Dr. Martha K. Presley and Dr. Bill Frist
Coronavirus has led to social isolation and lack of caregiver support. That can be fatal for fragile elderly people who don’t have the virus.
Coronavirus has changed the way we see life and health care. The immediate focus has been on infected patients. However, the effects of the pandemic are more widespread. Here are two patient stories that emphasize the far-reaching impact of COVID-19:
►Mr. Smith was an 83-year-old man who was in good physical and mental health, until he fell and broke his hip. He underwent surgery, but as many elderly patients do, suffered delirium from the surgical anesthesia. His delirium worsened with new medications and no family to help orient him to a normal daily routine. In bed with medical devices, new medications and no family is a recipe for disaster. But Mr. Smith could not have his family visit because of the appropriate visitation policies. He spent 30 days alone in the hospital. His delirium worsened, and eventually his wife chose to transition to hospice so she could be with him. He died a week later.
►Ms. Jones was a 93-year-old with Alzheimer’s disease. She was living in a memory care unit and was social, interacting with others and enjoying activities. When she was isolated because of COVID-19 precautions, she became confused and anxious. She could only see her family through a window. Because of her increasing agitation, her medications were increased. The amount of nursing oversight was decreased. One morning, she was found on the floor with bruises to her chin, a broken hip and a bleed in her brain. Her family did not want to put her through the stress of a hospitalization and surgery. She was admitted to a hospice house so her family could visit. She died a week later.
These cases illustrate the impact of isolation on elderly mortality. Hip fractures are serious in patients over 70 years old. But for Mr. Smith, his one-year mortality was only about 27%. With family support, he was likely to recover. For Ms. Jones, her prognosis was poor. Patients with advanced dementia over 70 who break a hip have a 55% six-month mortality. However, without social isolation and resultant loneliness, agitation and increased medication, Ms. Jones might not have fallen and possibly would have had more months to live.
Social isolation and loneliness are well-known risk factors for increased mortality in patients with advanced disease and advanced age. Implementing isolation was not inappropriate for either the hospital or memory unit; it was necessary public health policy. Even so, it contributed to the deaths of these two patients and many more who were not infected with COVID-19. In the end, hospice was the only time these patients were not alone.
There are many people who are even less fortunate than these patients, who spend their final days in institutions without any loved ones by their side. Universal testing in long-term care facilities and visitations in hospitals for the elderly should be a priority. Facility testing has been recommended by the White House, and many states are implementing testing for patients and staff and screening for visitors. The most significant issue is cost: One group estimates almost $440 million if every nursing home patient and staff member in the United States were tested.
These costs can be decreased. “Pooling” would allow batch testing, which could reduce cost as much as 80%. Though this is still significant, testing and screening should be a priority because of the high cost of prolonged admissions and the cost of life from preventable deaths.
Visitation for elderly patients
In addition to testing, policymakers should focus on a comprehensive plan to safely enable visitation for elderly patients in facilities and hospitals. The strategy should include testing for all patients and staff, but also screening for visitors, proper use of masks, availability of hand hygiene and a plan for isolating infected patients.
Ideally, this would be a federal, state and local collaboration. The federal government should provide guidance, but given the variation in infection rates, state and local governments will need to work with local hospitals and facilities to develop plans that consider PPE availability, infection rates and the composition of patient populations.
This is a fine line to walk. The facility death toll from COVID-19 is a tragedy. But the safety of institutionalized elderly patients is often in peril in our health care system. It is necessary we understand the implications of that in this pandemic and develop policies to address the silent COVID-19 deaths.