What is the recommended treatment for a 69‑year‑old woman with dementia who has COVID‑19, influenza and streptococcal pharyngitis, is on amlodipine, atorvastatin, an ACE‑inhibitor (donzepril), lev‑thyroxine and lorazepam, is allergic to moxifloxacin, and is maintaining a supervised exercise program?

Treatment for 69-Year-Old Woman with Dementia and Triple Infection (COVID-19, Influenza, Streptococcal Pharyngitis)

Initiate nirmatrelvir/ritonavir (Paxlovid) 300 mg/100 mg orally twice daily for 5 days immediately for COVID-19, start oseltamivir 75 mg orally twice daily for 5 days for influenza, and treat streptococcal pharyngitis with amoxicillin 500 mg orally three times daily for 10 days (avoiding fluoroquinolones due to moxifloxacin allergy). 1, 2

COVID-19 Treatment (Highest Priority)

Start Paxlovid immediately as the first-line antiviral therapy, given within 7 days of symptom onset. 1, 2

• Dosing: Nirmatrelvir 300 mg (two 150 mg tablets) with ritonavir 100 mg (one 100 mg tablet), all three tablets taken together orally twice daily (morning and bedtime) for 5 days. 2
• Critical drug interaction screening required: Ritonavir is a strong CYP3A inhibitor that can cause potentially severe, life-threatening interactions. 2

Specific Drug Interactions to Address in This Patient:

• Atorvastatin: Must be temporarily discontinued during the 5-day Paxlovid course due to risk of severe myopathy/rhabdomyolysis from CYP3A inhibition. 2
• Amlodipine: May require dose reduction or temporary hold; monitor for hypotension as ritonavir increases amlodipine levels. 2
• Lorazepam: Generally safe to continue as it undergoes glucuronidation, not CYP3A metabolism, but monitor for increased sedation. 2
• Levothyroxine and donepezil: Can be continued without adjustment. 2

Special Monitoring for Dementia Patients:

• Atypical COVID-19 presentation is common: Watch for sudden cough, fever, diminished taste/smell, nausea, diarrhea, shortness of breath, falls, dehydration, delirium, confusion, or disordered sleep rather than typical respiratory symptoms. 3, 1
• Patient may not self-report symptoms: Careful identification and documentation of changes in health status, mood, or behavior by caregivers is essential. 3, 1

Influenza Treatment

Start oseltamivir (Tamiflu) 75 mg orally twice daily for 5 days as soon as possible after symptom onset, ideally within 48 hours but still beneficial if started later in high-risk patients. 1

• No significant drug interactions with Paxlovid or current medications.
• Can be taken with or without food; taking with food may reduce nausea.

Streptococcal Pharyngitis Treatment

Prescribe amoxicillin 500 mg orally three times daily for 10 days as first-line therapy. 1

• Avoid fluoroquinolones (patient has documented moxifloxacin allergy).
• Alternative if penicillin allergy develops: azithromycin 500 mg on day 1, then 250 mg daily for days 2-5, or cephalexin 500 mg orally four times daily for 10 days (use cephalosporins cautiously if severe penicillin allergy).

Goals of Care Discussion (Critical in Dementia with COVID-19)

Initiate or revisit advance care planning conversations immediately with the patient (if capable) and family/surrogate decision-maker. 3, 1

• Discuss hospitalization decisions jointly within the interprofessional care team (nurses, physicians, palliative care specialists) as soon as possible. 3, 1
• Address preferred place of care: A familiar environment is likely preferred over hospital for this patient with dementia. 3
• Revise care goals as the situation changes: Long-term care residents over 80 years have a 9.3% case fatality rate from COVID-19. 1
• Be sensitive to family burden: Families may need to make hasty, difficult, and emotive decisions on behalf of their relative. 3

Supportive Care Measures

Physical Care:

• Encourage continued supervised exercise program: Stimulate movement by encouraging walking around the room or ward, changing positions regularly (sitting, standing, lying down). 3
• Maintain proper hand hygiene: Place dementia-friendly instruction boards in bathrooms, demonstrate thorough handwashing, use hand sanitizer as alternative. 3
• Monitor oral hygiene closely: COVID-19 may cause dry mouth; oral care is particularly important. 3
• Ensure adequate hydration and nutrition: Monitor for dehydration, which can present as confusion or falls in dementia patients. 3

Psychological Care:

• Reduce anxiety about COVID-19: Minimize media exposure, use simple reminders and visual instructions, use reassuring language and gestures. 3
• Avoid physical or chemical restraints: Do not use antipsychotics or sedatives for behavioral disturbances related to isolation. 3
• Maintain regular routines: Keep a regular schedule, encourage everyday activities (painting, cooking, folding towels), use old photographs or songs for distraction. 3
• Facilitate family contact: Arrange video calls to reduce distress and confusion; family interaction is critical. 3

Social Isolation Management:

• Balance isolation requirements against companionship needs: When nearing end of life or acute need for companionship exists, weigh visit importance against infection risk. 3
• Encourage letters, drawings, or packages from family and friends. 3
• Maintain social support through regular family check-ins via technology. 3

Critical Pitfalls to Avoid

• Do not fail to screen for Paxlovid drug interactions: Use the Liverpool COVID-19 Drug Interaction Tool before prescribing. 1
• Do not continue atorvastatin during Paxlovid therapy: Risk of rhabdomyolysis is significant. 2
• Do not assume typical COVID-19 presentation: Dementia patients often present atypically or asymptomatically. 3, 1
• Do not delay advance care planning: Complex hospitalization decisions should be discussed immediately, not when the patient deteriorates. 3, 1
• Do not use sedatives or antipsychotics for isolation-related behavioral disturbances: These worsen outcomes and increase fall risk. 3
• Do not isolate patient completely: Social isolation worsens dementia symptoms; arrange COVID-19 cohort units allowing freedom of movement if possible. 3

Medication Reconciliation During Treatment

Review all current medications for appropriateness:

• Lorazepam: Consider tapering or discontinuing if possible, as benzodiazepines worsen cognition and increase fall risk in dementia patients. 4
• Monitor for polypharmacy: This patient is already on multiple medications; avoid adding unnecessary drugs during acute illness. 4
• Avoid anticholinergic medications: These worsen cognitive decline in dementia patients. 4

Follow-Up Monitoring

• Daily assessment for clinical deterioration: Monitor respiratory status, oxygen saturation, mental status changes, and ability to maintain oral intake. 3, 1
• Complete full 5-day course of all antimicrobials even if symptoms improve. 2
• Resume atorvastatin after completing Paxlovid course. 2
• Reassess goals of care if hospitalization becomes necessary: If patient requires hospitalization for severe COVID-19, complete the full 5-day Paxlovid course per provider discretion. 2