Download Appendix 2: Key Points for Patients Download Appendix 3: Key Points for ED Clinicians View Supplement 1: Covid-19 Delirium Care View Supplement 2: Emergency Department Discharge of Older Adults with Viral Syndrome During the COVID-19 Pandemic View Supplement 3: Preservation of Function in Older Adults Who Are in the Emergency Department During COVID-19

As of noon March 18, 2020, 7,038 cases of COVID-19 have been reported in America.¹  Numbers are predicted to increase dramatically due to increases of testing.  There have been 116 deaths, mostly in older adults.  There are 106 patients now reported as fully recovered.  Twenty-three older adult deaths were a cluster from one nursing facility in Washington state.² Currently, 49 states have reported cases of COVID-19 infection, and President Trump has declared a National State of Emergency. Without widespread containment measures, the number of cases is projected to double every 6.4 days.³

COVID-19 differs from other viral URI’s because of virulence.  The virus lives on surfaces for up to 9-days and is more contagious than influenza. There also exists no herd immunity for this novel infection, and to date no vaccine exists.⁴

This manuscript presents two common case scenarios to illustrate the central role of the Emergency Department (ED) in the diagnosis, acute management, and community care coordination of complex older adults in this rapidly changing situation.

Due to physiologic changes of aging, decreased immune function, and multimorbidity, older adults are at significantly increased risk from COVID-19.⁵ See Appendix 1 for Key Points for Patients. Older adults are more susceptible to the infection itself and are more likely to suffer from the severe form of COVID-19 disease and to have complications.

Aging may also complicate diagnosis, as older adults with respiratory viruses often present atypically.  The median duration from symptom onset to death is 11.5 days in persons >70 years vs. 14 days in younger persons.⁶

The definition of fever may need to be altered for older adults. Please see the section on what is fever below.  A careful fever evaluation is essential in older adults as based on a new report by Cao et.al.⁷ Cao showed rapid increases in visits, with 40% of all ED visits for fever evaluation. Based on such numbers, administrators would anticipate the depletion of personal protection equipment effecting majority of ED providers.

A recent World Health Organization report found that the case fatality rate for COVID-19 patients older than 80 years in China was 21.9%, while patients of all ages with no underlying chronic conditions had a fatality rate of only 1.4%.⁸ It should be considered that issues such as inadequate ED or ICU care, or lack of resources could also adversely affect mortality and that age is one of many such factors.

Mortality data emerging from Italy reveals the staggeringly high risk of this virus for older adults.⁶ In Italy, where 23% of the population is over 65 years, 89% of COVID-19 deaths are over 70 years old (31% between 70-79 and 58% are over 80 years old).⁷

On the hopeful side, 103-year-old Zhang Guangfen was admitted to Wuhan’s Liyuan Hospital March 1^st and has completely recovered.

Should we use a temperature of only 100°F to screen for disease in older adults? COVID-19 symptom screenings often use fever as an important sign of illness.  Data from China inform that fever is the most common sign, with 83% of 99 inpatients with mean age 55 (15% over 70) exhibiting fever.⁹

However, fever may not be a sufficiently sensitive sign in older adults, as it is frequently blunted or absent even in serious infection.¹⁰ Lacking specific data from the evolving COVID-19 epidemic, influenza, another respiratory virus with significant mortality in older adults, also informs the sensitivity of fever in older adults.  One ED-based study shows that only 32% of patients over 60 years with proven influenza had triage temperatures >100˚F.¹¹ Temperature may be even less sensitive among our most frail older adults, those in senior living, who carry the highest risk from infection.

The Infectious Disease Society of America recommends modifying the definition of fever for older adults to:

• A single oral temperature over 100°F, or
• 2 oral repeated temperatures over 99°F or
• an increase in temperature of 2°F over the baseline temperature.¹²

Currently, COVID-19 testing is limited, and variable site-dependent guidelines exist. Restrictions on who can be tested will decrease as test availability increases. As of March 16, 2020, the CDC recommends priority COVID-19 testing for older adults, individuals with chronic medical conditions, and immunosuppressed individuals.²³ In practice, this means that older adults with fever and/or respiratory symptoms who test negative for influenza should be considered for priority COVID-19 testing.  If the individual has stable vitals and no, or only mild, clinical symptoms, it is wise to test in locations other than the ED when possible. Even when testing becomes more available older adults should receive preferential access.²¹ Follow CDC protocols.

