n the United States, the number of older I

Managing the challenge of herpes zoster
in the long-term care setting
By Angela DeRosa, DO, MBA, CPE, and
Kendra Gray
In the United States, the number of older
adults requiring long-term care services is
projected to more than double from
10 million in 2000 to 21 million in 2040.1
The long-term care environment predisposes patients to infectious outbreaks and
subsequent complications.2 Herpes zoster,
commonly known as shingles, is a highly
contagious infection of varicella-zoster
virus (VZV), which is transmitted from
person to person by direct contact with, or
aerosolization from, skin lesions or respiratory tract secretions.3
The risk of herpes zoster is closely related to the decline of VZV cell-mediated immune response with aging and immunosuppression. Research indicates that if an
individual older than age 60 years had
VZV-caused chickenpox as a child, he or
she has a 50% chance of getting shingles by
the age of 85 years.4 Because herpes zoster
is highly contagious, early detection and diagnosis are imperative to limit the spread of
the disease to other residents, healthcare
workers, and visitors in nursing homes and
other long-term care facilities.2,4
Presentation in elderly adults
Early diagnosis and treatment can shorten
the duration of shingles and also prevent
complications, such as the chronic pain of
postherpetic neuralgia (PHN) and secondary infections, which can occur long after
the shingles lesions have vanished. However, diagnosis can be challenging because
the initial symptoms of herpes zoster are
ambiguous in many cases, causing the disease to be mistaken for other ailments—
particularly in the elderly population.
Some patients become quite ill with the flulike symptoms of fever, chills, nausea and
headache. A rash develops soon after these
vague symptoms, along with tingling
and/or a painful feeling of being poked by
pins. Symptoms in elderly patients can be
so painful or illusive in their presentation
that such conditions as appendicitis, earaches, gallstones, kidney stones, myocardial
infarction or pleurisy may be suggested.5-7
A physician may not be able to conclusively determine shingles to be the source
of the symptoms until the appearance of
characteristic lesions 48 to 72 hours after
the onset of pain.3 Diagnosis can be even
more illusive in those patients who have dementia or multiple comorbidities or who
are taking medications with adverse effects
similar to herpes zoster symptoms.
Postherpetic neuralgia can have an overwhelming impact on quality of life and
level of daily functioning for the elderly
individual. Chronic fatigue, severe depression, thoughts of suicide, sleeplessness or
disordered sleep, anxiety, difficulty concentrating, anorexia and weight loss are commonly associated with PHN.5 In addition,
the excruciating pain that occurs with
PHN has been known to cause drastic personality changes in patients. These personality changes may be misdiagnosed as mental decline, acute infections, adverse effects
of medications, or other conditions.5,8
The increased level of patient assistance
needed from caregivers—and the consequent restriction of caregivers’ social activities—can cause great stress and anxiety
among the long-term care facility employees.5 The fact that many of the healthcare
workers in the long-term care setting are
too young to have personally experienced
shingles increases the challenge for these
employees in understanding the level of
suffering experienced by their patients.
Treatment implications
When herpes zoster occurs in the elderly
population, pharmacotherapeutic approaches to management must be modified and
nonpharmacotherapeutic approaches must
be augmented to decrease the duration and
19
severity of symptoms. Elderly patients, particularly those in long-term care facilities,
are at increased risk for adverse drug effects because of multiple comorbidities, use
of multiple medications and age-related
changes in pharmacokinetic dynamics.
Starting dosages of medications for elderly
individuals should be lower than those recommended for younger individuals, particularly for the anticonvulsants gabapentin
and pregabalin, nonsteroidal anti-inflammatory drugs, opioid analgesics and tricyclic antidepressants.3
Another important treatment consideration is the age-related and disease-related
decline in glomerular filtration rate
typically seen in the elderly patient. The
dosages of renally excreted medications
(eg, antiviral agents, gabapentin, pregabalin) must be adjusted to account for this
decline. Nonsteroidal anti-inflammatory
drugs should be avoided in elderly individuals who have congestive heart failure or
chronic kidney disease.
The oral or intravenous antiviral agents
acyclovir, famciclovir and valacyclovir have
been proven to accelerate healing and to decrease symptoms in older patients if given
within 72 hours of the onset of the herpes
zoster rash. The efficacy of these three
agents seems to be equivalent.3 Antihistamines, taken by mouth or applied to the
skin, are frequently used to reduce the itching associated with shingles. However, both
of these drug classes can produce adverse
effects—especially in elderly individuals.
Thus, precautions should be taken to reduce these risks.
The use of steroid therapy to prevent
the development of PHN is controversial.
Several studies suggest that prompt steroid
therapy upon recognition of VZV infection
may prevent long-term complications and
pain associated with acute infection. However, other studies indicate that risks of
steroid therapy, such as acute psychosis,
bone loss and elevated blood glucose, may
outweigh its benefits.
The National Guideline Clearinghouse9 recommendations for management
of herpes zoster warn that vulnerable and
frail elderly individuals need to be monitored closely in the long-term care setting
20
clothing and anything that comes in
contact with the rash—should not be
reused.
to detect inadequate responses to therapy.
For example, both pharmacotherapeutic
and nonpharmacotherapeutic approaches
require scrupulous monitoring in individuals with dementia. Herpes zoster-related
pain and acute inflammation may lead to
worsening cognition in these individuals,
and pain management in these individuals
is complicated because of the risk for “adverse cognitive effects of opioid analgesics,
gabapentin, pregabalin and tricyclic antidepressants.”9 Furthermore, traditional
pain measures (eg, the 0-to-10 numerical
rating scale) used to track patient response
to analgesics are not useful in assessing patients with advanced dementia.9
Nonpharmacotherapeutic approaches
important for improving patients’ comfort
and healing include the use of cool, wet
compresses to reduce pain and the use of
soothing baths and lotions (eg, colloidal
oatmeal baths, starch baths, calamine lotion) to help relieve itching and discomfort.9,10
The following list includes some basic
hygiene and dietary recommendations and
herbal remedies that can be useful in treating elderly patients with herpes zoster in the
long-term care setting, especially when attempting to limit the use of pharmacologic agents
y
The skin should be kept clean, and
contaminated items—towels, combs,
y
Nondisposable items such as towels,
combs and clothing should be washed
in boiling water or otherwise disinfected before reuse.
y
Avoid foods rich in arginine, which is
required for VZV to replicate. Such
foods include almonds, cashews, cereal
grains, chocolate, coconut, dairy products, oats, peanuts and soybeans.
y
Consume foods rich in the amino acid
lysine. Studies indicate that the process
of VZV replication extracts lysine—
which has a similar chemical structure
to arginine—from the bloodstream.
The virus attempts to use lysine as it
would use arginine—to make
protein VII, an arginine-rich protein
component of the viral core. However,
this attempt fails. Thus, lysine acts like
an arginine substitute, “fooling” the
virus and preventing it from replicating
and causing outbreaks. Foods that contain high levels of lysine include most
vegetables, including legumes, as well
as fish, chicken and turkey.
y
Use supplements containing the
vitamin B12/B6 complex, which aids
the body in recovery and reduces the
pain associated with shingles.
y
Apply capsaicin cream, which aids in
relieving pain associated with shingles.
y
Use olive leaf extract supplements,
which have antiviral properties.
y
Avoid foods that encourage an overly
acidic body system, such as chocolate,
fried foods and red meat, and do not
drink caffeine-containing or carbonated beverages (not even “fizzy” water).
y
Because sugar suppresses the activity
of white blood cells, refined sugar
products—including cakes, cookies,
sweet baked goods and sodas—should
be avoided. Naturally occurring sugars,
such as those in fruit, should be eaten
in moderation.
In addition to using hygiene and dietary
approaches and herbal remedies to treat
elderly patients with herpes zoster, consideration should be given to using osteopathic manipulative treatment, including lymphatic pump techniques, myofascial release
—which can aid in proper breathing and
cardiac output—and lymphatic drainage—
which can aid in healing. In addition,
aromatherapy, biofeedback and other
stress/pain reduction approaches may be
useful for increasing patient comfort and
sense of well-being.
To reduce the risk of cross-infectivity in
nursing homes and other long-term care
settings, the federal Centers for Disease
Control and Prevention (CDC) recommends that individuals with herpes zoster
be given private rooms to protect other patients and susceptible staff members.11
For immune-incompetent patients,
negative pressure ventilation and other
strict precautions are required to prevent
secondary infections. If a nursing home or
other long-term care facility is not
equipped to provide these recommended
services, a hospital setting may be more
suitable for those individuals requiring such
treatment.4
Prevention of VZV transmission
Prompt recognition and initiation of antiviral treatment for patients with herpes
zoster can prevent the spread of VZV to
susceptible individuals in the long-term
care setting. Prevention of VZV transmission in the long-term care setting includes
isolation of patients with herpes zoster from
immunocompromised individuals until all
lesions have crusted over.
Isolation is important not only to protect fellow residents of long-term care facilities, but also to protect facility healthcare
providers. This is especially important considering that many women of childbearing
age work in the long-term care setting.
Pneumonia is a common complication of
VZV infection in pregnant women. Death
rates in untreated varicella pneumonia in
pregnant women are as high as 45%.3,4,10
Herpes zoster vaccination
The vaccine for herpes zoster is crucial in
the long-term care setting. Elderly patients
with chronic illness are at high risk of infection and complications as a result of advanced age and age-related reduction in
cell-mediated immunity, as previously described.12
Recommendations of the Advisory
Committee on Immunization Practices,13
released in May 2008, state the following:
“Zoster vaccine is recommended for all persons aged >60 years who have no con-
traindications, including persons who report a previous episode of zoster or who
have chronic medical conditions. The vaccine should be offered at the patient’s first
clinical encounter with his or her healthcare provider. ... Zoster vaccination is not
indicated to treat acute zoster, to prevent
persons with acute zoster from developing
PHN, or to treat ongoing PHN.”
According to a recent survey published
in Geriatrics,14 however, the number of
physicians who are familiar with the
unique needs of patients in the long-term
care setting is declining. This “provider
gap” plays a major role in patient care. In
the Geriatrics survey, the following text describes the prescription of the herpes zoster
vaccine by medical directors of long-term
care facilities.
Medical directors reported ordering the
vaccine either never or rarely [for younger
patients], with a frequency that increased
with age—65% [of medical directors ordered the vaccine] for those [patients] aged
60 to 69 years and 83% [of medical directors ordered the vaccine] for those [patients] aged 90 or older. A small percentage
(3% to 5%) of medical directors indicated
that they always administer the vaccine,
and slightly higher percentages reported
that they administer it usually or occasionally in all age cohorts.15
Cost ratios have played a major role in
use of the herpes zoster vaccine, as evidenced by the following quote from Hornberger and Robertus:15 “Vaccination would
be more cost-effective in ‘younger’ older
adults (age 60 to 64 years) than in ‘older’
older adults (age >80 years).”
Longer life expectancy and a higher
level of vaccine efficacy offset a lower risk
for herpes zoster in the younger group.
Other factors influencing cost-effectiveness
include quality-of-life adjustments for
acute zoster, unit cost of the vaccine, risk
for herpes zoster, and duration of vaccine
efficacy.16
Group or herd statistics suggest that
nursing home administrators could play a
greater role in reducing VZV transmission
rates if more patients—especially younger
patients—were given the herpes zoster vaccine. However, most nursing home administrators base their disease-prevention and
cost-reduction decisions on statistics from
their own patient community, rather than
on published herd statistics.
Education and awareness
Preserving the dignity and comfort of patients in the expanding US elderly population is of growing importance. Public in-
21
formation campaigns on the issue of herpes zoster in elderly individuals and increased availability of information and resources for physicians and other healthcare
workers have resulted in improved understanding of this disease.
In early 2009, the Visiting Nurse Associations of America, the National Pain
Foundation and the National Council on
Aging announced the relaunch of AfterShingles.com (www.aftershingles.com/), an
online resource to help consumers learn
about shingles and PHN.16 The goal of this
Web site, which was originally launched in
2001, is to help facilitate discussion between patients and their physicians.
In the long-term care setting, AfterShingles.com is an excellent tool for healthcare workers—including licensed practical
nurses, licensed vocational nurses, and certified nursing assistants—to increase their
awareness of the signs and symptoms of
herpes zoster. These healthcare workers can
make a huge difference in patient outcomes
if herpes zoster is detected in its earlier
stages.
