Position Statement for Mental Health Care in Long-Term Care During COVID-19

Optimizing Older Adult Mental Health in Support of Healthy Ageing: A Pluralistic Framework to Inform Transformative Change across Community and Healthcare Domains

This paper describes a pluralistic framework to inform transformative change across community and healthcare domains to optimize the mental health of older adults in support of healthy ageing. An extensive review and analysis of the literature informed the creation of a framework that contextualizes the priority areas of the WHO Decade of Health Ageing (ageism, age-friendly environments, long-term care, and integrated care) with respect to older adult mental health. The framework additionally identifies barriers, facilitators, and strategies for action at macro (social/system), meso (services/supports), and micro (older adults) levels of influence. This conceptual (analytical) framework is intended as a tool to inform planning and decision-making across policy, practice, education and training, research, and knowledge mobilization arenas. The framework described in this paper can be used by countries around the globe to build evidence, set priorities, and scale up promising practices (both nationally and sub-nationally) to optimize the mental health and healthy ageing trajectories of older adults as a population.

Timely Yet Long Overdue: Canadian Standards for Long-Term Care Homes

The impact of the COVID-19 pandemic highlighted systemic problems in Canadian long-term care (LTC). While high mortality rates in LTC received significant attention, the pandemic also took an enormous toll on mental health of LTC residents, where mental health conditions, including cognitive disorders, are already much higher than in other community settings. The pandemic resulted in a renewed interest in improving quality of care in LTC and led to the recent development of several National Standards of Canada. The newly available Standards set ambitious targets, but many of the standards are practical and essential to moving beyond a focus on safety and physical needs in LTC and towards one that supports residents as whole persons. While the standards support good mental health indirectly, there is a need to recognize mental health in these settings as a fundamental human right and essential to quality of life, and for this to be reflected in ongoing and future standards development. Ensuring existing and forthcoming National Standards are meaningfully implemented, in whole or in part, will require extensive efforts at multiple levels. The guidance provided by Canadian Standards will shape this transformative process, necessitating aligned federal and provincial investments and policies, and stakeholder engagement to bring about the envisioned high-quality care.

Loneliness and depression among community-dwelling older adults in China during the COVID-19 epidemic: The mediating role of social support

The psychological condition of community-dwelling older adults is a global concern under coronavirus disease 2019. Loneliness is the key risk factor for depression among community-dwelling older adults. This study aims to explore the role of social support as a mediating factor in the relationship between depression and loneliness among community-dwelling older adults. We conducted a cross-sectional study in Chenzhou, Hunan Province, China, from June to December 2021. The sample consisted of 570 community-dwelling adults aged over 60 years. Data were collected through a general information questionnaire, the Social Support Rating Scale, the University of California at Los Angeles Loneliness Scale, and the Center for Epidemiological Survey, Depression Scale. Statistical Package for the Social Sciences PROCESS macro was used to examine the mediating effect of social support between loneliness and depression. This study found that depression was negatively associated with social support (r = -0.381, P < .001), but it was positively correlated with loneliness (r = 0.403, P < .001); loneliness was a predictor of depression (B = 0.333, P < .001). In addition, social support significantly mediated the relationship between loneliness and depression, with an indirect effect of 0.239 (95% Bootstrap CI -0.264 to -0.510), the overall effect value for depression was 0.572, accounting for 56.3% of the total variance in depression within this model. In conclusion, the findings suggest that social support plays a mediating role between depression and loneliness in older adults. This implies that interventions aimed at reducing loneliness and enhancing social support have the potential to alleviate depressive symptoms among this population. By addressing these factors, healthcare professionals and caregivers can promote the mental well-being of older adults and contribute to improved overall quality of life.

Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19

Background

Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use.

Objective

Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic.

Methods

Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods.

Results

Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01).

Conclusion

Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.

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.

This was my Crimean War: COVID-19 Experiences of Nursing Home Leaders

Objective

To describe professional and personal experiences of nursing home care leaders during early waves of the COVID-19 pandemic.

Design

Qualitative interpretive description.

Setting and Participants

Eight sites across 2 Canadian provinces. Sites varied by COVID-19 status (low or high), size (<120 or ≥120 beds), and ownership model (for-profit or not-for-profit). We recruited 21 leaders as participants: 14 managers and 7 directors of care.

Methods

Remote Zoom-assisted semi-structured interviews conducted from January to April 2021. Concurrent data generation and inductive content analysis occurred throughout. Sampling ceased once we reached sufficient analytic variation and richness to answer research questions.

Results

Most participants were female, ≥50 years of age, and born in Canada. We found 4 major themes. (1) Responsibility to protect: Extreme precautions were employed to protect residents, staff, and leaders’ families. Leaders experienced profound distress when COVID-19 infiltrated their care homes. (2) Overwhelming workloads: Changing public health orders and redeployment to pandemic-related activities caused administrative chaos. Leaders worked double shifts to cope with pandemic demands and maintain their usual work. (3) Mental and emotional toll: All participants reported symptoms of anxiety, depression, and insomnia, leading to ongoing exhaustion. Shifting staff focus from caring to custodial enforcement of isolation caused considerable distress, guilt, and grief. (4) Moving forward: The pandemic spotlighted deficiencies in the nursing home context that lead to inadequate quality of resident care and staff burnout. Some leaders indicated their pandemic experience signaled an unanticipated end to their careers.

Conclusions and Implications

Nursing home leaders faced mental distress and inordinate workloads during the pandemic. This is an urgent call for systemic change to improve working conditions for leaders and quality of care and quality of life for residents. Nursing home leaders are at increased risk of burnout, which must be addressed to mitigate attrition in the sector.