What is the recommended treatment for Covid-19 in long term care residents?

COVID-19 Treatment in Long-Term Care Residents

For long-term care residents with COVID-19, initiate nirmatrelvir/ritonavir (Paxlovid) 300 mg/100 mg orally every 12 hours for 5 days as first-line treatment, starting as soon as possible after diagnosis and within 7 days of symptom onset, after carefully screening for drug interactions using the Liverpool COVID-19 Drug Interaction Tool. 1

Risk Stratification and Treatment Urgency

Long-term care residents face dramatically elevated mortality risk from COVID-19, with case fatality rates reaching 9.3% in those over 80 years compared to <0.2% in those under 60. 2 Residents with dementia are particularly vulnerable due to:

• Pre-existing dementia being the strongest independent risk factor for severe COVID-19 symptoms in adults over 65 3
• Higher prevalence of comorbidities including cardiovascular disease, diabetes, and pneumonia 3
• Difficulty understanding and adhering to infection prevention measures 3
• Rapid viral spread once introduced into facilities 3

Treatment must be initiated within 7 days of symptom onset for maximum efficacy. 1

First-Line Antiviral Therapy

Nirmatrelvir/Ritonavir (Paxlovid)

This is the preferred first-line agent based on high-certainty evidence showing important reduction in hospitalization and moderate certainty of survival benefit in high-risk patients. 1

Dosing:

• Standard: 300 mg nirmatrelvir/100 mg ritonavir orally every 12 hours for 5 days 1
• Renal adjustment (eGFR 30-59 mL/min): 150 mg nirmatrelvir/100 mg ritonavir orally every 12 hours for 5 days 1

Critical pre-treatment requirements:

• Mandatory drug interaction screening using the Liverpool COVID-19 Drug Interaction Tool before prescribing 1
• Ritonavir is a potent CYP3A4 inhibitor causing numerous clinically significant interactions 1
• Common problematic medications in long-term care residents include statins, certain antiarrhythmics, benzodiazepines, and immunosuppressants 1
• Check renal function before dosing 1

Alternative Antiviral Options

Remdesivir

Use when nirmatrelvir/ritonavir is contraindicated due to drug interactions or unavailable. 1

Dosing for residents weighing ≥40 kg:

• Loading dose: 200 mg IV on Day 1 4
• Maintenance: 100 mg IV daily for 2 additional days (3-day course for non-hospitalized patients) 4
• Extended to 5-10 days for hospitalized patients depending on severity 4

Advantages:

• May result in larger reduction in hospitalization compared to molnupiravir 1
• No dosage adjustment needed for any degree of renal impairment, including dialysis 4
• Can be administered without regard to timing of dialysis 4

Requirements:

• Must be administered in settings where healthcare providers have immediate access to medications for severe infusion/hypersensitivity reactions and ability to activate emergency medical system 4
• Perform hepatic laboratory testing before starting and during treatment 4
• Determine prothrombin time before starting and monitor during treatment 4

Molnupiravir

Only use for high-risk patients when nirmatrelvir/ritonavir and remdesivir are unavailable. 1

Critical contraindication:

• Should NOT be used in patients of childbearing potential due to mutagenic mechanism and potential carcinogenesis concerns 1

Supportive Care for Hospitalized Residents

Corticosteroids

Administer dexamethasone 6 mg daily for 10 days for residents requiring supplemental oxygen, noninvasive ventilation, or mechanical ventilation. 1

This recommendation is based on strong evidence with moderate certainty from the RECOVERY trial. 5

Monitoring considerations:

• Watch for hyperglycemia, immunosuppression, and delayed viral clearance 5
• Particularly important in residents with diabetes 5

Anticoagulation

Provide prophylactic-intensity anticoagulation for hospitalized residents with acute COVID-19 who do not have suspected or confirmed VTE. 1

Immunomodulatory Therapy

Consider tocilizumab or sarilumab for hospitalized residents requiring oxygen or ventilatory support, administered with systemic corticosteroids. 1

Medications to Avoid

Do NOT use the following agents as they lack benefit or increase mortality: 1

• Hydroxychloroquine 1
• Lopinavir-ritonavir 1
• Ivermectin 1

Dose Adjustments for Elderly Residents

For residents 60-80 years: administer 3/4 to 4/5 of standard adult doses. 2

For residents over 80 years: administer 1/2 of standard adult doses. 2

These adjustments apply to supportive medications and should be made according to organ function and drug interactions. 2

Monitoring for Complications

Closely monitor elderly residents for: 2

• Secondary bacterial infections (neutrophil ratio is significantly elevated in elderly patients) 2
• Disseminated intravascular coagulation (D-dimer levels are markedly elevated) 2
• Atypical presentations including falls, dehydration, delirium, confusion, disordered sleep 3

Special Considerations for Residents with Dementia

Symptom Recognition

COVID-19 may present atypically or asymptomatically in residents with dementia. 3

Watch for:

• Sudden cough and fever 3
• Diminished taste or smell 3
• Nausea and diarrhea 3
• Shortness of breath 3
• Falls, dehydration, delirium or confusion 3
• Disordered sleep 3

Residents with dementia may not self-report changes, requiring careful identification and documentation by staff. 3

Behavioral Management During Isolation

Report and respond to behaviors that may pose risk to others, such as wandering during isolation. 3

Collaborate with mental health and dementia teams to manage wandering behavior of residents requiring isolation. 3

Psychosocial interventions to manage behavioral disturbances: 3

• Use old photographs, objects, or songs for distraction 3
• Stimulate movement, exercise, and creative or household activities 3
• Keep regular schedule and routine 3

Oral Hygiene

Pay particular attention to oral hygiene for residents with dementia who contract COVID-19, as the infection may cause oral complications. 3

Reduced salivary flow is common in older people with dementia, impairing natural self-cleaning mechanisms, and can be exacerbated by COVID-19. 6

Advance Care Planning

Initiate or revisit advance care planning conversations early, discussing potential scenarios and end-of-life care options proactively. 3

Complex decisions about hospitalization should be discussed jointly within the interprofessional care team including nurses, physicians, and palliative care specialists. 3

For residents with COVID-19, discuss goals of care as soon as possible and revise as the situation changes. 3

Document wishes clearly in transferable digital files accessible to all care agencies and emergency personnel. 3

Infection Prevention in Facilities

Balance isolation requirements against the need for companionship, particularly for those nearing end of life. 2

Implement telehealth consultations to reduce exposure while maintaining care continuity. 2

Reduce social isolation through: 3

• Encouraging letters, drawings, or packages from family 3
• Facilitating technology use for video calls with additional support as needed 3
• Maintaining regular check-ins by family members 3
• Arranging individual outdoor activities when possible 3

Common Pitfalls to Avoid

Delayed treatment initiation: Establish rapid testing and prescription fulfillment protocols, as treatment must begin within 7 days of symptom onset. 1

Missed drug interactions: Review ALL medications before prescribing nirmatrelvir/ritonavir; interactions can persist for several days after treatment completion. 1

Standard dosing without adjustment: Always adjust for age and organ function; do not use standard adult dosing in elderly residents. 2

Strict isolation without considering mental health impact: Do not implement isolation without addressing detrimental effects on cognitive function and mental health. 2

Overlooking atypical presentations: COVID-19 in residents with dementia may not present with typical respiratory symptoms. 3

Failure to check renal function: Always assess kidney function before dosing nirmatrelvir/ritonavir to avoid adverse effects. 1