SciLine interviewed: Dr. Bruce Troen, a professor of medicine and chief of the Division of Geriatrics and Palliative Medicine at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences. His research is focused on geriatric medicine, aging, and care for older patients.
What is the current state of the COVID-19 pandemic, particularly among older adults?
BRUCE TROEN: We are still in the thick of things. Matter of fact, as many people have been making some sports analogies, maybe we’re in the second inning of a nine-inning game. It’s easy to understand how everybody is eager to get out and that we’ve perhaps overcome the initial surge, but that’s really not what’s gone on. The surge has peaked in a number of states – states like New York, Massachusetts, New Jersey, even Louisiana. And deaths have come down there, but deaths are – hospital cases. So new cases, hospitalizations and deaths are continuing to rise in now at least 20 other states, and many of those rises are actually occurring in rural areas that, by their infrastructure inadequacies, are often ill-equipped to handle what might be an influx of new patients into hospitals and patients that might need intensive care. So we have a long, long road ahead of us. And so we’ve been able to make some important strides, and we can talk a bit about what those strides are and what we continue to need to do. But no – and I realize this is a message which is not too positive. But the opportunity is to, say, figure out what’s worked, let’s continue doing that and then really be diligent and vigilant so that we can try to minimize the impact and, of course, the deleterious consequences to vulnerable members of our population.
Is this a risk for all older people or just those living in nursing homes?
BRUCE TROEN: Yeah, that’s a great question. First off, we don’t have the full evidence to be able to comment with certainty on this, but I think we can make some extrapolations. So first, let’s try to delineate what it is that puts individuals at risk. So it looks like age, likely as an independent risk factor, makes a difference. But we also know that there are significant increases in risk for people who have underlying heart disease, kidney disease, lung disease, diabetes and if you are obese. Now, we know that people in nursing home settings or residential care facilities have been at higher risk for a number of other factors, a lot of them environmental in the sense that there are a lot of individuals who are close together, they partake of meals together, there’s a lot of staff interacting with them. And on top of that, many of these individuals, as many as 50% to 55% of residents in nursing homes, have cognitive impairment or outright dementia. And while dementia, per se, doesn’t make you more likely to contract the illness, it does unfortunately make it more difficult for you to take precautions or for others to help you take precautions that would minimize the risk of infection. It turns out that many of our old, frail, vulnerable adults are cognitively impaired. So, yes, we have a cauldron of incubation in nursing homes and assisted living facilities that clearly is exceptional. But now to get to your question, actually – so our best estimate is that indeed older adults, even if you’re not in a nursing home, will be at higher risk. And we do have evidence that the consequences for those people coming from the community who are older and have underlying conditions are more severe. And I think that we have to say that we need to be prudent, discretion is the better part of valor and that if you are 75 years old or even 62 years old – because the increase in risk begins as early as in the low 60s – and especially if you have an underlying condition, you are at higher risk, and the chance that you take in possibly exposing yourself may mean that once you get the illness, if you do get the illness, dire consequences could ensue.
Are COVID-19 symptoms different in older adults?
BRUCE TROEN: The answer is yes. So we know that the classic symptomatology is fever, cough, respiratory illness. But we’ve learned, actually pretty early on, that many of our frail, older adults don’t manifest those in the same way. And what often happens is there might be confusion, disorientation. Technically, the technical term is delirium. That might be the first and only manifestation. In addition, if you have an underlying medical condition and it worsens without an apparent trigger, then that could also be a sign of a coronavirus infection – so, again, exacerbation of congestive heart failure or chronic obstructive pulmonary disease or your diabetes. So that’s another key indicator, potentially, one without necessarily having fever or cough or shortness of breath. In addition, we could have what are called constitutional symptoms. So you might just feel achy. You might have decreased appetite. You might feel like you fatigue more easily. Those also, unfortunately, could be a sign of COVID-19 infection. And so – and one other group of symptoms, and that is gastrointestinal symptoms. You could have nausea, vomiting, diarrhea and completely to the exclusion of fever and all the other symptoms. So, yes, this is a challenging set of symptoms that we need to factor in when we’re looking at older adults. And by the way, many of these in lesser degree – to a lesser degree, can be seen in younger individuals. But almost – I should say, often there are other accompanying symptoms. So, again, I would stress that we don’t have all the information yet, but we need to keep our eyes open and our threshold low when trying to diagnose COVID-19 infection in older adults.
