Our healthcare system faces an unprecedented strain as it struggles with the coronavirus disease 2019 pandemic. With cases now reported in 53 states and territories, community spread is either already occurring or is imminent in most localities. Most healthcare systems are experiencing limited access to diagnostic tests accompanied by delays in test results of >24 hours. 1 Trials to assess potential treatments are underway, with mounting difficulty in acquiring agents as the demand for them increases.Without question, the segment of our population most at risk for severe and potentially lethal COVID-19 are older adults. 2 Among older adults, residents living in long-term care (LTC) settings are among the most vulnerable by virtue not only of their healthcare needs but also by living in a communal setting populated by other individuals at high risk for disease acquisition. To date, LTC settings are the segment of the healthcare system with the most notable burden of COVID-19 cases. 3 What is more alarming is that the overall quality ratings of LTC settings with COVID-19 outbreaks in King's County, Washington, are least 3 of 5 stars. 4,5 Furthermore, the average daily hours for direct care of residents by licensed nursing staff at these sites is at or above the national average. This finding suggests that the outbreaks of COVID-19 reported in these settings are not due to lapses in infection prevention and control; rather, the outbreaks detected are occurring in LTC settings despite reasonable practice.The mandate for LTC settings is to provide a "safe, clean, comfortable, and homelike environment." 6 Although they provide some medical care, LTCs are not staffed or otherwise resourced to care for acutely ill individuals. Furthermore, at present staffing levels, few LTCs even have the capacity for effective and facility-wide monitoring of their residents for rapid clinical deterioration. This situation is acceptable in ordinary circumstances, but with the COVID-19 pandemic, we have entered into extraordinary times.These extraordinary times call for unprecedented measures to protect our vulnerable LTC residents. Inevitably, hospitals will need to discharge patients to LTC settings, including some individuals that are known to have COVID-19 and, as is the nature of infections, some that are not yet known to have COVID-19. To that end, we propose the following measures to help protect the 1.4 million individuals that already occupy beds in 1 of 15,600 LTC settings. 7

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident, and their family.Published by Elsevier Inc. on behalf of AMDA e The Society for Post-Acute and Long-Term Care Medicine.

In response to a rising concern for multi-drug resistance and Clostridium difficile infections, the Centers for Medicare & Medicaid services (CMS) will require all long-term care facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in long-term care facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA—The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the long-term care setting. The intent of this policy, which can be adapted by individual facilities, is to help long-term care facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in long-term care settings, including a list of free resources to support those efforts.

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Preventing influenza infections is a national health priority, particularly among geriatric and adults with frailty who reside in post-acute and long-term care (PALTC) settings. Older adults account for more than 70% of deaths from influenza, a reflection of decreased vaccine effectiveness in that age group. Annually vaccinating health care personnel (HCP) working with these patients against influenza is critical to reducing influenza morbidity and mortality among patients. PALTC HCP have the lowest influenza vaccination rate when compared to HCP in other settings. The Advisory Committee on Immunization Practices recommends that all HCP receive an annual influenza vaccination, including those who do not have direct patient care responsibilities. Here, we discuss the importance of influenza vaccination for HCP, detail recommendations for influenza vaccination practice and procedures for PALTC settings, and offer support to PALTC settings and their staff on influenza vaccinations.

BACKGROUND: Persistent pain is grossly undertreated in older adult sufferers, despite its high prevalence in this age group. Because of its multidimensional impacts, including depression, sleep disruption and physical disability, patients with persistent pain often benefit from interdisciplinary pain clinic treatment. This treatment is expensive, however, and may not be required by all patients. The Multiaxial Assessment of Pain (MAP) has demonstrated value in predicting response to treatment in younger adults with persistent pain.OBJECTIVE: To examine the feasibility of a MAP taxonomy for community-dwelling adults age 65 years or older.PARTICIPANTS AND PROCEDURES: One hundred eight subjects with persistent pain (mean age 73.8 years, SD=8.4 years) were interviewed and data collected on demographics, pain intensity, depressive symptoms, sleep disruption, pain interference with performance of basic and instrumental activities of daily living, frequency of engagement in advanced activities of daily living, cognitive function and comorbidity. A subset of these subjects underwent physical capacities testing, including maximal isometric lift strength, dynamic lifting endurance, timed chair rise and balance.RESULTS: Analyses derived three primary clusters of patients. Cluster 1 (24%) reported less intense pain, less depression and sleep disruption, and higher activity levels. Cluster 3 (30%) suffered from more pain and were more functionally disabled. Cluster 2 (46%) had characteristics of cluster 1 and cluster 3, but with some characteristics that were clearly unique.CONCLUSIONS: While these results are preliminary and require further validation, they indicate that older adults are heterogeneous in their response to persistent pain. Future studies should be performed to examine whether the MAP taxonomy is applicable to older adults regardless of medical diagnosis. Ultimately, this information may have meaning with regard to both treatment prescribing, and the design and interpretation of intervention studies.

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