June 22, 2020
Older people are particularly vulnerable to Covid-19 and can experience serious health effects from the virus. Research is showing that adults age 60 and older, especially those with pre-existing conditions – heart disease, lung disease, diabetes or cancer – are more likely to have a severe and even deadly infection than other age groups.
Overall, eight out of 10 deaths from Covid-19 reported in the U.S. have been in adults age 65 and older, according to the U.S. Centers for Disease Control and Prevention. The CDC has also said that more than a third of Covid-19 deaths in the country have occurred in nursing homes and long-term care facilities.
Dr. Anne Halli-Tierney is a geriatrician who practices at University Medical Center and one of only a handful of physicians in Tuscaloosa who specializes in geriatrics. She said geriatricians care for adults over the age of 65, as well as people younger than that who suffer from multiple health conditions and who might be considered “physiologically old.”
Halli-Tierney is also assistant professor of family, internal, and rural medicine at The University of Alabama College of Community Health Sciences, which operates UMC, and she directs the College’s Geriatrics Fellowship.
Halli-Tierney said the care that geriatric patients need ultimately depends on the patient, but that older adults aren’t the same, physiologically, as younger adults. She said some geriatric patients require special attention in regard to their medication regimens “because some drugs that you take when you’re younger might affect you differently when you’re older.” She said as people age, they might be more prone to mental health issues, such as depression and anxiety, and cognitive issues, such as dementia, “and those things need to be addressed.”
“A person’s age is literally just a number,” Halli-Tierney said. “I’ve had some patients who are 80 years old and running half marathons. I’ve also had some patients who are 50 years old and who have very bad chronic conditions that have built up over time. So, when you look at the 50-year-old you would think that person is technically older than the fit, healthy 80-year-old.”
Halli-Tierney offers an inter-professional geriatrics clinic, which includes health-care professionals in medicine, pharmacy, geropsychology and social work collaborating and developing holistic care plans for patients. She said UMC has psychologists and psychiatrists who can provide mental health care, and social workers who can help with at-home care needs and living arrangements. “We also have a nurse practitioner who provides home visits for patients who might not be able to get out,” she said.
“One of the things that we’ve learned with the evolution of the disease is that people who are older, and people who have co-morbid conditions, particularly cardiac and lung conditions, are more likely to be seriously impacted and more likely to die from the disease,” Halli-Tierney said. “It seems that age is an independent risk factor for severity of the disease if you contract it.”
Halli-Tierney said she advises all of her patients to wash their hands often, wear a mask if they leave home, stay six feet away from people with whom they don’t share a household and to try and avoid places where people aren’t wearing masks.
If older adults can stay home that’s best, especially if they have other health conditions, “but that’s tricky,” Halli-Tierney said. “I also realize that life happens, and people need to get food and they might not have a social support system that can bring them groceries.” She advises patients that have to go out to choose times when stores might be less crowded, “maybe early in the morning or later at night.”
“I think it is important for there to be interaction, either through technology or appropriate social distancing,” Halli-Tierney said, adding that she sometimes suggests picnics on the front lawn. “One of the things we’re finding is that older adults who are increasingly isolated, and who have anxiety about contracting the virus, are also feeling shut off from their family.” She tells patients that if they are appropriately socially distanced, “it might be a good thing to visit, but I wouldn’t have a grandchild run up and hug grandma or grandpa.”
Halli-Tierney serves as medical director of the assisted living facility at UA’s Capstone Village retirement community, while a UMC nurse practitioner provides care for independent living residents there. She said one of her colleagues at UMC is medical director of a nursing home in Tuscaloosa, while another provides care for nursing home patients in the city.
Most have implemented screening measure to try and ensure that health-care professionals coming into the facilities aren’t bringing the virus in with them, Halli-Tierney said. She said most nursing homes and assisted living facilities aren’t allowing visitors, although they might make exceptions if residents are at end of life. “They’ve been trying to do some visitation through windows, and they’re trying to do FaceTime visits to try and keep people from contracting the virus,” she said.
