Implications of COVID-19 on the Loneliness of Older Adults in Residential Care Homes

Understanding the social and leisure needs of lonely and socially isolated older adults living in residential care: a qualitative study

Objectives: Rates of loneliness and social isolation increase following the transition to residential care and are associated with poor health outcomes. One way to mitigate these experiences is through meaningful recreation, however, there is research to suggest that currently available programming does not meet the needs of lonely and socially isolated residents. Therefore, the objectives of the current study were to investigate: (1) the lived experience of loneliness and social isolation in residential care, (2) engagement and use of available resources by these residents, and (3) insights as to how programming can further address their needs.Methods: Qualitative interviews were conducted with ten staff members and 14 residents. Interviews were transcribed and analysed using thematic analysis.Results: Three themes emerged from the data: (1) Feelings of loneliness and social isolation (subthemes: loneliness and social isolation differ, contributors, and coping strategies), (2) Recreation and social participation (subthemes: program engagement and barriers to participation), and (3) Supporting residents' needs (subthemes: suggestions for meaningful recreation and resources).Conclusion: Loneliness and social isolation are idiographic experiences. Contributors to loneliness and social isolation are also reported as barriers to attending programming. Recommendations are made, many of which rely on greater staffing resources and psychoeducation.

"We are still tired": staff and administrators' experiences during the COVID-19 pandemic within California residential care facilities for older adults

BACKGROUND

Extensive research has been conducted on the impacts of the COVID-19 pandemic on long-term care workers in specialized care facilities. However, little is known about the impacts faced by facilities that provide generalized long-term support and care, such as residential care facilities for older adults (RCFs). This study describes the challenges experienced by staff and administrators of RCFs during the COVID-19 pandemic.

METHODS

An electronic questionnaire collecting data using both closed- and open-ended questions on staff experiences was sent to 5,721 unique RCF administrator emails within the state of California between June-December 2021. Email addresses were obtained from the public database of RCFs available through the California Health and Human Services Open Data Portal. Descriptive statistics were calculated on quantitative data regarding staff preparedness training, access to resources, and administrators' confidence in meeting recommended guidelines during the pandemic. Inductive thematic analysis was conducted on qualitative data regarding the confidence levels in meeting pandemic guidelines and challenges faced related to staff stress and morale.

RESULTS

A total of 150 RCF administrators across California (response rate of 2.6%) completed the survey. Over three-fourths of respondents indicated their facilities had a designated staff member to train other staff members on emergency preparedness plans and the most frequently used resources during the COVID-19 pandemic were the Department of Social Services Community Care Licensing Division (88.7%), the county health department (86.7%), and the Centers for Disease Control and Prevention (80.7%). Administrators felt least confident in their facilities' ability to maintain adequate staffing (52.0%), communication with nearby hospitals (62.1%) and communication with state and local public health officials (69.8%) during the pandemic. Three central themes emerged from the thematic analysis on staff stress and morale: (1) physical safety, mental and emotional impact of the COVID-19 pandemic; (2) staffing issues; and (3) challenges with guidelines in managing the ongoing pandemic.

CONCLUSIONS

Findings from this research study can be used to actively target training resources for facility administrators and staff that have been identified as most frequently used and relevant for emergency preparedness in these understudied facilities. Additionally, developing a better understanding of the staffing stress and morale difficulties in RCFs can provide insight on how policymakers can assist these critical facilities in better preparing for future crises.

Community engagement and loneliness in older adults in China: mediation effects of social support in the wake of COVID-19

Introduction

Loneliness is a key indicator of well-being in older adults. Drawing from the ecological model of aging, the active aging perspective, and the convoy model of social relations, this study investigates the extent community engagement influences loneliness and whether the relationship is mediated by social support during the COVID-19 pandemic.

Methods

Data was collected from 1,067 retired older adults in a cross-sectional design in Chengdu, China in 2022. Structural equation modeling was conducted to examine the direct and indirect effects of community engagement on loneliness through the hypothesized mediator of social support.

Results

The results show community engagement was positively associated with social support (β = 0.26, p < 0.001) and social support was negatively related to loneliness (β = -0.41, p < 0.001). Social support fully mediated the relationship between community engagement and loneliness. Additionally, community engagement had an indirect effect on loneliness via social support (β = -0.11, p < 0.001).

Discussion

The findings from the moderation analysis suggests community engagement and social support are likely to have large effects on loneliness for older adults over the age of 70 and who have low educational attainment. The findings suggest community engagement could be an important factor for improving social support and reducing loneliness amongst retired, older adults in China, especially in the wake of the COVID-19 pandemic where millions of individuals were isolated for extended periods of time.

Consequences of contact restrictions for long-term care residents during the first months of COVID-19 pandemic: a scoping review

During the early stages of the COVID-19 pandemic, stringent measures were implemented in most countries to limit social contact between residents of long-term care facilities (LTCF) and visitors. The objective of this scoping review was to identify and map evidence of direct and indirect consequences of contact restrictions, guided by three conceptual perspectives: (1) stress and learned helplessness (i.e., failure to use coping behaviors even when they are available and actionalble); (2) social contact loss; and (3) 'total institution' (i.e., a facility operates following a fixed plan due to spelled-out rules and norms, controlled by institutional representatives). We used the framework for conducting a scoping review by Arksey and O'Malley; included were peer-reviewed manuscripts reporting on the outcomes of contact restrictions from the beginning of the pandemic until the end of 2020. After removing duplicates, 6,656 records were screened and 62 manuscripts included. Results pertaining to the stress and learned helplessness perspective primarily focused on depressive symptoms, showing substantial increases compared to the pre-pandemic period. Studies examining cognitive and functional decline, as well as non-COVID-19 related mortality, were limited in number and presented mixed findings. The majority of study outcomes related to the social contact loss perspective focused on loneliness, but the study designs did not adequately allow for comparisons with the pre-pandemic status. The evidence concerning outcomes related to the 'total Institution' perspective was inconclusive. Although detrimental effects of social isolation in the long-term care context found support particularly in the negative affect domain, other outcome areas did not allow for definitive conclusions due to considerable variations in findings and, in some cases, insufficient statistical power.

Loneliness in nursing homes: A qualitative meta-synthesis of older people's experiences

BACKGROUND

Older people in the nursing home environment are much less mobile and capable of taking care of themselves as they age, and most of them face the plight of loneliness, which seriously affects the quality of life of older people in their later years.

AIMS

A systematic review and synthesis of older people's experiences of loneliness in nursing homes.

DESIGN

Following ENTREQ, do a systematic evaluation and synthesis of qualitative investigations.

METHODS

A search of PubMed, Cochrane Library, Web of Science, Embase, the Chinese biomedical literature service system, the China National Knowledge Infrastructure, the Wanfang Database and the Wipu Database for qualitative studies of older people's experiences of loneliness in nursing homes was conducted with a search time frame of March 2023. Evaluation of the quality of the literature using the Joanna Briggs Institute's Australian Centre for Evidence-Based Health Care Quality Assessment Criteria for Qualitative Research, And the data were synthesised using Thomas and Harden's method of thematic and content analysis.

RESULTS

A total of 13 papers were included, and 36 research findings were distilled and integrated into three themes: causes of loneliness; feelings of loneliness; coping with loneliness; and seven sub-themes: aging and loss; environmental transformation; loneliness is a pain; loneliness is a choice; participation; strengthening social ties; and diverting attention.

CONCLUSIONS

Older people in nursing homes face varying degrees of loneliness, which is a subjective feeling influenced by the interplay between personal awareness and the external environment, so future care interventions should be developed in a comprehensive manner, taking into account the characteristics of the older people themselves and their external environment.

NO PATIENT OR PUBLIC CONTRIBUTION

This study is a meta-synthesis and does not require relevant contributions from patients or the public.

Loneliness at end-of-life: A scoping review

AIMS AND OBJECTIVES

To map and synthesise the literature on loneliness at end-of-life and identify key knowledge gaps in loneliness research.

BACKGROUND

Declined health conditions, reduced social engagement, loss of social roles, and fear of death may lead to loneliness at end-of-life. However, systematic information about loneliness at end-of-life is scant.

METHODS

This scoping review followed the methodology proposed by Arksey and O'Malley. Nine electronic databases were searched from January 2001 to July 2022. Studies about loneliness at end-of-life were included. Two review authors independently screened and selected relevant studies and performed the data charting. The PAGER framework was employed to collate, summarise and report the results. The PRISMA-ScR checklist was included.

RESULTS

A total of 23 studies were included in this review (12 qualitative, 10 quantitative, and one mixed-methods design). There was not reliable data about the prevalence of loneliness among adults at end-of-life internationally. Three or 20-item UCLA loneliness scale was frequently used to measure loneliness. Factors predisposed adults at end-of-life to loneliness included passive and active withdrawal from social networks, inability to share emotions and to be understood, and inadequate support on spirituality. Four strategies were identified to alleviate loneliness, yet none have been substantiated in clinical trials. Interventions facilitating spirituality, social interactions and connectedness seem effective in alleviating loneliness.

