key: cord-0930668-8tud5fao
authors: McArthur, Caitlin; Saari, Margaret; Heckman, George A.; Wellens, Nathalie; Weir, Julie; Hebert, Paul; Turcotte, Luke; Jiblou, Jalila; Hirdes, John P.
title: Evaluating the effect of COVID-19 pandemic lockdown on long-term care residents’ mental health: a data driven approach in New Brunswick
date: 2020-10-26
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.10.028
sha: 7a7e50be625d3125ba2f175766b26c16d341a672
doc_id: 930668
cord_uid: 8tud5fao

Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the LTCF can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behaviour problems in a network of seven LTC homes in New Brunswick, Canada where mitigative strategies were deployed to minimize poor mental health outcomes (e.g., virtual visits, increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modelled the change within and between residents for depression, delirium, and behavioural problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, p<0.0001), the number of residents experiencing delirium (4.5% to 3.5%, p=0.51) and behavioural problems (35.5% to 30.2%, p=0.19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (p<0.002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioural problems. Our analyses demonstrate poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment and researchers can examine the data to identify better management strategies for when pandemic strikes again.

J o u r n a l P r e -p r o o f demonstrate poor mental health outcomes associated with lockdown can be mitigated with 24 thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers 25 can use outputs to guide resource deployment and researchers can examine the data to identify 26 better management strategies for when pandemic strikes again. to be a pandemic. As we put pen to paper, the WHO is reporting over 30 million cases and over conditions including depression, delirium, and behavioural problems. Depression is one of the 39 most common psychiatric condition in LTC, 5 with rates ranging from 11% 6 to 16.9%. 7 Delirium, 40 an acute change in attention and cognition that develops rapidly over several hours or days, 8 has 41 been estimated to affect 14% of LTC residents. 9 b Across Canada, an estimated 26 to 66% of 42 LTC residents exhibit behavioural problems, 10 which can be disruptive, distressing or 43 challenging to persons in the LTC environment including other residents, staff, and family. 11

Reduced social interaction associated with lockdown during the COVID-19 pandemic could 45 further increase the risk for worsening mental health outcomes. Stress among LTC staff could 46 lead to stress among residents, increasing the risk for delirium and behavioural problems. 47 Isolation, lack of family contact, and lack of stimulation from social activities within the home 48 could lead to boredom, loneliness, and depression. Indeed, in the general population quarantine 49 measures during COVID-19 have consistently been associated with negative psychological 50 J o u r n a l P r e -p r o o f outcomes. 12 Reports from LTC homes in Italy suggest as many of 50% of LTC residents 51 experienced hypokinetic delirium superimposed on dementia (e.g., residents refused food and 52 had difficulty getting out of bed). 13 Calls have arisen to overcome limited physical interaction 53 and improve social interaction via virtual strategies (e.g., FaceTime, Zoom) and through creative 54 outlets to overcome workload barriers (e.g., student visitors). 14 However, the implementation of 55 such programs may be limited by access to resources (e.g., tablets or smartphones), and their 56 effect on mental health outcomes is unclear. The purpose of our article is to demonstrate how thoughtful use of mitigating strategies (e.g., 74 window visits, use of technology) and clinical information systems like the interRAI LTCF can 75 inform clinical care and prevent worsening mental health outcomes (depression, delirium, and 76 behavioural problems) during the COVID-19 pandemic. Our discussion will focus on 77 internationally adopted interRAI instruments (i.e., interRAI LTCF). The interRAI LTCF is a standardized assessment tool which is administered by trained registered 106 nurses within New Brunswick LTC homes. Information to complete the assessment is collected 107 through interaction with residents, their families, and the clinicians who work with them, and 108 chart review if required. In New Brunswick, the interRAI LTCF is administered within 11 days 109 of admission, and on a quarterly basis thereafter, or if there is a significant change in status.

Importantly, all New Brunswick LTC homes continued to complete scheduled and change of 111 status LTCF assessments throughout the lockdown period.

112 Table 1 provides a summary of the outcomes and covariates examined. We described social 113 engagement with family through two items in the LTCF, one capturing in-person visits the other 114 capturing other interaction (e.g., telephone or email) in the last 3 days, and using the Revised 115 Index of Social Engagement (RISE) scale (Table 1) . correlation matrix was deemed to be more suitable for these data because the correlation between 127 responses is expected to decrease over time. Age, sex, and lockdown were included in all models 128 regardless of significance. We modelled the LTC home's effect by comparing to a reference 129 home, called 'Facility X', which demonstrated differences in univariate analyses. Interactions 130 that were hypothesized a priori to influence the outcomes were entered into the multivariate 131 models and quadratic terms were used to test for curvilinearity of the continuous covariates. The 132 final multivariate models were constructed by adding all variables to the model and retaining 133 those significant at p<0.05.

We included 4209 assessments from 765 LTC residents. On average, residents had 4.7 (standard 136 deviation, 3.3) assessments between January 2017 and June 2020. Table 2 After: 30.2%, p=0.19) and with delirium (Before: 4.5%; After:3.5%, p=0.51) was not different.

The final multivariate models (Table 3) We document an example of how clinical information systems like the interRAI LTCF can be 171 used in a community of practice to examine changes in resident outcomes over time and evaluate 172 strategies put in place to mitigate negative outcomes. In particular, the network of seven private, 173 not-for-profit LTC homes in our study who did not experience COVID-19 outbreaks but were 174 locked down for three months were able to mitigate the negative effects of social isolation on 175 depression, delirium, and behavioural problems. Using depression, delirium, and an aggressive 176 behaviour outcome embedded within the interRAI LTCF quantified changes over time including 177 effects of COVID-19 policies such as lockdown without requiring additional documentation or 178 data collection. In addition, homes can use these routinely collected data to monitor residents' 179 mood over time and evaluate the effect of home-level strategies (e.g., redeploying activity staff).

Likewise, policymakers can use these data at a jurisdiction-level to evaluate the effect of 181 strategies (e.g., providing iPads) and plan for additional resources as needed.

Our data suggest that with thoughtful deployment of strategies to improve LTC residents' social Monitoring the individuals' needs and the staffing available will be a marathon of post-outbreak 218 follow up, as the crisis profoundly affects both.

However, obtaining data and using it to guide decisions requires ongoing assessments. In our 220 example of the seven homes in New Brunswick, assessments continued to be completed 221 throughout lockdown, so it could be used to guide practice and evaluate changes over time.

Granted, there were no COVID-19 outbreaks in the seven homes, but home-level stress and In this study, we were most interested in the temporal effects of lockdown on mental health 244 outcomes, we did not examine fully explanatory models for our outcomes. We were able to 245 determine changes in our study group but did not have contemporaneous controls to ensure the 246 effects were real. In addition, outcomes other than mental health concerns were not fully Global measure of cognitive status based on functional parameters rated by severity. Scored 0 (intact) to 6 (very severe impairment).

Revised Index of Social Engagement 33

Measures positive features of LTC residents' social behaviour using 6 items. 0 (no engagement) to 6 (high engagement)

LTC=long-term care 

COVID-19) in Long-term Care 274 Facilities in Ontario, Canada

COVID-19 Directive #3 for Long-Term Care Homes under the LongTerm Care Homes 279 Act

Loneliness and Isolation in Long-term Care and the COVID-19 Pandemic

Depression in the elderly

The management of depression in older nursing home residents

The prevalence and recognition of 287 major depression among low-level aged care residents with and without cognitive impairment

102 Diagnostic 290 and Statistical Manual of Mental Disorders: DSM-5

$199 (hbck)

£45 $69 (pbck)

Longitudinal patterns of delirium 294 severity scores in long-term care settings

Beyond the "iron lungs of gerontology": Using 297 evidence to shape the future of nursing homes in Canada

dementia/Caring-for-someone/Understanding-symptoms/Responsive-behaviours

Quarantine Measures during Serious Coronavirus Outbreaks: A Rapid Review

Nursing homes or besieged castles: COVID-19 in northern Italy. The 307 Lancet Psychiatry

Competing crises: COVID-19 countermeasures and social 309 isolation among older adults in long-term care

Chronic disease management: a primer for physicians

Reliability of the interRAI suite of assessment 312 instruments: A 12-country study of an integrated health information system

Sharing clinical information across care settings: The birth of an 316 integrated assessment system

Measuring depression in nursing home residents with 318 the MDS and GDS: An observational psychometric study

The Seniors Quality Leap Initiative (SQLI): An 322 International Collaborative to Improve Quality in Long-Term Care

The impact of COVID-19 measures on well-330 being of older long-term care facility residents in the Netherlands

Delirium in hospitalized older patients: Recognition and risk factors

Risk Factors for Depression in Long-Term Care: A Systematic 335 Review

Factors associated with aggressive behavior between residents 337 and staff in nursing homes

Nurse Aide Retention in Nursing Homes

Evaluation of a staff training 342 programme to reimplement a comprehensive health assessment

InterRAI Clinical Assessment Protocols (CAPs) for Use with 345 Community and Long-Term Care Assessment Instruments. Version 9

The aggressive behavior scale: A new scale to measure aggression based 348 on the minimum data set

The MDS-CHESS scale: a new measure to predict mortality in 351 institutionalized older people

Scaling ADLs within the MDS

MDS cognitive performance scale

A revised Index for 360 Social Engagement for long-term care