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      Direct and Indirect Effects of COVID-19 on Long-Term Care Residents and Their Family Members


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          The first cases of COVID-19 in Israel were reported in February 2020. Family visits were prohibited from March 10, 2020, and then allowed on a limited basis on April 20, 2020. This article examines how COVID-19 impacted long-term care residents and their family members from the perspective of long-term care facility (LTCF) administrative staff.


          An online survey was sent to Israeli LTCF administrators between mid-July and mid-October 2020, resulting in 52 completed questionnaires. Quantitative analysis involved descriptive statistics using SPSS, with differences compared via t tests, ANOVA, and χ<sup>2</sup> tests. Qualitative analysis involved thematic analysis of responses to open-ended questions.


          COVID-19 was reported to have multiple types of negative impact on residents, including direct effects on morbidity and mortality as well as indirect effects manifested as negative reactions to measures aimed at limiting infection, including isolation from relatives, decreased activities for residents, and COVID-19 testing. The impact of isolation on LTCF residents was reported as negative or very negative by over three-quarters of the respondents. Behavioral problems among residents increased in 32% of the facilities. The qualitative results suggested that adverse effects on residents and family members were partially mitigated by the use of communication technologies.


          The interplay of multiple factors affected LTCF residents against the backdrop of COVID-19 restrictions. The emergence of mitigating factors which provide solutions to some of the challenges has the potential of improving quality of care for LTCF residents as the pandemic continues and thereafter.

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          Allowing visitors back in the nursing home during the COVID-19 crisis – A Dutch national study into first experiences and impact on well-being

          Objectives To prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents’ well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context, the compliance to local protocols and the impact on well-being of residents, their family caregivers and staff. Design A mixed-methods cross-sectional study was conducted Setting and participants In total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study. Methods A mixed-method cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (i.e. local visiting protocols) and a WhatsApp group. Results Variation in local protocols was observed, for example related to the use of personal protective equipment, location and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time. Conclusions and implications These results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance.
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            Association Between Nursing Home Crowding and COVID-19 Infection and Mortality in Ontario, Canada

            Nursing home residents have been disproportionately affected by coronavirus disease 2019 (COVID-19). Prevention recommendations emphasize frequent testing of health care personnel and residents, but additional strategies are needed.
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              The Impact of COVID-19 Measures on Well-Being of Older Long-Term Care Facility Residents in the Netherlands