CONCLUSIONS

This is the first scoping review on loneliness at end-of-life, synthesising evidence from qualitative, quantitative, and mixed-methods studies. Loneliness among adults at end-of-life is under-investigated and there is a prominent need to address existential loneliness at end-of-life.

RELEVANCE TO CLINICAL PRACTICE

All nurses should proactively assess loneliness or perceived social isolation for clients with life-limiting conditions, regardless of social networks. Collaborative efforts (e.g., medical-social collaborations) to promote self-worthiness, social engagement and connectedness with significant others and social networks are needed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

What are the holistic care impacts among individuals living through the COVID-19 pandemic in residential or community care settings? An integrative systematic review

INTRODUCTION

To critically synthesise evidence in relation to the holistic care impacts (physical, psychological, social, spiritual, and environmental well-being) among individuals living in residential aged care facilities (RACFs) with restrictions during the COVID-19 pandemic.

METHODS

An integrative systematic review followed a pre-registered protocol and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guidelines. Electronic databases were searched from inception to June 2022. Qualitative, quantitative, and mixed methods studies were included. All articles were double screened according to a pre-determined eligibility criterion. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted.

RESULTS

18 studies were included. The impact of restrictive practices and periods of lockdown impacted older people on all levels of individual quality-of-life. With or without COVID-19, residents experienced functional decline and many experienced malnutrition, increased incontinence, increased pain, and poorer general health and significant psychological distress. Depression increased with reduced social contact, as did anxiety and loneliness. Some residents spoke of suicidal ideation.

CONCLUSION

It is highly plausible that further outbreaks may prompt knee-jerk reactions from public health departments and governing bodies to continue to restrict and lockdown facilities. Public health COVID-19 outbreak policy for aged care across the globe will need to consider the benefits verses risk debate given the findings uncovered in this review. These findings showed that it is vital that policy considers quality-of-life domains not solely survival rates.

The Buffering Role of Self-compassion in the Association Between Loneliness with Depressive Symptoms: A Cross-Sectional Survey Study Among Older Adults Living in Residential Care Homes During COVID-19

The coronavirus disease 2019 (COVID-19) pandemic is an ongoing geriatric health emergency with a substantial increase in the prevalence of medical and mental health issues, particularly among older adults living in residential care homes. The knowledge of the risk and protective factors related to the psychological impact of the COVID-19 pandemic on older adults living in residential care homes is based on limited data. This study aimed to investigate whether loneliness mediates the effects of fear generated by a pandemic on depression. Additionally, we hypothesized that self-compassion moderates the effect of loneliness on depression. A sample comprised 323 older adults (females: n = 141, males: n = 182) with mean age = 74.98 years (standard deviation = 6.59, age 65-90) completed a survey comprising the Fear of COVID-19 Scale, De Jung Gierveld Loneliness Scale, the nine-item Patient Health Questionnaire, and the Self-compassion Scale. The results revealed that the total effect of fear on depression was statistically significant, with a medium effect size (Cohen's f 2 = .14) and this association was partially mediated by loneliness (β = .11, SE = .04, P < .001, t = 2.91, 95% CI 0.04-0.19). The self-compassion also moderated the loneliness effect on depression. The findings of this study support COVID-19 evidence, indicating that a greater level of fear generated by the pandemic is linked to depression and loneliness. The findings support the notion that self-compassion mitigates the adverse effects of stressful events in older adults. Customized self-compassion programs may be effective loneliness-mitigating interventions for older adults living in residential care homes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-023-01014-0.

The perceived relationship quality with migrant domestic workers is correlated with a lower level of loneliness among community-dwelling older adults: A cross-sectional study

PURPOSE

To explore older adults' perceived relationship quality with migrant domestic workers (MDWs) and examine the correlation between older adult/MDW (O-M) relationship quality and loneliness of community-dwelling older adults.

MATERIALS AND METHODS

In this cross-sectional study, older adults living with MDWs were conveniently recruited from neighbourhood elderly centers in Hong Kong. Loneliness and O-M relationship quality were assessed by the 6-item De Jong Gierveld Loneliness Scale and the mutuality scale, respectively. Older adults' demographic and functional characteristics, and MDW's nationality, spoken language and years of service in the dyad were also collected. Hierarchical multiple regression analyses were conducted to examine the contributions of 1) demographic variables and functional status, 2) MDW characteristics, 3) perceived social network and 4) perceived O-M relationship quality on loneliness.

RESULTS

The 178 participants [mean age 83.44 (SD 7.05 years); 155 (87.1%) women and 23 men (22.9%)] were socially lonely (1.07 ± 1.15) and close to being lonely overall (1.90 ± 1.68), and emotionally (0.84 ± 0.97). The mean O-M relationship quality was poor (1.42 ± 0.79), which was significantly correlated with overall (β= -0.33, 95% CI: -0.65 to -0.01, P value = 0.045), and social (β= -0.24, 95% CI: -0.46 to -0.01, P value = 0.04) loneliness, but not significantly correlated to emotional loneliness.

CONCLUSION

Better perceived O-M relationship quality is correlated with a lower level of loneliness among older adults. Strategies to improve O-M relationship quality may alleviate loneliness among older adults.

The Impacts of the COVID-19 Pandemic on Hong Kong Nursing Students' Mental Health and Quality of Life

Evidence shows that university students, especially healthcare students, experienced considerable health impacts during COVID-19. This study examined Hong Kong general nursing students' mental health and quality of life during the COVID-19 pandemic. An online questionnaire composed of personal demographics, the Fear of COVID-19 scale (FCV-19S), the Depression Anxiety Stress Scale short version (DASS21), and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) was used for data collection in early 2021. Among 380 respondents, 170 (45%) did not attend clinical practicum during the pandemic. Students who did not participate in clinical training scored lower in FCV-19S but higher in WHOQOL-BREF than those who participated (p = 0.001 or p < 0.001). FCV-19S and WHOQOL-BREF were negatively correlated (r = -0.623 to -0.446, p < 0.001). Slight negative correlations were found between the FCV-19S and DASS-21 scores. Although there were no significant differences in DASS21 (p = 0.294-0.931) between these two student groups, there was a considerably high prevalence rate of depression (57.1%), anxiety (47.6%), and stress (39.5%). Hong Kong nursing students, especially those who attended clinical practicum during the pandemic, experienced substantial emotional and quality of life implications. Local universities are recommended to organize appropriate interventions to prepare and support nursing students' wellbeing and health in coping with future disasters.

A 'good dyadic relationship' between older couples with one having mild cognitive impairment: a Q-methodology

BACKGROUND

Cognitive impairment gradually brings changes to the relationship between older married couples. Therefore, this study aimed to understand the individual viewpoints of couple dyads on the important attributes of a 'good dyadic relationship' in the context of mild cognitive impairment (MCI), and to explore if the congruencies and discrepancies in their perceptions related to the quality and closeness of their relationship and well-being.

METHODS

Q-methodology was used to reveal the perceptions of a 'good dyadic relationship' among couples with one having MCI. The participating couples were separated in two rooms and independently ranked 18 relationship attributes from least to most important on a 7-point Q-sort response grid. All participants also completed a post-sort interview and surveys to assess their psychological well-being and closeness. Q-sorts were analyzed using by-person factor analysis.

RESULTS

Forty people with MCI and forty spousal partners completed the Q-sort. Three viewpoints, accounting for 48% of the total variance, were identified and were labeled 'Provider,' 'Problem-solver,' and 'Partner.' Different viewpoints of a 'good dyadic relationship' primarily varied by perceived importance of commitment, dedication, tolerance, and personal space. Despite these differences, there was wide consensus that respecting each other and cherishing the current moment are two universally salient attributes of a good relationship across all viewpoints. Couples with discrepant views scored significantly higher on perceptions of the quality of the relationship and closeness with the partner.

CONCLUSIONS

This study advances the theoretical understanding of the dyadic relationship between couples with one having MCI, from both perspectives. MCI is a state in which couples can openly discuss their expectations. The findings provide practitioners with insights to work with couples experiencing MCI.

Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update

Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine "booster" doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.

Ethical challenges experienced by care home staff during COVID-19 pandemic

BACKGROUND

Care homes have been disproportionately affected during the COVID-19 pandemic. Practical challenges of enacting infection control measures in care home settings have been widely reported, but little is known about the ethical concerns of care home staff during the implementation of such measures. .

OBJECTIVES

To understand the ethical challenges perceived by care home staff during the early months of the COVID-19 pandemic.

RESEARCH DESIGN

An exploratory qualitative study.

PARTICIPANTS AND RESEARCH CONTEXT

A purposive sample of 15 care home staff in different roles and ranks in Hong Kong was recruited to take part in semi-structured interviews between June and August 2020.

