Interim guidance: Care of residents in long term care homes during the COVID-19 pandemic

Last updated: July 17, 2020.

Table of contents

Preamble

This document provides care guidance specific to the COVID-19 pandemic in Canadian homes/facilities where older adults require continuous supervised care, including professional health services, personal care and other services such as meals, laundry and housekeeping. These facilities may have different names, including but not limited to care homes/facilities, continuing care homes/facilities, personal care homes/facilities, nursing homes/facilities, centres d'hébergement et de soins de longue durée (CHSLDs), or other long term care homes/facilities, all hereafter referred to as LTCHs. Some of the content may be adapted to other settings as appropriate (i.e. retirement homes).

This guidance provides employed and contracted LTCH staff including physicians (most often family physicians, medical specialist consultants), nurse practitioners, registered nurses, licensed or registered practical nurses, clinical pharmacists, and health care aides/assistants, continuing care/personal care attendants/assistants, resident attendants/care workers, and personal support workers (all hereafter referred to as support workers), and others who provide care for residents in LTCHs, with interim advice on important aspects of care for all LTCH residents during the COVID-19 pandemic, and on the timely and safe supportive management of residents with suspected or confirmed COVID-19. The guidance in this document is also important for medical and nursing administrators/directors and their associates who can play a pivotal role in building infrastructure and collaborating with LTCH care providers to implement recommended measures.

Recommendations for LTCH staff, resident and family/caregiver preparedness, resident assessment, active medical management, palliative care, mental health disorders, delirium and responsive behaviours, and psychosocial aspects of care are included.

Important guidance related to infection prevention and control (IPC) is not detailed here; however, IPC measures to prevent and control transmission of COVID-19 will impact many aspects of resident care in LTCHs. More detailed national guidance on Infection Prevention and Control for COVID-19 in LTCHs has been published.

This guidance is not meant to replace clinical judgment or specialist consultation, but rather to provide a framework to strengthen care for LTCH residents and staff. It has been informed by currently available scientific evidence and expert opinion, and is subject to change as new information becomes available. All national guidance should be considered in conjunction with relevant provincial, territorial and local legislation, regulations, and policies.

1.0 Background

In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. These cases were caused by infection with a novel coronavirus that causes a disease now referred to as COVID-19. A pandemic was declared by the World Health Organization on March 11, 2020. For current information on the pandemic, please refer to the Public Health Agency of Canada Coronavirus Disease (COVID-19): Outbreak Update and to local, provincial or territorial public health authorities.

COVID-19 is spread from an infected person through respiratory droplets generated through cough or sneezing, close personal contact such as touching or shaking hands, or touching something with the virus on it and then touching one's mouth, nose or eyes before washing one's hands. COVID-19 can also be spread through the air during aerosol-generating medical procedures (AGMPs).

COVID-19 may be transmitted from asymptomatic, pre-symptomatic, and minimally symptomatic infected staff or residents. (Footnote 1,Footnote 2,Footnote 3,Footnote 4,Footnote 5, Footnote 6) LTCH residents are vulnerable to infection with COVID-19 due to significant personal care needs that often require frequent close interaction and touch, behavioural factors and limitations associated with cognitive impairment (e.g., wandering and difficulties practicing physical distancing and hand hygiene), shared common spaces and toileting facilities, exposure to staff and visitors, and transit between healthcare facilities. (Footnote 7, Footnote 8)

Older adults with COVID-19 may have atypical or subtle symptoms. (Footnote 2, Footnote 7 , Footnote 9,Footnote 10,Footnote 11,Footnote 12,Footnote 13,Footnote 14,Footnote 15,Footnote 16, Footnote 17) While most people with COVID-19 develop mild or uncomplicated disease, older adults and those with pre-existing medical conditions (risk factors present in most residents of LTCHs) are at higher risk for more severe disease when infected with COVID-19.(Footnote 7 , Footnote 13, Footnote 14 , Footnote 18,Footnote 19,Footnote 20,Footnote 21,Footnote 22, Footnote 23) Older adults have high mortality;(Footnote 13 , Footnote 19, Footnote 22 , Footnote 24) as of June 23, 2020, the case fatality rate among reported cases of COVID-19 for different age groups in Canada was: <1% aged <60, 6% aged 60-69, 20% aged 70-79, and 34% aged ≥ 80 years.( Footnote 13) Eighty-two percent of Canadian deaths attributed to COVID-19 have been linked to LTCHs.(Footnote 13 )

As of June 23, 2020, there are no vaccines or evidence-based therapies in widespread use to prevent or treat COVID-19 in Canada. Evidence is rapidly evolving and there are several clinical trials underway, (Footnote 25,Footnote 26,Footnote 27, Footnote 28) therefore information on management of COVID-19 infection may change over time. Supportive care for those with more than mild or moderate disease involves provision of supplemental oxygen and hydration.( Footnote 14, Footnote 23 , Footnote 29, Footnote 30) For people who become severely or critically ill, hospitalization and intensive care unit admission with mechanical ventilation may be required to support life.(Footnote 14, Footnote 29, Footnote 30 , Footnote 31) However, mortality is high even with these interventions, with a strong age gradient and potential for significant morbidity and suffering in older adults.(Footnote 13, Footnote 19 , Footnote 21, Footnote 22 , Footnote 32,Footnote 33,Footnote 34,Footnote 35, Footnote 36)

There is extensive published guidance on IPC aspects of care of LTCH residents, but less on other important aspects of care in this population. ( Footnote 37) LTCHs are not uniformly well-prepared to care for increased numbers of sick residents and staff. Delirium and responsive behaviours may be precipitated by COVID-19, or worsen with reduced or new staff or new routines in the context of measures to prevent and control outbreaks of COVID-19. Stress and anxiety associated with fear of infection, isolation and visitor restrictions, and family and caregiver burden may cause significant psychosocial stress.

This document provides guidance on LTCH staff, resident and family/caregiver preparedness, resident assessment, active medical management, palliative care, mental health disorders, delirium and responsive behaviours, and psychosocial aspects of care in the context of the COVID-19 pandemic.

