Multimorbidity, COVID-19 and Mental Health: Canadian Longitudinal Study on Aging (CLSA) Longitudinal Analyses.

OBJECTIVES: This paper examines the longitudinal effects of the COVID-19 pandemic on older adults (65+) with multimorbidity on levels of depression, anxiety, and perceived global impact on their lives. METHODS: Baseline (2011-2015) and Follow-up 1 (2015-2018) data from the Canadian Longitudinal Study on Aging (CLSA), and the Baseline and Exit waves of the CLSA COVID-19 study (April-December, 2020) (n = 18,099). Multimorbidity was measured using: a) an additive scale of chronic conditions; and b) six chronic disease clusters. Linear Mixed Models were employed to test hypotheses. RESULTS: Number of chronic conditions pre-pandemic was associated with pandemic levels of depression (estimate = 0.40, 95% CI: [0.37,0.44]); anxiety (estimate = 0.20, 95% CI: [0.18, 0.23]); and perceived negative impact of the pandemic (OR = 1.04, 95% CI: [1.02, 1.06]). The associations between multimorbidity and anxiety decreased during the period of the COVID-19 surveys (estimate = -0.02, 95% CI: [-0.05, -0.01]); whereas the multimorbidity association with perceived impact increased (OR = 1.03, 95% CI: [1.01, 1.05]). CONCLUSIONS: This study demonstrates that pre-pandemic multimorbidity conditions are associated with worsening mental health. CLINICAL IMPLICATIONS: Clinicians treating mental health of older adults need to consider the joint effects of multimorbidity conditions and pandemic experiences to tailor counseling and other treatment protocols.

Antibiotic Management Decisions and Use of a Multiplex PCR Panel for Pneumonia Diagnosis among Critically Ill Patients with COVID-19

Background. Antibiotic use among patients with COVID-19 is common, exceeds the prevalence of probable bacterial co-infection, and promotes development of resistant organisms. Lack of diagnostic microbiological data may prolong empiric broad-spectrum therapy. Here we evaluate the use of the BioFire FilmArray pneumonia panel (PP), a novel rapid diagnostic test, and antibiotic decisions among intensive care unit (ICU) patients with COVID-19. Methods. We conducted a retrospective review of adult ICU patients admitted with COVID-19 between January 2020 and May 2021 at an academic medical center. ICU patients who underwent bronchoscopy/bronchoalveolar lavage (BAL) with PP (PP group) were matched by age (< 65 or ≥65), BMI (< 30 or ≥30), and BAL date (within 60 days) to ICU patients who did not undergo BAL (no-BAL group). PP patients were matched by age and BMI to ICU patients who underwent BAL without PP (no-PP group). Antibiotic use was compared between groups. Chi squared analysis, t-test, and ANOVA were used for comparisons as appropriate. Results. 65 patients were included;the majority were male (65%), < 65 years (86%), and had BMI ≥30 (54%) (Table 1). Only 17 no-PP matches were identified for PP patients due to infrequent BALs. Similar proportion of patients in PP and no-PP groups had organisms identified from BAL (54% vs. 47%, p=0.65). Among PP patients with a detected organism, all (n=13) had subsequent changes in antibiotic regimen ≤72 hours after BAL;10/13 (77%) had a change targeted to detected organism and 5/13 (39%) had antibiotic narrowing. Among PP patients with no detected organism, only 4/11 (36%) had antibiotic narrowing or maintenance off antibiotics. In all groups, average antibiotic use exceeded 70% of admission duration. Table 1. Patient characteristics and antibiotic management. Abbreviations: BAL - bronchoalveolar lavage Conclusion. Rapid, highly sensitive diagnostic tests have potential to guide clinical decisions and promote antibiotic stewardship among patients with severe viral pneumonia and suspected bacterial co-infection. In this descriptive analysis, antibiotic management did not differ significantly with use of PP. While most patients with detected organism on PP had targeted antibiotic changes, a negative PP did not appear to influence antibiotic narrowing. Larger studies and provider education are needed to evaluate potential of the PP for antibiotic stewardship.

Multimorbidity resilience and COVID-19 pandemic self-reported impact and worry among older adults: a study based on the Canadian Longitudinal Study on Aging (CLSA).

BACKGROUND: The Coronavirus Disease-2019 (COVID-19) pandemic has created a spectrum of adversities that have affected older adults disproportionately. This paper examines older adults with multimorbidity using longitudinal data to ascertain why some of these vulnerable individuals coped with pandemic-induced risk and stressors better than others - termed multimorbidity resilience. We investigate pre-pandemic levels of functional, social and psychological forms of resilience among this sub-population of at-risk individuals on two outcomes - self-reported comprehensive pandemic impact and personal worry. METHODS: This study was conducted using Follow-up 1 data from the Canadian Longitudinal Study on Aging (CLSA), and the Baseline and Exit COVID-19 study, conducted between April and December in 2020. A final sub-group of 9211 older adults with two or more chronic health conditions were selected for analyses. Logistic regression and Generalized Linear Mixed Models were employed to test hypotheses between a multimorbidity resilience index and its three sub-indices measured using pre-pandemic Follow-up 1 data and the outcomes, including covariates. RESULTS: The multimorbidity resilience index was inversely associated with pandemic comprehensive impact at both COVID-19 Baseline wave (OR = 0.83, p < 0.001, 95% CI: [0.80,0.86]), and Exit wave (OR = 0.84, p < 0.001, 95% CI: [0.81,0.87]); and for personal worry at Exit (OR = 0.89, p < 0.001, 95% CI: [0.86,0.93]), in the final models with all covariates. The full index was also associated with comprehensive impact between the COVID waves (estimate = - 0.19, p < 0.001, 95% CI: [- 0.22, - 0.16]). Only the psychological resilience sub-index was inversely associated with comprehensive impact at both Baseline (OR = 0.89, p < 0.001, 95% CI: [0.87,0.91]) and Exit waves (OR = 0.89, p < 0.001, 95% CI: [0.87,0.91]), in the final model; and between these COVID waves (estimate = - 0.11, p < 0.001, 95% CI: [- 0.13, - 0.10]). The social resilience sub-index exhibited a weak positive association (OR = 1.04, p < 0.05, 95% CI: [1.01,1.07]) with personal worry, and the functional resilience measure was not associated with either outcome. CONCLUSIONS: The findings show that psychological resilience is most pronounced in protecting against pandemic comprehensive impact and personal worry. In addition, several covariates were also associated with the outcomes. The findings are discussed in terms of developing or retrofitting innovative approaches to proactive coping among multimorbid older adults during both pre-pandemic and peri-pandemic periods.

Reduced ability to engage in social and physical activity and mental health of older adults during the COVID-19 pandemic: longitudinal analysis from the Canadian Longitudinal Study on Aging

Background Restrictions implemented to mitigate the transmission of COVID-19 have affected the ability of many older adults to engage in social and physical activities. We examined the mental health outcomes for older adults whose ability to be socially and physically active was reduced during the course of the COVID-19 pandemic. Methods Data from the Canadian Longitudinal Study on Aging (CLSA), a nationally representative longitudinal cohort of Canadian residents aged 45–85 years, at CLSA baseline (2012–15), follow-up 1 (2018), COVID-19 baseline (April–May, 2020), and COVID-19 exit surveys (September–December, 2020) were used. Participants were asked the degree to which their ability to participate in social and physical activity had been affected by the COVID-19 pandemic. Binary logistic regression was used to examine the relationship between the risk of a positive screen for depression (Center for Epidemiological Studies Depression Scale score >10) and anxiety (Generalised Anxiety Disorder Assessment-7 score >10) and reduced participants' ability to participate in social and physical activity. Models were adjusted for age group, dwelling type, geographic area, household composition, Center for Epidemiological Studies Depression Scale, and smoking status at COVID-19 baseline;alcohol consumption at COVID-19 exit;and multimorbidity, physical activity, income, social participation, and diagnosis of anxiety or mood disorders before the COVID-19 pandemic. Findings Of the 24 108 participants who completed the COVID-19 exit survey, 5219 (22·0%) screened positive for depression and 1132 (5·0%) screened positive for anxiety. Depression and anxiety were associated with a decreased ability to participate in social activity (odds ratio [OR] 1·85 [95% CI 1·67–2·04] for depression;1·66 [1·37–2·02] for anxiety) and physical activity (2·46 [2·25–2·69] for depression;1·96 [1·68–2·30] for anxiety). Interpretation Older adults whose ability to participate in social and physical activities was reduced during the COVID-19 pandemic had poorer mental health outcomes than those whose ability remained the same or improved. Individuals who had low pre-COVID-19 levels of social and physical activity had a higher frequency of positive depression and anxiety screens. These findings highlight the importance of fostering social and physical activity resources in advance of, and during, future lockdown measures. Funding The CLSA COVID-19 Questionnaire study was funded by the Juravinski Research Institute, Faculty of Health Sciences, McMaster University, McMaster University Provost Fund, McMaster Institute for Research on Aging, Public Health Agency of Canada, and Government of Nova Scotia. The CLSA is funded by the Government of Canada through the Canadian Institutes of Health Research (grant number LSA94473) and the Canada Foundation for Innovation. PR holds the Raymond and Margaret Labarge Chair in Optimal Aging and Knowledge Application for Optimal Aging, and a Tier 1 Canada Research Chair in Geroscience. TDC is a Michael Smith Foundation for Health Research Scholar (grant number SCH-2020-0490).

Overcoming Barriers for Older Adults to Maintain Virtual Community and Social Connections during the COVID-19 Pandemic.

OBJECTIVES: We describe the evaluation of remote training, an innovative use of technology to maintain older adults' virtual connection with their community and socialization, which were disrupted by the pandemic. Remote training was conducted via telephone using principles of cognitive rehabilitation and delivered by trained clinicians. METHODS: We thematically analyzed trainer reflection notes and interviews with older adult participants. RESULTS: The main facilitators were technology training with exposure, and the main barrier was fear of technology. CONCLUSIONS: We describe how telephone-based training grounded in principles of cognitive rehabilitation can be used to remotely train older adults to use new technology and to help them maintain their community-based connections and engage in socialization. CLINICAL IMPLICATIONS: Fear of technology during the pandemic can cause significant impairment in social functioning for older adults, at least when the only method for socialization is technology mediated such as during the COVID-19 pandemic. Empathically delivered remote training in an understanding manner can reduce fear and increase social and community connections in the era of physical distancing.

Long-term sequela of SARS-CoV-2 infection in a retrospective New York City Cohort

Background: The long-term sequelae of coronavirus disease 2019 (COVID-19) have been increasingly recognized. Cardiac, pulmonary, and neuropsychiatric symptoms have been reported to persist up to two months after hospitalization. However, much remains to be learned about the durable long-term effects of COVID-19 for patients and the health care system. Here, we describe the persistence of COVID-19 sequelae up to six months after presentation. Methods: We examined the electronic medical records of the first 1190 patients diagnosed with SARS-CoV-2 infection by reverse transcriptase polymerase chain reaction assay and hospitalized at a quaternary-care center in New York City. All initial hospital presentations occurred between March 1 and April 8, 2020. We manually abstracted data for two follow-up periods representing three-and six-months post-hospitalization. Abstracted information included type and dates of encounters;use of tele-health;presence and persistence of symptoms;morbidity;and mortality. Descriptive statistics for categorical and continuous variables were tabulated and distributions were examined by visit;at presentation, three months and six months. Results: Patients had a median age of 60 and 61 years at three and six months, respectively. About 45% were female and 50% identified as Hispanic/Latinx. Of 1190 patients, 78% (N=928) survived their initial hospitalization. Among the 61% (n=570) of survivors who had follow-up encounters at three and six months, patients frequently reported cardiopulmonary symptoms (35.7% and 28%), dyspnea (22.1% and 15.9%), generalized symptoms (25.4 % and 26.4%) and neuropsychiatric symptoms (20.1% and 24.2%). Tele-health encounters represented 59% and 28.2% of encounters at three and six-months, respectively. Twenty-percent of patients had reduced mobility or reduced independence in the six months after hospitalization. Of survivors, 17% weredischarged to a nursing or rehabilitation facility and 10.3% remained there at three months post-hospitalization. Conclusion: The prevalence was high of at least one COVID-associated symptom six months after hospitalization. Cardiopulmonary symptoms were most common and persisted longer than previously reported. Providers, patients, and their families must be sensitized to and anticipate these potential sequelae. Further follow-up and studies of COVID-19 survivors are necessary to confirm these findings and investigate outcomes beyond six months. (Figure Presented).

Sustained seroprevalence in health care workers at a quaternary center, New York city

