Long Covid, MD
Explore paths to Long Covid recovery with Dr Zeest Khan, a Stanford-trained physician who is battling the disease herself. On “Long Covid, MD” she translates complex medical research into actionable steps for meaningful recovery. Dr Khan empowers patients with science-backed insights, demystifies the health care system, and shares her personal journey navigating new limitations. Whether you or a loved one has Long Covid, tune in to gain clarity and learn tools to maintain a meaningful life after diagnosis. Discover hope, understanding and resilience on every episode of Long Covid, MD.
Long Covid, MD
#42: Long COVID in the Elderly and Long-Term Care, with Dr Jean Storm, DO
In this episode, Dr Zeest Khan is joined by Dr Jean Storm, a specialist in long-term care medicine and the medical director of Quality Insights, a healthcare quality improvement organization. Dr Storm worked as a physician in nursing homes during the height of the COVID-19 pandemic and now she's urging us to recognize the impact of long COVID in this population.
Dr Khan and Dr Storm discuss the needs of long-term care residents, how long COVID presents and how it is often overlooked. Dr Storm explains ways to advocate for loved ones in nursing homes and strategies to avoid severe COVID infections in long-term care.
Links
Dr Storm's Podcast: Taking Healthcare by Storm
Function Calculator: Barthel Index for Activities of Daily Living
Resources for COVID-19 treatment, surveillance, and vaccinations in the long-term care population: https://covid.nymda.org
Articles
Prevalence and Predictors of Persistence of COVID-19 Symptoms in Older Adults: A Single-Center Study
Audio engineering by True Media Solutions
Subscribe for more at LongCovidMD.substack.com, and follow Dr Khan on X @doctor_zeest
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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.
(00:17:16):
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.
(00:17:38):
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,
(00:17:44):
going to the restrooms,
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things that we kind of take for granted.
(00:17:47):
You know,
(00:17:48):
people with long COVID don't take them for granted because they know how much their
(00:17:51):
symptoms are affecting these things.
(00:17:53):
But individuals in nursing homes are experiencing a decline in these activities of
(00:17:59):
daily living for nine months after their acute COVID infection.
(00:18:03):
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.
(00:18:10):
Um,
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so it's really important,
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I think,
(00:18:15):
um,
(00:18:15):
you know,
(00:18:15):
for facilities to understand that,
(00:18:18):
that these things are going on so they can really tailor their approach so they can
(00:18:24):
really communicate well with residents,
(00:18:26):
um,
(00:18:26):
in the facilities as well as family members.
(00:18:29):
Um,
(00:18:30):
Do you have an idea of the prevalence of long COVID among residents of long-term
(00:18:37):
care facilities?
(00:18:39):
That is such a challenging question.
(00:18:42):
And I think in the general population, it's about like 11 to 15%.
(00:18:49):
I think that it is much higher than that in the long-term care population.
(00:18:54):
I think it is very challenging to probably find that exact number because I don't
(00:19:02):
know any physicians who are really making that diagnosis.
(00:19:05):
in long-term care facilities,
(00:19:07):
but we know that there are repeated infections of COVID,
(00:19:12):
repeated outbreaks of COVID in long-term care facilities continuing now.
(00:19:17):
So we know that those repeated infections really put an individual at risk for
(00:19:22):
developing long COVID.
(00:19:23):
So,
(00:19:24):
I wouldn't be surprised if it was over 50%, quite honestly.
(00:19:28):
I don't know if maybe it is that high, but I think it's very high.
(00:19:31):
We've seen increased falls in facilities.
(00:19:34):
I think that is an indication that we have effects of long COVID.
(00:19:39):
So again, I would love to know, but I think it's probably impossible to find out.
(00:19:47):
But I think it's very high.
(00:19:49):
Talk to me about the cognitive impacts of COVID on nursing home populations.
(00:19:56):
I myself have had a huge cognitive hit and continue to work on COVID.
(00:20:04):
Bringing my brain back up to speed.
(00:20:06):
What are the cognitive implications of COVID in this population?
(00:20:10):
And how do you sort of tease out a post COVID mentation change that might be due to
(00:20:18):
COVID or might,
(00:20:20):
you know,
(00:20:20):
be diagnosed as dementia?
(00:20:23):
So this is a very interesting question.
(00:20:26):
It is just a, it was a great question.
(00:20:28):
And I will say,
(00:20:30):
I think overall facilities are really not doing a great job at really critically
(00:20:37):
looking at this question.
(00:20:39):
You know, we,
(00:20:41):
as you stated,
(00:20:42):
we know that COVID has effects on the brain,
(00:20:44):
whether that's due to neural inflammation,
(00:20:46):
whether the virus plays,
(00:20:48):
you know,
(00:20:48):
it's a direct viral effect on the brain.
(00:20:51):
I think we're still trying to figure all of that out.
(00:20:55):
But we have individuals who are mostly of advanced age.
(00:20:59):
So their brains are more at risk for the effects of the virus.
(00:21:07):
The stress is,
(00:21:08):
being sick, the isolation from being sick.
(00:21:12):
Because when these individuals,
(00:21:14):
you know,
(00:21:14):
when they're in a communal facility and you test positive for COVID,
(00:21:20):
typically you are isolated.
(00:21:22):
You know, maybe your room is moved.
(00:21:24):
You maybe were living with a roommate who you really enjoyed and,
(00:21:29):
And now you're put into another room, so you're disrupted, you're isolated.
(00:21:34):
You feel,
(00:21:35):
I think,
(00:21:36):
almost like,
(00:21:37):
oh my goodness,
(00:21:38):
I have this horrible virus and they've isolated me.
(00:21:42):
And so you have kind of all of those effects.
(00:21:45):
Maybe there's a depression aspect.
(00:21:48):
And so individuals who then have...
(00:21:52):
any amount of cognitive impairment,
(00:21:54):
we know that when these individuals get sick,
(00:21:57):
their cognitive impairment often worsens.
(00:22:01):
So any kind of sickness,
(00:22:02):
whether it be a urinary tract infection,
(00:22:04):
whether it be a pneumonia,
(00:22:07):
whatever is going on with an individual's cognitive impairment,
(00:22:10):
when they get sick,
(00:22:11):
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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(00:53:51):
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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.