              The fear of the new Coronavirus Disease 2019 (COVID-19) globally forced health authorities to take drastic actions to prevent spreading of infections among citizens. Long-term care facility (LTCF) residents are especially susceptible for fatal or severe outcomes of COVID-19 infection because of high prevalence of frailty and comorbidity, sometimes atypical COVID-19 symptoms, and circumstances such as insufficient personal protective equipment and testing capacity, and staff working while having mild symptoms. 1 , 2 On March 20, 2020, the Dutch government implemented a visitor ban in all LTCFs. In many instances physical visits were replaced by social contact via telephone and video calls, or through windows. Many LTCFs closed social facilities and stopped daytime programs. Although the LTCF's policy prioritized safety, scarce attention was paid to well-being and autonomy. The study aims to gain insight into the consequences of COVID-19 measures on loneliness, mood, and behavioral problems in residents in Dutch LTCFs. Methods A cross-sectional design was applied. Data were collected anonymously between April 30 and May 27, 2020, in 3 independent samples of residents without severe cognitive impairment (CI), family members of residents with and without CI, and care staff from all unit-types in Dutch LTCFs (nursing homes and residential care facilities), using a semi-open online survey. A total of 357 LTCF organizations were invited by e-mail to participate by distributing information about the study and a link to the survey to eligible participants. Classification of residents' loneliness level was assessed with 1 item. 3 Mood in residents was assessed with the Mental Health Inventory 5-index (MHI-5; range 0–100, scores <60 indicate poor mental health). 4 Change in frequency of residents' mood symptoms since the start of the visitor ban was assessed among relatives who had contact with residents in the 4 weeks before the assessment. Change in severity of problem behavior on unit-level was assessed among staff working in direct care, using 10 domains of behavioral functioning from the Neuropsychiatric Inventory. 5 Descriptive statistics, frequencies, independent t tests and χ2 tests were performed using SPSS 25.0 (IBM Corp, Armonk, NY). Results A total of 193 residents participated; 1387 of 1609 relatives had spoken with a resident in the past 4 weeks; 849 (61%) were relatives of a resident with CI. There were 623 of 811 care professionals who worked in direct care; 246 (39%) in psychogeriatric units. Loneliness was reported by 149 (77%) residents: 50% perceived themselves as moderately, 16% as strongly, and 11% as very strongly lonely. Relatives and staff classified respondents as not lonely (14%; 19%, respectively), moderately (50%; 34%), strongly (25%; 31%), and very lonely (11%; 16%). Staff classified residents without CI more lonely than residents with CI (P < .006). Mean MHI-5 score for residents was 56.6 (SD 20.4), 51% had scores <60. Only 27% of relatives reported no change in residents' mood status. On average, the frequency increased in 2.2 (SD 1.9) of 6 mood symptoms (Figure 1 ). Changes were reported more often in residents without CI (P = .035). Happiness was less often and sadness was more often reported by family of residents without CI than with CI (P = .000; P = .008, respectively). Fig. 1 Change in mood and behavioral problems in LTCF residents during the visitor ban due to COVID-19, as compared with before the visitor ban. Change in frequency of residents' mood symptoms is reported from the perspective of relatives who have spoken to the resident in the 4 weeks before the assessment (n = 1387). Change in severity of residents' behavioral problems is reported by direct care staff (n = 623) and was responded on a unit level. Responses from those who indicated specific mood or behavior were not present or who did not know, were not taken into account. More than half of the staff reported an increase in severity of agitation, depression, anxiety, and irritability (Figure 1). On average, an increased severity in 4.0 (SD 2.7) of 10 problem behaviors was reported on units. Increased severity was reported more often by staff of nonpsychogeriatric units as compared with psychogeriatric units [mean 4.4 (SD 2.5) vs 3.3 (SD 2.8); P = .000]. The largest differences were found for increased severity of symptoms in appetite disorders, respectively nonpsychogeriatric units (57%) vs psychogeriatric units (22%), depression (78% vs 53%), and anxiety (76% vs 52%). Conclusions During the COVID-19 measures, well-being of older LTCF residents was severely affected. Six to 10 weeks after implementation of the visitor ban, high levels of loneliness, depression, and a significant exacerbation in mood and behavioral problems were reported. Residents without CI seemed to be the most affected. The implementation of the measures has reduced the incidence of COVID-19 infections and thus the number of deaths in LTCFs; however, a better balance between physical safety and well-being is necessary, as social isolation is a serious health threat for older residents and increases the risk of mortality. 6 , 7 During a Dutch pilot, the cautious opening of nursing homes using a Dutch guideline adapted to the local context, did not lead to new infections. 8 As social contact and meaningful daytime activities are essential for LTCF residents, 9 , 10 LTCFs should implement policies on allowing visitors and continuing daytime activities as much as possible in times of COVID-19. This should be done in conjunction with residents, family, and staff, prioritizing residents' well-being and autonomy again.

                Author and article information

                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                8 March 2022
                8 March 2022
                : 1-9
                [1] aDepartment of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
                [2] bMinerva Center for the Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
                [3] cIgor Orenstein Chair for the Study of Geriatrics, Tel Aviv University, Tel Aviv, Israel
                Author notes
                *Jiska Cohen-Mansfield, jiska@ 123456tauex.tau.ac.il
                Copyright © 2022 by S. Karger AG, Basel

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                : 3 May 2021
                : 21 November 2021
                Page count
                Figures: 1, Tables: 2, References: 20, Pages: 9
                Behavioral Science Section: Research Article

                covid-19 restrictions,isolation of older adults,behavioral issues for older adults,israel,nursing homes


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