Risk of Death in Nursing Home Residents After COVID-19 Vaccination.

OBJECTIVES: In the first months of 2021, the Dutch COVID-19 vaccination campaign was disturbed by reports of death in Norwegian nursing homes (NHs) after vaccination. Reports predominantly concerned persons >65 years of age with 1 or more comorbidities. Also, in the Netherlands adverse events were reported after COVID-19 vaccination in this vulnerable group. Yet, it was unclear whether a causal link between vaccination and death existed. Therefore, we investigated the risk of death after COVID-19 vaccination in Dutch NH residents compared with the risk of death in NH residents prior to the COVID-19 pandemic. DESIGN: Population-based longitudinal cohort study with electronic health record data. SETTING AND PARTICIPANTS: We studied Dutch NH residents from 73 NHs who received 1 or 2 COVID-19 vaccination(s) between January 13 and April 16, 2021 (n = 21,762). As a historical comparison group, we included Dutch NH residents who were registered in the same period in 2019 (n = 27,591). METHODS: Data on vaccination status, age, gender, type of care, comorbidities, and date of NH entry and (if applicable) discharge or date of death were extracted from electronic health records. Risk of death after 30 days was evaluated and compared between vaccinated residents and historical comparison residents with Kaplan-Meier and Cox regression analyses. Regression analyses were adjusted for age, gender, comorbidities, and length of stay. RESULTS: Risk of death in NH residents after one COVID-19 vaccination (regardless of whether a second vaccination was given) was decreased compared with historical comparison residents from 2019 (adjusted HR 0.77, 95% CI 0.69-0.86). The risk of death further decreased after 2 vaccinations compared with the historical comparison group (adjusted HR 0.57, 95% CI 0.50-0.64). CONCLUSIONS AND IMPLICATIONS: We found no indication that risk of death in NH residents is increased after COVID-19 vaccination. These results indicate that COVID-19 vaccination in NH residents is safe and could reduce fear and resistance toward vaccination.

The Effects of the 2020 COVID-19 Lockdown on Mood, Behavior, and Social and Cognitive Functioning in Older Long-Term Care Residents.

OBJECTIVES: We aimed to explore the effects of the Dutch COVID-19 lockdown (March 20-May 25, 2020) on mood, behavior, and social and cognitive functioning of older residents of long-term care facilities (LTCFs) prospectively. DESIGN: Mixed methods: historically controlled longitudinal cohort study and focus groups. SETTING AND PARTICIPANTS: Residents of Dutch LTCFs. METHODS: Residents who were assessed during and prior to the lockdown were compared to residents of the same wards with 2 assessments prior to the lockdown. We used mixed models and generalized estimating equation analyses to explore differences in changes in mood, withdrawal and aggressive behavior, loneliness and conflict, and cognition and delirium. We also explored whether the effect of the lockdown differed for different subgroups. In 2 online focus groups, LTCF care professionals, ranging from care staff to physicians, reflected on their experiences of the effect of the lockdown and the cohort study results. RESULTS: The lockdown group of 298 residents was compared to the control group of 625 residents. Self-reported mood symptoms showed a slightly greater increase during the lockdown. During the first half of the lockdown, the level of conflict with other residents decreased whereas it increased in the control group. The subgroup with moderate-severe cognitive impairment showed a decrease in withdrawal during the lockdown, whereas the group with no-mild cognitive impairment showed a statistically nonsignificant relative increase. Professionals described great individual variation in the effects of the lockdown on residents. Facilities attempted to preserve the experienced positive effects, for example, by promoting tranquility in shared rooms and continuing to organize individualized ward-based activities. CONCLUSIONS AND IMPLICATIONS: We did not find clinically relevant negative effects of the lockdown on mood, behavior, and social and cognitive functioning in older residents of LTCFs at the group level. Possibly, staff mitigated the negative effects at the group level. Meanwhile, they learned lessons that they continue to apply to enhance resident well-being.

Implementing a Personalized Integrated Stepped-Care Method (STIP-Method) to Prevent and Treat Neuropsychiatric Symptoms in Persons With Dementia in Nursing Homes: Protocol for a Mixed Methods Study.

BACKGROUND: Neuropsychiatric symptoms occur frequently in many nursing home residents with dementia. Despite the availability of multidisciplinary guidelines, neuropsychiatric symptoms are often inadequately managed. Three proven effective methods for managing neuropsychiatric symptoms were integrated into a single intervention method: the STIP-Method, a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms. The STIP-Method comprises 5 phases of clinical reasoning to neuropsychiatric symptoms and 4 stepped-care interventions and is supported with a web application. OBJECTIVE: This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. METHODS: A mixed methods design within a participatory action research was used to implement the STIP-Method in 4 facilities of 2 Dutch nursing home organizations. In total, we aimed at participation of 160-200 persons with dementia and expected an intervention fidelity of 50% or more, based on earlier studies regarding implementation of effective psychosocial interventions to manage neuropsychiatric symptoms. All involved managers and professionals were trained in the principles of the STIP-Method and in using the web application. An advisory board of professionals, managers, and informal caregivers in each facility supported the implementation during 21 months, including an intermission of 6 months due to the COVID-19 pandemic. In these 6-weekly advisory board meetings, 2 researchers stimulated the members to reflect on progress of the implementation by making use of available data from patient records and the web application. Additionally, the 2 researchers invited the members to suggest how to improve the implementation. Data analysis will involve (1) analysis of facilitators and barriers to the implementation derived from verbatim text reports of advisory board meetings to better understand the implementation process; (2) analysis of patient records in accordance with multidisciplinary guidelines to neuropsychiatric symptoms: personalized, interdisciplinary, and proactive management of neuropsychiatric symptoms; (3) evaluation of the web application in terms of usability scores; (4) pre- and postimplementation analysis of patient records and the web application to evaluate the impact of the STIP-Method, such as changes in neuropsychiatric symptoms and informal caregiver burden. RESULTS: We enrolled 328 persons with dementia. Data collection started in July 2019 and ended in December 2021. The first version of this manuscript was submitted in October 2021. The first results of data analysis are expected to be published in December 2022 and final results in June 2023. CONCLUSIONS: Our study may increase understanding of facilitators and barriers to the prevention and treatment of neuropsychiatric symptoms in nursing home residents with dementia by implementing the integrated STIP-Method. The need for well-designed implementation studies is of importance to provide nursing homes with optimal tools to prevent and treat neuropsychiatric symptoms. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34550.

The Recovery After COVID-19 in Nursing Home Residents.

Introduction: Many nursing homes (NHs) are affected by COVID-19 and 30-day mortality is high. Knowledge on recovery of NH residents after COVID-19 is limited. Therefore, we investigated the trajectory in the first three months after a COVID-19 infection in NH residents. Methods: Retrospective observational cohort study of Dutch NH residents with COVID-19 between 1 September 2020 and 1 March 2021. Prevalence of COVID-19 symptoms and functioning was determined using interRAI (ADL-Hierarchy Scale (ADL-HS), Cognitive Performance Scale (CPS) and Revised Index of Social Engagement (RISE)) at four time points. Descriptive and pattern analyses were performed. Results: Eighty-six residents were included. Symptom prevalences after three months were higher than at baseline. At group level, functioning on all domains deteriorated and was followed by recovery towards baseline, except for ADL functioning. There were four trajectories; 9.3% had no deterioration. Total and partial recovery occurred in respectively 30.2% and 55.8% of the residents. In 4.7% there was no recovery. Conclusion: In 86% of NH residents surviving three months after COVID-19, occurrence of COVID-19 symptoms and deterioration in functioning was followed by recovery. COVID-19 symptoms fatigue and sleeping behaviour were significantly more prevalent, and ADL functioning was significantly lower, at three months compared to baseline.

The course of neuropsychiatric symptoms and psychotropic drug use in Dutch nursing home patients with dementia during the first wave of COVID-19: A longitudinal cohort study.

