Older Adults in Long Term Care Amid COVID-19

Drug Topics®: Hi, this is Gabrielle Ientile with Drug Topics® and today I'm talking to Amie Blaszczyk, associate professor and division head of geriatrics at Texas Tech University Health Sciences Center School of Pharmacy, who will be discussing issues surrounding geriatric and long term care during the COVID-19 pandemic. Dr. Blaszczyk, thanks so much for joining me today.

Blaszczyk: You bet. It's my pleasure.

Drug Topics®: What is the potential of the pandemic to affect older residents’ mental and emotional health in nursing homes and assisted living?

Blaszczyk: I would definitely say that this is something that's looming large, and a lot of our team meetings and certainly with healthcare professionals that care for elders in this in this particular venue of care. So much of the social opportunities within long term care have been have been either reduced or eliminated: eating together, group activities, get togethers, all of those things have really been either drastically limited or just gotten rid of all together, and it's definitely a recipe for loneliness.

I think if any of us, even outside of the nursing home, people are struggling with this. Our staff are definitely on the lookout for depression, anxiety, insomnia, behavioral disturbances, maybe even just the atypical presentations of those disease states within our older adult patients. Speaking of those behavioral disturbances, sometimes those can signal issues with maybe sort of an augmented issue with dementia, your pre-existing dementia, or it could be delirium. And so we want to make sure that our frontline care providers know what is this look like when it presents atypically and really bringing that to the attention of the people who need to be made aware.

As pharmacists, we're also looking at medication regimens to ensure that medications are being utilized appropriately, and that important monitoring is in place so that they can be used safely. One of the other things that we have within long term care regulations that require us to recommend gradual dose reductions, and certainly this might not be the time for that; however, I think pharmacists are going to be really important when we kind of come to the other side of this pandemic - oh, gosh, hoping sooner than later. But I think pharmacists are going to be really important that if there was something that was started within the pandemic, and perhaps it could be perceived as situational, that perhaps, once the pandemic is over, or maybe it's subsided, and we're able to get visitors and families back into the facilities that were on the lookout for maybe medicines that were required during the pandemic that maybe aren't necessary now.

Drug Topics®: So a lot of the COVID-19 protocols that we're seeing such as stay at home orders, social distancing, and closing businesses are for at-risk people who are at higher risk of developing more severe COVID-19 symptoms, rather than just protecting ourselves. There's a real push for having more compassion, more empathy for other people, rather than just thinking of ourselves or even just our immediate family. Has there been something that you've experienced at your facility uplifting to you? We've seen people visiting their families through the windows just to make sure that they're seeing a person during the day, so has there been anything like that at your facilities?

Blaszczyk: Those are the most uplifting and heartbreaking at the same time, right? I would say that with our facilities, we've I've heard a couple of stories kind of trickle out from team meetings, but really with a lot of these group activities being shut down, this is definitely a time where you rely on the creativity of the activities directors in these facilities. I would say we need them more now than ever. What we're seeing a lot of use of video conferencing platforms like FaceTime or Skype so that people can still interact with their loved ones, can still see their grandkids and a lot of our frontline care providers. There are a lot of times they're the ones that are assisting with that. I know that one of our facilities actually had a scavenger hunt that they did with a limited number of residents and sometimes it's just getting people out of their rooms, getting them up and moving and looking around, so that they’re not feeling so cooped up because sometimes that can definitely have an impact on our behaviors that we could see, but also our psychological well-being.

Drug Topics®: What do you hope will come out of this pandemic in terms of improvement to caring for assisted living in nursing home residents and in Geriatric Care overall.

Blaszczyk: Okay, well, so this is a total pharmacist answer, but I'm certainly hopeful that we'll see more attention paid to de-prescribing. I always tell my students, deprescribing is this sort of new kind of fun thing that people focusing on deprescribing, but people in geriatrics have been deprescribing for years.

I'm just I'm old school deprescribing back when it was just called let's get rid of the medicines to people. But really, I'm hopeful that people will give a second thought to starting medications in the first place, but also taking a look at that entirety of that medication regimen, and looking for thing like: does this person actually need all of these medicines; recognizing that the more medicines that a person is on, the more adverse effects they can have. But also, the more often that they're being exposed to 1 or more individuals who are maybe passing meds.

We've also seen some facilities within the company taking a hard look at standing lab orders, recognizing that phlebotomists are typically not employed by the facility - they're typically going from facility to facility, sometimes within companies, and certainly they could be carriers of COVID. Taking a minute to think about whether your frail elderly patient truly needs that weekly INR or monthly CDC is always a good idea.

I would also say, taking off my pharmacist hat and as a human being who loves older adults and working with them, I hope it brings national attention to the isolation and loneliness that our residents can feel from time to time or maybe even every single day, even outside of the pandemic. I hope that it stirs people to volunteer, to visit these facilities, even if they don't have loved ones there, to shine a national spotlight on the fact that we've got an entire cohort of frail, elderly individuals who this is their home, but they may not have visitors. Hopefully the pandemic can shine a spotlight on the fact that there is some significant loneliness in some of our residents.

Drug Topics®: Those are all the questions that I have. Is there any other topics or any other things you see as important that you want to add before we wrap up?

Blaszczyk: Any chance I get it to talk about just the amazing frontline health care providers that we have in nursing homes. I've seen some reports that have kind of vilified nursing Home staff and placing blame on their shoulders for the spread of COVID within facilities, but if I can help somebody understand that it's just not that simple. Long term care is essentially, for lack of a better term, built for this disease to be devastating and spread the way it does. You're combining a resident patient population who's frail, has comorbid diseases, many have memory impairments, secondary to dementia. Then you put them all in a group living environment.

It's important to understand that while we can sort of look at a long term care facility - it kind of looks like a hospital, there's hospital beds, everybody has kind of a room, there are nurses everywhere - that this is the home for the residents who live there. A lot of these residents have Alzheimer’s and they wander or don't remember what we taught them 30 seconds ago about social distancing, so their life, their friends, their bedroom, it's all in this facility, and so we can't just tie someone down or lock them in the room to keep them from spreading it around. As I mentioned before, within long term care where we definitely have a lot of our frontline cleaning crew that are taking care of high touch surfaces because of the wandering. I've worked with some incredible nurses, incredible frontline health care providers who come to work, day in and day out, and bring joy and caring to the residents that they serve. I just always have to give them a big shout out, as big as I can possibly make it because I kind of think they're the unsung healthcare heroes of the pandemic for sure.

Drug Topics®: Dr. Blaszczyk, thank you so much for opening up conversation on this super important topic and for your continued work during the pandemic as well.

Blaszczyk: Absolutely. Thank you for having me.

Editor's note: This interview transcription has been lightly edited for style and clarity.

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