What should nursing homes or other places where older adults live together do to prevent spread of COVID-19?
BRUCE TROEN: Well, the first three answers are testing, testing, testing. I think we all know that. And that’s a resource issue. And it’s not just money when I say resource; it’s about availability of supplies. It’s availability of procedures to make this happen. We know that nursing homes, even before the COVID pandemic, were centers for infection. And indeed as many as 300- to 400,000 deadly infections a year occur in nursing homes, and that’s in a population that usually is only about 1.3, 1.4 million. So there already was an existing problem. Now, on top of that, you have an environment, as I mentioned before, where we have close quarters. We often have cognitive impairment. We have vulnerable residents. And now they are in a situation which almost is a perfect storm. So what can nursing homes do? Well, we’ve learned a lot for both good and worst in the last several months. We know that you have to test. So many states are now mandating that nursing home residents be tested on a regular basis, probably at least once a week. So while you may have had a COVID test previously, it doesn’t stop there. You need to continue to test because we know that symptoms can come on, they may be delayed, and you may have a new chance of getting infected. In the state of New York, there is a requirement for testing twice a week for the staff of nursing homes. So this is just as important, of course, because people in nursing homes got COVID-19 because of transmission from the community. And I think this also points to how they are so vulnerable because it was community spread – not nursing home spread, community spread – by all of us who are out there that ultimately led to the infections in nursing homes. So what do we do at this circumstance, at this stage? Well, actually, I very much like what the Department of Health for the state of Indiana has recommended. So one of the questions I want to blend into this is whether or not there’s – we’re now at a stage where family members can visit their loved ones who are in nursing homes. So Indiana has said that if a nursing facility has not had a COVID-19 positive infection for at least 14 days, the answer is yes, but it’s a contingent answer. It’s an answer that says that the visit should take place outside, something we can now do in the warmer months, and that the resident and the staff and all family members who are visiting – and they need to be above the age of 12, need to have adults here or people who are aware of the situation – have to follow the strictest of preventive procedures. And that means wearing a mask. It means washing hands. It means maintaining a distance. In general, though, nursing home facilities are really strapped. Many of them already were at a very thin financial margin before this. And if you think about the costs associated with twice-a-week testing of staff, once-a-week testing of residents and then the supply situation with personal protective equipment, this is going to be a huge challenge and perhaps – not perhaps – it’s a crisis already for nursing homes.
What about risks other than the disease itself, like loneliness in this time of social distancing?
BRUCE TROEN: Yes, right. So, in fact, I personally don’t like the term social distancing because we don’t want to be socially distant; we want to engage. We want to maintain personal communication. So I’d rather it just be distancing. And indeed, that physical distancing is what is key. So we know that, again, people in nursing homes or even older adults in the community are at higher risk for social isolation. This is a well-known phenomenon even before the COVID-19 pandemic. So in a nursing home setting, we already have had case reports of increased agitation for especially those who have dementia if they can’t see family members. We actually have many reports of older adults in nursing homes who don’t eat as well, who are subject to a decreased activity ’cause family members aren’t there. So this is another crisis. There was actually a report in the journal Psychiatry Research – this is already about a month and a half ago – where – and this is just a case report; so it’s not a study – where they reported that by providing a tablet, an iPad, for a video conference capability, that the daughters of the individual were able to communicate with him in a manner that helped to reduce his anxiety and agitation. So I think that if it is possible – and, again, this is a resource issue – if you can maintain communication that’s not just by phone but visual communication, that’s very important. We know, though, that members, even in the community, older adults, are at risk for social isolation and depression. Now, we don’t have good data as to what the consequences are long term of this, but we can, from previous understanding of circumstances, know that if you unfortunately have a set of circumstances that can trigger the feelings of loneliness and isolation, that could contribute to either preexisting depression, may actually be a catalyst for onset of new depression, and it’s not good to be depressed. If people are severely depressed, it could lead to very horrible consequences. But also, quality of life can be significantly diminished. So we have a big challenge as a community, as a nation. How do we maintain social connectedness, social engagement, while practicing the wise distancing measures, along with personal protective equipment and hand-washing and face mask-wearing so that we can hopefully maintain our equilibrium in these troubling times?
