Stopping COVID19 in Nursing Homes is No Easy Task

My city, Louisville KY, recently had a spike in COVID19 infections. It came from a handful of nursing homes.

That nursing home and long-term care facilities account for large percentages of COVID19 cases has been well documented. In some cities, the majority of cases come from these facilities.

These facts have sprouted platitudes about “protecting our elderly.” What makes this a platitude is that it belies the challenges faced by nursing facilities.

Two recent papers shed light on these challenges.

First is an article by Chris Pope in the City Journal. Second is an academic-like defense of Stockholm City’s elderly care. The latter paper came in response to the former chief epidemiologist of the Public Health Agency of Sweden Johan Giesecke who bluntly said that Sweden has failed in protecting those in elderly care.

My wife spent a handful of years practicing palliative care and hospice in nursing homes. Her stories confirm the challenges brought out in both these papers.

I don’t think many people get the reality of life in nursing facilities.

Taken from these two articles, here are 7 challenges for protecting people from COVID19 who live in nursing facilities:

• Residents spend most of their day in close contact with others, indoors, eating meals together, often sharing rooms, and needing high-touch care from caregivers who move room to room.
• How can you social distance when residents need on average of four hours daily of personal care? Why so much? Almost half of residents have dementia, 2/3rds have bladder incontinence, 1/3rd require rehab, 2/3rds are chair-bound and 15% require respiratory therapy.
• Healthy people do not get admitted to nursing homes. The vast majority of residents have not one but multiple chronic conditions, such as high-blood pressure, heart disease, diabetes and lung disease. (All risk factors for COVID19 mortality).
• People in nursing homes are already near death. [I]n 2016, while nursing-home residents made up just 0.4 percent of the U.S. population, they accounted for 19 percent of deaths.”
• Because of the last two points, residents of nursing facilities travel back and forth from hospitals–further increasing the risk of being infected with serious pathogens.
• Work in nursing home is neither glamorous nor well-paid. “Nursing-home staff often work in multiple facilities, share housing with those who work at other care homes, and rely on public transportation.”
• While many nursing residents have advanced dementia, many do not. The isolation of people from other people, including their loved ones, is hardly an easy intervention.

While these words lay out problems not solutions, I do so in hopes to provide some reality to the difficulties in protecting the most vulnerable.

Often heard on our hospital wards is something like this: “Mrs Jones is going to the nursing home to get stronger.”

While this is true for a select few elders who’ve had a recent surgery or brief illness, for many elders, the truth is they are going to the nursing home because they are too frail to be home. And that frailty is a result of their long life.

I’ve said before that I hate this virus. I wish it never came.

But its presence does seem to be teaching us a lot.

One lesson has been the dangers of accepting shoddy medical evidence (hydroxychloroquine); another is the limits of epidemiological models, and a third may be the stark realities of protecting older vulnerable patients who are close to the end-of-life.

We can hope that advances, say, better testing, more protective gear for nursing home workers, a vaccine, or even smarter policy changes will help reduce the effect of COVID19 on nursing home residents.

But it won’t be easy. We will have to be careful with what we consider success and failure.

JMM

P.S. I wonder if mandatory 2-month rotations in nursing facilities for medical trainees might help doctors better understand the realities faced by older patients.