2.0 Long term care home staff, resident, and family/caregiver preparedness

LTCH staff, residents, and their families or other caregivers can make changes and prepare for care of residents in the context of the COVID-19 pandemic. These measures apply to all LTCH residents, and are not specific to those with suspected or confirmed COVID-19.

2.1 Infection prevention and control

There are many important IPC measures that LTCH staff, residents, and family/caregivers should be familiar with in order to prevent and control the transmission of COVID-19 in LTCHs.

This document is not intended to provide comprehensive IPC guidance. Separate national IPC for COVID-19 interim guidance for LTCHs has been published, and includes guidance on LTCH and staff IPC preparedness, screening, visitors, resident care, Routine and Additional Precautions, resident placement and accommodation, resident activity, outbreak management, handling of resident care equipment, and environmental cleaning and disinfection.

2.2 Resident information: baseline health and medications

Information and documentation on resident baseline physical and mental health and medications should be reviewed to ensure it is up to date for each resident.

2.3 Goals of care and advance care planning

Goals of care and any advance care planning needs to be reviewed and updated for all residents.(Footnote 8)

2.4 Roles, responsibilities, and human resources planning

2.5 Establishing networks and acquiring and maintaining supplies

LTCHs should establish:

2.6 Communication

LTCHs should have policies and procedures in place for ongoing communication with attending physicians or nurse practitioners, staff, residents, and their families, caregivers, and SDMs on COVID-19 updates in the community and/or the home.

3.0 Assessment

3.1 Detecting signs and symptoms

Residents of LTCHs should undergo regular and thorough assessment for signs and symptoms of COVID-19.

3.2 Investigations

3.3 Severity assessment

4.0 Active medical management

Active medical management of residents suspected or confirmed to have COVID-19 can often be provided in the LTCH. There may be variation in the staffing skills and complement required to implement some of the following measures, but homes should work toward building capacity to provide care to residents who wish to receive active medical management while remaining in place within their LTCH. Interventions must be consistent with resident goals of care, expressed wishes and advance care plans, and informed consent obtained.

The care that can be provided may be challenged during outbreaks due to staff shortages, and homes should receive regional support to maintain quality and safe care. If the frequency or intensity of required care is greater than the capacity that can be provided in the LTCH, particularly when there are staffing shortages, consideration should be given to whether transfer to another facility is consistent with the resident's goals of care and can be safely arranged.

For those who wish to remain in place for active medical management and are not responding to management or are worsening, care should focus on alleviating pain and other distressing symptoms, and after discussion and consent from the resident or their SDM, transition should be made to comfort and end-of-life care (see Palliative Care section). Consider use of a decision pathway, for example: BC Centre for Disease Control, COVID-19 in LTC Residents.

4.1 Supplemental oxygen

4.2 Hydration and nutrition

4.3 Specific treatment

4.4 Other management

4.5 Medication review

4.6 Potential co/super-infection

There is no consensus on what circumstances should prompt initiation of antibiotics for possible bacterial infection in people who are suspected or confirmed to have COVID-19. The true rate of bacterial co-infection with COVID-19 is unknown, and there is minimal data on the LTCH population at this time.

One review suggested that the rate of bacterial co-infection in nine studies of patients with COVID-19 may be 8% (62/806), (range 2-17%), (Footnote 70) though another study suggested that this rate may be higher in older adults. (Footnote 71) Important limitations to these studies include variation in the rate and methods of diagnostic sampling, lack of information on clinical parameters used to determine the relevance of detected organisms, timing of sampling relative to initiation of antimicrobials, other risk factors (e.g., invasive devices) and the setting for co-infection (e.g., ICU), and potential publication bias.

4.7 Thromboembolism

Patients with COVID-19 are at risk for coagulopathy and this appears to be correlated with disease severity.(Footnote 14 , Footnote 83)

4.8 Influenza

When there is local influenza circulation, residents who develop influenza-like illness, pneumonia, or non-specific respiratory-illness, and are at high risk for influenza complications, should be tested and treated as soon as possible with a neuraminidase inhibitor (oseltamivir, inhaled zanamivir, or intravenous peramivir) until results of testing are known (Footnote 14, Footnote 23 , Footnote 84, Footnote 85)

5.0 Palliative care

Palliative care is an approach that aims to reduce suffering and improve quality of life for people who are living with life-limiting illness. (Footnote 86) It may occur alongside life-prolonging interventions and involves active interventions to ensure impeccable symptom management for those who will recover as well as for those who will need end-of-life care. Palliative care should be person-centred and family-centred.

It is important that LTCHs try to meet the physical, mental, emotional, and spiritual needs of ALL residents with palliative care needs, regardless of whether they have COVID-19. LTCHs should also be able to provide quality comfort and end-of-life care for residents with more severe or progressive COVID-19 for whom transfer for more advanced care in an acute care setting is not appropriate or consistent with previously expressed and current wishes.

The care that can be provided may be challenged during outbreaks due to staff shortages, and homes should receive regional support to maintain quality and safe care. If the frequency or intensity of required care is greater than the capacity that can be provided in the LTCH, particularly when there are staffing shortages, consideration should be given to whether transfer to another facility is consistent with the resident's goals of care and can be safely arranged.

All LTCHs should review their plans for meeting the palliative care needs of residents within their facility as part of the COVID-19 response.(Footnote 8, Footnote 18 , Footnote 37 , Footnote 87) LTCH staff with palliative care experience should be identified.(Footnote 18, Footnote 87 ) In the context of the COVID-19 pandemic, it should be anticipated that the need for end-of-life care will increase (particularly in the context of outbreaks) and may become more complex.(Footnote 8, Footnote 18, Footnote 87) LTCHs should ensure that they have access to specialized palliative care services for advice in managing complex cases, including assistance with the development of guidelines for symptom management and support, and education/training of non-specialists for their use.(Footnote 8, Footnote 87 ) In many jurisdictions, palliative care networks may be available to assist with finding palliative care expertise for a given LTCH.

