Health effects of social connectedness in older adults living in congregate long-term care settings: A systematic review of quantitative and qualitative evidence.

BACKGROUND: The overall impact of social connectedness on health outcomes in older adults living in nursing homes and assisted living settings is unknown. Given the unclear health impact of social connectedness for older adults in congregate long-term care settings worldwide, a comprehensive systematic review is required to evaluate the overall relationship between social connectedness and health outcomes for them. OBJECTIVES: The purpose of this article was to synthesize the literature regarding the health impact of social connectedness among older adults living in nursing homes or assisted living settings. METHODS: Using PRISMA guidelines, we identified eligible studies from Scopus, MEDLINE, PsycINFO, CINAHL and Cochrane databases (1990-2021). Bias and quality reporting assessment was performed using standardized criteria for cohort, cross sectional and qualitative studies. At each stage, ≥ 2 researchers conducted independent evaluations. RESULTS: Of the 7350 articles identified, 25 cohort (follow-up range: 1 month-11 years; with two also contributing to cross sectional), 86 cross sectional, eight qualitative and two mixed methods were eligible. Despite different instruments used, many residents living in nursing homes and assisted living settings had reduced social engagement. Quantitative evidence supports a link between higher social engagement and health outcomes most studied (e.g. depression, quality of life). Few studies evaluated important health outcomes (e.g. cognitive and functional decline). Most cohort studies showed that lack of social connectedness accelerated time to death. CONCLUSIONS: Social connectedness may be an important modifiable risk factor for adverse health outcomes for older adults living in nursing homes and assisted living facilities. Most studies were cross sectional and focused on quality of life and mental health outcomes. Longitudinal studies suggest that higher social engagement delays time to death. Evidence regarding other health outcomes important to older adults was scant and requires further longitudinal studies.

Longitudinal Dyadic Associations Between Loneliness and Cognition Among Older Couples in the United States.

OBJECTIVES: Loneliness is associated with diminished health and cognition for older individuals. However, little research has examined dyadic loneliness-that is, loneliness of both partners in a relationship-and its potential consequences for cognitive functioning among both spouses, nor whether one partner's cognition may affect both partners' loneliness over time. METHODS: We analyze 3-wave dyadic Health and Retirement Study data (2010-2020; N = 1,061 dyads) to determine (a) whether loneliness predicts participants' own and/or their partners' episodic memory and verbal fluency over 8 years, and (b) whether cognitive functioning predicts older spouses' own or their partners' loneliness over the same period. RESULTS: Loneliness predicted participants' own and their partners' loneliness at follow-up, at both time points. Loneliness was also associated with own episodic memory at follow-up, but not with verbal fluency. Episodic memory and verbal fluency predicted one another over time. Neither episodic memory nor verbal fluency predicted loneliness at follow-up. Significant dyadic mediation was established such that Time 1 loneliness was linked with partner's Time 3 episodic memory via that partner's Time 2 loneliness. DISCUSSION: Lonelier older adults displayed worse trajectories of episodic memory over time, yet poor memory did not precede changes to loneliness. Further, having a lonely partner was linked with poorer episodic memory 8 years later, indicating that both one's own and-to a lesser extent-a partner's emotional well-being may be consequential for maintaining cognitive functioning with age. Associations were more clearly established with episodic memory than with verbal fluency, suggesting potential domain-specific effects of loneliness.

Admission and Care of Individuals with Mental Illness in Massachusetts Nursing Homes: An Exploratory Study.

Rising rates of mental illness in nursing homes (NHs) led Congress to pass the 1987 Pre-Admission Screening and Resident Review (PASRR) mandate, aimed at limiting inappropriate institutionalization of people with mental illness (MI) and ensuring appropriate service of NH residents with MI. The law's flexibility results in significant cross-state variations. This study explores Massachusetts' experiences with PASRR implementation, using semi-structured interviews (N=8) with key informants representing major stakeholders. Thematic Content Analysis was used for analysis.Four themes emerged as follows: 1) PASRR screens MI, insufficient in ensuring services, 2) NHs face challenges implementing PASRR, 3) inadequate community-based services increase pressure on NHs, and 4) reactions to PASRR revisions were mixed. Participants agreed that PASRR's first aim was met-avoiding inappropriate institutionalization-but not the second-ensuring appropriate services, and highlighted the limited community alternatives for serving people with MI. More research is needed to understand state variations in PASRR implementation.

Health profiles of older nursing home residents by suicidal ideation: A latent class analysis.