Spotlight on Shingles (www.spotlight
onshingles.com/) is another educational
campaign about herpes zoster, sponsored
by the American Pain Foundation. This
program seeks to raise awareness and understanding among older people, healthcare professionals and personal caregivers
about shingles and its potential complications. Yet another online resource—the
CDC’s Immunization Toolkit (www2.
cdc.gov/nip/isd/immtoolkit/default.htm)
—offers information for healthcare personnel who provide immunization services.
afflicted with the disease. y ww
/ency/article/000858.htm. Accessed July 14, 2009.
References
11. Siegel, JD, Rhinehart E, Jackson M, Chiarellow L,
1. Johnson RW, Toohey D, Wiener JM. Meeting the
and the Healthcare Infection Control Practices
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Advisory Committee. 2007 Guideline for Isolation
changing families will affect paid helpers and
Precautions: Preventing Transmission of Infectious
Institutions. Washington, DC: The Urban Institute;
Agents in Healthcare Settings, June 2007. Available
May 2007. The Retirement Project, Discussion Paper
at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/
07-04. Available at: http://www.urban.org/
Isolation2007.pdf).
UploadedPDF/311451_Meeting_Care.pdf. Accessed
July 12, 2009.
12. Evans JM. Vaccination to prevent herpes zoster
and postherpetic neuralgia in the nursing home?
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13. Harpaz R, Ortega-Sanchez IR, Seward JF; Division
of Viral Diseases, National Center for Immunization
3. Tan JS, File TM, Salata RA, Tan, MJ. Infectious
and Respiratory Diseases. Prevention of herpes
Diseases—Expert Guide Series. 2nd ed. Philidelphia,
zoster—recommendations of the Advisory Committee
Pa: American College of Physicians; 2007.
4. Griffith RW. Herpes zoster (shingles) in older
people; April 10, 2001. Available at: Health and Age
Web site. http://www.healthandage.org/PHome/gm=
20!gc=38!l=2!gid2=1146. Accessed June 16, 2009.
5. Schmader K. Management of herpes zoster in elderly patients. Infect Dis Clin Pract. 1995;4:293-299.
6. Lim LS, Takahashi PY. 80-year-old man with fever
and ear pain. Mayo Clin Proc [serial online] 2004;79:
1055-1058. Available at: http://www.mayoclinic
proceedings.com/content/79/8/1055.long. Accessed
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7. Filippone LM. Diagnosis: herpes zoster [quick consult]. Emerg Med News [serial online]. 2006;28:27.
Available at: http://www.em-news.com/pt/re/
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14. Long-term care: how MDs fit in (and what they’re
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16. New, interactive health Web site provides information about a painful and often debilitating condition
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Final notes
8. Schmader K. Postherpetic neuralgia in immunocom-
prnewswire.com/DisplayReleaseContent.aspx?ACCT=
The osteopathic approach of considering a
patient’s mind, body and spirit in treatment can provide a unique perspective on
treating elderly individuals with herpes
zoster in the long-term care setting. By
combining this approach with future
research results on optimizing implementation of the herpes zoster vaccine and
preventing complications of VZV infection, the osteopathic medical community
will be better able to prevent the spread of
herpes zoster and to treat those patients
petent elderly people. Vaccine. 1998;16:1768-1770.
104&STORY=/www/story/03-312009/0004998021
22
&EDATE=. Accessed July 31, 2009.
9. Dworkin RH, Johnson RW, Breuer J, Gnann JW,
Levin MJ, Backonja M, et al. Recommendations for
the management of herpes zoster. Clin Infect Dis.
2007;44(suppl 1):S1-S26. Modified November 3, 2008.
Available at: http://www.guideline.gov/summary/
pdf.aspx?doc_id=10222&stat=1&string=. Accessed
July 14, 2009.
10. Herpes zoster. US National Library of Medicine,
National Institutes of Health Web site; updated June 19,
2008. Available at: http://www.nlm.nih.gov/medlineplus
Angela DeRosa, DO, MBA, CPE, is vice president
of medical affairs for Matrix Medical Network in
Brooklyn, NY. Matrix is a provider management
company for physicians who practice in the longterm care setting. Correspondence can be directed
to Dr DeRosa at [email protected].
Kendra Gray is a premed student interested in
pursuing osteopathic medical education.