key: cord-1051865-uftnh7er authors: Soysal, Pinar; Aydin, Ali Ekrem; Isik, Ahmet Turan title: Challenges experienced by elderly people in nursing homes due to the coronavirus disease 2019 pandemic date: 2020-10-09 journal: Psychogeriatrics DOI: 10.1111/psyg.12620 sha: 16ac0ed329719cc74e498f4f2a686bfe79f4aee6 doc_id: 1051865 cord_uid: uftnh7er nan Nursing homes (NH) constitute an important part of eldery care services in Turkey and around the world. According to data from February 2020, there are 426 public and private nursing homes in Turkey. They provide care for 27 575 elderly persons, as well as active service for another 19 407 elderly individuals. Including the 8302 personnel serving NH, approximately 60 000 people in Turkey live, receive treatment, and work at NH. The size of this population highlights the potential risk posed by interactions between elderly persons and staff in NH during the coronavirus disease 2019 (COVID-19) pandemic if appropriate care and precautions are not taken. Although COVID-19 affects people from all age groups, it is more fatal in the elderly than in younger groups. The most common clinical presentations of COVID-19 infection in the elderly are fever, dry cough, and chest distress. 1 However, in geriatrics, it is well known that older people do not always have a fever response during the course of infectious diseases and that common infections can sometimes present only with acute mental state changes such as lethargy and confusion. 2 For example, a lifethreatening condition such as massive pulmonary embolism can cause hypoactive delirium. 2 Accordingly, serious infections such as COVID-19 pneumonia can sometimes present only with non-specific symptoms such as altered mental status, weight loss, fatigue, falls, or functional decline in the elderly. Therefore, during the pandemic, it is necessary to evaluate elderly persons in NH at least three times a day and to measure nursing home residents' vital signs, such as fever, respiratory rate, oxygen saturation, and functionality, during each visit. To ensure infectious control during the COVID-19 pandemic, NH should immediately undertake wellestablished precautionary measures such as banning visitors and group activities and minimizing time spent in common areas. Although social isolation (SI) is preferable for elderly individuals in NH, it can be difficult to provide and maintain. Elderly persons with cognitive impairment may have difficulty remembering or retaining information and understanding and following instructions, such as wear a mask. A failure to fully comply with protective measures may increase their risk of infection. Additionally, SI can lead to negative consequences, which is especially problematic as it has emerged as one of the the most important steps in controlling the spread of COVID-19. Geriatricians recommend continuous social and physical activities for elderly individuals to provide cognitive and emotional benefits and to prevent the development of sarcopenia and dynapenia. However, long-term SI can increase the risk of falls and related injuries in the elderly with multiple comorbidities and disability. 3, 4 Moreover, it is inappropriate to isolate elderly individuals who may have delirium, dementia, behavioural disorders, or incontinence-all of which are common in NH-alone in a room for a long time. 3 In some patients, procedures that require restricted movement, such as vascular access or the measurement of vital signs, can aggrevate delirium development and behavioural disorders in patients; this can also make it difficult for health-care professionals to complete such procedures. 3 Patients must be approached from the perspective of geriatrics. While in SI, patients should be able to communicate with their family members and loved ones as much as possible with the help of telecommunications and gerotechnology. Also, training and support should be provided to capable patients so that they can perform respiratory exercises and physical activities in their room on their own. Any factor that could cause falls or delirium should be reviewed individually, unnecessary restrictions should be avoided, and treatment and interventions should be simplified. Additionally, if a patient's COVID-19 test is positive, 3-day hydroxychloroquine prophylaxis should be initiated for all NH residents and staff; thereafter, ongoing treatment should be arranged on follow-up. This can prevent, the spread of the epidemic in NH. In the treatment of COVID-19, the combination of azithromycin and hydroxychloroquine may prolong the QT interval and create a tendency to ventricular tachycardia. 4 Cardiac comorbidities, electrolyte disturbances, and drugs that prolong QT further increase this risk in geriatric patients. 4 Also, polypharmacy, inappropriate drug use, and drug-drug interactions are common in the elderly in NH and may present a risk. 5 Likewise, drugs commonly prescribed in NH populations, such as antipsychotics, anti-dementia drugs, antidepressants, and antihypertensive drugs, prolong QT distance and predispose patients to arrhythmia. 6 Therefore, elderly patients' medications and their possible interactions should be reviewed before or during COVID-19 treatment. During the initiation of COVID-19 treatment, it is important to abide by the principle of 'start low, go slow'. COVID-19 treatments can interact with benzodiapezine and psychotropic drugs used to treat delirium, causing cardiac sideeffects or falls, which may result from fear of death, depressive symptoms, or delirium. Additionally, healthcare professionals must be mindful that anorexia and malnutrition may accompany infections and should plan early in case nutrition therapy is needed. A complex and detailed geriatric approach to evaluating elderly patients with suspected COVID-19, rather than a simple approach of classical medicine, is needed to prevent delays in the diagnosis and treatment of COVID-19. Such an approach to disease management, especially in the elderly, can be successfully sustained as the world continues to struggle against COVID-19. The authors have no conflicts of interest to declare. Clinical characteristics and outcomes of older patients with coronavirus disease 2019 (COVID-19) in Wuhan Hypoactive delirium caused by pulmonary embolus in an elderly adult Characteristics of nursing home residents and physical restraint: a systematic literature review Guidance on minimizing risk of drug-induced ventricular arrhythmia during treatment of COVID-19: a statement from the Canadian Heart Rhythm Society Drug prescription patterns, polypharmacy and potentially inappropriate medication in Swiss nursing homes: a descriptive analysis based on claims data QTc prolongation with antipsychotics: is routine ECG monitoring recommended?