COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Evaluation of uptake of COVID-19 temporary allied health services for residential aged care in Australia
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Caughey GE, Collier L, Cations M, Wesselingh S, Inacio MC.
Journal of the American Medical Directors Association
A key recommendation of Australia’s Royal Commission into Aged Care Quality and Safety COVID-19 Special Report was to increase provision of allied and mental health services to residents of residential aged care facilities (RACFs). Strict restrictions were implemented in RACFs in Australia during the COVID-19 pandemic to mitigate infection risk (e.g., lock downs) and significant concerns for residents’ due to reduced mobility, increase in sedentary behaviors, and potential declines in mental health were raised. In response in December 2020, the Australian Government announced temporary government supported Medicare Benefits Schedule (MBS) allied health services specific for RACF residents. These services were available to RACF residents whose health care was being managed under an eligible MBS-funded treatment, management or care plan (e.g., general practitioner management plan, multidisciplinary care plan). This included an additional five face-to-face services for specific physical therapies (physiotherapy, exercise physiology and occupational therapy), above the standard allocation of five services a year, aimed to reduce deconditioning and improve resident health and wellbeing. This national population-based study aimed to evaluate the uptake of these temporary COVID-19 MBS allied health services by RACF residents in 2021.

Covid-19 as an Independent Risk Factor for Weight Loss in Older Adults living in Nursing Homes.
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Courtois-Amiot P, Allart H, de Cathelineau C, Legué C, Eischen P, Chetaille F, et al.
Gerontology. 2023 Feb 17.
Introduction In nursing homes, where residents are at elevated risk for malnutrition, the specific additive effect of the coronavirus disease 2019 (COVID-19) on weight loss has not yet been adequately evaluated. This study aimed to determine the factors independently associated with weight loss in nursing home residents who survived the first wave of the COVID-19 pandemic, whether they have contracted COVID-19 or not. Methods This research was a retrospective study conducted in three nursing homes. Residents who survived the first French COVID-19 lockdown (March to May 2020) were included, provided their weight records were available. Baseline data included the body mass index (BMI), capacity to self-feed, need for texture-modified food, disability, and legal guardianship status. The diagnosis of COVID-19 was based on the results of a positive reverse transcriptase-polymerase chain reaction test. Univariate and multivariate logistic regression analyses were used to investigate associations between resident characteristics, COVID-19 status and at least 5% weight loss. Results Of the 316 included residents (72% female, mean age of 88 years, 48% severely disabled, and 38% under legal guardianship), 111 (35%) contracted COVID-19 and 102 (32%) lost at least 5% of their body weight. No difference was observed between the baseline characteristics of residents subsequently affected or unaffected by COVID-19. In the univariate analysis, old age, severe disability, texture-modified food, the need for close mealtime supervision, and COVID-19 were significantly associated with at least 5% weight loss. In the multivariate logistic regression analysis, COVID-19 (p = 0.02) and the need for close mealtime supervision (p = 0.02) were associated with weight loss in a model that also included age, BMI, texture-modified food, disability and nursing home. Discussion/Conclusion For nursing home residents, COVID-19 was an independent risk factor for weight loss. Weight loss was most common in residents needing close mealtime supervision, suggesting that organizational issues may have affected the quality of the nutritional care provided during the lockdown.

Let me touch him”: Perceptions and experiences of family caregivers of nursing home residents during the COVID-19 outbreak in Israel.
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Dolberg P, Lev S, Even-Zahav R.
J Aging Stud. 2023 Mar;64:101115.
Older adults in nursing homes were particularly vulnerable to COVID-19 morbidity and mortality worldwide. Due to the COVID-19 pandemic, visitations in nursing homes were restricted. The present study examined the perceptions and experiences of family caregivers of nursing home residents during the COVID-19 crisis in Israel and their coping strategies. Online focus group interviews were held with 16 family caregivers of nursing home residents. Three main categories were identified through Grounded Theory techniques: (a) Anger and decreased trust in nursing homes; (b) Perception of the residents as victims of the nursing home policy; (c) Coping strategies at different levels. The outbreak redefined family caregivers’ understanding of their role. Practical implications include making the voice of the family caregivers heard, identifying effective coping strategies, and creating a dialogue between family caregivers, nursing home managements, and staff.

Family caregivers’ experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective.
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Gonella S, Cornally N, Antal A, Tambone S, Martin P, Dimonte V, et al.
Palliat Support Care. 2023 Feb 27;1–12.
OBJECTIVES: Family caregivers’ (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative’s conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs’ experience of communication with NH staff during the COVID-19 pandemic from admission to end of life. METHODS: A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed. RESULTS: Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs’ need to interact with health-care professionals they trusted. Knowledge of residents’ preferences mitigated FCs’ turbulent emotions throughout the overall caregiving trajectory. SIGNIFICANCE OF RESULTS: Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents’ care preferences should be encouraged.

Virtual Fracture Care in LTC Homes Avoiding ED Visits
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Ng G, Larouche J, Feldman S, Verduyn A, Ward S, Wong BM, et al.
Journal of the American Medical Directors Association
Long Term Care residents with suspected fractures as a result of a fall typically transfer to the Emergency Department (ED) for diagnostic imaging and care. During the COVID-19 pandemic, transfer to the hospital increased the risk of COVID-19 exposure and resulted in extended isolation days for the resident. A fracture care pathway was developed and implemented to provide rapid diagnostic imaging results and stabilization in the care home, reducing transportation and exposure risk to COVID-19. Eligible residents with a stable fracture would receive a referral to a designated fracture clinic for consultation, fracture care is provide in the care home by long term care staff. Evaluation of the pathway was completed and demonstrated that 100% of residents did not transfer to the ED and 47% of the residents did not transfer to a fracture clinic for additional care.

Clinical expressions, characteristics and treatments of confirmed COVID-19 in nursing home residents: a systematic review.
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Nilsen A, Lichtwarck B, Eriksen S, Mork Rokstad AM.
BMC Geriatr. 2023 Feb 17;23(1):101.
BACKGROUND: The coronavirus 2019 (COVID-19) pandemic has led to a high rate of infections, frequent outbreaks, and high mortality rates in nursing homes (NH) worldwide. To protect and improve the treatment and care of the vulnerable NH population, it is pivotal to systematise and synthesise data from cases of COVID-19 among NH residents. In our systematic review, we therefore aimed to describe the clinical expressions, characteristics, and treatments of NH residents confirmed to have COVID-19. METHODS: We conducted two comprehensive literature searches in several electronic databases: (1) PubMed, (2) CINAHL, (3) AgeLine, (4) Embase, and (5) PsycINFO in April and July 2021. Of the 438 articles screened, 19 were included in our sample, and we used the Newcastle-Ottawa Assessment Scale to assess the quality of the reported studies. A weighted mean (M(weighted)), was calculated to account for the large variation in sample sizes of the studies, and due to heterogeneity among the studies, we report our findings in a narrative synthesis. RESULTS: According to the mean weights (M(weighted)), common symptoms and signs in NH residents confirmed to have COVID-19 were fever (53.7%), cough (56.5%), hypoxia (32.3%), and delirium or confusion (31.2%). Common comorbidities were hypertension (78.6%), dementia or cognitive impairment (55.3%), and cardiovascular diseases (52.0%). Six studies presented data concerning medical and pharmacological treatments, such as inhalers, oxygen supplementation, anticoagulation, and parenteral/enteral fluids or nutrition. The treatments were used to improve outcomes, as part of palliative care, or as end-of-life treatment. Transfers to hospital for NH residents with confirmed COVID-19 were reported in six of the included studies, and the rate of hospital transfers ranged from 6.9% to 50% in this population. In the 17 studies reporting mortality, 40.2% of the NH residents died during the studies’ observation periods. CONCLUSIONS: Our systematic review allowed us to summarise important clinical findings about COVID-19 among NH residents and to identify the population’s risk factors for serious illness and death caused by the disease. However, the treatment and care of NH residents with severe COVID-19 warrant further investigation.

Prevalence and Spread

Three Outbreaks of COVID-19 in a Single Nursing Home over Two Years of the SARS-CoV-2 Pandemic.
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Čokić V, Popovska Z, Lijeskić O, Šabić L, Djurković-Djaković O.
Aging Dis. 2023 Feb 1;14(1):99–111.
Older people in nursing homes (NH) have been hit particularly hard by the COVID-19 pandemic. We conducted a retrospective study of three outbreaks of COVID-19, occurring during the waves of the initial pre-Alpha, Delta and Omicron SARS-CoV-2 variants, in one NH in suburban Belgrade, Serbia. All staff and 95% residents were vaccinated in February 2021, mostly with BBIBP-CorV, and two thirds were boosted with a third dose in August 2021. COVID-19 was diagnosed by positive PCR and/or antigen test. After the first outbreak, 80 affected individuals were tested for SARS-CoV-2 specific antibodies. The first outbreak involved 64/126 (50.8%) residents and 45/64 (70.3%) staff, the second 22/75 (29.3%) residents and 3/40 (7.5%) staff, and the third involved 36/110 (32.7%) residents and 19/56 (33.9%) staff. Clinical presentation ranged from asymptomatic to severe, with severe cases referred to hospital ICUs. Deaths occurred only in residents, and the case fatality rate was 31.2%, 9.1% and 0%, respectively in outbreaks 1, 2 and 3. Specific IgG antibodies were detected in all 35 residents and 44 of the 45 staff, and higher IgG levels were detected in the residents (417.3±273.5) than in the staff (201.9±192.9, p<0.0001) despite a double difference in age (79.0±7.4 vs. 40.1±11.5 years). Outbreaks 2 and 3 involved four and 23 breakthrough infections, respectively. Older individuals mounted a good immunological response to SARS-CoV-2 infection and vaccination, which prevented significant mortality and severe morbidity in the subsequent outbreaks, despite a significant number of breakthrough infections.

A Molecular and Epidemiological Investigation of a Large SARS-CoV-2 Outbreak in a Long-Term Care Facility in Luxembourg, 2021.
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Ernst C, Pires-Afonso Y, Bejko D, Huberty C, Dentzer TG, Wienecke-Baldacchino A, et al.
Geriatrics (Basel). 2023 Jan 26;8(1).
In spring 2021, a long-term care facility (LTCF) of 154 residents in Luxembourg experienced a large severe, acute respiratory-syndrome coronavirus 2 (SARS-CoV-2) outbreak a few days after a vaccination campaign. We conducted an outbreak investigation and a serosurvey two months after the outbreak, compared attack rates (AR) among residents and staff, and calculated hospitalization and case-fatality rates (CFR). Whole genome sequencing (WGS) was performed to detect variants in available samples and results were compared to genomes published on GISAID. Eighty-four (55%) residents and forty-five (26%) staff members tested positive for SARS-CoV-2; eighteen (21%) residents and one (2.2%) staff member were hospitalized, and twenty-three (CFR: 27%) residents died. Twenty-seven (21% of cases) experienced a reinfection. Sequencing identified seventy-seven cases (97% of sequenced cases) with B.1.1.420 and two cases among staff with B.1.351. The outbreak strain B.1.1.420 formed a separate cluster from cases from other European countries. Convalescent and vaccinated residents had higher anti-SARS-CoV-2 IgG antibody concentrations than vaccinated residents without infection (98% vs. 52%, respectively, with >120 RU/mL, p < 0.001). We documented an extensive outbreak of SARS-CoV-2 in an LTCF due to the presence of a specific variant leading to high CFR. Infection in vaccinated residents increased antibody responses. A single vaccine dose was insufficient to mitigate the outbreak.

