As essential partners in care, family caregivers support feeding, mobility, personal hygiene, cognitive stimulation, communication, meaningful connection, relational continuity, and assistance in decision-making. 1,2,13,14,15,16,17 Prior to the pandemic, research indicates that on average, 37.4 hours of informal care was provided in LTC per resident each month by informal caregivers, most often described as family. 3 Visitor restrictions inclusive of family caregivers reduced available resources for resident care, intensifying staff shortages.1,2,3,5,13 Designation of essential caregivers, distinct from general visitors, in policy and legislation was in part recognition of these roles and contribution to resident care.1,2,13
Prior to the pandemic, the role family caregivers in providing care for other residents was described as evolving over time as family members and friends become familiar with the needs of other residents. Roles described by family members in their care of other residents include providing companionship, assisting with meals, bring additional food or supplies when brought for their own family member, and assisting with leisure activities. 17
LTC volunteers roles during the pandemic reduced their activities to maintaining (limited) activities for residents, assisting residents with use of technology to communicate with family/physicians, and providing emotional support.4
A commentary article describes an example of family caregivers who were hired on short (90 day) contracts to care for residents during acute staffing shortages (Kensington Health 2021).5 Personal communication intended as an environmental scan (AB and ON) spoke to the variability of staffing needs and the individualized response by LTC homes to address these staffing shortages. If family caregivers were to be invited to provide additional resources in the context of staff shortages, this decision was made by individual homes, in communication with residents and families and aligned with provincial visitation policy.
During the pandemic, a new paid role of comfort care aide was also created by Alberta Health Services The job involved providing comfort, support and assistance to residents, portering residents, mealtime assistance, ensuring PPE was always available, refilling equipment and care supplies as needed, cleaning and disinfecting high touch surfaces, supporting reception duties, supporting screening of staff and visitors, receiving deliveries and stocking supplies, and performing other duties as assigned.6
Myge, I; Ward, H; Tupper, S; Fox, L; Howell-Spooner, B. What are the roles or function of family caregivers in providing care to other residents in LTC? 2022 Jan 27, Document no.: LTC220101 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2022. 13 p. (CEST rapid review report).
The majority of studies show elderly persons (>65 years) have significantly longer COVID-19 incubation periods compared to younger adults with a mean difference of +3.9 days (Lieu J et al. 2020; Kong TK et al. 2020; Jiang et al. 2020; Guo et al. 2020). One study showed no difference between those >60 years and younger patients (Lian et al. 2020).
Median incubation period across all studies (all ages) was 5 days (5.4 days mean). Jiang et al. (2020) report a mean incubation period of 7 days for younger adults and 10.9 days for those over age 65.
Upper limit of incubation period is 12-14 days with one study reporting 27 days (Nanda et al. 2020).
Median duration from symptom onset to death is 11.5 days in persons >70 years vs. 14 days in younger adults (Geriatric Emergency department collaborative March 2020).
Older age and more severe infections are associated with higher viral loads; however, viral shedding is not associated with infectivity. (European Centre for Disease Prevention and Control, 2020).
Doubling time of COVID-19 among residents from a single long-term care home was estimated to be 3.4 days compared to 5.5 days in the general population in the surrounding county (Arons et al. 2020).
Infected patients over the age of 65 years remain contagious for a significantly longer period (22 days vs. 19 days, p=0.015; Ziao et al. 2020).
Viral shedding may be longer for immune compromised patients (BC CDC 2020).
Symptom duration varies by nature of the symptom with a median time from diagnosis to discharge from hospital ranging from 13 days (range = 7-17; Ki et al. 2020) to 18.5 days (range = 11-27; Kim et al. 2020).
There is limited information on basic reproduction number in older adult populations. These values vary by region and over time. R0 values for whole populations (all ages) have been reported as low as 0.48 (Ki et al. 2020) to 2.5 (Lewnard et al. 2020)
Please see related reports by the Laboratory Working Group available in the SHA COVID-19 repository (not specific to elderly).
o LAB041601 RR Antibody development, viral shedding and infectiousness.
o LAB040701-01 RR Proportion of disease transmission due to asymptomatic, pre-symptomatic and symptomatic cases.