5.1 Palliative symptom management at end-of-life

Palliative symptom management for COVID-19 includes active interventions to make someone more comfortable, ideally in familiar surroundings, and may involve addressing a variety of potential issues such as pain control, breathlessness, nausea, delirium or agitation.

Symptom management guidance typically relies on frequent reassessment every few hours initially to allow for careful dose titration. In some LTCHs, particularly those experiencing an outbreak, high frequency of reassessment may not be feasible. In this context, consider a reasonable starting dose and interval based on age, degree of distress, comorbidities, previous medication use, and renal clearance.

If staff have the training and expertise, many comfort medications can be administered by the subcutaneous route, and efforts should be made to improve staff competence in the use of subcutaneous medications. A subcutaneous line can be inserted to allow for repeated access. Multiple lines can be used with each one being used for a different medication, or a single line can be used for multiple medications as long as it is flushed with an appropriate volume of saline after each injection and the site is able to tolerate this volume. Use of continuous subcutaneous infusion systems may be considered if experienced administrators are present. If staff are unable to administer subcutaneous medication, then administration via a buccal or sublingual (SL) route can be considered.

Examples of medications that may be used to treat symptoms in residents who appear to be nearing end-of-life are shown in Table 1. If frequent administrations are needed, the most responsible physician or nurse practitioner should be contacted for further guidance and consideration of standing rather than solely as needed dosing. If a resident who has chosen to be cared for in the home without transfer to hospital experiences severe respiratory distress refractory to the usual medications for symptom management (Table 1), this is a palliative care emergency. If continuous palliative sedation therapy (CPST) is needed for refractory symptoms in the imminently dying patient, then consultation with a palliative care specialist is recommended.( Footnote 18, Footnote 88) This should be done in accordance with approved CPST guidelines (example guidelines can be found under the Canadian Society of Palliative Care Physicians Statement on Continuous Palliative Sedation Therapy).(Footnote 88) Consultation with a palliative care specialist could be conducted remotely (e.g. by telephone or videoconferencing) if in-person consultation is not available. ( Footnote 88) Informed consent for CPST must be obtained from the resident or SDM. (Footnote 88)

Additional resources can be found in the Appendix. Provinces and territories may have palliative care networks or societies with additional guidance.

Table 1. Medications D that may be used for symptom management in residents of long term care homes (LTCHs) who appear to be nearing end-of-life due to COVID-19
Symptom Medication Dose/Route Frequency Notes
Fever Acetaminophen Acetaminophen 650 mg PO/PR q4h prn 1) Max 4,000 mg/day; in older adults with hepatic impairment or history of alcohol abuse, suggested max is 3,000 mg/day, though consider potential benefit versus risk in a resident near end-of-life
Pain Acetaminophen Acetaminophen 650 mg PO/PR q4h prn 1) Note as above for acetaminophen
Hydromorphone

OR

Morphine

Hydromorphone typical starting dose: 0.5 - 1 mg PO OR 0.2 - 0.4 mg Subcut. q2h prn

1) Convert to standing q4h (use q6h for frail or older adults) and prn after 1-2 days when dose-response and frequency of use are known

2) Higher doses may be needed in a resident with history of chronic opioid use; may consider increasing chronic dose by 25-50%

3) Provision of a range of dosing will help care providers titrate up or down as needed

4) Doses will need to be adjusted if converting from PO to Subcut. - conversion varies between 2:1 and 3:1 (e.g. hydromorphone 2 mg PO may convert to hydromorphone 0.5-1 mg Subcut.)

Morphine typical starting dose: 2.5 - 5 mg PO OR 1 - 2 mg Subcut. q2h prn
Shortness of breath Hydromorphone

OR

Morphine

Hydromorphone typical starting dose: 0.5 - 1 mg PO OR 0.2 - 0.4 mg Subcut. q2h prn

1) Notes as above for hydromorphone and morphine

2) With COVID-19, shortness of breath can change quickly and may require rapid dose titration until symptoms are managed

Morphine typical starting dose: 2.5 - 5 mg PO OR 1 - 2 mg Subcut. q2h prn
Anxiety Lorazepam Lorazepam 0.5 - 1 mg PO OR Subcut. OR SL q2h prn
Nausea Haloperidol

OR

Methotrimeprazine

OR

Olanzapine

Haloperidol 0.5 - 1 mg Subcut. q4h prn
Methotrimeprazine 6.25 - 25 mg PO OR Subcut. q4h prn
Olanzapine 2.5 - 5 mg PO

OR

5 mg oral disintegrating tablet (ODT)

Daily +/- one additional 2.5 - 5 mg PO OR 5 mg ODT dose q24h prn
Hyperactive delirium or agitation Methotrimeprazine

OR

Haloperidol

Methotrimeprazine 6.25 - 25 mg PO OR Subcut. q4h prn

1) If the resident is agitated or restless at the end-of-life, orders should be written for scheduled and prn dosing

2) If PO or Subcut. routes are not an option for medication delivery, SL lorazepam or olanzapine Orally Disintegrating Tablets may be considered

Haloperidol 0.5 - 2 mg Subcut. q2h prn
Secretions in an imminently dying comatose patient Scopolamine

OR

Glycopyrrolate

OR

Atropine 1% (ophthalmic drops)

Scopolamine 0.4 mg Subcut.

OR

q4h prn

1) It is important to proactively educate LTCH staff, families and caregivers that upper respiratory secretions are often expected and may be a normal part of the dying process

2) Evidence suggests medications used for secretions may be of limited benefit

3) In an outbreak situation, it may not be appropriate to use staff time to administer medication routinely for secretions, but consideration should be given to alleviate family/caregiver distress (the transdermal patch may be preferable if available)

4) For more severe secretions, consider glycopyrrolate or atropine

Scopolamine transdermal q72h
Glycopyrrolate 0.4 mg Subcut. q4h prn
Atropine 1% 1-2 drops SL q4h prn
D The above table is a guide and not a substitute for clinical judgment. When prescribing any new medication, resident comorbidities and need for dose adjustment, current medications, potential drug interactions, adverse events, and known drug allergies should be reviewed. If using 4 or more PRNs in 24 hrs, re-evaluate and consider titrating up dose and/or frequency.