Forward triage is the EMS sorting of from senior living (nursing home, assisted living facility, independent living communities) and of homebound older adults.  This triage is critical to optimizing emergency and inpatient resources while minimizing risk of harm to patients^.15 Decisions to transfer older adults from facility-based care are often variable and site specific. To limit demands that could overwhelm EDs, transfer decisions may be adapted based on co-morbid illness burden or frailty.⁴ Ideally, preexisting protocols for transfer can be cooperatively augmented by the hospital, the ED, EMS, public health officials, and referring facilities and agencies to address COVID-19 specific concerns.¹³  Decisions may change as based on disease activity, and hospital and community diagnostic and treatment capacity.¹⁴

Resources for community-based forward triage vary by region and may include telehealth, community paramedicine, home-based primary care, home health nursing, and facility-based complex care management.

Older adults needing only COVID-19 and influenza testing, or those with less acute medical needs should be referred to testing locations or medical settings outside of the ED. People experiencing only subtle symptoms may be observed/monitored by caregivers where they live, with follow up by telephone to support any changes in condition. However, all patients at risk of COVID-19 should be appropriately isolated from other vulnerable older adults.

Transfers of older patients’ to and from assisted care is critical in the management of those most vulnerable in our society.  Care from the ED may become delayed by nursing facilities’ ability to receive transfers back of their own patients. On March 12, 2020, CMS waived an important restriction to nursing home and skilled nursing facility (SNF) access called the “the 3-day rule”.²⁴ This CMS regulation required 3 days of inpatient hospitalization for a patient to qualify for CMS payment of admission into SNF rehabilitation.

Relaxation of this rule with this waiver now allows direct transfer of appropriate stable older adults to SNF from the ED. The implications of this new transfer ability to free both ED and inpatient resources is clear and may greatly reduce burden of stable patients who require only skilled care.²⁴

SNFs may have limited ability to isolate patients with suspected COVID-19 infection as many have limited private rooms. Proactive planning between hospitals and area SNFs around infection control resources and capacity is high priority during this outbreak. Guidance has been provided by the CDC, CMS and trade associations to reduce risk of transmission.

Training of SNF and NH workers in appropriate techniques is paramount. Instructions for implementation of isolation/contact precautions can be found at:

https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html.

See Appendix 1 for additional systems- based resources.

Older adults living in senior living facilities are at highest risk of mortality from COVID-19, given their baseline co-morbidities and exposures resulting from their congregate setting. Of the 120 residents at LifeCare Center in Kirkland, WA, 63 tested positive for COVID-19; 13 died in the hospital with confirmed COVID-19 and 11 died at the center without results of postmortem testing.² Over four dozen staff members were also infected. Because of close interpersonal interactions among residents, and between residents and staff members, teams in these living arrangements should check CDC and Department of Public Health websites for updated instructions on limitation of transmission.

Assisted living facilities and SNFs across the country have curtailed access to their facilities for family and friends, as well as vendors. Facilities are limiting activities, as well as congregate meals and reducing the number of patients’ individual staff work with, when possible. Of note, assisted living facilities provide a lower level of care than SNFs. While most SNFs can provide oxygen, IV medications, and nebulizer treatments, assisted living facilities have much less nurse staffing, clinician presence and decreased ability to provide medical care.

Telehealth is more important than ever during the COVID-19 pandemic. Utilizing telehealth can keep patients safer by minimizing exposure to infection. Telehealth can serve to triage patients to best care and testing locations, avoiding the ED when appropriate. Finally, telehealth can also provide care for certain routine medical appointments.

Telehealth in senior living models exist and show promising results. Shah and colleagues described a telehealth model in which long term health workers, in partnership with emergency physicians, provided a basic assessment of changes in vulnerable older adults’ condition.¹⁶ Other systems such as Avera Health¹⁷ and Dartmouth Hitchock¹⁸ have advanced telehealth systems providing acute care over long distances. The West Health Foundation has considerable expertise in telehealth.¹⁹

The spread of telehealth has been limited by lack of consistent Medicare coverage; however, CMS reduction of regulations during the COVID-19 crisis will increase available telehealth options rapidly.²⁰ All health care systems should be actively implementing telehealth systems as telehealth is clearly a useful component of the strategy to fight the spread of COVID-19.

The Center for Medicare Services reported March 17^th that it will immediately expand coverage for telemedicine nationwide to help seniors with health problems stay home to avoid COVID-19 infection.²⁰ This new option will allow millions of older people to address ongoing medical problems as well as new concerns, while heeding public health advice to stay home during the outbreak.

All attempts should be made to limit spread to and among patients. Rapid spread will create acute resource limitations.  Overcrowded EDs increase risk of viral spread.²⁵ Plans to separate patients with respiratory illness from others should be immediately enacted. Triage of those not requiring emergent evaluation should be implemented wherever possible. The possible establishing of COVID-19 units, rapid discharge of non-COVID “well” patients, and postponement of elective surgeries can all be useful in decreasing ED overcrowding and limiting viral spread.²¹

All attempts should be made to limit spread to and among providers. Lack of personnel protective equipment (PPE) has been reported at many hospitals. PPE includes surgical masks, N95 respiratory masks, goggles, face shields, gloves, and gowns. Emergency clinicians are in the forefront of initial patient contact and care during disasters. The American College of Emergency Physicians has reported two emergency physicians are now in intensive care with COVID-19 disease.²⁶ Society cannot afford to lose the pivotal care of those on the front line. Therefore, it is imperative that we all practice careful use of PPE with correct donning and doffing of equipment and take needed self-care measures for health especially during times of disaster.

The current and future potential limitation of facilities and equipment should be immediately addressed. Many countries with active COVID-19 are experiencing shortages of ventilators and ICU or inpatient beds. Given the current data on the severity of disease in older adults, this shortage will disproportionately affect older adults.

Access to prescription medication is important. Older adults in the community may have difficulty accessing necessary medications after discharge. Some EDs have the resource to provide medications directly to patients,²⁷ which can not only enhance access but decrease spread by eliminating trips to the pharmacy. Many pharmacies offer home delivery. Caregivers should be instructed to review patients’  medication to ensure adequate supply. Organizations recommend having additional drugs on hand for quarantine situations.  30-day supplies are typical and often covered by insurance. However, people with difficult access should consider having physicians prescribe a 90-day supply.²⁸ A “quantity limit exception insurance form” may allow patients early refills. Such Medicare forms can be found at:

https://www.express-scripts.com/art/medicare16/pdf/CoverageReviewFaxForm.pdf.

Fortunately, many plans already allow these exceptions for the COVID-19 National State of Emergency.

Over the counter medications are also important especially those used for control of viral symptoms and fever. Please ensure adequate acetaminophen is available for fever control.

All people may feel anxious as they hear repeated news reports of the COVID-19 pandemic and deal with quickly changing circumstances. Up to 30% of older adults have age related cognitive impairment.²⁹ Rapidly evolving situations are more difficult to navigate for these older adults.

Sleep and maintenance of circadian rhythms are critically important to immune function.³⁰ Sleep deprivation affects various components of the immune system, such as the percentage of CD4+ and CD8+, subpopulations, and cytokine levels.³¹ One of the simplest recommendations we can make to older adults to help prevent disease transmission and mitigate anxiety is to sleep well.  Healthcare providers are also encouraged to protect their own sleep during this stressful time.

Anxious patients often reach out to their health providers. It is important to direct such calls appropriately. Ensure that clear, easily accessible directions are provided. Family and caregiver check-ins for patients who are vulnerable and have cognitive limitations are essential as this provides baseline information for clinician decision making that if absent may lead to overtreatment.

Social isolation and anxiety generating news reports may take an emotional toll in older adults and their care partners. Many experience isolation at baseline, due to institutionalization, and impaired function and cognition, and thus face loneliness and anxiety with little reserve. Lack of family visitors may limit the most meaningful part of an older person’s life. Lack of regular interactions may decrease ability for a caregiver to pick up on changes in cognition and function. Additionally, isolation may restrict needed access to food and medication, and lead to unrecognized falls or health deterioration.³² If possible, regular phone calls or video conferencing with caregivers can be very helpful. Additionally, all of us should reach out by telephone or video, to older adults in our sphere, and encourage others to do the same.

Older adults may have home care aides, therapists, or other professionals coming into their homes. Emergency providers may have the first or only opportunity to educate support personnel on infection precautions. Clear guidance must be provided to home care & home health agencies.²² It may be useful to refer to discipline specific websites for direction. These health care providers must also protect themselves and their patents from COVID-19 exposure.

Older adults with cognitive impairment will pose unique needs during isolation. Many dementia care supporters such as family or care partners, trained sitters, volunteer visitors may become limited secondary to illness or concern for spread of disease. Caregivers or medical personnel should understand that their use of personal protective equipment may be disorienting for the person with dementia. Further, as illustrated in the second vignette, it may be difficult concurrently to keep face masks or oxygen on patients who cannot understand the situation. Frequent prompting will be important to remind patients and caregivers of hygienic practices both in the ED and home care setting. Check with caregivers for alternative plans for care management if the primary caregiver should become ill. EDs should discuss the risk/benefit of allowing caregivers to be with older adults with cognitive impairment and consider whether to limit visitors for containment purposes.

