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Welcome to Long COVID MD.

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I'm your host,

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Dr.

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Zeest Khan,

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a licensed and board certified physician who is also a patient with long COVID.

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I've applied all of my medical expertise and understanding of the healthcare system

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to my recovery.

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And now I want to share what I've learned with you.

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On this podcast,

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we talk about my own experience with long COVID,

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I share evolving science behind this disease,

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and we discuss safe,

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reliable treatment strategies that you can consider with your healthcare team.

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Remember,

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nothing I say here replaces personalized medical advice from a licensed medical specialist.

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Now let's get started.

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Hello and welcome back to Long COVID MD.

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I'm Dr. Zeest Khan.

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You know,

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a couple of weeks ago we talked about long COVID and how it presents in children,

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the specific challenges that this patient demographic faces,

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the challenges that their caregivers face.

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And today we're talking about long COVID presenting in the elderly and specifically

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in those who live in long-term care facilities.

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I don't want to bring up any bad memories,

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but if we think back to 2020 and 2021,

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we may remember how devastated the people who lived in long-term care facilities

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were by the COVID-19 virus.

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That's because long-term care facilities have always been vulnerable to infection.

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It's also because this is a

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vulnerable and marginalized community.

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And those are words that may reflect how you are feeling now as somebody in the

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long COVID community in general.

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So today I am talking with an expert in this field, Dr. Jean Storm.

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Dr. Storm is an internal medicine physician.

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She has a special interest in geriatric care and long-term care facilities.

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She worked on the medical front lines in 2020 and 2021,

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and boy,

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she saw a lot that she's going to share a little bit of today.

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Now, however, she works to impact change at a broader level.

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She is the Medical Director for Quality Insights, which is a quality improvement organization.

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Quality improvement organizations play a very important role in our U.S.

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healthcare structure.

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They are typically nonprofit organizations that track the safety of medical

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facilities and help those facilities improve their outcomes.

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As Medical Director for Quality Insights,

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Dr.

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Storm provides clinical guidance to the organization's initiatives in the nursing home,

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hospital,

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and outpatient settings.

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Previously,

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she served as Medical Director for five long-term care facilities across

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Pennsylvania and West Virginia,

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and as a Regional Medical Director for 38 West Virginia long-term care facilities.

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Dr.

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Storm is board certified by the American College of Osteopathic Internists and is a

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certified medical director by the American Board of Post-Acute and Long-Term Care Medicine.

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She is also board certified in healthcare quality and management by the American

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Board of Quality Assurance and Utilization Review Physicians.

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We love a certified queen.

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We love someone who keeps pushing forward and learning more.

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And Dr. Storm really embodies that.

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Dr.

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Storm also,

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through Quality Insights,

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hosts a podcast where she talks about pressing concerns on our healthcare structure.

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In our conversation today, however, we're going to talk about what is a long-term care facility?

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Who lives there?

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Why are they vulnerable to infections?

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How are people in long-term care facilities impacted after a COVID infection?

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How many people in long-term care facilities have long COVID and is it being

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diagnosed and treated adequately?

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Like our conversation about children with long COVID,

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what are the specific management strategies that work best in this patient population?

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And if we have a loved one in a long-term care facility who we're concerned has long COVID,

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How can we be effective advocates for them?

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We also, as often happens on Long COVID MD, get a little philosophical.

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What does the way we care for our most vulnerable members of our population do?

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say about us and our values.

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It's a really great conversation.

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So without further ado, here is Dr. Jean Storm.

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Dr. Jean Storm, thank you so much for joining us.

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Welcome to Long COVID MD.

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Thank you so much.

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I am just really delighted to be here.

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I'm excited to have you on and I've been really happy to get to know you and to get

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to know your work.

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When I hear you talk about elder care and nursing home care,

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I hear this real deep passion that we need to protect a vulnerable population.

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What drew you to long-term care facilities and the elderly?

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It's really an interesting thing.

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I had a podcast guest who said,

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I feel like the most wonderful things in our lives often happen by surprise.

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And that is kind of how I came into long term care medicine.

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A father is an internist.

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He's retired and he did a lot of nursing homework and he used to take me there as a child.

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And so I kind of grew up in nursing homes,

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but I had returned to the workforce after being home.

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My husband had been deployed and he went through his own medical training.

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So I was kind of tasked with staying home for about five years with my daughters.

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And I decided to go back into the workforce in 2012, I believe.

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And I was working in an office.

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I received a call from a recruiter from a long-term care company and asked if I

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would be interested in doing some side work in a long-term care facility.

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And that...

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It has been common for a really long time that primary care doctors typically go

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into nursing homes on their off hours.

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They have their primary duties,

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whether that's hospital work or office work,

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and they kind of do the nursing home work on the side.

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Yeah, I'll take a look.

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And that really started my journey.

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I was greeted in the foyer of this facility by the most wonderful nursing home administrator.

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I am still friends with him today.

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He's like a beacon of hope in long-term care medicine.

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But since then, I just felt like I was in the right place.

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And it didn't take me that long to kind of decide that I wanted to do nursing home

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medicine full-time.

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very right about being there.

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It is for me just really the most wonderful place to be.

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I can't even describe it.

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And if you meet individuals who are in long-term care medicine and feel drawn there

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due to whatever feeling they have in their heart,

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they kind of describe the same feeling.

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So I think that's, that's my place.

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Yeah.

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Yeah, it sounds like it.

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You pivoted your career.

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You're the medical director of a healthcare quality organization.

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What do these types of organizations, what role do they play in our healthcare system?

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So I was in nursing homes during the pandemic.

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So I was in nursing homes where I was the only physician in the whole facility kind

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of going in and fighting the good fight.

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And I really wanted to take a different approach to quality improvement, to patient safety.

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I have always loved patient safety.

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You know,

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the idea of looking at systems and making sure that we are doing our absolute best

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to keep patients safe.

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So we kind of help in that.

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We're kind of another hand.

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We provide education and support to long-term care.

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facilities,

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hospitals,

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primary care offices,

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community organizations,

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and we're looking at quality,

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you know,

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quality in many different ways,

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and whether that's,

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you know,

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patient safety,

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medication uses,

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vaccinations,

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and

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we just can help these organizations,

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providers,

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long-term care facilities to really look at their quality in a different way.

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And we're helping them.

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So we're helping, you know, bring in the data and to drive their initiatives.

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And it's,

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Really meaningful work,

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I will say,

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to do that and see results and know that you're impacting patients,

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which is what is important.

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COVID continues to be a threat to the health of people in long-term care facilities.

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Who is the typical long-term care resident?

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Yeah.

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It was probably has changed somewhat in the last five to 10 years.

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I was a little girl going into nursing homes that used to be like the confused older adults.

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But what we're seeing now are individuals who are very, very sick, typically over 65.

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So

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The age is typically older adults,

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but these individuals are very,

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very sick,

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multiple chronic medical conditions.

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They typically have

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some kind of condition that makes it difficult for them to ambulate on their own.

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So they're using assistive devices, whether that be a walker or most often it's wheelchairs.

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You have a lot of individuals who have

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Chronic wounds.

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Wounds are a very big challenge in long-term care facilities.

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And it kind of just goes with advanced age.

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They have probably poor nutritional status and complex chronic medical conditions

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that put them at risk.

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And we also have the individuals who have dementia.

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Alzheimer's and other kind of cognitive impairments that are in facilities because

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of that reason.

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And these individuals are not always, but often are ambulatory and they have cognitive deficits.

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So they don't understand perhaps infection control practices.

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As someone who spent a long time during the pandemic in facilities,

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it's very challenging to get a resident with dementia who's ambulating,

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who's walking around,

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understand you can't go through that door because we are in a unit.

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This unit is locked.

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We are locked, isolated.

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You can't go out there.

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You can't go out to activities.

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You can't go out to the dining room.

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If you're outside of your room, you have to wear a mask.

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You can imagine.

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Incredibly challenging.

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So nursing homes are typically this mix of individuals,

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you know,

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which makes it truly the perfect storm for infections like COVID.

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And it's really challenging with multi-drug resistant organisms or MDROs.

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I like to say that nursing homes are the canaries in the coal mine.

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The nursing homes are the first to,

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you know,

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have their COVID,

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the first COVID case,

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I believe,

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in the country,

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you know,

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way back.

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They are really, like I said, the perfect storm for infections.

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So I'm going to take a deep breath and think about the beginning of the pandemic,

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the height of the pandemic,

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and the huge impact that COVID had on long-term care facilities and nursing homes.

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I know that you have seen a lot,

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and that was a really,

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really challenging time for this vulnerable population.

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You've now brought more attention to the fact that long COVID is also a risk to

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patients in long-term care facilities.

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When did you start noticing that this was an issue today?

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So I obviously have treated a lot of COVID patients.

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I've seen, you know, early on in the pandemic, I watched a lot of patients die.

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And at that point in time, I did not know anything about long COVID.

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I had

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No idea.

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You know,

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I think probably like a lot of health care providers,

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I was just thinking that it's like a severe virus that patients,

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you know,

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if they recover,

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then they kind of just go on and that's kind of it.

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But in this work, I was reading about long COVID.

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That kind of came into my sphere.

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And I'm going to say the research around long COVID in nursing homes is very slim.

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There's not a lot to find.

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And at that point in time,

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I think it was about two years ago where I started to think about long COVID and

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get very interested in long COVID,

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there was nothing that I could find at all about long COVID in nursing homes.

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And I started to kind of dig into the research because,

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I mean,

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the individuals in nursing homes obviously were and are

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experiencing severe symptoms of COVID.

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They are being hospitalized.

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I mean,

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we still have individuals from nursing homes who have an acute COVID infection now

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and are being hospitalized.

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They're being put on ventilators still.

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I know a lot of people think, you know, that's not happening.

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Still, it is.

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It's happening in nursing homes every day.

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Of course, the nursing homes are experiencing high rates of

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all kinds of viruses right now, influenza, norovirus, and, you know, all kinds of things.

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But the individuals in nursing homes are so frail and have so many chronic diseases,

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and many are of advanced age,

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so they are...

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at increased risk of severe infection with COVID.

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And you know,

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and I know,

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we know that severe infection with COVID makes an individual more at risk of

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developing long COVID.

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And so for me,

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It just completely made sense.

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And facilities are really not aware that that is happening.

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So they have an individual who has a severe COVID infection and whether they're

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treated in the facility or they have to go to the hospital and then they return to

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the facility,

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they're not really aware that

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these individuals could be experiencing the effects of long COVID for a very long

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time after their initial infection.

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And because they're not aware,

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they're maybe not preparing themselves to treat these individuals appropriately.

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I found was a study that was done in Italy, and it was just 165 patients.

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And these patients were hospitalized due to acute COVID infection.

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And what they found were if these individuals were hospitalized,

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that three months after their hospitalization,

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after their infection,

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more than 80% still had symptoms.

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And the most common symptoms were fatigue,

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shortness of breath or dyspnea,

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joint pain,

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and cough.

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So still having all of these effects,

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you know,

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which are significant because those things we know,

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especially in frail individuals,

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individuals with chronic disease can almost cause a cascade effect.

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So they're not eating as well.

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They're not feeding themselves as well.

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They're not walking as well.

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They're not...

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going to the restroom as well as they maybe once were.

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They're laying in bed more.

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So all of those things kind of lead to more malnutrition.

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We're losing muscle mass, sarcopenia.