PO = per os (oral), PR = per rectum, Subcut. = subcutaneous, SL = sublingual

5.2 Mental and emotional needs at end-of-life

LTCHs may need to help dying residents and families/caregivers cope with mental or emotional distress.

5.3 Spiritual care

Persons nearing end-of-life should have access to spiritual support and a representative of their faith community (e.g., chaplain, rabbi, or other religious leader or spiritual care provider) if desired.

6.0 Mental health disorders, delirium and responsive behaviours

Chronic mental health disorders are common in residents of LTCHs. Approximately 10-20% have depression, schizophrenia, or bipolar disorder. (Footnote 89, Footnote 90)

Delirium is common with COVID-19, and may be the first sign of illness.(Footnote 14 , Footnote 91) Hypoactive, hyperactive and mixed delirium are all possible, with hypoactive delirium more common and easy to miss. Hypoactive delirium related to COVID-19 can present as lethargy, refusal to participate in care, and refusal to eat and drink.

Responsive behaviour refers to actions, words or gestures (e.g. aggression) exhibited by a person with dementia, that are often in response to something negative or frustrating in their personal, social or physical environment. Responsive behaviours in LTCH residents with or without underlying cognitive impairment or mental health disorders may be more common during the COVID-19 pandemic. (Footnote 92,Footnote 93, Footnote 94)

Changes (e.g., IPC measures and visitor restriction) implemented in LTCHs due to COVID-19 may precipitate or worsen delirium and responsive behaviours, and make it more difficult to address the care needs of people with delirium and responsive behaviours.

Responsive behaviours can also present a barrier to implementation of IPC measures, and it is important to plan and prepare for how to address the needs of residents with a history of these behaviours.(Footnote 94 , Footnote 95) LTCH clinicians should enlist the support of geriatricians and geriatric psychiatrists where possible when faced with challenging situations where non-pharmacologic measures have been unsuccessful.

6.1 Delirium

6.2 Responsive behaviours

7.0 Psychosocial aspects of care

Resident, family/caregiver, and staff need for psychosocial support will increase during the COVID-19 pandemic. This increase may be due to strain on care systems and changing access to health care resources, strained family care systems due to acute illness, financial worries due to drastic changes in the economy, introduction of new staff who are unfamiliar to residents, and death of residents or friends.(Footnote 8, Footnote 14, Footnote 93 )

IPC measures necessary to prevent and control transmission of COVID-19 in LTCHs may cause distress for residents and families/caregivers related to restriction of visitors, cancellation of communal activities and excursions, and potential resident restrictions on returning to facilities if on voluntary leave during an outbreak.(Footnote 8 , Footnote 14)

LTCH staff may suffer anxiety and concern for personal and family safety due to direct experience or media coverage of outbreaks, concerns about adequate supplies of PPE, financial concerns and worries about securing childcare in the context of the COVID-19 pandemic (e.g., school and daycare closures), and witnessing illness and death in residents.( Footnote 92) Staff shortages place strain on the ability of those remaining to deliver quality care and may adversely affect remaining staff members' psychological health.

LTCHs should anticipate the increased needs for support and be able to provide or refer residents, families, caregivers, and staff to appropriate supports or services. Mental health professionals, social workers, and LTCH directors and administrators with their staff should work collaboratively to support LTCH residents and other staff.

7.1 Resident and family/caregiver support

7.2 LTCH staff support

8.0 Acknowledgments

This guidance document was prepared by : Dr. Cheryl Volling, Dr. Robert G. Stirling, Dr. Peter Uhthoff, Dr. Marina Salvadori, Dr. James Brooks, Dr. Michelle Acorn, Dr. Barry Clarke, Ms. Helen Eby, Dr. Russell Goldman, Dr. Andrea Iaboni, Dr. Ralph Jones, Dr. Fred J. Mather, Dr. Andrea Moser, Dr. Patrick Quail, Dr. Benoît Robert, Dr. Nathan Stall, Dr. Camilla Wong, Mr. Chris Fan-Lun, Ms. Yung-En Chung, Ms. Althea House and Dr. Marianna Ofner.

This guidance document has been endorsed by:

The Canadian Academy of Geriatric Psychiatry

The Canadian Coalition for Seniors' Mental Health

The Canadian Geriatrics Society

The Canadian Gerontological Nursing Association

The Canadian Nurses Association

The Canadian Society for Long Term Care Medicine

The Canadian Society of Palliative Care Physicians

The Canadian Support Workers Association

The Nurse Practitioner Association of Canada

This guidance document is supported by:

The College of Family Physicians of Canada

The authors gratefully acknowledge the additional review and/or contributions of : Dr. Amit Arya, Dr. Paul Bonnar, Dr. Anne Boyle, Dr. Nick Daneman, Dr. Sidney Feldman, Dr. Robert Fowler, Dr. Allan Grill, Dr. Leonie Herx, Dr. Andrew Morris, Dr. Shaqil Peermohamed, Dr. Richard Rusk, Dr. Samir Sinha, Dr. Rebecca G. Stovel, Dr. Anna Voeuk, and Dr. Roger Y.M Wong.

9.0 Appendix

Example emergency medication* list for long term care homes during the COVID-19 pandemic

Antibiotics

This should be informed by local treatment guidelines and antibiotic susceptibility data (where available) and may include some or all of the following:

Antidotes

Antipsychotics

Antipyretics

Acetaminophen oral tablets and rectal suppositories

Anti-seizure medications

Phenobarbital 120 mg/mL inj

Anxiolytics and sedatives

Cardiovascular medications

Corticosteroids

Diuretics

Furosemide oral tablets and 40 mg/mL inj

Insulin

Insulin, rapid acting 100 units/mL inj

Opioids

Respiratory medications

Secretion management

*Formulary elixir or injectable medication concentrations and some formulary restrictions may differ by jurisdiction. Caution should be exercised when stocking more than one concentration of an opioid, with clear labeling and separation to avoid errors in administration. Pharmacist consultation is advised.

Resources list

Note: the following list of resources has been compiled with input from experts in long-term care, geriatric medicine, palliative care, and geriatric psychiatry. They do not constitute medical advice, and clinical judgment must be exercised when using any of the attached resources or tools. The Public Health Agency of Canada cannot verify the accuracy of all statements or recommendations provided in these resources.

Resources related to resident information

Source: University of Alabama at Birmingham Center for Palliative and Supportive Care

Resources related to goals of care and advance care planning

Source: British Columbia Divisions of Family Practice (original source Ariadne Labs: A Joint Center for Health Systems Innovation (www.ariadnelabs.org) and Dana-Farber Cancer Institute. Licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, http://creativecommons.org/licenses/by-nc-sa/4.0/);

Source: BC Centre for Palliative Care (original source Ariadne Labs: A Joint Center for Health Systems Innovation (www.ariadnelabs.org) and Dana-Farber Cancer Institute. Licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, http://creativecommons.org/licenses/by-nc-sa/4.0/);

Source: Ontario Palliative Care Network

Source: Speak Up Ontario

Resources related to communication

Source: COVID-19 Health Literacy Project

Resources related to palliative care

Source: BC Centre for Palliative Care

Source: Regional Geriatric Program of Toronto

Source: Hospice Palliative Care Ontario/ Speak Up Ontario

Source: Pallium Canada

Resources related to mental and emotional needs at end-of-life

Sources: Ontario Association of Residents' Councils, Family Councils Ontario, and Tech Coaches Inc.

o Mygrief.ca: Because losing someone is hard (as of June 14, 2020 includes information on grieving, coping with unexpected loss, managing emotions, and self-care)

Source: Canadian Virtual Hospice

Resources related to delirium

Source: Regional Geriatric Program of Toronto

Source: Hospital Elder Life Program

Resources related to responsive behaviours

Source: P.I.E.C.E.S™ Learning and Development Model: Supporting Relationships for Changing Health and Health Care

Source: The brainXchange

Source: Regional Geriatric Program of Toronto

Source: Behavioural Supports Ontario/Soutien en cas de troubles du comportement en Ontario

Source: Centre for Effective Practice

Resources related to resident and family/caregiver support

Source: The Ontario Caregiver Organization

Source: Canadian Virtual Hospice

Resources related to staff support

Source: Hospice Palliative Care Ontario

Source: CAMH

Source: Pallium Canada

Source: Ontario Centres for Learning, Research & Innovation in Long-Term Care

Source: Ontario Centres for Learning, Research & Innovation in Long-Term Care

10.0 References

Footnote 1

He X, Lau EHY, Wu P, Deng X, Wang J, Hao X, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. 2020.

Return to footnote 1 referrer

Footnote 2

Kimball A, Hatfield KM, Arons M, James A, Taylor J, Spicer K, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility - King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):377-81.

Return to footnote 2 referrer

Footnote 3

Dora A, Winnett A, Jatt LP, Davar K, Watanabe M, Sohn L, Kern HS, Graber CJ, Goetz MB. Universal and Serial Laboratory Testing for SARS-CoV-2 at a Long-Term Care Skilled Nursing Facility for Veterans - Los Angeles, California, 2020. MMWR Morb Mortal Wkly Rep. 2020.

Return to footnote 3 referrer

Footnote 4

Nishiura H, Kobayashi T, Suzuki A, Jung SM, Hayashi K, Kinoshita R, et al. Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis. 2020.

Return to footnote 4 referrer

Footnote 5

Wei WE LZ, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23 - March 16, 2020. Morbidity and Mortality Weekly. 2020.

Return to footnote 5 referrer

Footnote 6

Huff HV, Singh A. Asymptomatic transmission during the COVID-19 pandemic and implications for public health strategies. Clin Infect Dis. 2020.

Return to footnote 6 referrer

Footnote 7

D'Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19. J Am Geriatr Soc. 2020;68(5):912-7

Return to footnote 7 referrer

Footnote 8

Strengthening the Health Systems Response to COVID-19 Technical guidance #6: Preventing and managing the COVID-19 pandemic across long-term care services in the WHO European Region (21 May 2020): World Health Organization; 2020 [Available from: http://www.euro.who.int/__data/assets/pdf_file/0004/443605/Tech-guidance-6-COVID19-eng.pdf?ua=1.

Return to footnote 8 referrer

Footnote 9

Norman DC. Clinical Features of Infection in Older Adults. Clin Geriatr Med. 2016;32(3):433-41.

Return to footnote 9 referrer

Footnote 10

Yoshikawa TT, Reyes BJ, Ouslander JG. Sepsis in Older Adults in Long-Term Care Facilities: Challenges in Diagnosis and Management. J Am Geriatr Soc. 2019;67(11):2234-9.

Return to footnote 10 referrer

Footnote 11

Jarrett PG, Rockwood K, Carver D, Stolee P, Cosway S. Illness presentation in elderly patients. Arch Intern Med. 1995;155(10):1060-4.

Return to footnote 11 referrer

Footnote 12

Talbot HK, Falsey AR. The diagnosis of viral respiratory disease in older adults. Clin Infect Dis. 2010;50(5):747-51.

Return to footnote 12 referrer

Footnote 13

Epidemiologic summary of COVID-19 in LTC residents and seniors. Public Health Agency of Canada - unpublished data; 2020.

Return to footnote 13 referrer

Footnote 14

Clinical Management of COVID-19: interim guidance: World Health Organization; 2020 [Available from: https://www.who.int/publications-detail/clinical-management-of-covid-19.

Return to footnote 14 referrer

Footnote 15

Tay HS, Harwood R. Atypical presentation of COVID-19 in a frail older person. Age Ageing. 2020.

Return to footnote 15 referrer

Footnote 16

Norman RE, Stall NM, Sinha SK. Typically Atypical: COVID-19 Presenting as a Fall in an Older Adult. J Am Geriatr Soc. 2020.