OBJECTIVE: To describe the course of neuropsychiatric symptoms in nursing home residents with dementia during the step-by-step lifting of restrictions after the first wave of the COVID-19 pandemic in the Netherlands, and to describe psychotropic drug use (PDU) throughout the whole first wave. METHODS: Longitudinal cohort study of nursing home residents with dementia. We measured neuropsychiatric symptoms using the Neuropsychiatric Inventory-Questionnaire (NPI-Q). From May to August 2020, the NPI-Q was filled in monthly. Psychotropic drug use was retrieved from the electronic prescription system, retrospectively for the months February to April and prospectively for the months May to August. RESULTS: We followed 252 residents with dementia in 19 Dutch nursing homes. Agitation was the most prevalent type of neuropsychiatric symptom at each assessment. Overall, the prevalence and severity of agitation and depression significantly decreased over time. When considering more in detail, we observed that in some residents specific neuropsychiatric symptoms resolved (resolution) while in others specific neuropsychiatric symptoms developed (incidence) during the study period. For the majority of the residents, neuropsychiatric symptoms persisted over time. Psychotropic drug use remained stable over time throughout the whole first wave of the pandemic. CONCLUSIONS: At group level, lifting the measures appeared to have beneficial effects on the prevalence and severity of agitation and depression in residents with dementia. Nevertheless, on an individual level we observed high heterogeneity in the course of neuropsychiatric symptoms over time. Despite the pressure of the pandemic and the restrictions in social contact imposed, PDU remained stable.

Implementation of a national testing policy in Dutch nursing homes during SARS-CoV-2 outbreaks.

BACKGROUND: To evaluate how a national policy of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regardless of symptoms was implemented during outbreaks in Dutch nursing homes in the second wave of the pandemic and to explore barriers and facilitators to serial testing. METHODS: We conducted a mixed-method study of nursing homes in the Netherlands with a SARS-CoV-2 outbreak after 15 September 2020. Direct care staff and management from 355 healthcare organizations were invited to participate in a digital survey. A total of 74 out of 355 (20.9%) healthcare organizations participated and provided information about 117 nursing homes. We conducted 26 in-depth interviews on the outbreak and the testing strategy used. We also conducted four focus group meetings involving managers, physicians, nurses, and certified health assistants. Recordings were transcribed and data were thematically analyzed. RESULTS: One hundred and four nursing homes (89%) tested residents regardless of their symptoms during the outbreak, and 85 nursing homes (73%) tested the staff regardless of their symptoms. However, interviews showed testing was sometimes implemented during later stages of the outbreak and was not always followed up with serial testing. Barriers to serial testing regardless of symptoms were lack of knowledge of local leaders with decisional making authority, lack of a cohort ward or skilled staff, and insufficient collaboration with laboratories or local public health services. Important facilitators to serial testing were staff willingness to undergo testing and the availability of polymerase chain reaction (PCR) tests. CONCLUSIONS: Serial testing regardless of symptoms was only partially implemented. The response rate of 21% of nursing home organizations gives a risk of selection bias. Barriers to testing need to be addressed. A national implementation policy that promotes collaboration between public health services and nursing homes and educates management and care staff is necessary.

Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic.

OBJECTIVES: To explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic. DESIGN: Qualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic. SETTING AND PARTICIPANTS: Physicians in Dutch nursing homes. METHODS: Respondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data. RESULTS: A total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP, and decision making in ACP. COVID-19-specific changes in ACP indicated by respondents included (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making. CONCLUSIONS AND IMPLICATIONS: ACP in Dutch nursing homes has changed because of the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision-making process in ACP.

Clinical evaluation of single-swab sampling for rapid COVID-19 detection in outbreak settings in Dutch nursing homes.