ETHICAL CONSIDERATIONS

Ethical approval for this study was obtained. Participation was voluntary and anonymous. Participants had the right to withdraw from the study at any time without reprisal.

FINDINGS

Three themes were identified: unclear legitimacy regarding infection control measures, limited autonomy in choices over infection control measures and inevitable harms to residents' well-being. While the participants expected that they would have legitimated power to implement infection control measures, they were resistant when their right to self-determination of testing and vaccination was infringed. They also felt trapped between ethical duties to protect care home residents from infection risk and the anticipated detrimental effects of infection control measures.

CONCLUSIONS

The findings of this study reveal tensions among the ethical obligations of care home staff in response to a public health emergency. They highlight the importance of strengthening ethical sensitivity and ethical leadership in identifying and resolving the challenges of pandemic responses.

Caring for Homebound Veterans during COVID-19 in the U.S. Department of Veterans Affairs Medical Foster Home Program

The onset of the COVID-19 pandemic made older, homebound adults with multiple chronic conditions increasingly vulnerable to contracting the virus. The United States (US) Department of Veterans Affairs (VA) Medical Foster Home (MFH) program cares for such medically complex veterans residing in the private homes of non-VA caregivers rather than institutional care settings like nursing homes. In this qualitative descriptive study, we assessed adaptations to delivering safe and effective health care during the early stages of the pandemic for veterans living in rural MFHs. From December 2020 to February 2021, we interviewed 37 VA MFH care providers by phone at 16 rural MFH programs across the US, including caregivers, program coordinators, and VA health care providers. Using both inductive and deductive approaches to thematic analysis, we identified themes reflecting adaptations to caring for rural MFH veterans, including care providers rapidly increased communication and education to MFH caregivers while prioritizing veteran safety. Telehealth visits also increased, MFH veterans were prioritized for in-home COVID-19 vaccinations, and strategies were applied to mitigate the social isolation of veterans and caregivers. The study findings illustrate the importance of clear, regular communication and intentional care coordination to ensure high-quality care for vulnerable, homebound populations during crises like the COVID-19 pandemic.

The Health Impacts and Life Challenges Caused by the COVID-19 Pandemic on Hong Kong Chinese Women

The COVID-19 pandemic has caused a massive global crisis. The adverse impacts on Asian women, including Hong Kong Chinese women, have been considerable. The pressure on Hong Kong women is immense due to cultural, social, familial, and personal responsibilities. This study aims to illustrate the health impacts and life challenges for Hong Kong Chinese Women during the pandemic. An interpretive phenomenological approach with purposive sampling was adopted. Semi-structured, face-to-face, in-depth interviews were conducted from August 2020 to January 2021. Twenty-five women participated in the interviews, lasting an average of 48 min. The transcribed interviews were analyzed using interpretative phenomenological analysis. The core theme identified was “Perceived family caregiving as paramount self-obligation in times of the pandemic”, in the context of the role of daughter, wife, or mother (or a combination). Three interconnected themes have been identified in individual, relational, and external contexts: deterioration of personal health, unfavorable to family relationships, and adaptation to social challenges. Eight subthemes have emerged related to health impacts and life challenges. The pandemic has increased women’s perception of their caregiver roles in the family, but it has diminished their quality of life. The promotion of strategies and activities that could enhance women’s physical, psychological, emotional and social quality of life is recommended.

Wrist accelerometry for monitoring dementia agitation behaviour in clinical settings: A scoping review

Agitated behaviour among elderly people with dementia is a challenge in clinical management. Wrist accelerometry could be a versatile tool for making objective, quantitative, and long-term assessments. The objective of this review was to summarise the clinical application of wrist accelerometry to agitation assessments and ways of analysing the data. Two authors independently searched the electronic databases CINAHL, PubMed, PsycInfo, EMBASE, and Web of Science. Nine (n = 9) articles were eligible for a review. Our review found a significant association between the activity levels (frequency and entropy) measured by accelerometers and the benchmark instrument of agitated behaviour. However, the performance of wrist accelerometry in identifying the occurrence of agitation episodes was unsatisfactory. Elderly people with dementia have also been monitored in existing studies by investigating the at-risk time for their agitation episodes (daytime and evening). Consideration may be given in future studies on wrist accelerometry to unifying the parameters of interest and the cut-off and measurement periods, and to using a sampling window to standardise the protocol for assessing agitated behaviour through wrist accelerometry.