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We're developing skin breakdown.

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So we have a cascade of effects.

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So

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I thought, you know, like, let me sound the alarm.

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Like, we really need to kind of focus on these things.

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And interestingly,

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more recently,

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the Journal of the American Geriatric Society published an account that individuals

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who have COVID in long-term care facilities...

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experience a decline in their activities of daily living.

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So,

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you know,

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whether that's getting dressed,

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you know,

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washing themselves,

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going to the restrooms,

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things that we kind of take for granted.

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You know,

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people with long COVID don't take them for granted because they know how much their

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symptoms are affecting these things.

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But individuals in nursing homes are experiencing a decline in these activities of

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daily living for nine months after their acute COVID infection.

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So that

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that is long COVID.

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Absolutely.

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You know, so we're just calling it a decline in, in activities of daily living.

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Um,

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so it's really important,

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I think,

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um,

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you know,

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for facilities to understand that,

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that these things are going on so they can really tailor their approach so they can

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really communicate well with residents,

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um,

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in the facilities as well as family members.

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Um,

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Do you have an idea of the prevalence of long COVID among residents of long-term

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care facilities?

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That is such a challenging question.

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And I think in the general population, it's about like 11 to 15%.

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I think that it is much higher than that in the long-term care population.

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I think it is very challenging to probably find that exact number because I don't

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know any physicians who are really making that diagnosis.

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in long-term care facilities,

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but we know that there are repeated infections of COVID,

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repeated outbreaks of COVID in long-term care facilities continuing now.

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So we know that those repeated infections really put an individual at risk for

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developing long COVID.

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So,

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I wouldn't be surprised if it was over 50%, quite honestly.

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I don't know if maybe it is that high, but I think it's very high.

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We've seen increased falls in facilities.

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I think that is an indication that we have effects of long COVID.

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So again, I would love to know, but I think it's probably impossible to find out.

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But I think it's very high.

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Talk to me about the cognitive impacts of COVID on nursing home populations.

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I myself have had a huge cognitive hit and continue to work on COVID.

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Bringing my brain back up to speed.

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What are the cognitive implications of COVID in this population?

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And how do you sort of tease out a post COVID mentation change that might be due to

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COVID or might,

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you know,

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be diagnosed as dementia?

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So this is a very interesting question.

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It is just a, it was a great question.

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And I will say,

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I think overall facilities are really not doing a great job at really critically

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looking at this question.

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You know, we,

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as you stated,

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we know that COVID has effects on the brain,

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whether that's due to neural inflammation,

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whether the virus plays,

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you know,

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it's a direct viral effect on the brain.

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I think we're still trying to figure all of that out.

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But we have individuals who are mostly of advanced age.

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So their brains are more at risk for the effects of the virus.

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The stress is,

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being sick, the isolation from being sick.

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Because when these individuals,

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you know,

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when they're in a communal facility and you test positive for COVID,

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typically you are isolated.

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You know, maybe your room is moved.

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You maybe were living with a roommate who you really enjoyed and,

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And now you're put into another room, so you're disrupted, you're isolated.

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You feel,

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I think,

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almost like,

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oh my goodness,

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I have this horrible virus and they've isolated me.

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And so you have kind of all of those effects.

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Maybe there's a depression aspect.

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And so individuals who then have...

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any amount of cognitive impairment,

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we know that when these individuals get sick,

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their cognitive impairment often worsens.

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So any kind of sickness,

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whether it be a urinary tract infection,

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whether it be a pneumonia,

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whatever is going on with an individual's cognitive impairment,

(00:22:10):
when they get sick,

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the stress from that illness worsens their cognitive impairment.

(00:22:18):
whatever kind of impairments they have.

(00:22:20):
So if an individual has dementia,

(00:22:22):
their dementia may temporarily or permanently worsen due to an infection.

(00:22:29):
When an individual with dementia gets hospitalized, they're at risk of developing delirium.

(00:22:36):
So if an individual is COVID and it's severe and they have to leave the facility to

(00:22:42):
go into the hospital,

(00:22:44):
that is just catastrophic.

(00:22:47):
For an individual who has dementia, their dementia oftentimes worsens a significant amount.

(00:22:58):
They're at risk of developing delirium.

(00:22:59):
So all of these things kind of play a role.

(00:23:02):
So when an individual returns to the facility and they're having these effects for months,

(00:23:10):
The facilities often chalk it up to worsening dementia because that's kind of what

(00:23:15):
their wheelhouse is.

(00:23:16):
That's kind of what they see.

(00:23:19):
You know, so they're not attributing it to perhaps effects of long COVID.

(00:23:26):
And unfortunately, I think that is the case probably across the board.

(00:23:32):
All the studies have shown us that even individuals who don't have cognitive impairment,

(00:23:36):
who live in long-term care facilities and develop COVID,

(00:23:40):
they do have a cognitive decline in the nine months to a year following their illness.

(00:23:50):
And so facilities I don't fully feel on a whole are saying this cognitive decline

(00:23:55):
could be due to long COVID.

(00:23:57):
It may be reversible.

(00:23:59):
It's going to take some time,

(00:24:00):
but we really need to focus on speech therapy,

(00:24:05):
occupational therapy,

(00:24:06):
you know,

(00:24:06):
these disciplines that really will optimize an individual's cognitive function.

(00:24:12):
I don't really think they're doing that.

(00:24:15):
And I hope it would be wonderful in the coming years if we could see some tailored

(00:24:23):
speech therapy,

(00:24:24):
occupational therapy programs that are really just looking at optimizing an

(00:24:29):
individual's cognition to prevent decline following a COVID infection.

(00:24:34):
If there's anyone out there, I mean, I think that would be just a wonderful thing to initiate.

(00:24:42):
There's also psychiatric manifestations of COVID.