The Alzheimer’s Association has a 24/7/365 Helpline for care partners and health professionals, and local chapters that can provide additional support and resources.³³

Older adults are particularly vulnerable to adverse events during care transitions (changing from one location or one set of care providers to another). These may include adverse drug events or medication errors, falls, abuse or neglect, pressure ulcers, dehydration. The risk of dehydration and delirium are increased with infections such as COVID-19. Protocols should include specific guidance on care transitions.  Use of checklists and warm hand-offs, calling the next site of care to ensure coordinated transition, will help ensure essential steps are consistently followed.

Older adults may have family members, paid or unpaid care partners who are friends, neighbors or others in the community who provide care.  There is anxiety around COVID-19, and caregivers need reassurance and information so that they know what steps they should take to protect themselves and the patient. They also need to know who to call or email for further direction. Simple 1-page, easily understandable written materials can be developed and distributed to care partners by the ED, nursing facilities and home care agencies. See Appendix 2.

Many physicians and nurses are themselves older adults and hence are at high risk during this pandemic. Those who have concerns for their health should be invited to “tap out” to allow for their younger counterparts to provide direct patient care or should consider using telehealth strategies to provide patients’ care. The closure of schools in most states, will strain childcare needs and limit healthcare staff availability. Nursing administration may need to consider flexible staffing hours to fill openings. Health care workers who have COVID-19 symptoms (fever, cough, shortness of breath) should remain at home. Health professionals should be directed to the latest and reliable resources for COVID-19 testing and information. Also, see Table 1 and Appendix 3.

Older patients who are sent to the ED, instead of being sent to alternate testing sites, will place patients at risk for exposure and potentially overextend limited ED resources. Review appropriate updated CDC criteria for testing and know the testing protocols. A remarkable aspect of the case series from China was the human-to-human hospital-associated transmission among 41% of cases.⁶ This high rate of transmission occurred to other patients and hospital workers.

The ED is a critical site of care coordination. In anticipation for a surge of patients in the ED, hospital administrators should consider many simultaneous strategies to keep patient flow safe and decrease overcrowding.  Hospitals can collaborate with outpatient resources such as area SNFs, home health, primary care providers, office of aging, EMS, and hospice settings. The goal is to assist with transitions of COVID-19 affected older adults in an efficient and timely manner. Similarly, EDs must coordinate clear and rapid transitions to inpatient units especially intensive care units, and respiratory/pulmonary medicine. Use of palliative care resources can improve coordination of care and optimal use of the ED for those at greatest need. Initiating a 24/7 call line between the ED and individual SNF administrators will allow for coordinated care and decision making.

Since older adults are most likely to require present with severe or critical presentations and require critical care it is important to acknowledge the limitations of current therapies and inform providers of evolving treatments. COVID-19 treatments are evolving on a daily basis. Providers must update themselves fully at the time of implementing any treatment strategies.

Severe patients present with dyspnea, tachypnea >30/min, saturation <90% and >50% develop lung infiltrates within 1-2 days.³⁴ Critical patients present with septic shock similar to that of sepsis from any cause, median duration from illness onset to dyspnea was 8 days and to mechanical ventilation was 10.5 days.

Antiviral drugs including oseltamivir, ribavirin, lopinavir, and ritonavir have been tried. Remdisivir was used in one United States case with good results.³⁵ Studies using corticosteroids did not show survival benefit and noted delay in viral clearance.^36,37 Angiotensin converting enzyme 2 is critical for COVID-19 entry into host cells.  The therapeutic potential of soluble recombinant ACE2 proteins³⁸ are being tried. Chloroquine phosphate has shown efficacy in COVID-19 associated pneumonia in clinical studies.³⁹

Finally, prior pandemics from other corona viruses such as Severe Acute Respiratory Syndrome (SARS) in 2012, and Middle East Respiratory Syndrome (MERS) in 2002 have occurred.  These corona viruses spread across populations in similar fashions.  Although these pathogens are still active, they disrupted society for only short periods and have since shown limited impact on human populations.  This is despite the fact that no commercial vaccines for MERS exist.⁴⁰ Fatality rates for MERS was >35% and SARS was >10% both significantly higher than current COVID-19 death rates.

We hope that with the current level of attention and marshalling of our health care resources against this outbreak, we can limit harm to all our patients including the most vulnerable older adults.

Co-Editors in Chief: Michael L. Malone, MD and Teresita M. Hogan, MD, FACEP

Conflict of Interest: Michael L. Malone owns stock in Abbott Labs and Abbvie.

The authors would like to thank West Health, The John A. Hartford Foundation, and the Institute for Healthcare Improvement for their contributions and collaboration in creating this edition of JGEM. Likewise, the authors thank Rebecca Stoeckle, from the Education Development Center, for her input on this paper. Finally, the authors thank Stephanie Steger for her administrative support.