Return to footnote 16 referrer

Footnote 17

High KP, Bradley SF, Gravenstein S, Mehr DR, Quagliarello VJ, Richards C, et al. Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(2):149-71.

Return to footnote 17 referrer

Footnote 18

Arya A, Buchman S, Gagnon B, Downar J. Pandemic palliative care: beyond ventilators and saving lives. CMAJ. 2020;192(15):E400-E4.

Return to footnote 18 referrer

Footnote 19

Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. 2020.

Return to footnote 19 referrer

Footnote 20

Nie X, Fan L, Mu G, Tan Q, Wang M, Xie Y, et al. Epidemiological characteristics and incubation period of 7,015 confirmed cases with Coronavirus Disease 2019 outside Hubei Province in China. J Infect Dis. 2020.

Return to footnote 20 referrer

Footnote 21

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020.

Return to footnote 21 referrer

Footnote 22

Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020.

Return to footnote 22 referrer

Footnote 23

Gandhi RT, Lynch JB, Del Rio C. Mild or Moderate Covid-19. N Engl J Med. 2020.

Return to footnote 23 referrer

Footnote 24

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-62.

Return to footnote 24 referrer

Footnote 25

Vaccines and treatments for COVID-19: List of all COVID-19 clinical trials authorized by Health Canada: Health Canada; 2020 [Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/covid19-clinical-trials/list-authorized-trials.html.]

Return to footnote 25 referrer

Footnote 26

"Solidarity" clinical trial for COVID-19 treatments: World Health Organization; 2020 [Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments.

Return to footnote 26 referrer

Footnote 27

International Clinical Trials Registry Program (ICTRP): World Health Organization; 2020 [Available from: https://www.who.int/ictrp/en/.

Return to footnote 27 referrer

Footnote 28

"COVID-19" clinical studies search: ClinicalTrials.gov; 2020 [Available from: https://clinicaltrials.gov/ct2/results?cond=COVID-19

Return to footnote 28 referrer

Footnote 29

COVID-19 Treatment Guidelines: National Institutes of Health; 2020 [Available from: https://files.covid19treatmentguidelines.nih.gov/guidelines/covid19treatmentguidelines.pdf.

Return to footnote 29 referrer

Footnote 30

Clinical management of patients with moderate to severe COVID-19 - Interim guidance: Public Health Agency of Canada; 2020 [Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html.

Return to footnote 30 referrer

Footnote 31

Berlin DA, Gulick RM, Martinez FJ. Severe Covid-19. N Engl J Med. 2020.

Return to footnote 31 referrer

Footnote 32

Du RH, Liang LR, Yang CQ, Wang W, Cao TZ, Li M, et al. Predictors of mortality for patients with COVID-19 pneumonia caused by SARS-CoV-2: a prospective cohort study. Eur Respir J. 2020;55(5).

Return to footnote 32 referrer

Footnote 33

Aggregated Observations from 6,479 Hospitalized COVID-19 Patients in the CarePort Network United States: CarePort; 2020 [Available from: https://careporthealth.com/wp-content/uploads/2020/04/COVID-19-Mortality-Report.pdf.

Return to footnote 33 referrer

Footnote 34

Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ. 2020;369:m1985.

Return to footnote 34 referrer

Footnote 35

Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020.

Return to footnote 35 referrer

Footnote 36

Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, et al. Covid-19 in Critically Ill Patients in the Seattle Region - Case Series. N Engl J Med. 2020;382(21):2012-22.

Return to footnote 36 referrer

Footnote 37

Joni G, Lara P, Unroe Kathleen T, Lieve VDB. International COVID-19 palliative care guidance for nursing homes leaves key themes unaddressed. J Pain Symptom Manage. 2020.

Return to footnote 37 referrer

Footnote 38

Performing Facility-wide SARS-CoV-2 Testing in Nursing Homes: Centers for Disease Control and Prevention; [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-facility-wide-testing.html.

Return to footnote 38 referrer

Footnote 39

Responding to Coronavirus (COVID-19) in Nursing Homes: Centers for Disease Control and Prevention; 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html.

Return to footnote 39 referrer

Footnote 40

Long-Term Care facilities: interRAI; [Available from: https://www.interrai.org/long-term-care-facilities.html.]

Return to footnote 40 referrer

Footnote 41

Update on the use of pneumococcal vaccines in adults 65 years of age and older - A Public Health Perspective: National Advisory Committee on Immunization - Public Health Agency of Canada; 2018

Return to footnote 41 referrer

Footnote 42

Zhao L, Young K, Gemmill I. Summary of the NACI Seasonal Influenza Vaccine Statement for 2019-2020. Can Commun Dis Rep. 2019;45(6):149-55. [Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2019-45/issue-6-june-6-2019/article-1-naci-influenza-vaccine-statement-2019-2020.html]

Return to footnote 42 referrer

Footnote 43

Updated Recommendations on the Use of Herpes Zoster Vaccines: An Advisory Committee Statement: National Advisory Committee on Immunization; 2018 [Available from: https://www.canada.ca/en/services/health/publications/healthy-living/updated-recommendations-use-herpes-zoster-vaccines.html.

Return to footnote 43 referrer

Footnote 44

Stone ND, Ashraf MS, Calder J, Crnich CJ, Crossley K, Drinka PJ, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol. 2012;33(10):965-77.

Return to footnote 44 referrer

Footnote 45

Preparing for COVID-19 in Nursing Homes: Centers for Disease Control and Prevention; [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html.

Return to footnote 45 referrer

Footnote 46

Improving Patient Safety in Long-Term Care Facilities: Agency for Healthcare Research and Quality; https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc.html

Return to footnote 46 referrer

Footnote 47

Ouslander JG, Bonner A, Herndon L, Shutes J. The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc. 2014;15(3):162-70.

Return to footnote 47 referrer

Footnote 48

Stall NM, Farquharson C, Fan-Lun C, Wiesenfeld L, Loftus CA, Kain D, et al. A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multi-Phase Emergency Response in Toronto, Canada. J Am Geriatr Soc. 2020.

