COVID-19

‘Covid Hit Us Over the Head With a Two-by-Four’: Addressing Ageism With Urgency

Earlier this year, the World Health Organization announced a global campaign to combat ageism — discrimination against older adults that is pervasive and harmful but often unrecognized.

“We must change the narrative around age and ageing” and “adopt strategies to counter” ageist attitudes and behaviors, WHO concluded in a major report accompanying the campaign.

Several strategies WHO endorsed — educating people about ageism, fostering intergenerational contacts, and changing policies and laws to promote age equity — are being tried in the United States. But a greater sense of urgency is needed in light of the coronavirus pandemic’s shocking death toll, including more than 500,000 older Americans, experts suggest.

“Covid hit us over the head with a two-by-four, [showing that] you can’t keep doing the same thing over and over again and expect different results” for seniors, Jess Maurer, executive director of the Maine Council on Aging, said in an October webinar on ageism in health care sponsored by KHN and the John A. Hartford Foundation. “You have to address the root cause — and the root cause here is ageism.”

Some experts believe there’s a unique opportunity to confront this concern because of what the country has been through. Here are some examples of what’s being done, particularly in health care settings.

Distinguishing old age from disease. In October, a group of experts from the U.S., Canada, India, Portugal, Switzerland and the United Kingdom called for old age to be removed as one of the causes and symptoms of disease in the 11th revision of the International Classification of Diseases, a global resource used to standardize health data worldwide.

Aging is a normal process, and equating old age with disease “is potentially detrimental,” the experts wrote in The Lancet. Doing so could result in inadequate clinical evaluation and care and an increase in “societal marginalisation and discrimination” against older adults, they warn.

Identifying ageist beliefs and language. Groundbreaking research published in 2015 by the FrameWorks Institute, an organization that studies social issues, showed that many people associate aging with deterioration, dependency and decline — a stereotype that almost surely contributed to policies that harmed older adults during the pandemic. By contrast, experts understand that older adults vary widely in their abilities and that a significant number are healthy, independent and capable of contributing to society.

Using this and subsequent research, the Reframing Aging Initiative, an effort to advance cultural change, has been working to shift how people think and talk about aging, training organizations across the country. Instead of expressing fatalism about aging (“a silver tsunami that will swamp society”), it emphasizes ingenuity, as in “we can solve any problem if we resolve to do so,” said Patricia D’Antonio, project director and vice president of policy and professional affairs at the Gerontological Society of America. Also, the initiative promotes justice as a value, as in “we should treat older adults as equals.”

Since it began, the American Medical Association, the American Psychological Association and the Associated Press have adopted bias-free language around aging, and communities in Colorado, New Hampshire, Massachusetts, Connecticut, New York and Texas have signed on as partners.

Tackling ageism at the grassroots level. In Colorado, Changing the Narrative, a strategic awareness campaign, has hosted more than 300 workshops educating the public about ageist language, beliefs and practices in the past three years. Now, it’s launching a campaign calling attention to ageism in health care, including a 15-minute video set to debut in November.

“Our goal is to teach people about the connections between ageism and poor health outcomes and to mobilize both older people and [health] professionals to advocate for better medical care,” said Janine Vanderburg, director of Changing the Narrative.

Faced with the pandemic’s horrific impact, the Maine Council on Aging earlier this year launched the Power in Aging Project, which is sponsoring a series of community conversations around ageism and asking organizations to take an “anti-ageism pledge.”

The goal is to educate people about their own “age bias” — largely unconscious assumptions about aging — and help them understand “how age bias impacts everything around them,” said Maurer. For those interested in assessing their own age bias, a test from Harvard University’s Project Implicit is often recommended. (Sign in and choose the “age IAT” on the next page.)

Changing education for health professionals. Two years ago, Harvard Medical School began integrating education in geriatrics and palliative care throughout its curriculum, recognizing that it hadn’t been doing enough to prepare future physicians to care for seniors. Despite the rapid growth of the older population, only 55% of U.S. medical schools required education in geriatrics in 2020, according to the latest data from the Association of American Medical Colleges.

Dr. Andrea Schwartz, an assistant professor of medicine, directs Harvard’s effort, which teaches students about everything from the sites where older adults receive care (nursing homes, assisted living, home-based programs, community-based settings) to how to manage common geriatric syndromes such as falls and delirium. Also, students learn how to talk with older patients about what’s most important to them and what they most want from their care.

Schwartz also chaired a committee of the academic programs in geriatrics that recently published updated minimum competencies in geriatrics that any medical school graduate should have.

Altering professional requirements. Dr. Sharon Inouye, also a professor of medicine at Harvard, suggests additional approaches that could push better care for older adults forward. When a physician seeks board certification in a specialty or doctors, nurses or pharmacists renew their licenses, they should be required to demonstrate training or competency in “the basics of geriatrics,” she said. And far more clinical trials should include a representative range of older adults to build a better evidence base for their care.

Inouye, a geriatrician, was particularly horrified during the pandemic when doctors and nurses failed to recognize that seniors with covid-19 were presenting in hospital emergency rooms with “atypical” symptoms such as loss of appetite and delirium. Such “atypical” presentations are common in older adults, but instead of receiving covid tests or treatment, these older adults were sent back to nursing homes or community settings where they helped spread infections, she said.

Bringing in geriatrics expertise. If there’s a silver lining to the pandemic, it’s that medical professionals and health system leaders observed firsthand the problems that ensued and realized that older adults needed special consideration.

“Everything that we as geriatricians have been trying to tell our colleagues suddenly came into sharp focus,” said Dr. Rosanne Leipzig, a professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York City.

Now, more Mount Sinai surgeons are asking geriatricians to help them manage older surgical patients, and orthopedic specialists are discussing establishing a similar program. “I think the value of geriatrics has gone up as institutions see how we care for complicated older adults and how that care improves outcomes,” Leipzig said.

Building age-friendly health systems. “I believe we are at an inflection point,” said Terry Fulmer, president of the John A. Hartford Foundation, which is supporting the development of age-friendly health systems with the American Hospital Association, the Catholic Health Association of the United States and the Institute for Healthcare Improvement. (The John A. Hartford Foundation is a funder of KHN.)

More than 2,500 health systems, hospitals, medical clinics and other health care providers have joined this movement, which sets four priorities (“the 4Ms”) in caring for older adults: attending to their mobility, medications, mentation (cognition and mental health) and what matters most to them — the foundation for person-centered care.

Creating a standardized framework for improving care for seniors has helped health care providers and systems know how to proceed, even amid the enormous uncertainty of the past couple of years. “We thought [the pandemic] would slow us down, but what we found in most cases was the opposite — people could cling to the 4Ms to have a sense of mastery and accomplishment during a time of such chaos,” Fulmer said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Nursing Home Residents Overlooked in Scramble for Covid Antibody Treatments

 
Of the dozens of patients Dr. Jim Yates has treated for covid-19 at his long-term care center in rural Alabama, this one made him especially nervous.

The 60-year-old man, who had been fully vaccinated, was diagnosed with a breakthrough infection in late September. Almost immediately, he required supplemental oxygen, and lung exams showed ominous signs of worsening disease. Yates, who is medical director of Jacksonville Health and Rehabilitation, a skilled nursing facility 75 miles northeast of Birmingham, knew his patient needed more powerful interventions — and fast.

At the first sign of the man’s symptoms, Yates had placed an order with the Alabama Department of Public Health for monoclonal antibodies, the lab-made proteins that mimic the body’s ability to fight the virus. But six days passed before the vials arrived, nearly missing the window in which the therapy works best to prevent hospitalization and death.

“We’ve been pushing the limits because of the time frame you have to go through,” Yates said. “Fortunately, once we got it, he responded.”

Across the country, medical directors of skilled nursing and long-term care sites say they’ve been scrambling to obtain doses of the potent antibody therapies following a change in federal policy that critics say limits supplies for the vulnerable population of frail and elder residents who remain at highest risk of covid infection even after vaccination.

“There are people dying in nursing homes right now, and we don’t know whether or not they could have been saved, but they didn’t have access to the product,” said Chad Worz, CEO of the American Society of Consultant Pharmacists, which represents 1,500 pharmacies that serve long-term care sites.

Before mid-September, doctors and other providers could order the antibody treatments directly through drug wholesaler AmerisourceBergen and receive the doses within 24 to 48 hours. While early versions of the authorized treatments required hourlong infusions administered at specialty centers or by trained staff members, a more recent approach allows doses to be administered via injections, which have been rapidly adopted by drive-thru clinics and nursing homes.

Prompt access to the antibody therapies is essential because they work by rapidly reducing the amount of the virus in a person’s system, lowering the chances of serious disease. The therapies are authorized for infected people who’ve had symptoms for no more than 10 days, but many doctors say they’ve had best results treating patients by Day 5 and no later than Day 7.

After a slow rollout earlier in the year, use of monoclonal antibody treatments exploded this summer as the delta variant surged, particularly in Southern states with low covid vaccination rates whose leaders were looking for alternative — albeit costlier — remedies.

By early September, orders from seven states — Alabama, Florida, Georgia, Louisiana, Mississippi, Tennessee and Texas — accounted for 70% of total shipments of monoclonals.

Those Southern states, plus three others — Arkansas, Kentucky and North Carolina — ordered new courses of treatment even faster than they used their supplies. From July 28 to Sept. 8, they collectively increased their antibody stockpiles by 134%, according to a KHN analysis of federal data.

Concerned the pattern was both uncontrolled and unsustainable given limited national supplies, officials with the Department of Health and Human Services stepped in to equalize distribution. HHS barred individual sites from placing direct orders for the monoclonals. Instead, they took over distribution, basing allocation on case rates and hospitalizations and centralizing the process through state health departments.

“It was absolutely necessary to make this change to ensure a consistent product for all areas of the country,” Dr. Meredith Chuk, who is leading the allocation, distribution and administration team at HHS, said during a conference call.

But states have been sending most doses of the monoclonal antibody treatments, known as mAbs, to hospitals and acute care centers, sidestepping the pharmacies that serve long-term care sites and depleting supplies for the most vulnerable patients, said Christopher Laxton, executive director of AMDA, the Society for Post-Acute and Long-Term Care Medicine.

While vaccination might provide 90% protection or higher against serious covid in younger, healthier people, that’s not the case for the elders who typically live in nursing homes.

“You have to think of the spectrum of immunity,” Laxton said. “For our residents, it’s closer to 60%. You know that 4 out of 10 are going to have breakthrough infections.”

The mAb treatments have been authorized for use in high-risk patients exposed to the virus, and experts in elder care say that is key to best practices in preventing outbreaks in senior facilities. That could include, for example, treating the elderly roommate of an infected nursing home patient. But because of newly limited supplies, many long-term care sites have started to restrict use to only those who are infected.

Still, some states have worked to ensure access to mAbs in long-term care sites. Minnesota health officials rely on a policy that prioritizes residents of skilled nursing facilities for the antibody therapies through a weighted lottery. In Michigan, state Medical Director Dr. William Fales directed emergency medical technicians and paramedics to the Ascension Borgess Hospital system in Kalamazoo to help administer doses during recent outbreaks at two centers.

“The monoclonal antibodies made a huge difference,” said Renee Birchmeier, a nurse practitioner who cares for patients in nine of the system’s sites. “Even the patients in the assisted living with COPD, they’re doing OK,” she said, referring to chronic obstructive pulmonary disease. “They’re not advancing, but they’re doing OK. And they’re alive.”

Long-term care sites have accounted for a fraction of the orders for the monoclonal treatments, first authorized in November 2020. About 3.2 million doses have been distributed to date, with about 52% already used, according to HHS. Only about 13,500 doses have gone to nursing homes this year, according to federal data. That doesn’t include other long-term care sites such as assisted living centers.

The use is low in part because the treatments were originally delivered only through IV infusions. But in June, the Regeneron monoclonal antibody treatment was authorized for use via subcutaneous injections — four separate shots, given in the same sitting — and demand surged.

Use in nursing homes rose to more than 3,200 doses in August and nearly 6,700 in September, federal data shows. But weekly usage dropped sharply from mid-September through early October after the HHS policy change.