Halli-Tierney said residents should be placed in isolation, essentially kept in their rooms. She said care needs to be provided in their rooms, and all meals need to be served there as well. “Some nursing homes, if they have more than one exposure, designate a separate wing or area where they put residents into isolation. They’re also trying to do contact tracing to see who the residents have been interacting with, and they keep those people isolated until they’ve developed symptoms or 14 days have passed,” she said. Halli-Tierney said if staff members contract Covid-19, they are to stay at home, self-quarantine until their symptoms have passed and until contact tracing can be done to determine who they might have cared for.
Halli-Tierney said that process has actually changed during the pandemic. She said at the beginning of Covid-19, nursing homes that experienced low rates of the virus among their residents preferred that residents didn’t return from the hospital until they tested negative for the virus. “Now, some of the nursing homes will accept residents back who are positive if they’ve got dedicated wings where they can stay and be isolated from the rest of the community and be cared for individually.”
At the beginning, Halli-Tierney said all of her patient visits moved from in-person to telemedicine. “We wanted to keep people at home so they wouldn’t be at risk for contracting the virus,” she said. At the end of March and beginning of April, “in-person visits began picking up and now my visits seem to be trending away from telemedicine and more into in-person visits.”
“I definitely do,” Halli-Tierney said. Even before Covid-19, she considered implementing a telemedicine program for homebound older adults, but insurance reimbursement proved a barrier. Before Covid-19, health insurers primarily reimbursed for in-person visits, but that policy has changed as a result of Covid-19. Halli-Tierney said many of the telemedicine visits she is doing now are with patients who can’t easily leave their homes or assisted living facilities to come to UMC. She said another benefit of telemedicine is that she can see patients in their home environments. During a recent telemedicine visit with a patient at risk for falls, Halli-Tierney had the patient show her the floors in the house. “Throw rugs are a risk factor for sustaining a fall and, sure enough, they had some throw rugs. We were able to tell them to secure (the rugs) or remove them,” she said.
Halli-Tierney said she is seeing an increase in anxiety in her patients. “The news is shifting constantly. People are hearing terrifying reports of different hospital capacities and growing positive (virus) numbers.” At the same time, she said the volunteer and church work that her patients might have done can’t be done now. She said she spends time listening to her patients and letting them talk about what’s going on. “We also have been connecting them with some of our (UMC) counseling services to help them with the anxiety that I think all of us are feeling,” she said, adding that there are also medications that can be prescribed for situational depression or anxiety.
The American Geriatric Society estimates that only 1 in 3 people over the age of 65 need a geriatrician, but that still leaves the U.S. short between 20,000 and 25,000 geriatricians. Halli-Tierney said there are currently only 7,000 geriatricians practicing in the U.S.
With the exception of the Veterans Administration Hospital, Halli-Tierney said there are five physicians in the city who have added qualifications in geriatrics, although one has retired from clinical practice. She said three practice at UMC and the other is in private practice.
A fellowship is additional training in a specific area of medicine beyond a residency program, Halli-Tierney said. For example, the College of Community Health Sciences operates a family medicine residency, a three-year program for medical school graduates who want to specialize in family medicine. Halli-Tierney said graduates of the residency who want to practice geriatrics can go through the fellowship, and once they take the appropriate exams become board-certified in geriatrics. She said the fellowship is about five years old and has trained three primary care physicians in geriatrics and a new fellow will start in July. “In the last two years, the fellowship has had the only geriatric fellow in Alabama, and the two geriatricians who graduated during the first year of the fellowship represented 1% of the geriatricians being trained in the country,” she said.
Halli-Tierney believes that as more people realize the need for and the importance of geriatrics, the workforce will expand. “Right now, the demand is much, much greater than the supply, unfortunately,” she said. “People are not going into (geriatrics) as rapidly as we would like.” Halli-Tierney said there were 400 geriatric fellowship spots available in the U.S. last year but only 200 filled. She said medical students don’t necessarily see geriatrics as a lucrative specialty “because you don’t get to do as many procedures; there’s a lot more listening and more cognitive work.” But as people realize the benefits of that cognitive work, she believes more people will choose to go into geriatrics. Halli-Tierney said she chose to also work in an academic setting like the College of Community Health Sciences to help train primary care physicians “so that when they graduate, they will be able to provide basic, competent geriatric care to their patients.”