“Out of options”: The implications of COVID-19 for hospitalized patients with cognitive impairment

This article is part of the following series: The Age of COVID-19

“How about a walk today?” I asked Mr. T each morning I arrived to the hospital, visiting him on my morning rounds. Mr T. grinned back at me from the edge of his bed beneath his bright red veteran’s baseball cap, a sharp contrast to the dull monotone hospital gown. “Oh you betcha, doc,” he smiled. Our daily stroll entailed walking up and down two windowless hallways on the floor, usually totaling three minutes before we ran out of space to walk. “I guess we’re all out of options,” Mr. T sighed as we turned back to his room each day.

Every day, Mr. T and I had the same daily exchange, but due to Mr. T’s advanced Alzheimer’s, he had no recollection of our conversation on the previous day.  Mr. T had been a patient on our service for over a month, although he had no medically active issues other than his dementia. His niece brought him to the emergency department after his behavior had become unmanageable at home, with occasional angry outbursts and frequent wanderings. 

Mr. T’s statement “I guess we’re all out of options” applied to more than our hallway stroll; it served as a poignant description of most of his hospitalization. Like many other elderly individuals in the hospital, Mr. T was in limbo, stuck in an indefinite holding pattern until a spot opened up for him at a nursing home or memory care center. Space in these institutions during the time of COVID had become increasingly limited with strict criteria for acceptance. Case managers reminded us daily in our multi-disciplinary rounds that each word in our notes for these patients mattered; use of a term like “agitation” or “aggression” might permanently disqualify a patient as a candidate for placement options.

Mr. T was repeatedly denied from local nursing homes in the area; we were repeatedly told that he did “not meet criteria” or they were no longer accepting new residents. Yet the hospital was also not an appropriate placement option for Mr. T. He was an active elderly gentleman, a former marine, accustomed to walking three to four miles a day around his neighborhood. He was labeled as an “elopement risk” by staff, as he frequently became confused as to where he was and decided he wanted to take a walk. He was assigned a 24-hour sitter to ensure he did not wander from his room and risk accidentally injuring himself or others. Thus, his days in the hospital were primarily filled with waiting between meals and embarking on a handful of three-minute hallway walks.

COVID, Connection, and Hospital Medicine 

As an internal medicine intern, I have witnessed first-hand over the last several months the devastating physical and emotional impact of COVID on patients and their families, in particular the virus’ cruel affinity for elderly individuals. I selfishly breathed a sigh of relief this past month when I was assigned to a non-COVID ward in the hospital, feeling that perhaps the non-COVID wards would provide a brief reprieve from witnessing the daily tragedies of COVID. Yet I quickly began to learn through the stories of individuals like Mr. T that equally powerful, though perhaps less visible, effects exist for patients without the disease, particularly those with chronic conditions like dementia.

Each day, Mr. T’s niece Claire would call to ask about him; calling was her only vehicle of communication given the hospital’s strict no visitor policy during COVID times. Claire called daily to try to speak to her uncle, but was rarely able to make contact. Each day that I spoke with Claire, she agonized over placement options. She was struck with panic at the thought of her uncle living in several of the local long-term care facilities, given rampant COVID outbreaks and reading abysmal reviews of their care. 

The Hospital as a Zone of Liminality

Discharge planning and issues of placement have always existed as an inevitable component of hospital care. Yet during the time of COVID, such issues have been magnified, as policies of nursing homes, independent living communities, and memory care units for accepting residents tighten, including accepting patients who are returning residents.

The paucity of options for elderly patients like Mr. T creates a unique predicament for these patients and their families. In the COVID world of medicine, the hospital becomes a zone of liminality; it does not function as a place of healing or improvement for a medical condition, nor does it serve as the final destination. Rather, it has become a layover for many elderly patients who are unsafe to live at home but fail to meet the increasingly stringent standards of care facilities. Limited placement options, restricted visitor policies, logistic difficulties of technologic communication, medical personnel not inadequately trained for this type of care culminate in a disconnect in which elderly patients exist in an institution inappropriately designed to cater to their needs.

Social Isolation and Health Care Institutions in the time of COVID

Patients with any form of cognitive impairment, including dementia, have limited ability to advocate for themselves and their health care needs. As we move forward in the COVID pandemic, it is critical to keep these patients in mind with designing hospital policy and services, reimagining new options and services expanded to meet the needs of patients like Mr. T. As researchers, health care providers, and family members, we must advocate for keeping these individuals visible to the greater health care system.

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Kelly Colas is a physician-anthropologist currently completing her residency training in Internal Medicine at Georgetown University.

“The Age of COVID-19” is a series being cross-posted at Somatosphere and the Association for Anthropology, Gerontology and the Life Course (AAGE) blog and is edited by Celeste Pang, Cristina Douglas, Janelle Taylor and Narelle Warren.