PURPOSE: To assess whether one swab can be used to perform both the antigen-detection rapid diagnostic test (Ag-RDT) and reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19 detection during an outbreak in the nursing home (NH) setting. METHODS: The single-swab method (SSM), where the Ag-RDT is performed with the transport medium used for RT-PCR, was evaluated in three Dutch NHs and compared to the laboratory setting. We collected Ag-RDT and RT-PCR results, NH resident characteristics and symptomatology. In addition, two focus groups were held with the involved care professionals to gain insight into the feasibility of the SMM in the NH setting. RESULTS: In the NH setting, the SSM had a sensitivity of 51% and a specificity of 89% compared to RT-PCR. These were lower than in the laboratory setting (69% and 100% respectively). Yet, when stratified for cycle threshold values, the sensitivity became comparable between the settings. Symptoms occurred more frequent in the Ag-RDT+ group than Ag-RDT- group. Resident characteristics did not differ between these groups. Based on the focus groups, the SSM was feasible to perform if certain requirements, such as availability of staff, equipment and proper training, were met. However, the rapid availability of the test results were perceived as a dilemma. CONCLUSION: The advantages and disadvantages need to be considered before implementation of the SSM can be recommended in the NH setting. For the vulnerable NH residents, it is important to find the right balance between effective testing policy and the burden this imposes.

Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance.

PURPOSE: To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. METHODS: The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society. RESULTS: This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. "General recommendations for geriatric rehabilitation" addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. "Specific processes and procedures", addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring. CONCLUSION: Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research.

Symptom- and Prevention-Based Testing of COVID-19 in Nursing Home Residents: A Retrospective Cohort Study.

Nursing homes (NH) residents with COVID-19 can either be tested because of presence of core symptoms (S-based) or because of transmission prevention (TP-based). The investigated study sample included all NH residents who underwent SARS-CoV-2 RT-PCR testing between March 16, 2020 and May 31, 2020 (n = 380). Clinical symptoms, temperature, and oxygen saturation were extracted from medical records, 7 days before to 14 days after testing. COVID-19 was confirmed in 81 (21%) residents; 36 (44%) S-based and 45 (56%) TP-based: 45. Cycle threshold (CT) values did not differ between the groups. In the 7 days prior to the test falling (32%), somnolence (25%) and fatigue (21%) occurred in both groups. Two days before the test, we observed a stronger decrease in oxygen saturation and an increase in temperature for the S-based group compared to the T-based group that remained up to 10 days after testing. Residents within the S-based group were 2.5 times more likely to increased mortality within 30 days than residents in the TP-based group (HR, 2.56; 95% 1.3-5.2). Although, 73% of the T-based group did eventually develop core symptoms. Thus, attention to falling and daily measures of temperature and oxygen saturation can contribute to earlier detection.

Dementia and Parkinson's Disease: Risk Factors for 30-Day Mortality in Nursing Home Residents with COVID-19.

BACKGROUND: The COVID-19 pandemic has led to high mortality rates in nursing homes (NHs) in Europe. For adequate risk management and good prognostications, it is essential to identify mortality risk factors. OBJECTIVE: This study aimed to determine whether previously identified risk factors for 30-day mortality in Dutch NH residents with COVID-19 are unique to COVID-19. METHODS: In this cohort study, we included 1,294 NH residents with COVID-19 (cases) and 17,999 NH residents without COVID-19 (controls, from the pre-COVID-19 period). We used descriptive statistics and Cox proportional hazard models to compare mortality rates in residents with and without COVID-19, categorized by risk factors. RESULTS: Cases had a more than 18 times higher hazard of death within 30 days compared to controls (HR 18, 95%CI: 16-20). For residents with COVID-19, being male, having dementia, and having Parkinson's disease (PD) were all associated with a higher 30-day mortality (HR 1.8 versus 1.3 versus 1.7). Being male was also associated with a higher mortality (HR 1.7) in the control group, whereas having dementia and PD were not. COVID-19 symptomatology was very similar for residents with and without dementia or PD, except for delirium and malaise which was more frequent in residents with dementia. CONCLUSION: Dementia and PD were significant additional risk factors for mortality in Dutch NH residents with COVID-19, whereas male gender was not unique to residents with COVID-19. The frailty of PD and dementia in NH residents with COVID-19 are relevant to consider in prognostication, communication, and care planning with residents and their families.

