COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Pushing back’: People newly diagnosed with dementia and their experiences of the Covid-19 pandemic restrictions in England.
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Dixon J, Hicks B, Gridley K, Perach R, Baxter K, Birks Y, et al.
Int J Geriatr Psychiatry. 2022 Oct;37(10).
BACKGROUND AND OBJECTIVES: Research into people with dementia’s experiences of the Covid-19 pandemic has tended to focus on vulnerabilities and negative outcomes, with the risk of reproducing a discourse in which people with dementia are positioned as passive. Informed by concepts positioning people with dementia as ‘active social agents’, we aimed to identify the pandemic-related challenges faced by people recently diagnosed with dementia and examine the ways in which they actively coped with, and adapted to, these challenges. RESEARCH DESIGN AND METHODS: In-depth interviews with 21 people recently diagnosed with dementia, recruited through an existing national cohort. Data was analysed thematically using Framework. FINDINGS: Key challenges included reduced social contact, loneliness and loss of social routines; difficulties accessing and trusting health services; dementia-unfriendly practices; and disparate experiences of being able to ‘get out’ into the physical neighbourhood. People with dementia responded to challenges by maintaining and extending their social networks and making the most of ‘nodding acquaintances’; learning new skills, for communication and hobbies; supporting others, engaging in reciprocal exchange and valuing connection with peers; seeking help and advocacy and challenging and resisting dementia-unfriendly practices; maintaining and adapting habitual spatial practices and being determined to ‘get out’; and employing similar emotional coping strategies for the pandemic and dementia. CONCLUSIONS: Support for people with dementia, especially during public health crises when carers and services are under pressure, should involve utilising existing capacities, appropriately supporting the acquisition of new knowledge and skills, ‘safety-netting’ through the availability of a named professional, advocacy and support and use of ‘check-in calls’ and creating supportive social and environmental circumstances for people with dementia to sustain their own well-being.

Surviving through solitude: A prospective national study of the impact of the early COVID-19 pandemic and a visiting ban on loneliness among nursing home residents in Sweden.
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Gustafsson PE, Schröders J, Nilsson I, San Sebastián M.
J Gerontol B Psychol Sci Soc Sci. 2022 Sep 2;gbac126.
OBJECTIVES: Targeted social distancing measures were widely implemented for nursing home residents when the extremely high COVID-19 mortality in this setting became apparent. Still, there is still scarce rigorous research examining how the pandemic and accompanying social distancing measures impacted loneliness in this group. This prospective nation-wide Swedish study of nursing home residents aimed to examine the impact on loneliness of the early phase of the pandemic and of a national visiting ban at nursing homes. METHODS: A panel was selected from a total population survey of all nursing home residents in Sweden March-May 2019 and 2020 (N=11,782; age range 70-110 years; mean age 88.2 years; 71% women). Prospective pretest-posttest and controlled interrupted time series designs were employed, with time trends estimated by date of returned questionnaire. Generalized linear models were used for estimation of effects, adjusting for demographic, survey-, and health-related covariates. RESULTS: Loneliness prevalence increased from 17 to 19% from 2019 to 2020 (Risk Ratio, RR (95% confidence interval, CI)=1.104 (1.060; 1.150)), but which was explained by self-reported health (RR(95%CI)=1.023 (0.982; 1.066)). No additional impact of the visiting ban on loneliness trends was found in the interrupted time series analyses (RR(95%CI)=0.984 (0.961; 1.008)). DISCUSSION: The moderate but health-dependent increased risk of loneliness, and the lack of impact of the nation-wide visiting ban at nursing homes, suggest that this ostensibly vulnerable group of nursing home residents also show signs of resilience, at least during the early phase of the pandemic.

Levels of Depression and Anxiety Among Informal Caregivers During the COVID-19 Pandemic: A Study Based on the Canadian Longitudinal Study on Aging.
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Wister A, Li L, Mitchell B, Wolfson C, McMillan J, Griffith LE, et al.
J Gerontol B Psychol Sci Soc Sci. 2022 Sep 1;77(9):1740–57.
OBJECTIVES: Studies on informal caregiving during the coronavirus disease 2019 (COVID-19) pandemic have mainly focused on subgroups of caregivers using cross-sectional or convenience samples, limiting the generalizability of findings. Conversely, this longitudinal study examines the effects of the pandemic and caregiving factors on depressive symptoms and anxiety over 9 months among informal caregivers in Canada. METHODS: This study uses data from the Baseline (2011-2015), Follow-up 1 (2015-2018), and COVID-19 Study Baseline survey (April to May 2020) and Exit surveys (September to December 2020) of the Canadian Longitudinal Study on Aging (CLSA). A total of 14,118 CLSA participants who were caregivers at Follow-up 1 and participated in the COVID-19 studies were selected. Linear mixed models were used to examine the effect of sex of caregiver, changes in caregiving (increase in caregiving hours and inability to care), and location of care (same household, another household, and health care institution) on depressive symptoms and anxiety from COVID-19 studies Baseline to Exit surveys (about 6-7 months apart). RESULTS: Informal caregivers reported more frequent depressive symptoms from the COVID-19 Baseline to Exit surveys, but not anxiety. Female caregivers reported greater depressive symptoms and anxiety, and male caregivers exhibited a greater increase in depressive symptoms and anxiety over time. More caregiving hours and inability to provide care were significantly positively associated with depressive symptoms and anxiety. Also, in-home caregivers reported more depressive symptoms and anxiety than those who cared for someone in health care institution, and more anxiety than those who cared for some in another household. DISCUSSION: The findings shed light on the change in mental health among informal caregivers during the outset of the pandemic. The demonstrated associations between studied variables and mental health among informal caregivers provide empirical evidence for intervention programs aiming to support caregivers, particularly those who are female, and providing intensive care at home.

Administration and Organization

A mixed-methods analysis of telehealth implementation in nursing homes amidst the COVID-19 pandemic.
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Powell KR, Winkler AE, Liu J, Alexander GL.
J Am Geriatr Soc. 2022 Aug 30.
BACKGROUND: The COVID-19 pandemic has forced nursing homes to adapt new models of care in response to the evolving crisis including rapid implementation of telehealth services. The purpose of our study was to investigate implementation of telehealth in nursing homes amidst the COVID-19 pandemic using a human factors model. METHODS: Using a mixed methods design, we conducted a secondary analysis of data from a national survey of nursing home administrative leaders (n = 204). Using six survey questions, we calculated a total telehealth score (range 0-42). Descriptive statistics and paired sample t-test were used to explore the change in telehealth in two consecutive years (2019-2021). Next, we conducted semi-structured interviews with (n = 21) administrators and clinicians to assess differences in implementation according to extent of telehealth use. RESULTS: The mean telehealth score in year 1 was 12.11 (SD = 9.85) and year 2 was 19.25 (SD = 11.25). There was a significant difference in telehealth scores from year 1 to year 2 (t = 6.83, p < 0.000). While 64% of nursing homes reported higher telehealth scores in year 2 compared to year 1, over 32% reported a decline. Qualitative analysis revealed facilitators of telehealth including training, use of integrated equipment, having staff present for the visit, and using telehealth for different types of visits. Barriers included using smart phones to conduct the visit, billing, interoperability and staffing. CONCLUSION: Training, adaptation of work processes to support communication, and restructuring teams and tasks are the result of interactions between system components that could improve usability and sustainability of telehealth in nursing homes.

Prevalence and Spread

Modeling the Impact of Vaccination Strategies for Nursing Homes in the Context of Increased Severe Acute Respiratory Syndrome Coronavirus 2 Community Transmission and Variants.
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Holmdahl I, Kahn R, Slifka KJ, Dooling K, Slayton RB.
Clin Infect Dis. 2022 Aug 24;75(1):e880–3.
Using an agent-based model, we examined the impact of community prevalence, the Delta variant, staff vaccination coverage, and booster vaccines for residents on outbreak dynamics in nursing homes. Increased staff coverage and high booster vaccine effectiveness leads to fewer infections, but cumulative incidence is highly dependent on community transmission.

Impaired immunity and high attack rates caused by SARS-CoV-2 variants among vaccinated long-term care facility residents.
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Obach D, Solastie A, Liedes O, Vara S, Krzyżewska-Dudek E, Brinkmann L, et al.
Immun Inflamm Dis. 2022 Sep;10(9):e679.
INTRODUCTION: Long-term care facilities (LTCF) residents are at high risk for severe coronavirus disease 2019 (COVID-19), and therefore, COVID-19 vaccinations were prioritized for residents and personnel in Finland at the beginning of 2021. METHODS: We investigated COVID-19 outbreaks in two LTCFs, where residents were once or twice vaccinated. After the outbreaks we measured immunoglobulin G (IgG) antibodies to severe acute respiratory syndrome coronavirus 2 spike glycoprotein, neutralizing antibody (NAb) titers, and cell-mediated immunity markers from residents and healthcare workers (HCWs). RESULTS: In LTFC-1, the outbreak was caused by an Alpha variant (B.1.1.7) and the attack rate (AR) among once vaccinated residents was 23%. In LTCF-2 the outbreak was caused by a Beta variant (B.1.351). Its AR was 47% although all residents had received their second dose 1 month before the outbreak. We observed that vaccination had induced lower IgG concentrations, NAb titers and cell-mediated immune responses in residents compared to HCWs. Only 1/8 residents had NAb to the Beta variant after two vaccine doses. CONCLUSIONS: The vaccinated elderly remain susceptible to breakthrough infections caused by Alpha and Beta variants. The weaker vaccine response in the elderly needs to be addressed in vaccination protocols, while new variants capable of evading vaccine-induced immunity continue to emerge.

An epidemiological investigation of COVID-19 outbreaks in a group of care homes in Wales, UK: a retrospective cohort study.
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Williams O, Williams C, Turner D, Bull M, Watkins J, Hurt L.
J Public Health (Oxf). 2022 Aug 25;44(3):606–13.
BACKGROUND: This study describes the epidemiology of COVID-19 outbreaks in four care homes in terms of spread, severity, presentation and interventions. METHODS: Participants were 100 residents and 102 staff from four co-located care homes in Wales. Data were collected from the homes and Public Health Wales, including demographics, presentations, test status and results, hospital admissions and deaths. Genomic sequencing of confirmed case samples was completed, where possible. Epi-curves, crude attack rates, a Kaplan-Meier survival curve and adjusted hazard ratios were calculated using R. RESULTS: About 14 confirmed and 43 possible resident cases, 23 confirmed and 47 possible staff cases occurred. Crude attack rates of possible and confirmed cases were 57% (residents) and 69% (staff). Genomic sequencing for 10 confirmed case PCR samples identified at least 5 different UK lineages of COVID-19.42 (42%) residents died, 23 (55%) with COVID-19 or suspected COVID-19 recorded on the death certificate. The hazard ratio for death amongst resident possible and confirmed cases compared to null cases, adjusting for age and sex, was 13.26 (95% CI 5.61-31.34). CONCLUSIONS: There were extensive outbreaks of COVID-19 in these homes with high crude attack rates and deaths. Universal testing and early isolation of residents are recommended.

Quality Improvement

Using the Consolidated Framework for Implementation Research (CFIR) to foster the adoption of a new dementia education game during the
COVID-19 pandemic.

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Hung L, Mann J, Upreti M.
Gerontologist. 2022 Aug 31;gnac138.
BACKGROUND AND OBJECTIVES: The pandemic of coronavirus disease 2019 (COVID-19) challenged educators to move staff education online and explore innovative ways to motivate learning to support dementia care for patients in geriatric settings. This article presents how the Consolidated Framework for Implementation Research (CFIR) was used to support the adoption of an online dementia education game in Canadian hospitals and long-term care homes (LTC). The dementia education was co-developed with local staff and patient partners to teach practical person-centered care communication techniques. RESEARCH DESIGN AND METHODS: CFIR guided our strategy development for overcoming barriers to implementation. Research meetings were conducted with practice leaders, frontline healthcare workers, and a patient partner. Our analysis examined four interactive domains: intervention, inner context, outer settings, and individuals involved and implementation process. RESULTS: Our analysis identified five effective strategies: Easy access, Give extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Engagement of champion. The CFIR provided a systematic process, a comprehensive understanding of barriers, and possible enabling strategies to implement gamified dementia education. Interdisciplinary staff (n=3,025) in ten hospitals and ten LTC played online games. The evaluation showed positive outcomes in knowledge improvement in person-centered dementia care. DISCUSSION AND IMPLICATIONS: Gamified education in dementia care offers a social experience and a component of fun to promote adoption. In addition, CFIR is useful for engaging stakeholders to conduct project planning and team reflection for implementation. The real-time discussion and adjustment helped overcome challenges and timely meet the needs of multiple organizations.

Impact on Healthcare Workers

Work Stress and Willingness of Nursing Aides during the COVID-19 Pandemic.
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Chang TS, Chen LJ, Hung SW, Hsu YM, Tzeng YL, Chang Y.
Healthcare (Basel). 2022 Aug 2;10(8).
OBJECTIVES: During the coronavirus disease 2019 (COVID-19) pandemic, nursing aides (NAs) experienced greater work stress than they do typically because they worked in highly contagious environments. This may have influenced their work morale and willingness to work, which can reduce patient satisfaction, influence their physical and mental health, and even endanger patient safety or cause medical system collapse. DESIGN: A cross-sectional survey with a structured self-report questionnaire was conducted. SETTING AND PARTICIPANTS: 144 NAs from a medical center in Central Taiwan participated. METHODS: We recruited NAs through convenience sampling to discuss their work stress, willingness to work, and patients’ satisfaction with them during the COVID-19 pandemic. RESULT: Of the 144 recruited NAs, 115 (79.9%) were women and 29 (20.1%) were men, and 89 (61.8%) had completed COVID-19 training courses. NAs with different work tenure lengths exhibited significant differences in work stress (p = 0.022), willingness to work (p = 0.029), and patient satisfaction (p = 0.029) scores during the pandemic. CONCLUSION: The study findings provide crucial data for the management of NAs during pandemics to prevent them from neglecting patients due to excessive work stress or losing their willingness to work, which may cause the medical system to collapse.