OBJECTIVES: Identify the health profiles of older nursing home residents with and without at-admission self-reported suicidal ideation (SI) and examine the association between the identified profiles and self-reported SI at 90 days. METHODS: Using the Minimum Data Set 3.0 and the ninth Patient Health Questionnaire-9 (PHQ-9) item, we identified 15,277 older residents with and 562,184 without self-reported SI at nursing home admission. Latent class analysis, using frailty, cognitive impairment, palliative care index, pain, and remaining PHQ-9 items as indicators, identified health profiles by at-admission SI and the BCH method estimated their association with SI at 90 days. RESULTS: Profiles identified for residents without at-admission SI were: (1) frail and depressedNoSI (prevalence: 33.9%); (2) frail and severe cognitive impairmentNoSI (38.1%); (3) pre-frailNoSI (28.0%). Residents in the frail and depressedNoSI group had greater odds [adjusted OR: 2.80; 95% Confidence Interval: 2.60-3.00] while those in the frail and severe cognitive impairmentNoSI group had lower odds [aOR: 0.79; 95% CI: 0.71-0.86] of 90-day SI than those in the pre-frailNoSI group. Profiles identified for residents with at-admission SI were: (1) frail and all depressive symptomsSI (22.8%); (2) frail and some depressive symptomsSI (32.2%); (3) frail and severe cognitive impairmentSI (22.9%); (4) pre-frailSI (22.0%). Compared to those in the pre-frailSI group, residents in the frail and all depressive symptomsSI group had greater odds of continuing reporting SI at 90 days [aOR: 1.22; 95% CI:1.09-1.35]. CONCLUSIONS: Findings indicated unique health profiles of nursing home residents at higher risk of new onset of or continued SI.

Health effects of loneliness and social isolation in older adults living in congregate long term care settings: A systematic review of quantitative and qualitative evidence.

BACKGROUND: Mounting evidence of loneliness and negative health impacts has placed loneliness among the "geriatric giants" in need of intervention by the healthcare system. OBJECTIVE: To evaluate the literature regarding the health impact of loneliness among older adults living in congregate living settings (i.e., assisted living, nursing homes). MATERIALS AND METHODS: Five databases were searched for quantitative and qualitative studies from January 1990 through August 2021. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies. Dual review assured the quality of the systematic review conduct. RESULTS: Five qualitative, 3 mixed method, 19 cross-sectional, and 4 cohort articles were eligible. Despite different tools used to measure loneliness, loneliness appeared common among older residents in congregate living situations. In most studies, loneliness was associated with depression (regardless of scale used), albeit all but one came from cross-sectional studies. Few studies noted the association between loneliness and suicidal ideation and frailty. The three cohort studies that evaluated loneliness and mortality had mixed results. Resilience and activities appeared to mediate the association between loneliness and negative health outcomes and social support appeared to moderate associations. CONCLUSIONS: For older adults living in congregate long term care settings, loneliness is a common phenomenon, with cross-sectional studies suggesting links to depression, suicidal ideation, and frailty. Additional longitudinal studies to understand the impact of loneliness on health outcomes in older adults living in congregate settings are needed, as are rigorous evidence-based interventions to address loneliness and mitigate its harmful effects during life's final chapter.

Loneliness and HbA1c among older Irish couples: Retirement as life stage context.

Loneliness is an important determinant of health and mortality among the aging population, including for cardiometabolic health. Yet research has largely focused on individual experiences of loneliness, rather than taking intimate relationships into account. However, recent studies have highlighted that loneliness of a partner may have implications for one's own health and well-being as well. Indeed, this is particularly true among older couples, as life events and shifting time horizons (e.g., retirement, reduced social networks) can lead to greater prominence and salience of one's closest relationships. This study uses dyadic structural equation modeling (SEM) to estimate actor-partner interdependence models (APIM) examining associations between loneliness and HbA1c levels among 1331 older married couples from The Irish Longitudinal Study on Aging (TILDA, 2009-2011). Furthermore, we test whether any such actor or partner effects vary by employment status. Results indicated that one's own loneliness was not significantly linked with HbA1c, irrespective of employment status. However, loneliness of a dyadic partner was significantly associated with elevated HbA1c among retired persons only. These findings underscore that relationship and life course context are crucial when considering the dyadic implications of loneliness for health among the older population.

Dyadic Loneliness and Changes to HbA1c Among Older US Couples: The Role of Marital Support as Stress Buffer.

Objectives: Both experiencing loneliness and having a lonely partner can be psychosocial stressors, with implications for health. Yet, marital support may buffer against the cardiometabolic effects of loneliness. This study examines (1) whether own and/or partner's loneliness predict changes in HbA1c over 4 years and (2) whether marital support moderates these effects. Methods: Actor-partner interdependence models analyzed data from 1,854 older couples who provided psychosocial and biomarker data at two timepoints (2008/2012 or 2010/2014) of the Health and Retirement Study. Results: Neither partner's loneliness predicted changes in HbA1c overall. However, significant interactions indicated that both own baseline loneliness and partner's baseline loneliness predicted significant increases to HbA1c over 4 years among those who reported below-average marital support. Discussion: Both the experience of loneliness and loneliness of a dyadic partner may have longitudinal consequences for cardiometabolic health. However, these effects are contingent upon perceived quality of the marriage, specifically marital support.

Immediate aftermath of a client's death: the experience of home health aides.

This study investigated Home Health Aides' (HHAs) experiences in the immediate aftermath of client death. Semi-structured in-person interviews with 80 HHAs explored how notification of death and reassignment to a new client were handled. Only 42.5% of HHAs were notified of the death; 40% had to notify the agency; 17.5% were not notified at all and had a negative experience. Reassignment preferences varied, but HHAs had a better experience when their preferences were taken into consideration. Study findings suggest that more mindful approaches to transitions following client death would be valued by HHAs and could improve their work experience.

Multitasking in Nursing Homes: Differences Between For-Profit and Nonprofit Quality Outcomes.

BACKGROUND AND OBJECTIVES: Nursing homes (NHs) in the United States face increasing pressures to admit Medicare postacute patients, given higher payments relative to Medicaid. Changes in the proportion of residents who are postacute may initiate shifts in care practices, resource allocations, and priorities. Our study sought to determine whether increases in Medicare short-stay census have an impact on quality of care for long-stay residents. RESEARCH DESIGN AND METHODS: This study used panel data (2005-2010) from publicly-available sources (Nursing Home Compare, Area Health Resource File, LTCFocus.org) to examine the relationship between a 1-year change in NH Medicare census and 14 measures of long-stay quality among NHs that experienced a meaningful increase in Medicare census during the study period (N = 7,932). We conducted analyses on the overall sample and stratified by for- and nonprofit ownership. RESULTS: Of the 14 long-stay quality measures examined, only one was shown to have a significant association with Medicare census: increased Medicare census was associated with improved performance on the proportion of residents with pressure ulcers. Stratified analyses showed increased Medicare census was associated with a significant decline in performance on 3 of 14 long-stay quality measures among nonprofit, but not for-profit, facilities. DISCUSSION AND IMPLICATIONS: Our findings suggest that most NHs that experience an increase in Medicare census maintain long-stay quality. However, this may be more difficult to do for some, particularly nonprofits. As pressure to focus on postacute care mount in the current payment innovation environment, our findings suggest that most NHs will be able to maintain stable quality.

A National-Level Analysis of the Relationship Between Nursing Home Satisfaction and Quality.

Little research has explored the relationship between consumer satisfaction and quality in nursing homes (NHs) beyond the few states mandating satisfaction surveys. We examine this relationship through data from 1,765 NHs in the 50 states and District of Columbia using My InnerView resident or family satisfaction instruments in 2013 and 2014, merged with Certification and Survey Provider Enhanced Reporting, LTCfocus, and NH Compare (NHC) data. Family and resident satisfaction correlated modestly; both correlated weakly and negatively with any quality-of-care (QoC) and any quality-of-life deficiencies and positively with NHC five-star ratings; this latter positive association persisted after covariate adjustment; the negative relationship between QoC deficiencies and family satisfaction also remained. Overall, models explained relatively small proportions of satisfaction variance; correlates of satisfaction varied between residents and families. Findings suggest that satisfaction is a unique dimension of quality and that resident and family satisfaction represent different constructs.

Nursing home Facebook reviews: who has them, and how do they relate to other measures of quality and experience?

BACKGROUND: The growing use of social media creates opportunities for patients and families to provide feedback and rate individual healthcare providers. Whereas previous studies have examined this emerging trend in hospital and physician settings, little is known about user ratings of nursing homes (NHs) and how these ratings relate to other measures of quality. OBJECTIVE: To examine the relationship between Facebook user-generated NH ratings and other measures of NH satisfaction/experience and quality. METHODS: This study compared Facebook user ratings of NHs in Maryland (n=225) and Minnesota (n=335) to resident/family satisfaction/experience survey ratings and the Centers for Medicare and Medicaid (CMS) 5-star NH report card ratings. RESULTS: Overall, 55 NHs in Maryland had an official Facebook page, of which 35 provided the opportunity for users to rate care in the facility. In Minnesota, 126 NHs had a Facebook page, of which 78 allowed for user ratings. NHs with higher aid staffing levels, not affiliated with a chain and located in higher income counties were more likely to have a Facebook page. Facebook ratings were not significantly correlated with the CMS 5-star rating or survey-based resident/family satisfaction ratings. CONCLUSIONS: Given the disconnect between Facebook ratings and other, more scientifically grounded measures of quality, concerns about the validity and use of social media ratings are warranted. However, it is likely consumers will increasingly turn to social media ratings of NHs, given the lack of consumer perspective on most state and federal report card sites. Thus, social media ratings may present a unique opportunity for healthcare report cards to capture real-time consumer voice.

Supporting home health aides through a client's death: The role of supervisors and coworkers.

This study evaluated home health aides (HHAs) experiences related to the support they received around a client's death. 80 HHAs who had recently experienced a client death participated in semi-structured interviews. They were asked to what extent they felt support was available to them from their supervisor or coworker, whether they sought support, the type of support they sought, and how helpful it was. They were also asked what type of support they would like to receive. Findings showed that just over one third of the HHAs felt they could turn to their supervisors for support and one fifth could turn to their coworkers. Even fewer sought support. However, those who did receive support, found it to be extremely helpful, in particular when the support came from supervisors. Desired types of support were primarily related to having someone to talk to or check in with them, pointing to an important role of nursing supervisors in providing critical support to direct care staff.

Home Health Aides' Experience With Client Death: The Role of Employer Policy.

Home health aides (HHAs) are members of a rapidly growing occupation. They often develop close ties to patients and their family and can experience significant grief when a patient dies. Yet agencies often provide little support or structure to help staff cope during this time. For instance, home care agencies do not always notify their staff of client death and some have policies in place to prevent any follow-up contact with a deceased client's family. Little is known about how these agency factors affect HHAs' work experience. This mixed-method study explored the experiences of 78 HHAs working either at an agency with a restrictive policy regarding contact with a client's family after client death or an agency without such a policy in place. Data were collected through semistructured in-person interviews. Employment outcomes included various aspects of job satisfaction and intention to change jobs. HHAs' responses to client death were assessed with measures of grief and grief processing, and with open-ended questions exploring their experiences in this context. Findings indicated that HHAs from the restrictive agency were significantly more likely to be considering other job options. They also reported significantly lower satisfaction with received supervision, and significantly less grief processing activity. Findings suggest that HHAs from the agency without a contact-restrictive policy had a more positive experience at work and more opportunity to process the client's death.

Coping With Client Death: How Prepared Are Home Health Aides and What Characterizes Preparedness?

This study explored the experiences of 80 home health aides (HHAs) whose client died within the last 2 months. Data collection involved comprehensive semi-structured in-person interviews to try to better understand characteristics of HHAs and their clients associated with preparedness for death. Among those, personal end-of-life (EOL) care preferences of HHAs and having knowledge of preferences and decisions regarding client's EOL care showed significant links to preparedness. Findings suggest that HHAs' preparedness for client death could be enhanced both by addressing their personal views on EOL care and by providing more information about the client's EOL care plans.

Preparedness for Resident Death in Long-Term Care: The Experience of Front-Line Staff.

CONTEXT: Although resident death is a common occurrence in long-term care, little attention has focused on how prepared certified nursing assistants (CNAs), who provide most of residents' daily care, are for this experience. OBJECTIVES: To identify characteristics of the resident, CNA, and care context associated with CNAs' preparedness for resident death and to determine differential patterns for emotional versus informational preparedness. METHODS: One hundred forty CNAs completed semistructured, in-person interviews concerning their experiences regarding resident death. The associations of CNA characteristics (e.g., personal end-of-life [EOL] care preferences), CNAs' perceptions of resident status (e.g., knowledge of resident's condition), and the caregiving context (e.g., support from coworkers and hospice involvement) with emotional and informational preparedness were examined by the use of bivariate and multivariate analyses. RESULTS: CNAs who reported that their resident was "aware of dying" or "in pain" expressed greater levels of both emotional and informational preparedness. CNAs who endorsed an EOL care preference of wanting all possible treatments regardless of chances for recovery were likely to report lesser emotional preparedness. More senior CNAs, both in regard to age and tenure, reported greater preparedness levels. Greater support from coworkers and hospice involvement also were associated with greater levels of both facets of preparedness, the latter in particular when hospice care was viewed positively by the CNA. CONCLUSION: Having more information about resident status and more exchange opportunities within the care team around EOL-related challenges may help CNAs feel more prepared for resident death and strengthen their ability to provide good EOL care.

Nursing home practices following resident death: the experience of Certified Nursing Assistants.

This study examined certified nursing assistants' (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident's body, filling the bed with a new resident, and how they were notified about the death. The facilities' practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience.