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June 24, 2023

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Long COVID Post-Acute and Mental Health Considerations

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By definition any long-term effects of COVID-19 extend into post-acute care. Many of the impacts result from the initial acute disease. Changes in healthcare systems, physiology and mental health have taken a huge toll on patients and providers.

Post-Acute Long COVID Symptoms

The SARS-CoV-2 virus has demonstrated a substantially higher attack rate, disease severity and case fatality rate for the elderly population. According to CDC data, when hospitalization and mortality are compared for relative risk, individuals in the 65-74 year age strata are five times more likely to be hospitalized and have a 60 times higher risk of death compared to 18-29-year-olds. This risk increases out to age 85 and older. This puts adults in long-term care facilities at significantly higher risk.

Perhaps one of the best indicators of Long COVID is the impact on an individual’s quality of Life (QOL). As with all severe diseases, QOL measures are adversely impacted more as disease severity increases. This is particularly true for COVID-19 that tends to have more intense and longer duration of impacts than most other viral diseases. A number of primary symptoms have been reported in the post-acute setting, including fatigue, dyspnea and psychoemotional disorder (PEMD).

  • Fatigue: Fatigue has been reported more commonly than any other symptom and is typically more substantial. Women tend to report it more commonly, and there is no discernable variation across ethnicities. Fatigue is also more common in patients meeting criteria for Post-Traumatic Stress Disorder (PTSD), cognitive disorders and dyspnea.
  • Dyspnea: Persistent post-COVID dyspnea is reported in around 66% of severe COVID-19 cases and 33% of moderate cases. More women tend to report it than men. However, this gap narrows with milder cases. Dyspnea has been reported almost twice as often in non-Caucasian individuals. When age is stratified, dyspnea is found more commonly in individuals over 60 years of age.
  • Psychoemotional Disorder (PEMD) Manifestations: PEMD, including PTSD, are reported in about 25% of severe COVID-19 cases. Women tend to report these problems more commonly than men, though data appear more gender equal as the disease severity decreases. It is reported slightly more commonly in middle-age ranges, and rates tend to remain stable across ethnic stratification. However, patients with preexisting PEMD have reported exacerbation, particularly for anxiety and depression.

A Bellwether Warning for the United States

One of the first serious COVID-19 clusters in the U.S. occurred in a long-term care near Seattle Washington on February 28, 2020 (18). In total, 129 COVID-19 cases were confirmed to be associated with this facility. There were 23 associated fatalities at this facility. The high case fatality and rapid disease spread served as an early indicator of the remarkable pathogenicity of the virus in a highly vulnerable population. This cluster also demonstrated its extraordinary transmissibility. Despite the facility initiating protective protocols, there were gaps in this protection, which were shared with similar facilities nationally.

Long-Term Care Facility Action Points

Long-term care facilities represent high-risk locations. Larger numbers of elderly individuals typically with co-morbid conditions are in a single residential environment. Staff attend to multiple residents often at several different facilities and represent a significant transmission risk. This is particularly true if they do not adhere to appropriate infection control procedures.

Once a pathogen enters a long-term care facility, the morbidity and mortality from that pathogen can be substantial. However, with appropriate support and training, along with the implementation of basic infection control procedures, the impact can be diminished. Some recommendations include:

  • Implementation of symptom screening and restriction policies for visitors and other personnel
  • Active screening of healthcare personnel and appropriate testing
  • Monitoring of staff compliance with infection control procedures
  • Symptom monitoring of residents with appropriate testing
  • Social distancing, including restricting resident movement and group activities
  • Staff training on infection control and PPE use
  • Establishment of plans to address local PPE shortages, including county and state coordination of supply chains and stockpile releases to meet needs

These strategies require coordination and support from public health authorities, community partnering of healthcare systems and regulatory agencies. And such processes need to exist before the next outbreak or pandemic.

Long COVID Disease Stigma, Isolation and Racism Impacts

Many diseases, including Long COVID, are associated with social stigma. The literature on stigmatized health conditions indicates that this issue pushes people away from seeking care for their condition. This has the unfortunate result of amplifying stress-related PEMD and compromising long-term recovery.

The level of isolation needed to combat the entry and spread of SARS-CoV-2 among residents in long-term care facilities had a significant impact on their well-being. Residents were often restricted to minimal non-physical visits with family and loved ones. These infection-control-related social restrictions resulted in significant alterations in residents’ activities and routines. Anger, fear, loneliness and feelings of abandonment were commonly noted. These issues also extended into home isolation. Families of residents also reported similar issues.

Another issue associated with elevated stress and stigmatization from acute and Long COVID is race-related discrimination. As example, a survey study found a significant COVID-19-related surge in racism-related events in the U.S. against Asian American and Pacific Islanders. Such racist activities have similar impacts on the individual’s health and well-being as other forms of stigma.

Long COVID Post-Acute and Mental Health Impacts

Despite a trend towards declining COVID-19 new cases in the U.S., approximately 36,300 new Long COVID cases are still occurring each month. The number of Long COVID cases should decline further as SARS-CoV-2 seeks out its endemic relationship with humans. However, because this virus will remain in the human population, Long COVID will continue to impact post-acute, mental health and other clinical services for years to come. Access a full list of references and resources. Read the other articles in TeamHealth’s Emerging Infectious Disease Taskforce Long COVID series.