Nursing homes and other long-term care sites were seemingly left behind in the new allocation system, said Cristina Crawford, a spokesperson for the American Health Care Association, a nonprofit trade group representing long-term care operators. “We need federal and state public health officials to readjust their priorities and focus on our seniors,” she said.

In an Oct. 20 letter to White House policy adviser Amy Chang, advocates for long-term care pharmacists and providers called for a coordinated federal approach to ensure access to the treatments. Such a plan might reserve use of a certain type or formulation of the product for direct order and use in long-term care settings, said Worz, of the pharmacy group.

So far, neither the HHS nor the White House has responded to the letter, Worz said. Cicely Waters, a spokesperson for HHS, said the agency continues to work with state health departments and other organizations “to help get covid-19 monoclonal antibody products to the areas that need it most.” But she didn’t address whether HHS is considering a specific solution for long-term care sites.

Demand for monoclonal antibody treatments has eased as cases of covid have declined across the U.S. For the week ending Oct. 27, an average of nearly 72,000 daily cases were reported, a decline of about 20% from two weeks prior. Still, there were 2,669 confirmed cases among nursing home residents the week ending Oct. 24, and 392 deaths, according to the Centers for Disease Control and Prevention.

At least some of those deaths might have been prevented with timely monoclonal antibody therapy, Worz said.

Resolving the access issue will be key to managing outbreaks as the nation wades into another holiday season, said Dr. Rayvelle Stallings, corporate medical officer at PruittHealth, which serves 24,000 patients in 180 locations in the Southeast.

PruittHealth pharmacies have a dozen to two dozen doses of monoclonal antibody treatments in stock, just enough to handle expected breakthrough cases, she said.

“But it’s definitely not enough if we were to have a significant outbreak this winter,” she said. “We would need 40 to 50 doses. If we saw the same or similar surge as we saw in August and September? We would not have enough.”

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

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Student Nurses Who Refuse Vaccination Struggle to Complete Degrees

Kaitlyn Hevner expects to complete a 15-month accelerated nursing program at the University of North Florida in Jacksonville in December. For her clinical training this fall, she’s working 12-hour shifts on weekends with medical-surgical patients at a hospital.

But Hevner and nursing students like her who refuse to get vaccinated against covid-19 are in an increasingly precarious position. Their stance may put their required clinical training and, eventually, their nursing careers at risk.

In early September, the Biden administration announced that workers at health care facilities, including hospitals and ambulatory surgery centers, would be required to receive covid vaccines. Although details of the federal rule won’t be released until October, some experts predict that student nurses doing clinical training at such sites will have to be vaccinated, too.

Groups representing the nursing profession say “students should be vaccinated when clinical facilities require it” to complete their clinical training. In a policy brief released Monday, the National Council of State Boards of Nursing and eight other nurse organizations suggested that students who refuse to be vaccinated and who don’t qualify for an exception because of their religious beliefs or medical issues may be disenrolled from their nursing program or be unable to graduate because they cannot fulfill the clinical requirements.

“We can’t have students in the workplace that can expose patients to a serious illness,” said Maryann Alexander, chief officer for nursing regulation at the national council. “Students can refuse the vaccine, but those who are not exempt maybe should be told that this is not the time to be in a nursing program.”

“You’re going to go into practice and you’re going to be very limited in your jobs if you’re not going to get that vaccine,” Alexander said.

Kaitlyn Hevner, a nursing student at the University of North Florida, has opted not to get vaccinated against covid even though many medical facilities require it. She questions whether “we give up our own religious rights and our own self-determination just because we work in a health care setting.” (Robert Working)

Hevner, 35, set to finish her clinical training in early October, said she doesn’t feel it’s acceptable to benefit from a vaccine that was developed using fetal cells obtained through abortion, which she opposes. (Development of the Johnson & Johnson covid vaccine involved a cell line from an abortion; the Pfizer-BioNTech and Moderna mRNA vaccines were not developed with fetal cell lines, but some testing of the vaccines reportedly involved fetal cells, researchers say. Many religious leaders, however, support vaccination against covid.)

With vaccines for nursing students still optional in many health care settings, nursing educators are scrambling to place unvaccinated students in health care facilities that will accept them.

Down the coast from Jacksonville in Fort Pierce, Florida, 329 students are in the two-year associate degree nursing program at Indian River State College, said Roseann Maresca, an assistant professor who teaches third-semester students and coordinates their clinical training. Only 150 of them are vaccinated against covid, she said.

Not all of the eight medical facilities that have contracts with the school require student nurses to be vaccinated.

“It’s been a nightmare trying to move students around this semester” to match them with facilities depending on their vaccination status, Maresca said.

Commonly, health care facilities have long required employees to be vaccinated against various illnesses such as influenza and hepatitis B. The pandemic has added new urgency to these requirements. According to a September tally by FierceHealthcare, more than 170 health systems mandate covid vaccines for their workforces.

In May, the federal Equal Employment Opportunity Commission made it clear that under federal law employers can mandate covid vaccinations as long as they allow workers to claim religious and medical exemptions.

Under the Biden administration’s covid plan, roughly 50,000 health care facilities that receive Medicare or Medicaid payments must require workers to be vaccinated. Until the administration releases its draft rule in October, it is unclear how nursing students assigned to health care sites for clinical training will be treated.

But the federal rule published in August that lays out regulations for government hospital payments in 2022 offers clues. It defined health care personnel that should be vaccinated as employees, licensed independent contractors and adult students/trainees and volunteers, said Colin Milligan, director of media relations at the American Hospital Association.

In addition to staff members, the Biden plan says mandates will apply to “individuals providing services under arrangements” at health care sites.

A spokesperson for the Centers for Medicare & Medicaid Services declined to clarify who would be covered by the Biden plan, noting the agency is still writing the rules.

Nonetheless, vaccination mandates threaten to derail the training of a relatively small proportion of nursing students. A recent survey by the National Student Nurses’ Association reported that 86% of nursing students and 85% of new nursing graduates who responded to an online survey said they had been or planned to be vaccinated against covid.

But the results varied widely by state, from 100% in New Hampshire and Vermont on the high end to 63% in Oklahoma, 74% in Kentucky and 76% in Florida on the low end. The survey had 7,501 respondents.

Students who don’t want to be vaccinated are asking schools to offer them alternatives to on-site clinical training. They suggest using life-size computer-controlled mannequins or computer-based simulations using avatars, said Marcia Gardner, dean of the nursing school at Molloy College in Rockville Centre, New York.

Last year, when the pandemic led hospitals to close their doors to students, many nursing programs increased simulated clinical training to give nursing students some sort of clinical experience.

But that’s no substitute for working with real patients in a health care setting, educators say. State nursing boards permit simulated clinical study to varying degrees, but none allow such instruction to exceed 50% of clinical training, said Alexander. A multisite study found that nursing students could do up to half their clinical training using simulation with no negative impact on competency.

The policy brief by the council of state nursing boards states that nursing education programs “are not obligated to provide substitute or alternate clinical experiences based on a student’s request or vaccine preference.”

As more nursing students become vaccinated, the issue will grow less acute. And if the Biden plan requires nursing students to be vaccinated to work in hospitals, the number of holdouts is likely to further shrink.

Hevner, the University of North Florida student, said she’s not opposed to vaccines in general and would consider getting a covid vaccine in the future if she could be assured it wasn’t created using aborted fetal cells. She filed paperwork with the college to get a religious exemption from vaccine requirements. It turned out she didn’t need one because Orange Park Medical Center, where she is doing her clinical training, doesn’t require staffers or nursing students to be vaccinated against covid “at this time,” said Carrie Turansky, director of public relations and communications for the medical center, in Orange Park, Florida.

Although Hevner opposes getting the vaccine, “I take protecting my patients and protecting myself very seriously,” she said. She gets tested weekly for covid and always wears an N95 mask in a clinical setting, among other precautions, she said. “But I would ask: Do we give up our own religious rights and our own self-determination just because we work in a health care setting?”

She hopes the profession can accommodate people like her.

“I’m concerned because we’re in such a divisive place,” she said. But she is eager to find a middle ground because, she said, “I think I would make a really great nurse.”

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