Tupper, S; Ward, H; Dalidowicz, M; Ellsworth, C. What is the incubation period, rate of spread, and duration of infectivity of COVID-19 in older adults? 2020 Jun 19; Document no.: LTC060202 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 28 p. (CEST rapid review report)
Signs and symptoms of COVID-19 are categorized as constitutional, respiratory, gastrointestinal, neurological, laboratory, imaging, and other.
Constitutional signs and symptoms include fever (Median=80% prevalence on cross-sectional retrospective chart reviews; range 30-98%), fatigue (M=41%; range 8-81%), myalgia or arthralgia (M=31%; range 5-63%), headache (M=9%; range 6-70%), sore throat (M=19%; range 11-53%), weight loss (M=31%; 23-50%), and hypotension (31%; Aggarwal et al., 2020).
Respiratory symptoms include cough (M=63%; range 33-88%), nasal congestion (M=41%; range 14-68%), rhinorrhea (M=7%; range 5-60%), dyspnea (M=53%; range 5-88%), phlegm (M=28%; range 18-40%), hemoptysis (5%; Xu et al., 2020) and chest tightness (M=40%; range 23-64%).
Gastrointestinal (GI) signs and symptoms include nausea and vomiting (M=14%; range 2-22%), diarrhea (M=18%; range 3-35%), and low appetite (M=21%; range 12-63%).
Approximately 36% of COVID-19+ patients present with neurological signs and symptoms which may include delirium, confusion, hallucinations, dizziness, seizure, or loss of senses of smell or taste. Presence of neurological findings is indicative of a worse outcome (Chen et al. 2020).
Abnormal laboratory findings are more common in older patients (Chen et al., 2020) and may include elevated C-reactive protein and erythrocyte sedimentation rate, lymphopenia, elevated D-dimer, leukopenia, elevated lactate dehydrogenase, lower white blood cell count, lower oxygen saturation (=94% or supplemental oxygen required), and hyponatremia (Duan et al., 2020; Ihle-Hansen, et al.2020; Xu et al., 2020; Fu et al., 2020).
The majority of COVID-19 + patients have abnormal imaging findings including multiple mottling and ground glass opacities (GGO) on chest CT scan. Bilateral pneumonia is present in between 73-98% of adults in critical care (Fu et al., 2020; Du et al., 2020).
Other signs and symptoms observed in LTC home residents with dementia include increased falls, change in behavior from the previous shift, more unsettled, and increased wandering (Ihle-Hansen et al., 2020).
The majority of patients (63%) of all ages present with symptoms that have lasted between 4 and 7 days (Buckner et al. 2020; Ihle-Hansen et al., 2020; Lin et al., 2020).
See Table 2 for a summary of infrequent (<10%), frequent (20-50%), and very frequent (>60%)clinical manifestations, laboratory test abnormalities and radiographic findings from a paper by Bonanad et al. 2020.
Screening and Testing Considerations:
Although 90.5% of COVID-19 + patients of all ages present with cough, fever, and/or breathlessness (Baker et al., 2020), screening for typical symptoms alone will fail to identify approximately half of those with COVID-19 who are elderly, particularly those with frailty and other co-morbidities (Kimball et al., 2020).
The majority of recommendations favour a more sensitive threshold for fever detection in older adults, i.e. 37.5°C or an increase of >1.5°C from usual temperature (Holroyd-Leduc et al., 2020).
Screening of older adults or those with comorbidities should include supplemental questions to determine if atypical symptoms are present such as fatigue, myalgias, headache, conjunctivitis, tachycardia, hypotension, and hypoxia. Presence of atypical symptoms should trigger COVID testing.
Tools developed by the Ontario Ministry of Health (2020) and Alberta Health Services (2020) may be useful guides for healthcare provider screening of individuals at higher risk of COVID-19 infections (i.e. frail older adults with comorbidities).
Prioritization of mass testing should be for those with atypical presentations. Specifically, testing should be commenced first for older adults with changes in delirium, unexplained or increased numbers of falls, weight loss, change in appetite, acute functional decline, or worsening chronic conditions (ON Ministry of Health COVID Screening Guide, 2020).
Tupper, S; Ward, H; Dalidowicz, M; Ellsworth, C. What is the case definition for COVID-19 in elderly people? 2020 Jun 12; Document no.: LTC060201 RR. In: COVID-19 Rapid Evidence Reviews [Internet]. SK: SK COVID Evidence Support Team, c2020. 39 p. (CEST rapid review report)