Background: Health care workers (HCWs) remain disproportionately affected by COVID-19. They experience higher transmission rates of SARS-CoV-2, and the extent, duration and pattern of antibody response remains under examined. The correlates of serological patterns are also unclear. We examined longitudinal SARS-CoV-2 sero-patterns and their correlates among a cohort of HCW. Methods: HCWs (N=465) were recruited at a large quaternary medical center in New York City and followed prospectively with bi-monthly assessments of the following;demographic characteristics, COVID-19 exposure in the work, home and community settings, and molecular and antibody COVID-19 laboratory tests including quantitative measurements of antibody titers. Baseline and longitudinal patterns in antibody response and titers over the first 4 months were used to characterize HCW who remained persistently seronegative, seropositive, those who acquired and lost seropositvity and those with variable seropositivity. Chi-square test for the association of seropattern correlates and loess regression was used to examine longitudinal trends. Results: Baseline seropositivity was 32.6% (N=148/465), 34.6% (N=153/441) at month 2 and 38.3% (N=125/326) by month 4. Exactly 63.9%, 27.3%, 1.5%, 1.5% and 5.7% of HCW tested overall were persistently seronegative, persistently seropositive, became positive after baseline, lost seropositivity and had variable positivity, respectively. Among seropositive HCW, mean antibody levels increased from 53.7 at baseline to 69.8 at month 2 and 82.9 at month 4 (figure 1). Factors significantly associated with being ever seropositive were, history of prior COVID-19 testing, household member testing COVID-19 positive, whether there were other essential employees in the home, and history or current symptoms. We also observed an association with contact of suspected or confirmed co-worker as significantly higher among HCW who were persistently positive (24.5%), incident seropositives (33.3%) and variable seropositivity (52.2%) than those who were persistently negative (19.9%) or lost seropositivity (16.7%). Conclusion: HCWs exposure risks continue to persist in the workplace and in the home. We observed few positive molecular tests, suggesting few transmission, but these exposure may potentially sustain seropositivity. These findings are preliminary and need to be further investigated.

COVID-19, Social Isolation, and Mental Health Among Older Adults: A Digital Catch-22.

One of the most at-risk groups during the COVID-19 crisis is older adults, especially those who live in congregate living settings and seniors' care facilities, are immune-compromised, and/or have other underlying illnesses. Measures undertaken to contain the spread of the virus are far-reaching, and older adults were among the first groups to experience restrictions on face-to-face contact. Although reducing viral transmission is critical, physical distancing is associated with negative psychosocial implications, such as increased rates of depression and anxiety. Promising evidence suggests that participatory digital co-design, defined as the combination of user-centered design and community engagement models, is associated with increased levels of engagement with mobile technologies among individuals with mental health conditions. The COVID-19 pandemic has highlighted shortcomings of existing technologies and challenges in their uptake and usage; however, strategies such as co-design may be leveraged to address these challenges both in the adaptation of existing technologies and the development of new technologies. By incorporating these strategies, it is hoped that we can offset some of the negative mental health implications for older adults in the context of physical distancing both during and beyond the current pandemic.

Aerosol and spatter mitigation in dentistry: Analysis of the effectiveness of 13 setups.

OBJECTIVES: The current study aims to investigate the aerosol and spatter mitigation quality of 13 dry-field isolation methods in a simulated setup that replicates real-life work scenarios encountered in dental practices. METHODS: A crown preparation on a manikin was performed on tooth number 30 and repeated five times for each setup to simulate a patient under care. Aerosol, environmental, and operator face shield spatter, and sound intensity was measured. Generalized linear mixed models were used, and posthoc pairwise comparisons were performed to compare least-squares means when appropriate using a Tukey adjustment. RESULTS: All tested setups showed some environmental spatter formation; however, these were able to control most (and in some cases all) spatter on the operator face shield. All methods resulted in excellent aerosol mitigation when a second line of high-volume evacuation (HVE) was added to the device setup. However, in most setups, total sound levels exceeded 85 dB, posing a concern for prolonged noise exposure. CONCLUSIONS: The Prototype device and four other tested setups with secondary HVE addition completely eliminated aerosol creation as tested. Spatter of the Face Shield was best eliminated using the Prototype device. CLINICAL SIGNIFICANCE: Within the limitations of this study, it can be concluded that the dental community has at its disposal equipment that can effectively mitigate aerosol and spatter.

What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review.

BACKGROUND AND AIM: The aim of this systematic review was to quantify the association between frailty and COVID-19 in relation to mortality in hospitalised patients. METHODS: Medline, Embase, Web of Science and the grey literature were searched for papers from inception to 10 September 2020; the search was re-run in Medline up until the 9 December 2020. Screening, data extraction and quality grading were undertaken by two reviewers. Results were summarised using descriptive statistics, including a meta-analysis of overall mortality; the relationships between frailty and COVID-19 mortality were summarised narratively. RESULTS: A total of 2,286 papers were screened resulting in 26 being included in the review. Most studies were from Europe, half from the UK, and one from Brazil; the median sample size was 242.5, median age 73.1 and 43.5% were female. In total, 22/26 used the Clinical Frailty Scale; reported mortality ranged from 14 to 65%. Most, but not all studies showed an association between increasing frailty and a greater risk of dying. Two studies indicated a sub-additive relationship between frailty, COVID-19 and death, and two studies showed no association. CONCLUSIONS: Whilst the majority of studies have shown a positive association between COVID-19-related death and increasing frailty, some studies suggested a more nuanced understanding of frailty and outcomes in COVID-19 is needed. Clinicians should exert caution in placing too much emphasis on the influence of frailty alone when discussing likely prognosis in older people with COVID-19 illness.

What is the relationship between validated frailty scores and mortality for adults with COVID-19 in acute hospital care? A systematic review. (preprint)

Background & aimThe aim of this systematic review was to quantify the association between frailty and COVID-19 in relation to mortality in hospitalised patients. MethodsMedline, Embase, Web of Science and the grey literature were searched for papers from inception to 10th September 2020; the search was re-run in Medline up until the 9th December 2020. Screening, data extraction and quality grading were undertaken by two reviewers. Results were summarised using descriptive statistics, including a meta-analysis of overall mortality; the relationships between frailty and COVID-19 mortality were summarised narratively. Results2286 papers were screened resulting in 26 being included in the review. Most studies were from Europe, half from the UK, and one from Brazil; the median sample size was 242.5, median age 73.1 and 43.5% were female. 22/26 used the Clinical Frailty Scale; reported mortality ranged from 14 to 65%. Most, but not all studies showed an association between increasing frailty and a greater risk of dying. Two studies indicated a sub-additive relationship between frailty, COVID-19 and death, and two studies showed no association. ConclusionsWhilst the majority of studies have shown a positive association between COVID-19 related death and increasing frailty, some studies suggested a more nuanced understanding of frailty and outcomes in COVID-19 is needed. Clinicians should exert caution in placing too much emphasis on the influence of frailty alone when discussing likely prognosis in older people with COVID-19 illness. Key pointsO_LIFrailty is being used to assess the risk of dying from COVID-19 C_LIO_LIEmerging studies demonstrate a complex relationship between frailty and COVID-19 related deaths C_LIO_LIClinicians should exert caution in placing too much emphasis on the influence of frailty in older people with COVID-19 C_LIO_LIResearchers should ensure that frailty scales are used as designed when planning and reporting future research. C_LI

Evaluation of the spatter-reduction effectiveness and aerosol containment of eight dry-field isolation techniques.

OBJECTIVE: The novel coronavirus that was first identified in Wuhan, China, in December 2019, created a pandemic that has the potential to change the paradigm of health care delivery. Of interest to the dental community is the presence of SARS-CoV-2 in the saliva of the affected patients that can potentially cause transmission of COVID-19 via droplets. The highly infectious nature of the pathogen has created a sense of urgency and a need for extra caution to prevent the spread of the disease and the potential infection of patients and the entire dental team. Spatter consists of droplets up to 50 µm in size that are effectively stopped by barriers such as gloves, masks, and gowns. Aerosols are defined as droplet particles smaller than 5 µm that can remain airborne for extended periods and that have been reported to be significant in viral respiratory infections. In this study, aerosol represented by particulate matter with a size of 2.5 µm (PM2.5) was measured. METHOD AND MATERIALS: Eight dry-field isolation methods were tested in a setup that included a realistic dental manikin and a high-speed handpiece that generated air-water spray. Environmental noise generated by the suction devices, suction flow rate of each setup, and the amount of environmental spatter and aerosols, were measured. RESULTS: The experimental setups showed significant variability in the suction flow rate, but this was not correlated to the level of sound generated. Some experimental setups caused a short-term level of noise that exceeded the NIOSH (National Institute for Occupational Safety and Health) guidelines and were close to the OSHA (Occupational Safety and Health Administration) recommended thresholds. It is also worth noting that the variability in the flow rate is not reflected in the efficacy of the experimental setups to mitigate spatter. All experimental setups, except the IsoVac system, provided statistically significantly better spatter mitigation compared to the control. All experimental setups also were efficient in mitigating aerosols compared with the positive control (P < .0001) and most systems yielded results similar to the negative control ambient PM (P > .05). CONCLUSION: Results indicate that spatter reduction was significantly better amongst the setups in which an additional high-volume evacuator (HVE) line was used. All setups were efficient at mitigating PM2.5 aerosols in comparison to the control. The conclusions of this study should be interpreted with caution, and additional mitigation techniques consistent with the Centers for Disease Control and Prevention recommendations must be implemented in dental practices.