‘Tremendous fear and uncertainty:’ Geriatric care in the time of COVID-19

From combatting the annual flu season to preventing the spread of C. diff, controlling infections in nursing homes is nothing new. But, like all who work in any health care facility now know, the COVID-19 outbreak was different. New Jersey geriatrician Kevin Overbeck, DO, called it a “roller coaster.”

“I’ve felt tremendous fear and uncertainty about keeping my family, nurses, patients and myself from getting sick,” Dr. Overbeck said. “In the early months of the pandemic, there was a growing sense of despair, because despite heroic efforts in our nursing home, some of our patients who we protect would get pretty sick and die. That’s been a really low point.”

Though New Jersey’s COVID-19 levels have tapered off considerably since the initial spring surge, the nursing home staff Dr. Overbeck is part of is working diligently to keep it that way for the residents in their care.

Since COVID-19 started, The DO has been speaking with osteopathic physicians about their experiences during the pandemic. If you are a physician and would like to be featured in an interview as we continue our COVID-19 coverage, please email abrown@osteopathic.org.

In this edited Q&A, Dr. Overbeck discusses the challenges of managing severe cases of COVID-19 in a vulnerable population, the mental health impacts that isolation and fear have had on his patients, and how working together to fight the virus brought his patient care team together.

At the height of the outbreak, what was the mood amongst residents?

In April, a lot of residents were anticipating and barricading in place. They felt scared. They felt like getting the virus was a death sentence. There were multiple cases where the person was doing alright, but when they found out they had it, I almost think because of what they were seeing on the news, they all of a sudden needed to be rallied. I was telling them “I’ve seen people older and sicker than you recover. You could beat this, too.”

There was a real effort to boost people up. You could feel that lack of energy and hope. Your own belief and hope are so important when you’re sick. They would say “when I get it, don’t perform CPR.” People were anxious to fill out their advance directive [laying out their preferences for possible end-of-life treatment] before they got sick.

What about the mood of the patient care staff?

At some points, we really felt like we were defeated. We were sleeping with our phones, and we were on 24 hours a day. We were doing everything we possibly could. The nursing home administration was sometimes buying PPE out of pocket for staff.

The solidarity has been the silver lining in all of this. There’s a team of five of us, one nurse practitioner and four doctors. We were talking every day, all day. We decided that nobody was going to make any decision unilaterally. We wanted to be unified and be able to spot all the blind spots. We knew that we were all fighting against the same enemy. Our team is pretty united, I’m pretty proud of that.

How did the virus generally progress in your patients?

It’s pretty aggressive. It takes away their appetite and even their will to go forward. You can hand-feed them and supplement them with IV fluids, but these are tremendously frail people already.

We would confirm someone positive and then within days five to 10, things seemed OK. But then they’d deteriorate in front of us, going from minimal symptoms to significant symptoms. I will say though, that lag is characteristic of older adults in general, regardless of the illness.

But nonetheless, some of them were asymptomatic or only had minimal symptoms. I had one 93-year-old going through chemotherapy who got the virus from visiting their spouse and recovered.

What was communication like between nursing home staff and residents’ families?

We would hold Zoom town halls for the residents and their families, and also sent out frequent communications on the number of residents infected and all relevant updates. As those numbers climbed, there was tremendous anxiety on the families’ part, because they couldn’t visit and couldn’t see what was going on.

It was also a little difficult to swallow that hospitals and other health care facilities were being hailed as heroes while the nursing home staffs were portrayed as criminals on the news. “How could they let this happen?” was a question I saw often. That impacted our team members, who felt defeated and vilified in the general news media coverage. There was tremendous tension in those town halls.

But our data showed that when we were the ones taking care of our patients, we had better outcomes. I’m not saying the hospitals haven’t been doing a good job, but when we had a patient who elected to not be hospitalized, we avoided the transition of care that can sometimes create confusion. We were very proud of a lot of our outcomes.

How’s it going these days, now that things have begun to settle down?

We have a recipe that works. We’re not overconfident about it, but we know that we were able to contain it. With testing, we can figure it out. If you have testing results in two to three days, you can cohort everyone who tests positive and protect everybody else. We have the buy-in of the families who were pretty uncertain about us in May, but have now seen that we were able to contain the outbreak.

Either way, our building has been COVID-19-free since July 9. We have faced our worst fear, which was the virus coming into the building and spreading everywhere. Going from that to where we are now is sensational.

What are some of the ongoing challenges for the elderly during this pandemic, even as infection rates have dropped in some places?

There’s decades of research that says social isolation is a problem for older adults. We’re seeing the effects of that mentally. Many older adults in New Jersey are socially isolated. They can’t visit in person with family members, and maybe they shouldn’t, for infection control.

But if I can go into a facility while taking proper precautions, then perhaps a family member can go into a facility doing the same. Our residents’ family members are sometimes monitors and hand-feeders. They do things that are essential to a thriving nursing home community. So that’s part of the challenge now, keeping the virus out while trying to relax some things as safely as possible.

Related reading:

For this DO, isolation was one of the most difficult parts of having COVID-19

How physicians cope with patient death