Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic.

OBJECTIVE: To evaluate whether assisted living (AL) residents with Alzheimer's disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020. METHOD: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects. RESULTS: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL. CONCLUSIONS AND IMPLICATIONS: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Dementia and COVID-19 infection control in assisted living in seven states.

BACKGROUND: Assisted living (AL) is the largest residential long-term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia-relevant COVID-19 infection control across different types of AL communities, and to discuss implications for the future. METHODS: From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID-19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia-specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types. RESULTS: Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia-specific AL communities were generally the most challenged with infection control during COVID-19. CONCLUSION: All AL community types experienced infection control challenges, more so in dementia-specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.

Risk factors for Veteran food insecurity: findings from a National US Department of Veterans Affairs Food Insecurity Screener.

OBJECTIVE: Food insecurity is associated with numerous adverse health outcomes. The US Veterans Health Administration (VHA) began universal food insecurity screening in 2017. This study examined prevalence and correlates of food insecurity among Veterans screened. DESIGN: Retrospective cross-sectional study using VHA administrative data. Multivariable logistic regression models were estimated to identify sociodemographic and medical characteristics associated with a positive food insecurity screen. SETTING: All US Veterans Administration (VA) medical centres (n 161). PARTICIPANTS: All Veterans were screened for food insecurity since screening initiation (July 2017-December 2018). RESULTS: Of 3 304 702 Veterans screened for food insecurity, 44 298 were positive on their initial screen (1·3 % of men; 2·0 % of women). Food insecurity was associated with identifying as non-Hispanic Black or Hispanic. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation and those with housing instability had higher odds of food insecurity, as did Veterans with a BMI < 18·5, diabetes, depression and post-traumatic stress disorder. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (48·9 % v. 5·9 %). CONCLUSIONS: Food insecurity was associated with medical and trauma-related comorbidities as well as unmet social needs including housing instability. Additionally, Veterans of colour and women were at higher risk for food insecurity. Findings can inform development of tailored interventions to address food insecurity such as more frequent screening among high-risk populations, onsite support applying for federal food assistance programs and formal partnerships with community-based resources.

A Technology Training Program to Alleviate Social Isolation and Loneliness Among Homebound Older Adults: A Community Case Study.

Despite substantial evidence of the negative health consequences of social isolation and loneliness and the outsized impact on older adults, evidence on which interventions are most effective in alleviating social isolation and loneliness is inconclusive. Further complicating the translation of evidence into practice is the lack of studies assessing implementation and scalability considerations for socialization programs delivered by community-based organizations (CBOs). Our primary objective was to describe the implementation barriers, facilitators, and lessons learned from an information and communication technology (ICT) training program aimed at reducing social isolation and loneliness for homebound older adults in a home-delivered meals program. Participants received in-home, one-on-one ICT training lessons delivered by volunteers over a 14-week period with the goal of increasing social technology use. To assess implementation facilitators and barriers, 23 interviews were conducted with program staff (n = 2), volunteers (n = 3), and participants (n = 18). Transcripts were analyzed using thematic analysis. Aspects that facilitated implementation included the organization's existing relationship with clientele, an established infrastructure to deliver community-based interventions, alignment of intervention goals with broader organizational aims, and funding to support dedicated program staff. Challenges to implementation included significant program staff time and resources, coordinating data sharing efforts across multiple project partners, participant and volunteer recruitment, and interruptions due to COVID-19. Implications of these facilitators and barriers for scalability of community-based ICT training interventions for older adults are described. Lessons learned include identifying successful participant and volunteer recruitment strategies based on organizational capacity and existing recruitment avenues; using a targeted approach to identify potential participants; incorporating flexibility into intervention design when working with the homebound older adult population; and monitoring the participant-volunteer relationship through volunteer-completed reports to mitigate issues. Findings from this formative evaluation provide insight on strategies CBOs can employ to overcome challenges associated with implementing technology training programs to reduce social isolation and loneliness for older adults, and thus improve overall well-being for homebound older adults. Recommendations can be integrated into program design to facilitate implementation of ICT programs in the community setting.

'It's not just about the dinner; it's about everything else that we do': A qualitative study exploring how Meals on Wheels meet the needs of self-isolating adults during COVID-19.

Meals on Wheels (MoWs), a service offered by local authorities in England, deliver meals to older, housebound and/or vulnerable adults, who might otherwise not be able to acquire and prepare their own meals. Research suggests that MoWs provide benefits beyond nutrition. Little is known about the actual interactions between service providers and clients, particularly during the COVID-19 pandemic. The aim of this small-scale, formative study was to explore MoWs service providers' experiences and their perceptions around the benefits and challenges faced by the service, and understand how these experiences changed during the first UK national lockdown. Semi-structured interviews were conducted in September 2020 with 18 service providers of MoWs (drivers who deliver the meals, service coordinators and managers) in two local authorities in England, and analysed thematically. Participants indicated that benefits of the service encompassed those to clients (e.g. welfare checks, encouraging independence and identifying and addressing isolation and loneliness), employees (e.g. sense of pride, rewarding relationships with clients) and the wider community (e.g. reducing pressures on families), and described MoWs as the 'fourth emergency service' (e.g. being the first responders to emergency situations). Participants identified several challenges faced by the MoWs service, including organisational challenges (e.g. funding cuts and closures, lack of appropriate publicity to raise awareness of the service) and restrictions on time spent with clients. The pandemic and lockdown resulted in increased demand on resources, concerns about client and staff wellbeing and uncertainty about how the service will cope if lockdowns continue. These findings provide important insights regarding the wide benefits of MoWs and the challenges the service faces, which can be used as the formative research base to guide future interventions and policies to protect vulnerable adults, not only during the COVID-19 pandemic, but beyond.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned.

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.

Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents.

Importance: Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics. Objective: To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes. Design, Setting, and Participants: Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020. Exposure: Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed. Main Outcome and Measures: Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term. Results: A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period. Conclusions and Relevance: The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.