Should we all be avoiding older people right now or are there safe ways to socialize and connect?
BRUCE TROEN: So I think the general answer is, we need to maintain appropriate distance from everyone if we are not in there – in our circle of COVID trust, our COVID circle of trust, as I like to say. So if we’re with family members in our homes, well, we don’t wear masks, assuming people have not been ill – in a sense, we have confidence that we can engage with them and interact physically closely and not get sick. But once you go outside your COVID circle of trust, you’re taking an increased risk. Now, that risk can be mitigated by the appropriate measures – making sure we always wash our hands, trying to reduce touching of face, wearing face masks and maintaining distance. I think the answer is we want to be able to connect, especially with family members, but how do we do it safely? Now, it’s interesting. Canada has started a new policy – I believe it’s called double bubble – where in a way to gradually reopen interactions with others, they’ve said that families can choose another family with whom they can interact and not have to practice these additional measures, OK? And that hopefully will increase comfort and positive engagement with others. But that’s not a solution for society at large. And the reason why I want to urge people to be cautious is that every time you enlarge your COVID circle of trust, you’re actually enlarging it often not just to the individual with whom you’re interacting, but with all the other individuals that that person interacted. And that’s risky. But we want to be able to do this in a manner that still allows us to continue going along each day with our lives. So I think the answer is, yes, we can engage, but we have to do it very, very carefully.
What does science tell us about how older people can stay healthy right now?
BRUCE TROEN: So older adults and all adults who need to see a physician or other health care clinicians regularly should continue to do so. It is safe to see your doctor. It’s also safe if you have an acute problem. Let’s say you are having chest pain or you’re having signs and symptoms of an asthma attack or a stroke – go to the emergency room. It is safe. It turns out that health care workers are actually infected at a lower rate than the rest of the community. You will almost certainly not get COVID by seeing your physician or going to the hospital. That’s No. 1. No. 2, you want to maintain your regular medical care – very, very important. You need to get your prescriptions refilled. You need to go ahead and see your doctors again on a regular basis. But I would also add a couple of other suggestions. There is evidence – though we don’t have the data now – but there’s what we call epidemiologic evidence and circumstantial evidence to suggest that if you stay active – that’s important – if you have a vitamin D supplement – and this is something that predated the COVID pandemic, where we all want to have adequate vitamin D levels. And there’s some at least postulation that with good vitamin D levels, your immune system is more capable of perhaps resisting infection but, maybe more importantly, if and when you do get infected, being able to handle that better. So I recommend to all of my patients that they take a minimum of 2,000 units of vitamin D every day. Vitamin D insufficiency and deficiency is widespread in this country, but it’s easy to supplement, and it’s really quite inexpensive to do so. Now, if you’ve got kidney disease, if you have a history of stone formation in the kidneys, if you have hypoparathyroidism, no, see your doctor. But I think that’s one thing you can do. Another recommendation – again, we don’t have firm evidence for this – is to have good vitamin C intake, a supplement of 250 to 500 milligrams once or twice a day. This is circumstantial, but the good thing with the recommended doses that I just suggested for vitamin D and vitamin C is that there’s very little harm for most people, and there may be a potential benefit.