(00:24:46):
And I learned from you that it's not uncommon for a long-term care resident to have

(00:24:54):
their first,

(00:24:56):
you know,

(00:24:56):
psychiatric diagnosis directly after an infection.

(00:25:00):
That must complicate the picture even more.

(00:25:04):
And then my other thought is,

(00:25:08):
Polypharmacy is also an issue.

(00:25:11):
We're really sensitive.

(00:25:13):
We meaning people my age are sensitive to medications and the side effects.

(00:25:19):
That is a standing issue for elderly people with multiple comorbidities,

(00:25:27):
but it must be even more so after a COVID infection.

(00:25:31):
Yeah.

(00:25:32):
Yes,

(00:25:33):
polypharmacy continues to be an issue in long-term care facilities as well as

(00:25:39):
behavioral health,

(00:25:41):
psychiatric challenges.

(00:25:43):
I will say during COVID, there was significant increase in worsening of...

(00:25:53):
any kind of psychiatric issue that residents had on a whole.

(00:25:59):
We saw an increase in prescribing of antipsychotics in long-term care facilities

(00:26:06):
during the pandemic.

(00:26:07):
And I will say that that may have been

(00:26:13):
primarily from patients who have dementia.

(00:26:15):
Antipsychotics are primarily prescribed in this patient population,

(00:26:19):
individuals who have dementia,

(00:26:20):
if they have agitation or behaviors,

(00:26:25):
and I'm putting behaviors in air quotes,

(00:26:27):
because problematic behaviors are somewhat subjective depending on the individual.

(00:26:33):
So a resident with dementia may be

(00:26:38):
saying they want to leave, they want to leave, attempting to leave.

(00:26:41):
You know,

(00:26:42):
the doors are typically locked in a long-term care facility,

(00:26:44):
but there may be a resident who's attempting to leave over and over and over and over.

(00:26:50):
And that may be a problematic behavior for certain staff.

(00:26:54):
And then an antipsychotic may be ordered by a physician who agrees.

(00:27:00):
So I know during the pandemic that behaviors increased because there was a lot of isolation.

(00:27:08):
There were no visitors that were allowed to come into facilities.

(00:27:12):
Yeah.

(00:27:13):
I know that was a big problem.

(00:27:16):
And I will say, I think the facilities are digging out of that increase in antipsychotic.

(00:27:23):
There was also an increase in opioid prescribing.

(00:27:25):
We know opioids can affect mood in various different ways.

(00:27:29):
So I think facilities are digging out from that increase in prescribing.

(00:27:36):
So I think

(00:27:38):
the nursing home population is at particular risk of being prescribed medication

(00:27:47):
for long COVID symptoms like depression,

(00:27:51):
like anxiety.

(00:27:52):
You know, we know with patients who have cognitive impairment, it's scary, right?

(00:27:57):
You can imagine if you are kind of in a reality that's

(00:28:02):
doesn't seem to be,

(00:28:04):
doesn't seem to quite match someone else's reality who seems to be in charge of you.

(00:28:08):
It's scary.

(00:28:10):
And some of these individuals, you know, act in ways because they're fearful and,

(00:28:16):
And, you know, COVID is worsening, long COVID is worsening this confusion.

(00:28:22):
And so they may act out in ways because they're fearful.

(00:28:25):
And then they get diagnosed with more medications.

(00:28:28):
And the medications always carry another side effect.

(00:28:32):
So whether that's nausea,

(00:28:34):
whether that's sleepiness,

(00:28:37):
whether that's more confusion,

(00:28:39):
you know,

(00:28:40):
so we're,

(00:28:41):
you know,

(00:28:41):
Adding to that.

(00:28:42):
And so it's so difficult to know what is the primary condition.

(00:28:47):
So what is the Alzheimer's dementia?

(00:28:49):
What is the cognitive impact of long COVID?

(00:28:53):
What is the anxiety?

(00:28:56):
So it's so very difficult.

(00:28:58):
Yeah.

(00:28:59):
in long-term care, everyone is moving fast.

(00:29:02):
Like I said, it's typically not the primary physician's only job.

(00:29:07):
They're doing other things.

(00:29:08):
So they're coming in kind of on the evening or on the weekend.

(00:29:11):
So they're really not taking the time to kind of look at this whole resident,

(00:29:16):
looking at their history,

(00:29:18):
seeing the kind of

(00:29:20):
cascade of medications that were put on,

(00:29:23):
looking at the timeline of these symptoms and really taking a detailed approach,

(00:29:29):
you know,

(00:29:29):
to make sure that we're not treating things with medications that maybe need to be

(00:29:37):
addressed with therapy or with activities or with

(00:29:44):
Music.

(00:29:44):
You know, I'm a huge proponent of creative therapy.

(00:29:48):
So music therapy in patients with dementia is just absolutely fantastic.

(00:29:54):
Activities like painting,

(00:29:56):
you know,

(00:29:57):
really finding out what the individual enjoyed in their life,

(00:30:00):
whether that be gardening or flower arranging and doing those kinds of things.

(00:30:05):
And those kinds of things have been shown to really have a huge impact on an

(00:30:11):
individual's mental health.

(00:30:14):
So I am just a huge proponent of really kind of having providers,

(00:30:19):
physicians,

(00:30:20):
you know,

(00:30:20):
whoever's seeing,

(00:30:21):
who's ever seeing that resident to really stop,

(00:30:24):
slow down,

(00:30:26):
take a detailed look,

(00:30:27):
like really do an individualized patient-centered approach for each patient.

(00:30:34):
I hear the need for personalized care in every population who has long COVID.

(00:30:40):
What are some ways that we can manage the symptoms in patients like this?

(00:30:46):
What's available?

(00:30:48):
Well,

(00:30:48):
I'll say,

(00:30:49):
you know,

(00:30:49):
even in the,

(00:30:50):
in the outpatient and individuals who are living in the community,

(00:30:53):
right?

(00:30:53):
That is the most, one of the most difficult things.

(00:30:57):
How do we find help?

(00:30:58):
Where do we find help?

(00:30:59):
What help is needed?

(00:31:00):
And it's interesting that,

(00:31:03):
Because there have been some physical and occupational therapists who have done

(00:31:10):
some research in this area and looking at individuals who are in long-term care

(00:31:17):
facilities and looking at their therapy needs and

(00:31:21):
I am, I'm really inspired by this work.

(00:31:25):
I'm actually on our podcast,

(00:31:28):
which you were a guest on,

(00:31:30):
but on our podcast,

(00:31:31):
I'm bringing on an occupational therapist who's been working in this area and is

(00:31:35):
published in this area.

(00:31:36):
And it's, you know, a really interesting thing.

(00:31:39):
And what,

(00:31:41):
again,

(00:31:41):
I talked about that cascade effect of when,

(00:31:43):
you know,

(00:31:44):
individuals have a long COVID and they

(00:31:47):
are eating less and then they kind of have this deterioration.

(00:31:51):
So I think the key here is to really identify and understand that an individual who

(00:32:00):
has severe COVID and if they've been hospitalized,

(00:32:02):
that there really needs to be an interdisciplinary approach to these individuals

(00:32:07):
and really making sure that

(00:32:10):
their occupational and physical therapy is really tailored.

(00:32:15):
The whole facility needs to understand that there really needs to be this group

(00:32:20):
team approach to make sure that they can maximize an individual's ADLs,

(00:32:27):
make sure their activities of daily living don't decline more than they need to.

(00:32:33):
I think also it's really important to bring in the dietician in the facility and

(00:32:39):
make sure that the individual,

(00:32:41):
you know,

(00:32:41):
we know that COVID alters taste and smell,

(00:32:44):
and so an individual might not be eating as well.

(00:32:47):
So really making sure that their nutrition is really maximized.

(00:32:53):
And I will say I'm going to put another plug out to physical therapy and occupational therapy.

(00:32:58):
One of our data scientists, one of my very favorite people,

(00:33:02):
His name is Sadiq Abdullai.

(00:33:04):
He recently published a paper that looked at therapy hours in facilities and in nursing homes.

(00:33:14):
And he found that nursing homes that have lower levels of physical therapy hours

(00:33:20):
actually have higher levels of emergency room admissions and

(00:33:26):
So I think it really, to me, comes all together in this...

(00:33:32):
post-pandemic,

(00:33:33):
as we're looking at a lot of long COVID in the facilities,

(00:33:38):
that we really need to maximize physical therapy because we're continuing to have

(00:33:44):
individuals who are declining.

(00:33:46):
I think that probably a lot of those emergency room visits are due to falls because

(00:33:51):
people are weak.

(00:33:52):
They are having fatigue.

(00:33:54):
They're having shortness of breath.

(00:33:55):
Maybe they're having pain.

(00:33:58):
And the physical therapists are not there just due to staffing to really make sure

(00:34:07):
that these individuals,

(00:34:09):
you know,

(00:34:09):
we're kind of trying to prevent as much as that decline that we can.

(00:34:14):
So I'm just going to put a plug to PT,

(00:34:17):
OT,

(00:34:18):
you know,

(00:34:18):
really maximizing those things in the facilities.

(00:34:22):
Yeah.

(00:34:24):
I am hearing advice that can be applied to people with multiple comorbidities in

(00:34:31):
advanced age who are in long-term care facilities and who live independently or who

(00:34:36):
don't live there.

(00:34:37):
Um,

(00:34:40):
Our treatments are limited right now.

(00:34:43):
How do we prevent long COVID in the elderly?

(00:34:49):
And how, you know, I guess, ultimately, how do we prevent a COVID infection?

(00:34:53):
So we prevent long COVID in the elderly.

(00:34:57):
And what is the role of vaccines?

(00:35:00):
Yeah.

(00:35:01):
So this is a million dollar question.

(00:35:03):
And I know vaccines are having a very, just a very unusual moment, I think, right now.

(00:35:11):
So we know, and I'm just going to speak, this is about the long-term care population.

(00:35:17):
These are

(00:35:18):
And typically individuals of advanced age,

(00:35:22):
we know that the COVID vaccination provides really good protection for these individuals.

(00:35:31):
I really want to kind of,

(00:35:33):
let's shout this from the rooftops,

(00:35:34):
but I really want individuals to understand that I see long-term care medicine as a

(00:35:41):
very special,

(00:35:42):
it's a specialty.

(00:35:44):
So individuals in long-term care facilities are

(00:35:48):
I advise, I think COVID vaccination is the best protection.

(00:35:54):
may not prevent a COVID infection.

(00:35:57):
We know influenza is the same way.

(00:35:59):
A flu shot may not prevent the flu, but it is your best bet to prevent severe infection.

(00:36:06):
And we know that severe infection increases an individual's risk of developing long COVID.

(00:36:15):
We know that individuals who go to the hospital with every higher level of care

(00:36:21):
For nursing home residents, maybe they're just being admitted to the regular medical floor.

(00:36:26):
Maybe they're being admitted to the ICU.

(00:36:29):
Maybe they're going on the ventilator.

(00:36:30):
So with every higher level of care, they have an increased risk of developing long COVID.

(00:36:36):
So I want to make sure that nursing home residents, number one, don't get COVID, right?

(00:36:43):
Right.

(00:36:44):
That is probably an impossible dream.

(00:36:47):
Nursing home residents get infections of all kinds.

(00:36:51):
So what we just want to try to prevent above all with good infection control in the facility,

(00:36:57):
making sure staff is aware,

(00:36:59):
washing their hands,

(00:37:00):
staff are not coming to work when they're sick,

(00:37:02):
they're wearing masks,

(00:37:03):
all of these kinds of things.

(00:37:04):
So we want to do prevention, obviously.

(00:37:08):
Next step is making sure that our residents are protected,

(00:37:13):
getting vaccinated to prevent severe infection and making sure that they aren't

(00:37:20):
going to the hospital.

(00:37:22):
I really like to make sure that residents and families understand that

(00:37:29):
Oftentimes, being treated in the facility is really the best protection.

(00:37:36):
One of the best things that can happen,

(00:37:38):
we've known from studies,

(00:37:39):
and this may seem counterintuitive,

(00:37:41):
but the more an individual is hospitalized,

(00:37:43):
the worse their quality of life.

(00:37:45):
Again,

(00:37:45):
I said,

(00:37:46):
there's an increase of long COVID as you go up in your levels of care into the hospital.

(00:37:54):
So we want to make sure that

(00:37:57):
the residents and the families understand that being treated in the facility is

(00:38:01):
oftentimes really good protection just to make sure that their quality of life is preserved.

(00:38:07):
We know that individuals who from long-term care facilities,

(00:38:10):
the more times they go out to the hospital,

(00:38:13):
the,

(00:38:13):
the lower their quality of life,

(00:38:15):
the shorter their life,

(00:38:17):
they have higher risks of death.

(00:38:19):
So, you know, we want to make sure we have all of these things in mind.

(00:38:24):
When we, when we have an individual who,

(00:38:27):
who has COVID and,

(00:38:29):
you know,

(00:38:30):
making sure that we're keeping the patient obviously first looking at each one.

(00:38:36):
I think a lot of physicians who work in long-term care facilities have the feeling

(00:38:40):
like they have their line in the sand.

(00:38:43):
So that's always the issue with a long-term care patient.

(00:38:47):
a physician who's taking care of patients in a nursing home,

(00:38:51):
when are you going to send the patient to the hospital?

(00:38:53):
And a lot of physicians really have just a low level of pulling the trigger.

(00:38:58):
You know,

(00:38:58):
they'll just get a call and a nurse will say,

(00:39:01):
I think this patient should go to the hospital.

(00:39:03):
And there's no question they just send, you know.

(00:39:05):
And I think those physicians aren't keeping in mind the data that I just cited.

(00:39:10):
So I think as we move forward that physicians really need to keep that in mind,

(00:39:15):
you know,

(00:39:16):
when they have to make that decision.

(00:39:20):
If a family member is concerned that their loved one in a long-term care facility

(00:39:25):
might have long COVID,

(00:39:27):
what kind of screening tools are available that might be helpful in determining that?

(00:39:36):
So I will say a lot of the screening tools really look at an individual's

(00:39:43):
activities of daily living.

(00:39:45):
So I would encourage family members to understand what their loved one's baseline

(00:39:53):
activities of daily living looks like.

(00:39:55):
A lot of studies look at a birthal index,

(00:39:59):
and that takes into account many activities of daily living.

(00:40:02):
It's really a good calculator that I use.

(00:40:04):
It's available online.

(00:40:05):
It's called MDCalc.

(00:40:07):
You can calculate it yourself.

(00:40:08):
You can ask the facility, you know, what was their baseline status?

(00:40:12):
And then maybe after their COVID infection,

(00:40:16):
They've recovered.

(00:40:17):
You can get another score.

(00:40:20):
These scores can be taken fairly easily.

(00:40:23):
It's just a composite of what the individual is doing.

(00:40:27):
And you can see if there is a decline.

(00:40:30):
And you can really encourage the facility.

(00:40:33):
I think the facility should really appreciate it,

(00:40:36):
bringing in some education and saying,

(00:40:39):
I feel that this could be a decline due to long COVID.

(00:40:45):
And I really would like to talk to the physical therapy department,

(00:40:50):
the whole therapy department to really see what they think,

(00:40:54):
hear what they think.

(00:40:56):
would like what they recommend, um, going forward.

(00:40:59):
I think those, these screening tools, um, are really, are really wonderful.

(00:41:04):
I, I don't know.

(00:41:05):
I feel like I want to do it myself.

(00:41:07):
If I got an illness,

(00:41:08):
like I want to make sure I would look,

(00:41:10):
cause I think sometimes we don't realize that we've had a decline in,

(00:41:14):
in something.

(00:41:15):
Um, I tease my husband all the time.

(00:41:17):
I have,

(00:41:18):
um,

(00:41:18):
my gym is right outside and I have all this equipment and I have two,

(00:41:23):
they're called D balls.

(00:41:24):
They're two big, um,

(00:41:25):
balls that you kind of throw over your shoulder and you can do squats with it,

(00:41:29):
all these different kinds of things.

(00:41:30):
I have a 50 pound and a 70 pound.

(00:41:33):
I first got the 70 pound ball.

(00:41:34):
I had a hard time just moving it around.

(00:41:36):
And now I'm like able to throw it around.

(00:41:38):
And he was too.

(00:41:39):
And then he kind of like fell off the wagon.

(00:41:42):
And then he told me the other day, he said, that 50 pound ball is

(00:41:46):
heavy.

(00:41:46):
I had a hard time.

(00:41:48):
I said, see, you didn't realize the decline that you had.

(00:41:51):
The 70 pound ball used to be able to handle, but now you can't.

(00:41:54):
So I think that it's really important to make sure that we are

(00:41:59):
documenting when our patients have these declines.

(00:42:04):
And it's a very easy thing for family members to do.

(00:42:06):
And then you have something really tangible to go to the physical therapy

(00:42:11):
department and other staff to really demonstrate that a more thorough approach is

(00:42:18):
needed for the declines.

(00:42:21):
I think you're speaking to quantifying function,

(00:42:24):
which is so challenging for all people or a lot of people with long COVID.

(00:42:30):
How do you answer the question?

(00:42:31):
How are you doing?

(00:42:33):
How are you progressing?

(00:42:34):
Are you better?

(00:42:35):
And so I'll leave links to all of those resources that you mentioned in the show notes.

(00:42:41):
How else can family members advocate for their loved ones?

(00:42:47):
I would make sure that they understand that they can have regularly scheduled

(00:42:55):
meetings with all staff in the facility.

(00:42:58):
So I will just say for anyone out there who has loved ones in a nursing home,

(00:43:04):
the nursing home is composed by,

(00:43:05):
it's almost,

(00:43:07):
I call it like the triangle.

(00:43:08):
There's three individuals in the facility that are kind of like the leadership.

(00:43:13):
There is the nursing home administrator who's kind of in charge of the business of

(00:43:17):
the nursing home.

(00:43:18):
There is the director of nursing who's kind of, you know, again, in charge of all the nurses.

(00:43:23):
And then there's a medical director who's

(00:43:24):
who is the physician.

(00:43:26):
Now,

(00:43:26):
the medical director may or may not be your loved one's physician,

(00:43:31):
but the medical director is essentially in charge of all medical care in the

(00:43:36):
facility and is also in charge of making sure that all the healthcare providers in

(00:43:42):
the facility,

(00:43:44):
aside from the nurses,

(00:43:46):
are doing what they're supposed to be doing in taking care of their patients.

(00:43:50):
So I would...

(00:43:53):
Make sure you understand that you can indeed,

(00:43:56):
no matter what anyone says,

(00:43:58):
you can have regular meetings with the interdisciplinary care team in the facility.

(00:44:04):
You can have regular meetings with the leadership team in the facility.

(00:44:09):
You can contact the social worker.

(00:44:11):
The social worker in the facility typically can organize those things.

(00:44:16):
I would make sure you really have an idea of what

(00:44:20):
what is going on on a day-to-day basis,

(00:44:23):
what the therapy schedule is,

(00:44:25):
making sure you understand how long therapy is going to last,

(00:44:28):
what they're focusing on,

(00:44:30):
and make sure you understand about activities.

(00:44:32):
Activities are just...

(00:44:35):
I feel like they're so very important in a facility and people don't understand the

(00:44:40):
importance of activities just in mitigation of depression and anxiety and

(00:44:47):
optimizing cognition.

(00:44:48):
So I would make sure you understand...

(00:44:50):
How often activities are offered?

(00:44:52):
Are they coming in and saying like, do you want to come to activities?

(00:44:54):
And someone says no,

(00:44:55):
and then they're leaving,

(00:44:56):
you know,

(00:44:56):
instead of saying,

(00:44:57):
what would you like to do?

(00:44:59):
What is something that you would enjoy?

(00:45:01):
You know, all of those things kind of should be offered.

(00:45:04):
So I would make sure you really understand.

(00:45:06):
I will say as a individual physician who has seen many, many nursing home patients, I

(00:45:15):
One thing that makes me so very sad,

(00:45:17):
I think about it often,

(00:45:18):
I have gone to see many individuals,

(00:45:21):
it's their first night,

(00:45:22):
and the family member maybe would be there.

(00:45:24):
So I go in the next morning,

(00:45:25):
an individual has arrived from the hospital,

(00:45:27):
they're coming into a nursing home,

(00:45:28):
and the next morning I arrive to do my exam and meet the patient and all of that

(00:45:33):
kind of thing.

(00:45:34):
And I don't know how many times a family member has said to me,

(00:45:38):
how does this work?

(00:45:39):
What is the schedule?

(00:45:41):
What is this?

(00:45:41):
I have no idea.

(00:45:43):
And it's scary.

(00:45:44):
And I can't imagine it's scary for the resident.

(00:45:46):
So to really have knowledge of what is going on on a daily basis,

(00:45:54):
the care,

(00:45:55):
meeting with the care team regularly is really,

(00:45:59):
really important.

(00:45:59):
I'm going to say as a physician who has had many meetings with family members,

(00:46:05):
I love it because I would rather have regular meetings with you than,

(00:46:09):
you know,

(00:46:10):
we get three months down the line and you come,

(00:46:12):
you're like,

(00:46:13):
what?

(00:46:13):
We've had this huge decline.

(00:46:15):
What happened?

(00:46:15):
You know, like I let's continue to meet regularly so we can address issues as they come.

(00:46:21):
We need to be vigilant and cognizant of what changes are happening in real time.

(00:46:28):
Is there anything else that we didn't cover that you want the listener to know?

(00:46:33):
I just think I want people to understand the long-term care world is kind of forgotten.

(00:46:40):
And it's not something about a society that don't take good care of their most

(00:46:47):
vulnerable members.

(00:46:50):
And individuals in nursing homes,

(00:46:53):
you know,

(00:46:54):
it's not,

(00:46:55):
I know a lot of people don't think it's a very pleasant place to be.

(00:46:59):
But if we don't understand the importance of taking care of this population,

(00:47:05):
I think we will be forced to understand at some point due to another pandemic,

(00:47:13):
a really significant drug-resistant organism that comes out of these long-term care facilities.

(00:47:21):
This is an area of healthcare that we really can't

(00:47:25):
just brush under the rug and forget for many reasons.

(00:47:30):
You know,

(00:47:30):
we have a lot of people across the country who are in these facilities and they deserve...

(00:47:38):
really wonderful care.

(00:47:40):
Um,

(00:47:41):
so,

(00:47:42):
you know,

(00:47:42):
I,

(00:47:43):
I'm going to stress if anyone feels it in their heart,

(00:47:46):
it is,

(00:47:46):
it is in a very underserved area of medicine.

(00:47:50):
I would encourage you if you're interested in going into long-term care medicine, um,

(00:47:56):
I'm a certified medical director,

(00:47:57):
so I did my certification in medical direction of nursing homes.

(00:48:01):
I teach the course.

(00:48:02):
I believe in it so very much.

(00:48:04):
If you are interested, please reach out to me.

(00:48:06):
I'm happy to talk to you about it if you're interested in going into this area.

(00:48:11):
And it's like the,

(00:48:12):
I think the Peace Corps,

(00:48:14):
the Peace Corps motto was it's the toughest job you'll ever love.

(00:48:17):
And it is.

(00:48:18):
It is.

(00:48:18):
Yeah.

(00:48:20):
I could just talk for hours about stories of individuals that have taken care of.

(00:48:25):
And it's just such a such meaningful work.

(00:48:30):
And, you know, if anyone is interested, I would encourage them to pursue it.

(00:48:35):
Well,

(00:48:35):
Dr.

(00:48:36):
Jean Storm,

(00:48:36):
I appreciate that you are doing this work and that you are adding to the safety and

(00:48:43):
trying to take care of our

(00:48:45):
Most vulnerable populations,

(00:48:47):
I think that's something that many of us with long COVID are realizing the

(00:48:52):
importance of because now we're vulnerable too.

(00:48:56):
Thank you for joining us.

(00:48:58):
Thank you so much for the opportunity.

(00:48:59):
I really enjoyed the conversation.

(00:49:02):
So did I. Thank you to Dr. Jean Storm once again for joining us and sharing her expertise.

(00:49:08):
I have a few takeaways and thoughts after our conversation.

(00:49:13):
One is that I have aspirational goals of throwing a 50 to 70 pound ball over my shoulder.

(00:49:21):
And one day, hopefully that will happen.

(00:49:24):
But you know, I think it speaks that conversation spoke

(00:49:27):
to the need for tracking loss or gain of function.

(00:49:32):
I see a lot of similarities between the ways long COVID presents in this

(00:49:39):
demographic and the ways that it presents in younger adult populations.

(00:49:46):
And it's more than the challenge of tracking loss of function.

(00:49:52):
There is also a cascade effect that Dr. Storm discussed.

(00:49:57):
one medical issue presents that then causes or leads to multiple other poor outcomes.

(00:50:05):
It happens very quickly in the elderly population,

(00:50:09):
but it certainly is occurring in the adult population,

(00:50:13):
maybe at a slower rate.

(00:50:15):
So we have gotten ill.

(00:50:18):
We are also spending more time in bed.

(00:50:21):
We are also losing muscle mass.

(00:50:24):
We are also losing the ability to

(00:50:27):
participate in activities that bring us satisfaction,

(00:50:30):
which often leads to naturally some sadness and depression.

(00:50:35):
We also have isolation.

(00:50:37):
Long COVID affects different populations in very similar ways, ultimately.

(00:50:44):
I'm also thinking about polypharmacy.

(00:50:47):
Polypharmacy has been a standing issue in geriatric care.

(00:50:53):
Whether or not you are elderly,

(00:50:55):
if you have long COVID,

(00:50:56):
you are also most likely dealing with the ramifications of polypharmacy.

(00:51:02):
and balancing the therapeutic benefit of each medication with its almost guaranteed

(00:51:10):
side effects.

(00:51:11):
Because of polypharmacy and side effects,

(00:51:15):
it can be difficult to tease out where symptoms are coming from and therefore more

(00:51:21):
difficult to track progress because it may not be

(00:51:26):
immediately clear if the new symptom is being caused by the medication or something

(00:51:33):
changing in your baseline status.

(00:51:36):
All of this to say is that long COVID is very, very complicated.

(00:51:40):
And I think through this conversation,

(00:51:43):
I am seeing more ties between the issues that we are facing with complex illness in

(00:51:50):
the adult population.

(00:51:51):
That's our technical medical term versus what has already been challenges in the

(00:52:00):
geriatric population.

(00:52:03):
The other couple of things I'm taking away is cognitive effects of long COVID.

(00:52:09):
I heard Dr.

(00:52:10):
Storm talk about chalking up worsening dementia or new onset dementia to something

(00:52:17):
you sort of quote unquote expected in geriatric population,

(00:52:21):
especially in long term care.

(00:52:23):
And that's similar to what many adults and children are experiencing when they have

(00:52:30):
cognitive changes,

(00:52:32):
except it gets chalked up to anxiety or depression.

(00:52:38):
Lastly,

(00:52:38):
I want to echo Dr.

(00:52:40):
Storm's message around vaccination for residents of long-term care facilities.

(00:52:47):
A lot of the science around COVID and post-COVID sequelae is still not clear.

(00:52:56):
Data is sort of equivocal.

(00:52:59):
But unequivocally,

(00:53:00):
COVID vaccination is beneficial for a population who are in long-term care facilities.

(00:53:08):
the benefits of vaccination far outweigh the risks.

(00:53:13):
So even though there is a lot that we wish was much more clear in the research realm,

(00:53:20):
the research seems pretty strong that long-term care residents should be vaccinated

(00:53:27):
against COVID to prevent bad outcomes.

(00:53:31):
So I want to thank Jean Storm again for joining us here on Long COVID and sharing

(00:53:36):
her expertise.

(00:53:37):
Let me know what you think.

(00:53:39):
You can reach me by email at longcovidmd at gmail.com.

(00:53:43):
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(00:53:45):
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(00:53:49):
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(00:54:00):
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(00:54:05):
So I'm looking forward to interacting with you there and here.

(00:54:09):
I hope you're feeling well in this moment.

(00:54:11):
If not, I hope you feel a little bit better in the next.

(00:54:14):
Take good care and bye for now.