Return to footnote 48 referrer

Footnote 49

Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19: World Health Organization; 2020 [Available from: https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IPC_long_term_care-2020.1-eng.pdf.

Return to footnote 49 referrer

Footnote 50

COVID-19 Recommendations for Clinicians: Choosing Wisely Canada; 2020 [Available from: https://choosingwiselycanada.org/covid-19/.

Return to footnote 50 referrer

Footnote 51

Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med. 2020.

Return to footnote 51 referrer

Footnote 52

Report of the WHO-China joint Mission on Coronavirus Disease 2019 (COVID-19): World Health Organization; 2020 [Available from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.

Return to footnote 52 referrer

Footnote 53

Ye Z, Rochwerg B, Wang Y, Adhikari NK, Murthy S, Lamontagne F, et al. Treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence-based guideline. CMAJ. 2020.

Return to footnote 53 referrer

Footnote 54

Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease: Centres for Disease Control and Prevention; 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html.

Return to footnote 54 referrer

Footnote 55

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.

Return to footnote 55 referrer

Footnote 56

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020.

Return to footnote 56 referrer

Footnote 57

Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020.

Return to footnote 57 referrer

Footnote 58

Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the Treatment of Covid-19 - Preliminary Report. N Engl J Med. 2020.

Return to footnote 58 referrer

Footnote 59

Horby P LW, Emberson J, Mafham M, Bell J, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Jusczak E, Bailie JK, Haynes R, Landry MJ, RECOVERY Collaborative Group. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. medRxiv preprint June 22, 2020 at https://wwwmedrxivorg/content/101101/2020062220137273v1. 2020.

Return to footnote 59 referrer

Footnote 60

Kalil AC. Treating COVID-19-Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics. JAMA. 2020.

Return to footnote 60 referrer

Footnote 61

Halpin DMG, Singh D, Hadfield RM. Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective. Eur Respir J. 2020;55(5).

Return to footnote 61 referrer

Footnote 62

Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, Cheng VC, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Clin Infect Dis. 2020.

Return to footnote 62 referrer

Footnote 63

Licskai C, Yang CL, Ducharme FM, Radhakrishnan D, Podgers D, Ramsey C, et al. Key highlights from the Canadian Thoracic Society's Position Statement on the Optimization of Asthma Management during the COVID-19 Pandemic. Chest. 2020.

Return to footnote 63 referrer

Footnote 64

Licskai C YC, Ducharme FM, Radhakrishnan D, Podgers D, Ramsey C, Samanta T, Cote A, Mahdavian M, Lougheed D. Addressing therapeutic questions to help Canadian physicians optimize asthma management for their patients during the COVID-19 pandemic. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2020;4(2):73-6.

Return to footnote 64 referrer

Footnote 65

Bhutani M HP, Bourbeau J, Dechman G, Penz E, Aceron R, Beauchamp M, Wald J, Stickland M, Olsen S, Goodridge D. KEY HIGHLIGHTS of the Canadian Thoracic Society's Position Statement on the Optimization of Chronic Obstructive Pulmonary Disease Management during the COVID-19 Pandemic. Chest preprint. 2020.

Return to footnote 65 referrer

Footnote 66

Bhutani M HP, Bourbeau J, Dechman G, Penz E, Aceron R, Beauchamp M, Wald J, Stickland M, Olsen S, Goodridge D. Addressing therapeutic questions to help Canadian health care professionals optimize COPD management for their patients during the COVID-19 pandemic. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2020;4(2):77-80.

Return to footnote 66 referrer

Footnote 67

Patel M, Steinberg K, Suarez-Barcelo M, Saffel D, Foley R, Worz C. Chronic Obstructive Pulmonary Disease in Post-acute/Long-term Care Settings: Seizing Opportunities to Individualize Treatment and Device Selection. J Am Med Dir Assoc. 2017;18(6):553 e17- e22.

Return to footnote 67 referrer

Footnote 68

Boockvar KS, Carlson LaCorte H, Giambanco V, Fridman B, Siu A. Medication reconciliation for reducing drug-discrepancy adverse events. Am J Geriatr Pharmacother. 2006;4(3):236-43.

Return to footnote 68 referrer

Footnote 69

Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545-50.

Return to footnote 69 referrer

Footnote 70

Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis. 2020.

Return to footnote 70 referrer

Footnote 71

Wang L, He W, Yu X, Hu D, Bao M, Liu H, et al. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. J Infect. 2020;80(6):639-45.

Return to footnote 71 referrer

Footnote 72

Using Antibiotics Wisely: Choosing Wisely Canada; 2020 [Available from: https://choosingwiselycanada.org/campaign/antibiotics/.

Return to footnote 72 referrer

Footnote 73

Antimicrobial Stewardship Essentials in Long Term Care: Antimicrobial Stewardship as Quality Improvement: Public Health Ontario; 2018 [Available from: https://www.publichealthontario.ca/-/media/documents/p/2018/primer-antimicrobial-stewardship-ltc.pdf?la=en.

Return to footnote 73 referrer

Footnote 74

Evidence Brief: Duration of Antibiotic Treatment for Pneumonia in Long Term Care Residents: Public Health Ontario; [Available from: https://www.publichealthontario.ca/-/media/documents/e/2018/eb-duration-antibiotics-ltc-pneumonia.pdf?la=en.

Return to footnote 74 referrer

Footnote 75

Evidence Brief: Duration of Antibiotic Treatment for Uncomplicated Cellulitis in Long-Term Care Residents: Public Health Ontario; 2020 [Available from: https://www.publichealthontario.ca/-/media/documents/E/2018/eb-duration-antibiotics-ltc-cellulitis.pdf?la=en.

Return to footnote 75 referrer

Footnote 76

Havey TC, Fowler RA, Daneman N. Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis. Crit Care. 2011;15(6):R267.

Return to footnote 76 referrer

Footnote 77

Sandberg T, Skoog G, Hermansson AB, Kahlmeter G, Kuylenstierna N, Lannergard A, et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012;380(9840):484-90.

Return to footnote 77 referrer

Footnote 78

Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004;164(15):1669-74.

Return to footnote 78 referrer

Footnote 79

Tellier G, Niederman MS, Nusrat R, Patel M, Lavin B. Clinical and bacteriological efficacy and safety of 5 and 7 day regimens of telithromycin once daily compared with a 10 day regimen of clarithromycin twice daily in patients with mild to moderate community-acquired pneumonia. J Antimicrob Chemother. 2004;54(2):515-23.

Return to footnote 79 referrer

Footnote 80

Yahav D, Franceschini E, Koppel F, Turjeman A, Babich T, Bitterman R, et al. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis. 2019;69(7):1091-8.

Return to footnote 80 referrer

Footnote 81

File TM, Jr., Mandell LA, Tillotson G, Kostov K, Georgiev O. Gemifloxacin once daily for 5 days versus 7 days for the treatment of community-acquired pneumonia: a randomized, multicentre, double-blind study. J Antimicrob Chemother. 2007;60(1):112-20.

Return to footnote 81 referrer

Footnote 82

Dunbar LM, Wunderink RG, Habib MP, Smith LG, Tennenberg AM, Khashab MM, et al. High-dose, short-course levofloxacin for community-acquired pneumonia: a new treatment paradigm. Clin Infect Dis. 2003;37(6):752-60.

Return to footnote 82 referrer

Footnote 83

Lee SG, Fralick M, Sholzberg M. Coagulopathy associated with COVID-19. CMAJ. 2020.

Return to footnote 83 referrer

Footnote 84

Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis. 2019;68(6):e1-e47.

Return to footnote 84 referrer

Footnote 85

Aoki FY AU, Mubareka S, Papenburg J, Stiver HG, Evans G. Use of antiviral drugs for seasonal influenza: Foundational document for practitioners - Update 2019. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2019;4(2).

Return to footnote 85 referrer

Footnote 86

Framework on Palliative Care in Canada: Health Canada; 2020 [Available from: https://www.canada.ca/content/dam/hc-sc/documents/services/health-care-system/reports-publications/palliative-care/framework-palliative-care-canada/framework-palliative-care-canada.pdf.]

Return to footnote 86 referrer

Footnote 87

Etkind SN, Bone AE, Lovell N, Cripps RL, Harding R, Higginson IJ, et al. The Role and Response of Palliative Care and Hospice Services in Epidemics and Pandemics: A Rapid Review to Inform Practice During the COVID-19 Pandemic. J Pain Symptom Manage. 2020.

Return to footnote 87 referrer

Footnote 88

Dean MM, Cellarius V, Henry B, Oneschuk D, Librach Canadian Society Of Palliative Care Physicians Taskforce SL. Framework for continuous palliative sedation therapy in Canada. J Palliat Med. 2012;15(8):870-9.

Return to footnote 88 referrer

Footnote 89

Creighton AS, Davison TE, Kissane DW. The prevalence of anxiety among older adults in nursing homes and other residential aged care facilities: a systematic review. Int J Geriatr Psychiatry. 2016;31(6):555-66.

Return to footnote 89 referrer

Footnote 90

Seitz D PN, Conn D. Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. International Psychogeriatrics. 2010;22(7):1025-39.

Return to footnote 90 referrer

Footnote 91

O'Hanlon S, Inouye SK. Delirium: a missing piece in the COVID-19 pandemic puzzle. Age Ageing. 2020.

Return to footnote 91 referrer

Footnote 92

Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo JL, et al. Dementia care during COVID-19. Lancet. 2020;395(10231):1190-1.

Return to footnote 92 referrer

Footnote 93

Simard J VL. Loneliness and Isolation in Long-term Care and the COVID-19 pandemic. Journal of the American Medical Directors Association. 2020;preprint.

Return to footnote 93 referrer

Footnote 94

Considerations for Memory Care Units in Long-term Care Facilities: Centers for Disease Control and Prevention; 2020 [Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/memory-care.html.

Return to footnote 94 referrer

Footnote 95

Iaboni A, Cockburn A, Marcil M, Rodrigues K, Marshall C, Garcia MA, et al. Achieving Safe, Effective, and Compassionate Quarantine or Isolation of Older Adults With Dementia in Nursing Homes. Am J Geriatr Psychiatry. 2020.

Return to footnote 95 referrer

Footnote 96

Stall N, Wong CL. Hospital-acquired delirium in older adults. CMAJ. 2014;186(1):E61.

Return to footnote 96 referrer

Footnote 97

Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911-22.

Return to footnote 97 referrer

Footnote 98

Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017;377(15):1456-66.

Return to footnote 98 referrer

Footnote 99

Woodhouse R, Burton JK, Rana N, Pang YL, Lister JE, Siddiqi N. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database Syst Rev. 2019;4:CD009537.

Return to footnote 99 referrer

Footnote 100

Stall N WC. Differential diagnosis of delirium (Appendix to Stall N, Wong CL. Hospital-acquired delirium in older adults. CMAJ. 2014;186(1):E61.): CMAJ; 2020 [Available from: https://www.cmaj.ca/content/cmaj/suppl/2013/09/03/cmaj.130299.DC1/five-delerium-1-at.pdf.

Return to footnote 100 referrer

Footnote 101

Iaboni A GA, Barned C, Rodrigues K, Kontos P, Chu C, Astell A, the Dementia Isolation Toolkit Team. Ethical guidance for people who work in long-term care: What is the right thing to do in a pandemic? 2020 [Available from: https://brainxchange.ca/Public/Files/COVID-19/Ethical-Guidance-for-LTC-v1-4-23-20.aspx.

Return to footnote 101 referrer

Footnote 102

COVID-19 Outbreak Guidance for Long-Term Care Homes (LTCH): Ministry of Health Ontario; 2020 [Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/LTCH_outbreak_guidance.pdf.

Return to footnote 102 referrer

Report a problem or mistake on this page
Please select all that apply:

Thank you for your help!

You will not receive a reply. For enquiries, contact us.

Date modified: