Older Adult Care in the COVID-19 Context

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The Older Adult Care in the COVID-19 Context tool is revised often and new content is added regularly to guarantee that the latest evidence and regulatory recommendations are included. The CEP is committed to ensuring this information is accurate and up to date.

Last reviewed: November 30, 2020

Last updated: November 24, 2020

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Now more than ever it is important for your patients to look after their health and receive care from you as their healthcare provider. It’s essential that patients continue to seek out care that they need.

This tool has been developed to support primary care providers in navigating and providing patient care in a world where COVID-19 is the ‘new normal’, with considerations and recommendations on what’s ‘new’ and what’s ‘changed’ in the delivery of care for older adults. While how care is delivered has changed, efforts should be made to ensure that the quality has not. As always, when treating your patients, continue to use your clinical judgement and follow standards of care, best practices, evidence and guidelines.

Seek support: The following information is for primary care providers who are proficient in geriatric care and management. If you need support providing the best care possible for your patients, consult specialists via OTN eConsult.

Key takeaway

Older adults ≥ 80 may be at an increased risk for contracting COVID-19 and have the highest mortality rate due to COVID-19 in Ontario (Public Health Ontario, November 22, 2020). It is therefore important to put measures in place to ensure continuity of care for chronic conditions and immunizations in order to help older adults during this time.

Click on the sections below to get started:

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What's new, what's changed New

Management

Older adults are at increased risk of adverse events (e.g. kidney), especially if they are also dehydrated, due to age related changes.

Putting it into practice

See Chronic conditions/disease management for information to help manage individual older adult patients with chronic conditions.
Avoid asking older adults to visit a clinic only for vaccinations at this time. However, if the opportunity arises, please vaccinate.
If possible offer immunization when it can be combined with another medical visit. Offer multiple vaccines if required in order to minimize the risk of acquiring COVID-19 and to reduce the number of health care encounters (Government of Canada, May 13, 2020).
It may be possible to adjust the timing of scheduled vaccines as long as the injection series is eventually completed (Canadian Pharmacist Association, March 26, 2020).
Note: beginning in mid-October, Ontario’s publicly funded shingles program will change vaccine to the Recombinant Zoster Vaccine (RZV) (Shingrix®) and current supplies of the publicly funded live attenuated zoster vaccine (LZV) (Zostavax®II) will expire in October 2020 (Toronto Public Health, October 6, 2020)
- For more information on how to proceed with vaccinations in light of this change, see the summarized NACI recommendations from Toronto Public Health (Toronto Public Health, October 9, 2020)
- For more information on the RZV vaccine, including details regarding when RZV is publicly funded and for whom, see Toronto Public Health’s Vaccine Alert (Toronto Public Health, October 6, 2020)

Immunization guidance

Ages 65+: Pneumococcal (pneu-C13 & penu-P23).
For adults 50+ who have received the first dose of recombinant zoster vaccine, the second dose can be deferred until the 6-12 month interval (doses are typically recommended 2-6 months apart, and may be considered up to 12 months apart) assuming that COVID-19 risk will be lower by that time. If an interval longer than 6-12 months after the first dose has elapsed, the vaccine series does not need to be restarted; the decision when to complete the series should take into consideration the local COVID-19 community transmission risk, recognizing that individuals may remain at risk of herpes zoster during a longer than recommended interval between doses 1 and 2 (Government of Canada, May 13, 2020).
Flu vaccination reminder: high dose trivalent inactivated influenza vaccine (HD TIV) is the preferential vaccine for adults 65 years and older without contraindications. Don’t delay vaccination: if HD-TIV is not available, provide standard QIV dose. For more information on why the HD TIV is beneficial for older adults, please refer to the Planning for influenza vaccination during COVID-19 pandemic (Toronto Public Health, October 6, 2020)

See the Toronto Public Health Immunization Update (April 23, 2020) for more information.
Consult the Canadian Immunization Guide (Government of Canada, 2017) for more detailed guidance on specific vaccines.

Delivering remote/virtual care

When engaging in remote/virtual care with older adults, utilize the guidance in Dr. Shelley Veinish and the Baycrest team’s virtual comprehensive geriatric assessment (March 20, 2020) for information on planning and scheduling a virtual comprehensive geriatric assessment, and instructions on how to conduct the assessment and the examination itself.

Putting it into practice

As a supplement to the virtual comprehensive geriatric assessment above, apply the points from the 4Ms Framework (What Matters, Medication, Mentation, Mobility) (Institute for Healthcare Improvement, July 9, 2020) to enhance the components of the assessment:

Ask “what matters most?”

This will help to convey that what matters to the older adult is also important to the provider.

Medications check

Make sure that the older adult has enough of each medication and ask if they need refills? do they understand how and why they are taking the medications? are there medications that can be discontinued?
Remember, before a new medication is added to work in combination with a current medication, consider gradually increasing the current medication to the maximum dosage to avoid polypharmacy.
When prescribing a medication that’s new for the patient, remember to consider starting with a lower dose and gradually increasing as needed.

Mentation check

In addition to the mental status exam suggested in the virtual comprehensive geriatric assessment consult the virtual approaches to cognitive screening during pandemics from the Canadian Geriatrics Society (May 8, 2020) for other possible assessment tools that can also be used.

Mobility check

Ask what the older adult is doing to keep moving inside or around their home. Suggest a plan to do steps or laps around a room or join an online exercise class. Also suggest 5-10 sit-to-stand repetitions 3-4 times a day. Stress the importance of remaining active even while staying home.

See the Institute for Healthcare Improvement’s “What to Say During Telehealth Visits with Older Adults” for suggested scripts to follow during these visits.

Resources

For patients

Combatting isolation and supports

Student-Senior Isolation Prevention Partnership (University of Toronto and UHN Toronto Western Family Health Team, 2020).
Senior’s Centre Without Walls (Good Companions Seniors’ Centre, 2020).
Seniors Safety Line: 1 866 299 1011 (For elder abuse/safety).

Local resources

For providers

Immunization guidance

Virtual care

These supporting materials and resources are hosted by external organizations. The accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

Acknowledgement and legal

The COVID-19 Resource Centre was developed by the Centre for Effective Practice (CEP) in collaboration with the Department of Family Medicine at McMaster University, the Ontario College of Family Physicians and the Nurse Practitioners’ Association of Ontario using a rapidly modified version of the CEP’s integrated knowledge translation approach.

They are some of several clinical resources developed as part of the Knowledge Translation in Primary Care Initiative. Funded by the Ministry of Health and Long-Term Care, this initiative supports primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

Clinical Working Group

A clinical working group was established and provides significant input and oversight into the development of this resource. Members include:

• Claudia Mariano, MSc, NP-PHC
• Darren Larsen, MD, CCFP, MPLc
• Derelie Mangin, MBChB (Otago), DPH (Otago), FRNZCGP (NZ)
• Dominik Nowak, MD MHSc, CCFP, CH
• Jennifer P. Young, MD, FCFP-EM
• Lee Donohue MD, CCFP, MHSc, MPLc
• Mira Backo-Shannon, MD, BSc, MHSc
• Paul Preston, MD, CCFP, CCPE, CHE
• Rob Annis, MD, CCFP
• Soreya Dhanji, MD, CCFP

In addition to our clinical working group the CEP also obtained feedback from others, including:

• Arun Radhakrishnan, MSC, MD, CM, CCFP
• David Price, BSC, MD, CCFP, FCFP
• Jose Silveira, BSC, MD, FRCPC, DIP, ABAM
• Michael Chang MD, FRCP(C)
• Payal Agarwal, MD, CCFP
• Robert Sauls MD, CCFP(PC), FCFP
• Tara Walton, MPH

Thank you to everyone who supported the development of this resource.

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In collaboration with:

With support from: