“Dying of failure to thrive”: Caregiver Perspectives on the Impact of COVID-19 Isolation on Residents' Cognitive and Functional Status

ABSTRACT

Background: The COVID-19 pandemic has profoundly affected skilled nursing facilities (SNFs). Our objective was to understand SNF staff perspectives on the unintended effects of isolation protocols and suggestions for future outbreaks. Methods: Qualitative analysis of semi-structured interviews from caregivers (n=17) from seven SNFs. Interviews focused on the impact of isolation on caregiving, SNF residents' cognitive and physical health, and best practices. Virtual interviews were recorded and transcribed. Qualitative framework analysis using a modified care preparedness model was used to identify themes related to the impact of COVID-19 isolation. Results: Caregivers observed withdrawal, irritability, depression, and lack of motivation among residents. Staff noted increased confusion in cognitively impaired residents and observed that cognitively intact residents displayed more symptoms of depression. Most participants related residents' emotional changes to lack of family visitation and loneliness. SNFs connected residents with families using technology and modified visits. Staff also developed creative programming to engage residents while maintaining physical distancing, such as a mobile ice cream cart. Challenges included less hands-on caregiving due to fear of COVID-19 transmission, staff turnover, personal protective equipment (PPE) shortages, and COVID-19 outbreaks. Many participants also noted inadequate administrative support and hoped for more aid and flexibility. Staff reported that increasing family communication and physical and psychological therapy interventions worked well for residents. Staff who perceived early initiation of infection control measures (e.g., closing admittance, frequent testing, maintaining PPE supplies) and/or had highly involved administrators (e.g., open door policy, visible on the floor) felt better equipped to care for residents. Most also noted strong coworker camaraderie. Staff recommendations for quantifying the effects of isolation included tracking physical and cognitive measures longitudinally to identify changes in resident status. For future epidemics, staff emphasized the need for communication and preparation with ample supplies and staff. Conclusions: This analysis includes suggestions for preparation, communication, enforcement of infection control policies for future outbreaks.