for a much safer and controlled response to outbreaks.This pandemic has taught us that the supply chain for medical and infection prevention supplies needs geographic diversification.A paucity of manufacturing sources and just-in-time inventory management limit the ability

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to rapidly increase PPE supplies in times of high Having stockpiles of important infection prevention items, such as N95 and surgical masks, can provide much needed protection for health care workers while a health care institution determines how to replenish supplies.There is also a need for more no-touch technology in hospitals and other care sites to decrease transmission risk for health care workers, patients, and visitors.The situation is often worse in nursing homes, where typically, less PPE is available on site, and adaption of novel infection prevention technology often occurs much later than in acute care settings.
A clear lesson from the COVID-19 pandemic is that nursing homes are an important, high-risk target for emerging pathogens due to the presence of vulnerable patients, frequent sharing of medical staff and patients with multiple other institutions, and frequent visitors (14).Proactive pandemic planning in nursing homes includes active symptom screening for illness among health care workers and staff, including temperature checks, strict visitor limitations, limiting group activities, and practicing universal masking and droplet precautions once local community transmission of COVID-19 has been identified (Table 1) (21).Developing a robust pandemic response plan in nursing homes requires not only physical but human capital.Sustaining a healthy and well-trained workforce is essential and requires investment through standardized education on hand hygiene and PPE use, as well as generous sick leave policies and overall prioritization of staff retention.Established lines of communication between institutional medical directors, corporate leadership, and local health department authorities allow for rapid coordination of infection control response plans.
COVID-19 has shown the ability to devastate vulnerable populations, including older adults.It has also resulted in rapid and unprecedented changes in health care delivery and restrictions on typical day-to-day community activities, both of which have an outsized impact on older adults.Public policy goals should prioritize pandemic preparedness in nursing homes, as well as civic and local government-based support programs for community-dwelling older adults, to ensure that risk of infection is mitigated while promoting wellness during a period of stress and uncertainty.Address correspondence to: John P Mills, University of Michigan Medical School, Division of Infectious Diseases, University Hospital South Room F4177, Ann Arbor, Michigan 48109, USA.Phone: 734.998.6060;Email: millsjo@umich.edu.Or to: Lona Mody, University of Michigan Medical School, Division of Geriatric and Palliative Care Medicine, 300 N. Ingalls Road, Room 905, Ann Arbor, Michigan 48109, USA.Phone: 734.764.8942;Email: lonamody@umich.edu.