Covid-19 in Older Adults: Findings and Lessons from Mass Screening in a Nursing Home

The COVID-19 epidemic is particularly serious in older adults. The symptomatology and epidemic profile remains little known in this population, especially in disabled oldest-old people with chronic diseases living in nursing homes. The objective of the present study was to comprehensively describe symptoms and chronological aspects of the diffusion of the SARS-CoV-2 infection in a nursing home, among both residents and caregivers.

First and foremost our spatial-based approach compiled nearly 130 variables from multiple sources to capture geographic variability in nursing homes, community-level socioeconomic characteristics, and cumulative Covid-19 incidence. Results demonstrated that country-level Covid-19 rates, per-capital income, average household size, population square miles, unemployment and a higher percentage of African Americans, in combination with nursing home staffing levels (LPNs and total staff) and a number of fines issued in 2020 were associated with an increased risk of Covid-19 transmission in nursing homes. Findings from regional models suggested a robust positive relationship between cumulative Covid-19 incidence and country level per capita income and Covid-19 rates. Our spatial results are confirmed with prior research, which found a higher risk of Covid-19 among nursing home residents in the North-eastern US and parts of the South-eastern US, all locations that were an early epidemic emerged.

However, these findings have important implications for national policy fro SARS-CoV-2 infection control recommendations applied to school settings. The practical implication of 6 feet of distancing recommendation is that many schools are unable to open for full in-person learning, or at all, due to physical limitations of school infrastructure. This is particularly true in public school districts, which are unable to limit the number of students enrolled, compared to private schools, which have been able to more successfully open 6 feet of distance between individuals. Three-foot of physical distancing is more easily achieved in most school districts, including public ones, and thus, relaxing distancing requirements would likely have the impact of increasing the number of students who are able to benefit from additional in-person learning. Our data also suggest that intermediate distances (4 or 5 feet) can also be adopted without negatively impacting safety; the adoption of intermediate distancing policies might be leveraged as a step-wise approach to return more students to the classroom.

Also, nursing homes are a congregate living setting, and despite social distancing measures, including no group dining or activities, most nursing homes have a majority of rooms with more than one occupant and a shared bathroom, facilitating transmission of the virus. Care includes 'higher-touch' activities, like bathing, dressing and toileting that do not allow for social distancing. Many residents with dementia and other forms of cognitive impairment will not be able to tolerate wearing a mask or cooperate with social distancing. Staff and clinicians who come in and out of the building, many of whom work in multiple facilities, can be pre-symptomatic or asymptomatically shedding the virus while passing screening questionnaires and temperature recording.

Again, many factors contribute to the global spread of infectious diseases, including the increasing speed and reach of human mobility, increasing volumes of trade and tourism, and changing geographic distribution of disease vectors. In particular, human travel and migration (especially via air travel) are now a major driving force pushing infections into previously nonendemic settings. Year by year, there are increasing numbers of international tourists, more international refugees and migrants, greater capacity for shipping by sea, and greater international air travel passenger volumes. Air travel poses a growing threat to global health security, as it is now possible for a traveller harbouring an infection in one location on earth to travel to virtually any other point on the planet in only 1-2 days. Infections introduced via travel may be sporadic and have little potential for further transmissions, such as the Lassa fever introduced in European settings. In other situations, infections introduced by air travel may cause self-limited local epidemics such as the Chikungunya virus in Italy. More recently, there are a growing number of examples of infections introduced to a new region that ultimately become endemic, such as the Chikungunya virus in Latin America and the Caribbean.

Once an acute emerging virus such as a new strain of flu is successfully established in a population, it generally settles into a mode of cyclical epidemics during which many susceptible people are infected and become immune to further attack. When most are immune, the virus moves on, only returning when a new susceptible population has emerged, which generally consists of infants born since the last epidemic. Before vaccination programmes became widespread, young children suffered from a series of well-recognized infectious diseases called ‘childhood infections’. These included measles, mumps, rubella, and chickenpox all caused by viruses of which only chickenpox remains widespread in the West today.

This monocentric observational study contributes to an emerging understanding of the presentation and trajectory of COVID-19 in nursing-home residents. This case series showed that frail older adults exhibit relatively few symptoms, and notably less often fever, cough and ENT signs than younger adults. In this sense, our results are consistent with the few previous studies on symptoms met in older adults infected with COVID-19. It is also consistent with the clinical presentation of other viral infections in older adults such as influenza. Here, the residents exhibited both general and respiratory signs (59 % hyperthermia, 49 % cough, 42 % polypnea) together with gastro-intestinal signs (12 % diarrhoea) and geriatric syndromes (15 % falls, 1 % altered consciousness). Surprisingly, delirium was less frequent compared to one previous report in adults aged 70 and over (7% here versus 26.7 % previously). This may be explained by the characteristics of the present sample, which involved mainly frail older residents with major neurocognitive disorders and behavioural disturbances. Delirium is commonly under-recognized when superimposed to major neurocognitive disorders, especially during the severe stages of the disease since a clear distinction between symptoms attributable to delirium or to underlying dementia proves difficult.

In conclusion, the paucisymptomatic expression of COVID-19 in older residents, together with the high prevalence of asymptomatic forms in caregivers, justifies conducting mass screening in nursing homes, possibly prioritizing residents with suggestive combinations of clinical signs including dyspnea, falls, anorexia andor altered consciousness. Moreover, the finding of initial contamination likely brought by non-professional visitors encourages isolation measures in nursing homes to break the contamination chain.