COVID-19 in older adult residents in nursing homes: factors associated with mortality and impact on functional capacity.
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Frigotto MF, Rodrigues R, Rabello R, Pietta-Dias C.
Sport Sci Health. 2023 Feb 24;1–9.
OBJECTIVE: To verify if the functional capacity prior to COVID-19 infection was different between Survivor and Non-survivor older adults. Also, to verify the effect of the isolation period after COVID-19 infection on the functional capacity of the Survivors residing in nursing homes. MATERIALS AND METHODS: Older adults residing in nursing homes were evaluated 30 days before the COVID-19 outbreak at the site for (i) general health characteristics (obtained from medical records); (ii) gait speed, handgrip strength and 30-s sit-to-stand; (iii) sarcopenia and (iv) estimated muscle mass. Comparisons were made between Survivors and Non-survivors of COVID-19. After the isolation, the Survivors performed the assessments again. RESULTS: Twenty-one (81 ± 9.3 years) participants tested positive for COVID-19 and participated in the study, 12 survivors. No difference was observed between Survivors and Non-survivors in any of the outcomes evaluated. However, a moderate effect size was observed for handgrip strength, with lower values for the Non-survivors group (- 16%; d = 0.53). The isolation period reduced the number of sit-to-stand repetitions with moderate effect size in the Survivors (p = 0.046, g (av) = 0.66). CONCLUSION: Although the null hypothesis analysis did not find significant differences between the groups, the effect size suggests that older adults residing in nursing homes who died from COVID-19 had lower handgrip strength. In the survivors, the isolation period after COVID-19 infection only negatively impacted the sit-to-stand performance.

Lessons From the Field: Rapid Antigen Testing Is Efficient and Practical for Mitigation of Coronavirus Disease 2019 Outbreaks in Long-Term Care Facilities.
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Miller DA, Duncan L, Termini L, Prebil LA, Witt D, McCurdy SA.
Open Forum Infect Dis. 2023 Feb;10(2):ofad048.
BACKGROUND: Mitigation of coronavirus disease 2019 (COVID-19) outbreaks in long-term care facilities (LTCFs) is facilitated by rapid identification and isolation of infectious individuals to interrupt viral transmission. Immunochromatographic (IC) tests, or rapid antigen tests, have high sensitivity and specificity during the contagious period for COVID-19. Mathematical modeling predicts frequent IC surveillance will be more efficient than polymerase chain reaction (PCR)-based strategies, especially during community surges when reporting of PCR results can be delayed. However, there are few published field studies evaluating IC testing strategies in this long-term care setting. METHODS: In fall and winter of 2020, the Marin Health and Human Services Department implemented thrice-weekly IC mass testing by nonlaboratory workers in outbreaks that occurred in 2 LTCFs, in addition to then-standard semiweekly PCR testing. The IC test performance was characterized using same-day PCR specimens as reference standard. Cumulative incidence and duration of transmission for the 2 IC intervention facility outbreaks were compared with 6 reference LTCFs that used weekly to semiweekly PCR alone during an outbreak response. RESULTS: Of 123 same-day test pairs, IC test sensitivity and specificity were 75% (95% confidence interval [CI], 48%-93%) and 100% (95% CI, 97%-100%), respectively. The median duration of outbreak transmission was 19.5 days in the 2 intervention sites and 28 days in the reference facilities (P = .40). Cumulative incidence for the outbreaks among LTCF residents was 41% in the intervention facilities versus 52% in the reference facilities (P = .04, Fisher 2-sided exact). CONCLUSIONS: Thrice-weekly mass IC testing as used by nonlaboratory personnel can be highly practical and effective for COVID-19 outbreak mitigation in the LTCF setting.

Resident Factors Associated with Breakthrough SARS-CoV-2 Infections
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Montoya A, Wen K, Travers JL, Rivera-Hernandez M, White E, Mor V, et al.
Journal of the American Medical Directors Association
ObjectiveTo examine incidence of and resident characteristics associated with BTIs and severe illness among residents with two mRNA vaccinations.

Predictors of COVID-19 Outcomes Among Residents of Swedish Long-Term Care Facilities-A Nationwide Study of the Year 2020.
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Najar J, Broms R, Nistotskaya M, Dahlström C.
Am J Geriatr Psychiatry. 2023 Feb 8;S1064-7481(23)00161-6.
OBJECTIVE: We analyzed predictors of SARS-CoV-2 infection and COVID-19 death among residents of long-term care facilities (LTCFs) in Sweden for the pandemic year 2020 and its different waves. METHODS: The study included 99% of Swedish LTCF residents (N = 82,488). Information on COVID-19 outcomes, sociodemographic factors, and comorbidities were obtained from Swedish registers. Fully adjusted Cox regression models were used to analyze predictors of COVID-19 infection and death. RESULTS: For the entirety of 2020, age, male sex, dementia, cardiovascular-, lung-, and kidney disease, hypertension, and diabetes mellitus were predictors of COVID-19 infection and death. During 2020 and the two waves, dementia remained the strongest predictor of COVID-19 outcomes, with the strongest effect on death being among those aged 65-75 years. CONCLUSION: Dementia emerged as a consistent and potent predictor of COVID-19 death among Swedish residents of LTCFs in 2020. These results provide important information on predictors associated with negative COVID-19 outcomes.

Evolution of the incidence of COVID-19 during the first five waves in residents and professionals of nursing homes in Normandy, France.
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Thibon P, Grenier C, Erouart S, Borgey F, Le Hello S, Martel M.
Aging Clin Exp Res. 2023 Mar 2;1–4.
BACKGROUND: Older adults living in nursing homes (NH) paid a heavy price to the COVID-19 pandemic, despite early and often drastic prevention measures. AIMS: To study the characteristics and the impact of the pandemic on NH residents and professionals over 2 years. METHODS: Cross-sectional study of COVID-19 clusters among residents and/or professionals in NH, from March 2020 to February 2022, in Normandy, France. We used data from the French mandatory reporting system, and cross-correlation analysis. RESULTS: The weekly proportion of NH with clusters was strongly correlated with population incidence (r > 0.70). Attack rates among residents and professionals were significantly lower in period 2 (vaccination rate in residents ≥ 50%) compared with periods 1 (waves 1 and 2) and 3 (Omicron variant ≥ 50%). Among residents, mortality and case fatality rates decreased drastically during periods 2 and 3. CONCLUSION: Our study provides figures on the evolution of the pandemic in NH.

Impact on Health Care Workers

A scoping review of the literature addressing psychological well-being of racial and ethnic minority nurses during the COVID-19 pandemic.
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Abrahim HL, Holman EA.
Nurs Outlook. 2022 Nov 17;101899.
BACKGROUND: The COVID-19 pandemic has affected the well-being of nursing professionals, especially long-term and acute care nurses, many of whom are nurses of color. PURPOSE: We examine the evidence and gaps in the literature addressing psychological well-being of racial/ethnic minority RN’s in the U.S. during COVID-19. METHODS: We searched eight databases during March 2022 and used Joanna Briggs’ Scoping Review Methodology and PRISMA-ScR reporting standards. DISCUSSION: Seven studies met inclusion criteria. Two exclusively examined nurses; five reported findings from heterogeneous samples of health care workers. No significant racial/ethnic differences in well-being were reported among health care workers. Among nurses, if a difference existed, White nurses reported decreased psychological well-being relative to ethnic and racial minority nurses. Two studies report modest racial/ethnic differences in nurses’ psychological well-being. CONCLUSION: Significant gaps in the literature remain; future studies should analyze groups of health care workers separately, clearly identify racial and ethnic groups, and examine the role of respondents’ work setting.