An Integrative Framework to Guide Social Engagement Interventions and Technology Design for Persons With Mild Cognitive Impairment.

Social isolation and loneliness in older adults are associated with poor health outcomes and have been linked to an increased risk of cognitive impairment and incident dementia. Social engagement has been identified as a key factor in promoting positive health behaviors and quality of life and preventing social isolation and loneliness. Studies involving cognitively healthy older adults have shown the protective effects of both in-person and technology-based social engagement. However, the benefits of social engagement for people who are already at-risk of developing dementia, namely those with mild cognitive impairment (MCI), have yet to be elucidated. We present a narrative review of the literature, summarizing the research on social engagement in MCI. First, we identified social networks (quality, size, frequency, and closeness) and social activities (frequency, format, purpose, type, and content) as two overarching dimensions of an integrative framework for social engagement derived from literature examining typical cognitive aging. We then used this framework as a lens to examine studies of social engagement in MCI to explore (i) the relationship between in-person and technology-based social engagement and cognitive, emotional, and physical health, and (ii) interventions that target social engagement including technology-based approaches. Overall, we found that persons with MCI (PwMCI) may have different levels of social engagement than those experiencing typical cognitive aging. Moreover, in-person social engagement can have a positive impact on cognitive, emotional, and physical health for PwMCI. With respect to activity and network dimensions in our framework, we found that cognitive health has been more widely examined in PwMCI relative to physical and emotional health. Very few intervention studies have targeted social engagement, but both in-person and technology-based interventions appear to have promising health and well-being outcomes. Our multidimensional framework of social engagement provides guidance for research on characterizing the protective benefits of social engagement for PwMCI and informs the development of novel interventions including technology-based approaches.

Ethical and regulatory implications of the COVID-19 pandemic for the medical devices industry and its representatives.

The development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be feasible. Given the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling.

PRISM 2.0: A Technology System to Support Resource Access and Social and Cognitive Engagement

Social isolation and lack of engagement are common among older adults and present a risk for emotional, physical and cognitive decline. Technology offers the potential of remediating these risks and enhancing opportunities for connectivity. In this paper we present an overview of the PRISM 2.0 multi-site RCT, which evaluated a simple to use Personalized Reminder Information and Social Management System (PRISM) among a sample of two hundred and forty-eight adults age 65+ in diverse contexts (Rural Locations, Assisted Living Communities and Senior Housing). PRISM 2.0 is a tablet-based system, intended to provide support for access to resources and information, new learning, social and cognitive engagement, and memory. We describe the goals and content of PRISM, the user-centered design process, and measurement strategies. We also discuss the challenges of conducting the trial during the COVID-19 pandemic and the strategies used to adapt the trial protocol within the three contexts.

PRISM 2.0: Technical Challenges

PRISM 2.0 was designed to run on Android tablets and made use of both customized apps that relied on Google’s browser and e-mail functionality as well as commercial apps, such as Microsoft’s Skype for videoconferencing. We also made use of functionality provided by our partner AT&T, such as their sim cards to provide cell-based internet connectivity to participants who did not have access to Wi-Fi internet services to their home (cable, DSL), as well as tablet management software to deploy updates. The Miami site provided central management and tablet deployment and redeployment services and support as well as coordinating locally provided tech support at the three sites. We discuss some of the technical challenges associated with these arrangements. We focus on how changes to the operating system broke some of our apps necessitating substitution of other apps and provision of new training, and how Covid-19 affected technical support.

Starts and Stops: Strategizing an Age-Friendly University Commitment During a Pandemic

The Global Network of Age-Friendly Universities seeks to enhance age-inclusivity and engagement in higher education, but delivering age-friendly programming became very challenging during the COVID-19 pandemic. We examine how two land-grant universities adapted to the pandemic and draw some lessons from those experiences that may be useful for other universities seeking to implement or resume the AFU programming. The two main responses were to either pause many of the age-friendly initiatives at the university or adapt to virtual or online delivery platforms. To ensure the health and safety of older adults, colleges and universities paused many age-friendly initiatives such as intergenerational service-learning, technological assistance to older adults, and influenza vaccinations. Other programs continued but in a modified delivery format. Examples include: converting a face-to-face balance-training program to telehealth delivery;transitioning visitation programs to pen pal communication;and replacing face-to-face workshops offered by Extension Services with webinar delivery. Despite these challenges, we conclude that moving to virtual platforms and other methods of delivery, including conventional mail, has in some cases increased access for many older adults and became a lifeline during a time of social isolation for many older adults. Taken together, these experiences highlight the need for age-friendly universities to have contingency plans to ensure continuation of age-friendly programming in the event of pandemics or disasters. Finally, the pause in programming creates opportunities to re-launch or re-organize those initiatives in accord with federal and state safety guidelines.

Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines.

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

Revisiting the equity debate in COVID-19: ICU is no panacea.

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic context.In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning.