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Forest W. Arnold, DO, MSc: Hello. I'm Dr Forest Arnold and welcome to Medscape's InDiscussion series on respiratory syncytial virus (RSV) in adults. Today we'll be discussing RSV in older adults. Dr Morton is currently an associate professor at the University of Louisville School of Medicine, specializing in geriatric medicine, home care and long-term care. Welcome to InDiscussion.
Laura Morton, MD: Thank you, Dr Arnold. I'm happy to be here.
Arnold: Dr Martin, we used to call this population elderly, but the new term is older adults, and for those greater than 85 years, the phrase old old is still used. I don't think they had any buy-in for that term. Regardless, we will use older adults for this episode. I would like to start with the case of somebody typical that you might see in your practice. What kind of patient do you see?
Morton: I recently saw a patient who had respiratory syncytial virus (RSV). She's a 90-year-old female living in the nursing-home setting, and she had a diagnosis of the typical older adult things that I see in the nursing home, including dementia, hypertension, and diabetes. A lot of these patients that I see daily are frail and require assistance with their activities of daily living, and that is why they're in the facility. She was living in the long-term care facility and doing relatively well. She did develop some vague symptoms, including cough and weakness but wasn't able to report the history to us, as she does have dementia. One day the nurses were checking on her and found that her oxygen saturations had dropped into the 80s, which was new for her. At that time, she was sent out to the emergency room for evaluation.
Arnold: Does your role extend to the care of the patient in the hospital?
Morton: No, it does not. As a nursing-home attending physician, I take care of the patients while they're in the facility. When they transition to the hospital, it goes on to the emergency room physicians and also to the hospitalist team there.
Arnold: Tell us about the course in the hospital.
Morton: In the emergency room she had a CT scan of her chest and the findings were consistent with bronchitis. They also did a respiratory panel in which she tested positive for RSV. Because she was frail, older, and had a lower oxygen saturation, she was admitted to the hospital and treated there with supportive care. She was placed on oxygen but did not require oxygen for very long, was given intravenous (IV) fluids, and remained in the hospital for about 2 days.
Arnold: She was not in the ICU.
Morton: She was not in the ICU. She was able to remain on the floor, but they were able to monitor her there and make sure that she did not have any decompensation while she was there.
Arnold: What was her treatment?
Morton: The treatment that they gave was IV fluids and the oxygen. They were monitoring her oxygen saturation closely, but she didn't need any additional therapy at that time.
Arnold: It sounds like she did well if she only spent 2 days in the hospital. What was her ultimate outcome?
Morton: After the 2 days in the hospital, she transferred back to the nursing facility. In our frail older adults, it is very easy for them to have a decline from any kind of acute event. Even a 2-day stay in the hospital can precipitate a decline. She did return to the facility and was able to work with physical therapy and occupational therapy to try to regain her strength. However, what we have seen with her is that she's still living, but she's had a cognitive decline. Because of her dementia, when she had this acute event and went to the hospital and came back, her cognitive function has not returned to the previous pre-infection baseline.
Arnold: She got supportive care. Our listeners may be wondering about ribavirin and its use in a case like this. Ribavirin is only FDA approved for hepatitis C and it is associated with certain side effects that would not be good for an older adult, such as pancytopenia, anemia, neutropenia, and thrombocytopenia, and it can exacerbate certain comorbidities like diabetes, coronary artery disease, arrhythmias, thyroid control, whether hypo- or hyperthyroidism, and colitis. The risk of using this medicine would be much greater than the benefit, so it makes sense that you would not use it. I've only used it off-label in bone marrow transplants who have pancytopenia; but again, that risk-benefit ratio is difficult because I'm already dealing with people who have pancytopenia. Supportive care is very important in a case like this. What is the course of RSV in patients who do not get admitted and stay in the long-term care facility?
Morton: Those who don't get admitted sometimes still have symptoms. We will isolate them usually for about 48-72 hours and monitor their vital signs closely to make sure they're not developing any oxygen saturations and listen to their breath sounds to make sure they're not developing pneumonia. Most of the patients that live in a long-term care facility have some level of immunocompromise and immunosuppression just by virtue of their age. In our older adults, we see the process of immunosenescence, or the aging of the immune system, which makes them at greater risk of having more significant complications with any kind of infection. In those who are older and frail and have other underlying lung problems, whether it's asthma, chronic obstructive pulmonary disease, pulmonary hypertension, or if they have underlying coronary artery disease, they're at greater risk of developing severe infection with RSV, including pneumonia. We have to monitor them closely and give them fluids if needed. We can do IV fluids in the nursing facilities. We try to avoid invasive procedures. Tubes and lines can contribute to delirium in that patient population, so we encourage oral intake as well.
Arnold: In those long-term facilities, what tests are available?
Morton: Generally, in the long-term care facilities, we have flu and COVID swabs readily available. We have not been routinely checking for RSV and doing the broad respiratory panels in the nursing facilities. They are a little bit harder to obtain and the cost is a barrier to getting those in the facilities.
Arnold: I'm more familiar with the hospital, and even there we have two panels: one that's long and has 10 or 12 viruses on it, and the other one is a triple test for influenza, COVID-19, and RSV. It's not the test that's typically in the facilities where you are. In long-term care facilities, you typically have a dual test of just influenza and COVID-19. That seems like an area where there is a need because it's difficult to treat somebody or isolate for RSV when you don't even know that they have it.
Morton: Absolutely. I would guess that over the years, there's been a lot of hidden RSV that's gone undiagnosed in long-term care facilities. With COVID-19, there's been a greater emphasis on testing and being more aware and aggressive with trying to determine what is going on with any kind of infection in that setting. COVID-19 has highlighted the need to try to enact control processes, whether it's isolation or being more proactive with masking. Prior to COVID-19, as we all know, we were not routinely wearing masks in the long-term care facility.
Arnold: To summarize, it sounds like the RSV in the older adult has a course similar to influenza, and there is no treatment available except for supportive care at this time. It benefits the patient to identify RSV early because the sooner you start supportive care, the better the outcomes, and you could also isolate sooner. We're familiar with outbreaks of influenza and COVID-19 in nursing homes, and RSV would likely be just as severe as the other two. I want to change subjects just for a second. You are on a task force. Can you tell us about that?
Morton: Yes. So at the beginning of COVID in 2020, I was appointed to the Kentucky Governor's Long-Term Care Advisory Task Force, which is for the Kentucky Cabinet for Health and Family Services. It was put together of leaders from various fields, including the infection prevention folks in the state; epidemiologists; the ombudsman with the state; representatives from AARP and the Alzheimer's Association; and state officials and other medical directors to focus on providing guidance for long-term care facilities as well as other congregate living settings, including assisted living, personal care facilities, and some group homes as well. We also worked to give advice to the adult day center, so the task force came together trying to provide guidance as we experience the rapidly changing environment to try to help providers — those providing care for those residents living in those facilities — some idea of what they could do in that ever-changing landscape. We came together to figure out how we could best work together to provide care for that population who was very frail. At the time this was started, there wasn't a lot that we could do for that population.
Arnold: This started for COVID-19, but it kind of changed to incorporate RSV, correct?
Morton: It has. The great thing is that we still meet, though we don't meet as frequently as we did early in the pandemic. We meet monthly and discuss other topics that are pertinent to this population, including RSV. We talked early on in the fall about COVID-19, flu, and RSV and what we can do to help provide these facilities with some guidance because there is not a lot of guidance out there about what to do with RSV in long-term care facilities.
Arnold: Now, when we look nationally, because your task force is at the state level, what guidance is there about RSV for nursing homes and long-term care facilities?
Morton: There really is not a lot of guidance out there for long-term care facilities for RSV on the national level. The CDC does have some general guidance about RSV in older adults. However, it is not specific to the long-term care setting. There are some states across the country that health departments have provided some very general and broad guidance regarding RSV in long-term care facilities. Most of the guidance for long-term care facilities is about isolating patients who have RSV, usually for 48-72 hours, depending on symptom course. The guidance also encourages those patients to wear masks, which can be challenging at times given the patient population that we serve and the supportive care that we've been talking about, including IV fluids, pushing fluids, and doing good respiratory therapy like flutter valves and incentive spirometry to try to promote the best oxygen and respiratory status we can.
Arnold: When I think about recommendations for influenza or COVID-19, it seems like there's much more literature and certainly CDC pages to read than I could get through. But for RSV, it's a limited amount. What guidance is needed with RSV specifically and what topics would you like guidance to be to elaborate on?
Morton: I think especially in the setting with congregate living, whenever there is a question, for example, about a patient who tests positive for RSV, the infection prevention nurse, which all facilities will have because of the regulations, will come to me and say, "Hey, Dr Morton, as medical director, what should we do with this patient regarding activities? What are they able to do? Are they able to go out to the dining room? Are they able to go to physical and occupational therapy gym, or do they have to do all of that in their room?" That very specific guidance about what that patient is able to do regarding activities and how they're able to interact with the staff and other residents is very important.
Arnold: It is, and probably most people can relate during COVID-19 because it seemed like there was for lack of knowledge. For safety, they kept patients in their rooms. My own father-in-law was in a nursing home. He needed physical therapy and wasn't getting it until finally somebody came into the room. We all felt like his rehabilitation took much longer than it would have otherwise, and he didn't even have COVID-19. Somebody with RSV, if you had guidance on how to get those people out into their activities and get the healthcare workers to them, then their rehabilitation would be faster. With an older adult, the more days they have not gotten out of bed, not even getting to the bedside commode, the harder it is once they get up. Do you find that to be true?
Morton: We always say if you don't move it, you're going to lose it. It's very important to get people up and mobile. During COVID, we saw the significant impact of isolation on patients, whether they were long-term patients in a nursing facility or were there for rehabilitation. Social isolation was also detrimental to their overall physical health as well as their psychological health. We recognize that need now because of COVID. We recognize how important it is to figure out how to get people, as soon as it's safe, out into the community where they can interact and where they can get the necessary services, including physical therapy, occupational therapy, and speech therapy. This is much more easily done in the therapy gyms and with the machines and equipment that are available there than in their rooms.
Arnold: Okay. Well, you're out in these long-term care facilities and you don't have a lot of guidelines, but you have to do something. What do you end up doing and recommending and advising the people there in their care of the older adults?
Morton: I give my staff and my infection prevention nurses a lot of reassurance. I think because RSV is not talked about in our older adult population, I think there is a little more anxiety about what that might mean for our older adults. People do know about RSV in children. They hear about it and are familiar with that, but they don't know how that translates into that older patient population. That can actually cause more anxiety because it's the fear of the unknown. I think a lot of our healthcare workers do have some kind of residual anxiety and trauma related to the early stages of the COVID-19 pandemic about not knowing what to do with the unknown. Anything we could do to help with that and bring out knowledge and awareness about RSV will address those issues. With my infection prevention nurses, I talk to them for RSV about hand hygiene, the things that we know that we should be doing. We remind the staff about the importance of hand hygiene and remind patients and staff about coughing etiquette. Though these are small things, they're very important. We learned that as well with COVID. We also talk about the environmental services staff and needing to really clean high contact surfaces to make sure that we are minimizing any kind of spread that way. Again, we try to encourage the patients who get sick to wear a mask. Hopefully, we have a patient who is cognitively aware enough and can tolerate a mask which will allow them to get the care they need more quickly than having to stay in their room because they can't remember to keep a mask on.
Arnold: These basic things are so important, like hand hygiene. It's also important to be able to understand how to deal with this. COVID-19 has certainly filled in some of the gaps that we can apply to RSV but not everything. More specific guidance would certainly help. Finally, how does RSV relate to advance care planning?
Morton: RSV and any kind of acute event, whether it's an infection, whether it's a fall or a change in mental status, is a great reminder and an opportunity for us to talk about advance care planning and goals of care. Whenever we do anything in medicine, we want to make sure that we're taking the guidelines and the guidance that is available and focusing it on the patient that is sitting in front of us and really looking at that in light of the patient's preferences and goals of care. In the nursing facilities, it's always important to talk about code status regarding full code vs do not resuscitate. We also want to talk about things like do not hospitalize orders which are available in facilities and whether going to the hospital is consistent with a patient's wishes or if they'd rather try to manage things in the facility and not undergo that stress or trauma of going out to the hospital. It's always important with any kind of infection or change in the patient's status to take a pause as a physician and review those with the patient or their healthcare surrogate and family as needed. It can be challenging at times to have those conversations, but our job as the healthcare team is to respect the patient's wishes and to help them make informed decisions. This is a great opportunity to circle back to that very important topic.
Arnold: What I've heard in the second half of the episode is that more national guidance for RSV in older adults is needed. The state-level task forces that may have been developed for COVID-19 could be expanded or at the very least recycled for RSV. Today, we've heard from Dr Morton discussing RSV in older adults. Thank you so much for joining us. This is Dr Forest Arnold for InDiscussion.
Resources
Respiratory Syncytial Virus Infection
The Immune System in the Elderly: A Fair Fight Against Diseases?
Gov. Beshear: Long-Term Care Task Force Working to Protect Kentuckians
RSV in Older Adults and Adults With Chronic Medical Conditions
Advance Care Planning: Advance Directives for Healthcare
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Cite this: How to Manage RSV in Long-Term Care Facilities - Medscape - May 10, 2023.
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