Chief of geriatric medicine at UB discusses the challenges faced by seniors during COVID-19 and his study of vitamin D as possible drug to protect people against coronavirus
By Chris Motola
Q: What challenges has the past year presented for geriatric medicine?
A: The pandemic has changed lives for both patients and physicians. From the standpoint of geriatrics, there’s been an amplification of things that were taking place before COVID, and then a host of all new issues. Perhaps the biggest one on the new side is that nursing home residents have been the single most at-risk group when it comes to COVID. I think over 100,000 nursing home deaths, which makes up close to 25% of all the deaths in this U.S. And yet nursing home long-term care residents represent a very small portion of the general population. There are 1.3 million long term care residents at any given time, so this is a really tragic outcome. There’s no doubt that there are some things that affect older adults that make them more susceptible to what we call delirium, when you have a significant illness that can cause a change in mental status. COVID very much fits the bill, not only as a significant stressor but because it can have direct impacts on the brain. So we’ve been sounding the alarm that this is manifestation of COVID-19 in older adults. And, of course, more broadly, it’s had an affect on how we interact with our patients.
Q: How so?
A: In order to protect patients, family members and also protect healthcare workers, we’ve gone to virtual interactions with our patients either by phone or video. That’s very challenging. The other aspect is, when we do have direct interactions, it’s behind masks and gowns. And when you’re dealing with a population that may have diminished hearing or eye sight, communicating with them can be a lot more difficult when they can’t see your lips. So, getting the information we need has been more of a challenge.
Q: What sort of effects does COVID-19 have on the brain?
A: So delirium is an acute confusion state where there may be disorientation, memory loss, difficulty communicating, even outright delusions and agitation. People most at risk of that already have an existing cognitive impairment. So 10% of everyone 65 and older has some kind of cognitive impairment. That gets as high as 50% for 85 and older. Many have other illnesses and are on multiple medications. When you have a significant stressor, the risk of delirium is much higher. In addition to that, COVID can have direct effects on the brain. It can alter blood flow to the brain and even, in some circumstances, directly infect brain tissue. So it’s a double whammy. And there can also been long-term effects. You may have heard of “long haulers” who appear to have recovered from the acute illness but seem to exhibit some ongoing symptoms. The book hasn’t fully been written completely on this, so we’re still trying to figure this out. We may discover that there are long-term effects on cognition in older adults.
Q: How does COVID care for older adults differ from that of younger patients?
A: The first way to approach that is considering risk factors, not only in terms of infection, but worse outcomes from the infection. If you look at the big picture, you can say that 98% to 99% of individuals who get COVID survive. That 1%-2% mortality is still huge when it comes to modern illnesses. To put it in perspective, the seasonal influenza death rate is 0.1%. So COVID is at least 10 times more deadly. Now the thing that’s unfortunate is there’s a very significant age association with the death rate. So the death rate for COVID for people 80 and over is 20% or more. That’s astonishing. So, on the surface, it’s age-related, but also risk factors like obesity, high-blood pressure, diabetes are all more common with age. We really don’t have age-specific treatments beyond making doubly sure that we manage the other aspects of their care. The interventions don’t tremendously vary by age. The best “cure” is prevention. Fortunately, the Pfizer and Moderna vaccines have been found in test cases to be just as effective in older patients as younger.
Q: One of your areas of interest is vitamin D. There’s been talk about vitamin D levels and their role in fighting COVID-19 infections.
A: What seems to be increasingly clear is that if you have better vitamin D status and you do get COVID, you have less of a risk of severe infection, less of a risk of transfer to the intensive care unit, and less of a chance of death. We’re conducting a study ourselves and have preliminary data, which is pointing in that direction. What I’d suggest is — and we don’t yet have proof — is that a good vitamin D status may offer some protection.
Q: Moving away from COVID. What do you think constitutes “successful aging?”
A: Even though we all want to live as long as possible — and that’s understandable — the focus should be just as much on what I call “healthspan” as lifespan. In other words, and this isn’t me being original, it doesn’t matter as much the years in your life as the life in your years. When you’re striving for a better healthspan, you want individuals with a high-functioning, high quality of life for as long as possible. None of us want to be incapacitated or cognitively impaired. So what I’m trying to do at both the clinical, research and educational level is provide that for older adults. We still have a long way to go, but so many opportunities to provide care for older adults. I think that it’s even imperative on a demographic level. Right now about 15% of the U.S. population is over 65. In our region it’s about 18% By 2030 20% with be 65 and older. In Western New York we’ll probably reach that by 2025. So we have a target-rich environment to do good things for older adults. There’s also some research that suggests if we improve the quality of life for older adults, we’ll be improving it for everyone. That’s because more efficient care also works for younger individuals, but also because functional older adults can help out with things like taking care of the grandkids.
Name: Bruce R. Troen, M.D.
Position: Chief of the division of geriatrics and palliative medicine, UBMD Internal Medicine; professor of medicine UB; director of the Center for Successful Aging, University at Buffalo; director of the Center of Excellence for Alzheimer’s Disease in Western New York, University at Buffalo; physician-investigator, Veterans Affairs Western New York Healthcare System
Affiliations: Kaleida; WNY VA; Erie County Medical Center
Organizations: American Geriatrics Society
Family: Wife, two sons
Hobbies: Skiing, tennis, sci-fiction, hockey