COVID-19 Disease Trajectories Among Nursing Home Residents

Jennifer L. Carnahan MD, MPH, MA; Kristi M. Lieb MD; Lauren Albert BS; Kamal Wagle MD, MPH; Ellen Kaehr MD; Kathleen T. Unroe MD, MHA


J Am Geriatr Soc. 2021;69(9):2412-2418. 

In This Article

Abstract and Introduction


Introduction: Older adults are at greater risk of both infection with and mortality from COVID-19. Many U.S. nursing homes have been devastated by the COVID-19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID-19.

Setting and Methods: This is a case series of 74 residents with COVID-19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents.

Results: The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID-19 infection. A subset of residents with COVID-19 infection experienced a rapidly progressive, fatal course.

Discussion/Conclusions: Nursing home residents infected with COVID-19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post-disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.


Approximately 40% of COVID-19-related U.S. deaths were among nursing home residents in 2020.[1] This is due to a combination of the vulnerability of older adults to the virus, the need for hands-on, prolonged care from caregivers, and the inherent risks of congregant settings. Inadequate supplies and personnel to address the crisis have been cited as contributors to outbreaks as well.[2] Given the high community spread, it is challenging to completely prevent entry of the virus into facilities from asymptomatic staff and then, once in the facility, to mitigate spread.[2]

Due to the immunophysiology of older adults and the high incidence of dementia in nursing homes, any acute illness in this population can present in an atypical manner.[3] Some older adults may not mount a fever in response to infection;[4,5] persons with dementia may be unable to report symptoms.[6–10] A range of presentations may be present in a COVID-19 infection. At least one inpatient study of COVID-19 in older adults noted a rapid disease course preceding death.[11] Other hospital-based studies have noted a prolonged course for intubated patients regardless of age, with a high risk of mortality among older adults.[12,13]

Most nursing home residents have cognitive impairment and those with moderate to advanced dementia, often have goals of care consistent with limited interventions or comfort care.[14,15] Thus, if they are to become ill, the goal is to care for them in the nursing home. Little is known about the expected disease course for nursing home residents who elect not to pursue aggressive measures if infected with the novel coronavirus. Further, the longer-term sequelae of COVID-19 infection are only beginning to be understood.[16] The objective of this study is to examine a case series of an outbreak of COVID-19 in a nursing home to identify the disease course pattern both for both decedents and survivors of the disease.


This is a case series describing the management and outcomes of residents during a COVID-19 outbreak in a privately managed nursing home in Indiana. During the outbreak, 74 out of 89 long-stay nursing home residents were infected with COVID-19. This outbreak is defined as the first positive test on March 29 to a positive case on June 17, 2020.

To prepare for a potential outbreak, facility-wide daily monitoring of residents' temperatures and oxygen levels started in mid-March. The first case diagnosed in the facility was in an individual recently admitted from the hospital who was tested on March 29 due to having a fever and asymptomatic hypoxia. This resident was isolated since admission from the hospital and remained in isolation; no other residents or staff exhibited symptoms.

The facility implemented facility-wide testing of all residents on April 16 fanning out from the first known facility-onset case. All residents were tested over a 5-day period. Residents who had close contact with those who were infected or who were symptomatic were placed in isolation until the test result was available. Those who tested positive were moved to a specially designated COVID-19 isolation wing. Due to the CDC's initial recommendation to obtain two negative test results to move a resident from the COVID-19 isolation unit, all residents with COVID were required to have two negative tests before they could be removed from isolation.

Test results during this outbreak took a minimum of 19 h to return and up to 4½ days. A clerical error in the laboratory led to one resident being falsely identified as having a negative test result that was later corrected to positive. Most of the residents of this facility share rooms, bathrooms, dining rooms, and other common space. Compassionate care visits by family members were allowed with nursing home residents with COVID-19 who were receiving comfort care, but many elected not to visit due to concerns about potential for infection.

At the time of this outbreak, treatment recommendations were for patients enrolled in clinical trials or who were hospitalized. Steroids were thought to potentially worsen COVID-19 infection. Thus, supportive cares were the mainstay of treatment with some additional interventions. Most residents were treated with thrombosis prophylaxis (enoxaparin) unless there was a contraindication, or unless they were already on an anticoagulant such as warfarin (Figure S1). Those not treated with an anticoagulant either had a contraindication or transferred to the hospital before initiation of the medication. Hypoxic patients received oxygen supplementation. No residents were given steroids or hydroxychloroquine during this outbreak. All residents had the frequency of vital sign monitoring increased and increased hydration support either orally with staff encouragement or via intravenous fluids.