Challenging behavior of nursing home residents during COVID-19 measures in the Netherlands.

OBJECTIVES: From the perspective of the nursing home (NH) practitioners, to gain understanding of (1) whether challenging behavior in NH residents changed during the COVID-19 measures, (2) whether the practitioners' involvement in the treatment of challenging behavior changed, (3) what can be learned from the experience of NH staff. METHODS: A mixed methods study with a survey in 323 NH practitioners (psychologists, elderly care physicians, nurse practitioners) in the Netherlands, and in-depth interviews in 16 NH practitioners. Nonparametric analyses were used to compare estimated proportions of residents with increased and with decreased challenging behavior. Content analyses were conducted for open-ended questions and in-depth interviews. RESULTS: Participants reported changes in challenging behavior with slightly higher proportions for increased (Q1/Mdn/Q3: 12.5%, 21.7%, 30.8%) than for decreased (8.7%, 14.8%, 27.8%, Z = -2.35, p = .019) challenging behavior. Half of the participants reported that their work load increased and work satisfaction worsened during the measures. Different strategies were described to respond to the effects of COVID-19 measures, such as video calls, providing special areas for residents to meet their loved ones, adjusting activities, and reducing the exposure to negative news. CONCLUSIONS: Because COVID-19 measures resulted in both increased and decreased challenging behavior in NH residents, it is important to monitor for their potential long lasting effects. Increased work load and worsened work satisfaction of the NH staff, together with the changes in type of challenging behavior, indicate that the harmful effects of the anti-pandemic measures should be taken seriously.

Clinical Suspicion of COVID-19 in Nursing Home Residents: Symptoms and Mortality Risk Factors.

OBJECTIVES: To describe the symptomatology, mortality, and risk factors for mortality in a large group of Dutch nursing home (NH) residents with clinically suspected COVID-19 who were tested with a reverse transcription-polymerase chain reaction (RT-PCR) test. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Residents of Dutch NHs with clinically suspected COVID-19 and who received RT-PCR test. METHODS: We collected data of NH residents with clinically suspected COVID-19 via electronic health records between March 18 and May 13, 2020. Registration was performed on diagnostic status [confirmed (COVID-19+)/ruled out (COVID-19-)] and symptomatology (typical and atypical symptoms). Information on mortality and risk factors for mortality were extracted from usual care data. RESULTS: In our sample of residents with clinically suspected COVID-19 (N = 4007), COVID-19 was confirmed in 1538 residents (38%). Although symptomatology overlapped between residents with COVID-19+ and COVID-19-, those with COVID-19+ were 3 times more likely to die within 30 days [hazard ratio (HR), 3.1, 95% confidence interval (CI) 2.7-3.6]. Within this group, mortality was higher for men than for women (HR 1.8, 95% CI 1.5-2.2), and we observed a higher mortality for residents with dementia, reduced kidney function, and Parkinson's disease, even when corrected for age, gender, and comorbidities. CONCLUSIONS AND IMPLICATIONS: About 40% of the residents with clinically suspected COVID-19 actually had COVID-19, based on the RT-PCR test. Despite an overlap in symptomatology, mortality rate was 3 times higher for residents with COVID-19+. This emphasizes the importance of using low-threshold testing in NH residents, which is an essential prerequisite to using limited personal protective equipment and isolation measures efficiently.

Dilemmas With Restrictive Visiting Policies in Dutch Nursing Homes During the COVID-19 Pandemic: A Qualitative Analysis of an Open-Ended Questionnaire With Elderly Care Physicians.

OBJECTIVES: To mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy. SETTING AND PARTICIPANTS: ECPs working in Dutch NHs. METHODS: A qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020. RESULTS: Seventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them. CONCLUSIONS AND IMPLICATIONS: ECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.