Long-term Care Population Research Articles

Something to Chew on; Plate-Waste at an Ontario Veteran's Centre.

There is paucity of data assessing levels of food/beverage waste in long-term care (LTC) facilities, especially in Ontario. Observations in the Veteran's Centre (VC) at Sunnybrook Health Sciences Centre (Sunnybrook) indicated food/beverage waste may be high, potentially impacting sustainability efforts within our institution. Before proceeding with waste reduction efforts, we conducted a comprehensive 3-day waste-audit of food/beverage items provided to VC residents with the goal of understanding the extent of food/beverage waste at VC, items wasted, and any other factors that may inform future changes. Our results indicate that 28% of items served to residents were wasted. Lunch was the meal with greatest waste at 31% and waste of solid items was 12% higher than that of liquids. We observed a large variability in waste between residents and within each resident, with 15% of residents wasting >50% of items provided. This study provides a deeper insight into the magnitude of food/beverage waste in a LTC population and highlights the importance of considering individualized strategies to address waste to avoid negative impact on residents.

Utilization and Potential Disparities in Access to Physical Therapy for Spine Pain in the Long-Term Care Population

ObjectiveTo determine the frequency of physical therapy (PT) services and potential disparities in receiving PT among Medicare fee-for-service beneficiaries with a history of spine pain who live in long-term care (LTC) settings. DesignSecondary cross-sectional analysis of Medicare administrative data on beneficiaries with a history of spine pain from 2017-2019. We identified LTC residents using a validated algorithm, then identified and described PT episodes that occurred after the LTC index date. To identify potential disparities in access to PT services, we performed multivariable logistic regression to determine resident demographic, clinical, and community factors associated with receiving PT. SettingNot applicable. ParticipantsMedicare fee-for-service LTC residents aged ≥65 years. InterventionsNot applicable. Main Outcome MeasuresReceiving PT services. ResultsOf the 999,495 LTC residents with a history of spine pain, 49.6% received PT. Only 12.1% of PT episodes specifically treated spine pain. The odds of receiving PT were higher for residents with pain in multiple spine regions or neuropathic pain (OR, 1.27; 95% confidence interval CI, 1.26-1.29) and for residents with inpatient admissions (OR, 1.76; 95% CI, 1.75-1.78). Odds of receiving PT were lower for residents from minoritized racial and ethnic groups, and for residents with dementia (OR, 0.89; 95% CI, 0.88-0.90), depression (OR, 0.95; 95% CI, 0.94-0.96), or who lived in urban or more socioeconomically deprived areas. ConclusionsAlthough nearly half of LTC residents with histories of spine pain received PT services, most PT was not for spine pain. There are potential disparities in access to PT for LTC residents from minoritized groups living in urban and more deprived areas. Further work should examine PT outcomes and remove barriers to PT for LTC residents with histories of spine pain.

Reliability and Validity of the Minimum Data Set 3.0 Standardized Self-Care and Mobility Data Elements Among Long-Stay Nursing Home Residents.

To assess the reliability and validity of a subset of the Minimum Data Set (MDS) 3.0 Section GG data elements (i.e., standardized self-care, mobility) among 147 long-stay nursing home residents in seven nursing homes in five states. Trained clinicians assessed residents' functional abilities using select Section GG items and Section G activities of daily living items. We examined the reliability and construct validity of the data using Cronbach's alpha, correlations between Section G and Section GG items, confirmatory factor analysis (CFA), and Rasch measurement analysis. We observed acceptable internal consistency values for all (0.98), self-care (0.93), and mobility (0.98) standardized items. Correlations between conceptually related Section G and Section GG items ranged from -0.53 to -0.84. CFA findings found acceptable values for all fit indices. Rasch analysis showed most items had acceptable fit statistics, except for the easiest and most difficult activities. These findings establish the feasibility of data collection, internal consistency reliability, and construct validity of the selected Section GG items among long-stay nursing home residents. Use of the same standardized data elements in post-acute and long-term care populations can support improved coding of function and enhance our understanding of resident functioning. [Research in Gerontological Nursing, 17(2), 57-64.].

Integrating health and social care in the community to support a new model of Long-term Life Care at home.

Background: Long-term care (LTC) reform was an international priority well before the COVID-19 pandemic. While strategies to promote de-institutionalization, rehabilitation, caregiver support and enhanced home and community care have varied by country in terms of implementation and success, the pandemic universally reinforced existing system-specific barriers and weaknesses. In Canada, heightened access issues and silo-ed delivery of community-based medical, functional and social care and support services contributed to increased caregiver burnout and growing residential care waitlists.
 Aims: This study aimed to develop an alternative model to residential LTC that would enable older adults to live, age and receive care at home long-term. The specific objectives were to: 1) describe variation in medical, functional and psychosocial ‘life care’ needs of community-dwelling older adults; 2) develop a model of needs-based care with packages to support variation in needs; and 3) to assess preliminary feasibility of the model using the Ontario, Canada (population 15 million) health care market. 
 Approach: An exploratory, sequential, mixed methods design was applied (5). Phase 1 involved historical analysis of 2017-18 Ontario interRAI home care assessments (n=283,601) and 2018-19 Ontario service utilization data (n=115,000) to develop unique patient vignettes. Phase 2 was a 6-week modified eDelphi process with interdisciplinary home care clinicians (n=42) to develop care packages for the model, including types and dose of care and services. Six focus groups (n=67) were then conducted with older adults, caregivers and health and social care providers across Ontario to validate and refine the model. Phase 3 explored feasibility of the emerging model through comparison of the home care patient vignettes with the needs of the residential LTC population using 2017-18 Ontario interRAI data (n=115,000). Preliminary costing of the model was based on existing system per diems and direct care costs in comparable transitional care models.
 Results: A model of ‘Long-term Life Care’ at home (LTLifeC model) includes care packages to meet the dominant life care needs of 6 unique patient groups representing known predictors of LTC home admission: social frailty, caregiver distress, chronic disease, cognition/ behaviours, medical complexity, and geriatric syndromes. Overlap in care needs of home care and LTC populations confirms potential to shift care to the community; yet current home care clients receive six times less daily care hours on average, compared to residential LTC standards. New LTLifeC packages of home-based interdisciplinary care ranged from 3.1-8.9 hours daily, including comprehensive assessment, integrated care planning, direct care provision and community referral(s). Initial cost comparisons suggest plausible short and long-term system benefits of model adoption.
 Learnings: Evidence-informed decision making for sustainable home and community care as part of an integrated system of LTC requires attention to both routinely collected health information, or ‘big data’, and expertise by lived-experience. Adoption of the LTLifeC model will require decision-making to prioritize societal values for living and aging at home and in community. 
 Next Steps: An evaluation framework will be developed to guide pilot implementation and testing of the LTLifeC model through the lens of the quadruple aim.

IDENTIFYING ACUTE PRECIPITANTS AND CONSEQUENCES OF RACIAL/ETHNIC CONFLICTS IN RESIDENT-TO-RESIDENT AGGRESSION

Abstract Resident-to-resident aggression (RRA) includes negative and aggressive physical, sexual, or verbal interactions between long-term care residents that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Though not explored in detail, previous research has shown that ethnic stereotyping may contribute to RRA. Our goal was to examine, for the first time, acute precipitants and consequences of RRA involving racial and ethnic conflicts. The parent study included comprehensive quantitative and qualitative information of 2,011 residents in 10 randomly-selected New York State nursing homes. Our qualitative analyses used an events perspective, focusing on how aggressive situations unfolded. We identified 51 single or repeated incidents of racial and ethnic conflicts during the study observation period. At the facility level, racial and ethnic conflicts were most commonly triggered by congested living spaces. At the relational level, racial and ethnic conflicts were frequently preceded by negative reactions to residents with cognitive impairment. At the individual level, racial and ethnic conflicts were found to be preceded by residents’ unmet or unrecognized needs. Unresolved racial and ethnic conflict commonly resulted in aggression escalation and spillover. Our results indicated racial and ethnic conflicts occurred commonly and repeatedly. Such behavior appeared tolerated and normalized, with limited institutional response. As the long-term care population becomes increasingly diverse, recognizing and addressing potential racial and ethnic conflicts becomes more pressing. Targeting racial and ethnic conflicts in RRA for intervention may also improve interactions between residents and frontline workers.

ANTIHYPERTENSIVE DEPRESCRIBING AND DISABILITY IN VA NURSING HOME RESIDENTS WITH AND WITHOUT DEMENTIA

Abstract Deprescribing antihypertensives is of growing interest in geriatric medicine, yet clinical trial evidence is lacking. We leveraged the Veterans Affairs (VA) electronic health data and emulated a target trial of antihypertensive deprescribing on longitudinal change in disability, measured by activities of daily living (ADL), ranging 0-28. Residents included were ≥65 years with long-term stays ≥12 weeks from 2006-2019 (n=42537). We excluded those not on antihypertensives and with very high blood pressure or heart failure. The eligible residents (n=13041) were divided into newly deprescribed (reduced number of antihypertensives or dose of ≥30% after a 4-week washout) and stable users and followed up for 2 years or censored at death, discharge, or non-adherence. We used linear mixed-effects regressions to estimate per-protocol effects, with inverse probability of treatment weighting (IPTW) to adjust for confounders and additional inverse probability of censoring weighting to account for informative censoring. Analysis was stratified by dementia (yes/no) to examine the potential modification. In non-dementia subgroup (n=5954), newly deprescribed residents (n=561) had a worse ADL score (βtreat [95% CI] = 1.36 [0.82, 1.91]) compared to stable users (n=5393). Over time, ADL scores increased (worsened) 0.13 per 3 months (βtime = 0.13 [0.09, 0.17]) while antihypertensive deprescribing statistically significantly attenuated this increase by 0.25 per 3 months (βtime × treat = -0.25 [-0.48, -0.03]). The dementia subgroup showed imprecise effect (βtime × treat = -0.0003 [-0.13, 0.12]). More evidence is needed on the benefits and harms of deprescribing in long-term care populations and the importance of dementia in these relationships.

Intercultural adaptation and influencing factors analysis of the Chinese version of the anxiety scale for the older adults in a long-term care population.

The purpose of this study was to translate the Geriatric Anxiety Scale-Long-Term Care into Chinese and to assess its reliability and validity in a long-term care population, as well as to explore factors contributing to anxiety in older adults requiring long-term care. The study recruited 399 older adults residents requiring long-term care and used the Brislin double translation-back-translation method to create the initial Chinese version of the Geriatric Anxiety Scale-Long-Term Care. The study used internal consistency and split-half reliability to assess the reliability of the scale, as well as exploratory factor analysis, validation factor analysis, and content validity to assess the validity of the scale. Linear regression was used to analyze the relationship between the independent variables and anxiety levels in the long-term care population. The Cronbach's coefficient value of the Chinese version of the Geriatric Anxiety Scale-Long-Term Care was 0.81, and the split-half reliability was 0.80. The results of exploratory factor analysis showed support for a one-dimensional factor structure. The results of the validation factor analysis indicated a good fit for the one-factor model. Gender (β = 0.190, 95% CI:0.540 ~ 1.546, p < 0.001), self-rated health (β = 0.220, 95% CI:0.379 ~ 0.953, p < 0.001), life satisfaction (β = -0.315, 95% CI: -1.355 ~ -0.734, p < 0.001) and participation in activities (β = -0.106, 95% CI: -1.122 ~ -0.084, p < 0.05) were significant predictors of anxiety levels in the long-term care population. The Chinese version of the Geriatric Anxiety Scale-Long-Term Care has good reliability and validity in the long-term care population. The Geriatric Anxiety Scale-Long-Term Care is effective in assessing the anxiety level of the Chinese long-term care older adults population and provides an opportunity to detect and observe anxiety disorders in the long-term care population.

Neighborhood resources and risk of cognitive decline among a community-dwelling long-term care population in the U.S.

ObjectiveTo examine the associations between neighborhood resources (i.e., number of restaurants, recreation centers, or social services for seniors and persons with disability per land area) and cognitive decline among a community-dwelling long-term care population and whether they differ by baseline cognition status. Study designProspective longitudinal cohort study. MethodsWe used a longitudinal dataset that assessed over a two-year period older adults receiving state-funded home- and community-based services in Michigan Metropolitan areas (N = 9,802) and applied nonlinear mixed models with a random intercept with Poisson distribution. ResultsCognitively intact older adults were less likely to experience cognitive decline when they resided in resource-rich neighborhoods, compared to those cognitively intact but living in neighborhoods that lacked resources. But their cognitively impaired or dementia-diagnosed counterparts did not similarly benefit from living in neighborhoods with rich resources. ConclusionsNeighborhood resources may be an important aspect of intervention to mitigate cognitive decline before older adults become cognitively impaired.

Cerebrovascular Manifestations of SARS-CoV-2: A Comprehensive Review.

The risks of cerebrovascular manifestations due to SARS-CoV-2 infection are significantly increased within the first 6 months of the infection. Our work aims to give an update on current clinical aspects of diagnosis and treatment of cerebrovascular manifestations during acute and long-term SARS-CoV-2 infection. The incidence of acute ischemic stroke and haemorrhagic stroke during acute SARS-CoV-2 patients is estimated at 0.9 to 4.6% and 0.5-0.9%, respectively, and were associated with increased mortality. The majority presented with hemiparesis, dysarthria, sensory deficits, and a NIHSS score within 5-15. In addition, beyond the first 30 days of infection people with COVID-19 exhibited increased risk of stroke. During acute phase, age, hypertension, diabetes, and medical history of vascular disease were increased in patients with COVID-19 with new onset of cerebrovascular manifestations, while during long-COVID-19, the risk of cerebrovascular manifestations were found increased regardless of these factors. The management of patients with large-vessel ischemic stroke fulfilling the intravenous thrombolysis criteria are successfully treated according to the guidelines, while hyperosmolar therapy is typically administered in 4- to 6-h intervals. In addition, prophylaxis of anticoagulation therapy is associated with a better prognosis and low mortality during acute and post hospital discharge of patients with COVID-19. In this work, we provide a comprehensive review of the current literature on acute and post-acute COVID-19 cerebrovascular sequelae, symptomatology, and its pathophysiology mechanisms. Moreover, we discuss therapeutic strategies for these patients during acute and long-term care and point populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease are more likely to develop cerebrovascular complications.

Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents.

Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications. Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications). More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group). The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

Developing Acute Event Risk Profiles for Older Adults with Dementia in Long-Term Care Using Motor Behavior Clusters Derived from Deep Learning.

This paper uses deep (machine) learning techniques to develop and test how motor behaviors, derived from location and movement sensor tracking data, may be associated with falls, delirium, and urinary tract infections (UTIs) in long-term care (LTC) residents. Longitudinal observational study. A total of 23 LTC residents (81,323 observations) with cognitive impairment or dementia in 2 northeast Department of Veterans Affairs LTC facilities. More than 18months of continuous (24/7) monitoring of motor behavior and activity levels used objective radiofrequency identification sensor data to track and record movement data. Occurrence of acute events was recorded each week. Unsupervised deep learning models were used to classify motor behaviors into 5 clusters; supervised decision tree algorithms used these clusters to predict acute health events (falls, delirium, and UTIs) the week before the week of the event. Motor behaviors were classified into 5 categories (Silhouette score= 0.67), and these were significantly different from each other. Motor behavior classifications were sensitive and specific to falls, delirium, and UTI predictions 1week before the week of the event (sensitivity range= 0.88-0.91; specificity range= 0.71-0.88). Intraindividual changes in motor behaviors predict some of the most common and detrimental acute events in LTC populations. Study findings suggest real-time locating system sensor data and machine learning techniques may be used in clinical applications to effectively prevent falls and lead to the earlier recognition of risk for delirium and UTIs in this vulnerable population.

COVID-19 in Long-Term Care: The Built Environment Impact on Infection Control.

The purpose of this article is to review available literature for evidence-based impact of the built environment upon the prevention and management of COVID-19 with a view to emphasizing lessons learned for future infection control of pandemics. This is urgently needed given the devastation brought upon long-term care residents worldwide. Long-term care (LTC) facilities face a battle to protect their residents. Previous studies of infection control design issues have focused generally on Fomites: that is, contaminated objects and surfaces. As COVID-19 has been shown to be largely spread through the air, this article will broaden the focus to include engineering controls that effect this type of transmission. A literature search was conducted using key words such as long-term care facilities, built environment, COVID-19, infection control, and nursing homes. Results were sorted using an engineering controls pyramid developed by the author to stratify approaches to LTC infrastructure. Basically, six elements were supported: ventilation, spatial separation, physical barriers, hand hygiene stations, resident room zones, and private rooms. Conclusions were that the built environment has a major impact on infection control that can be deleterious or beneficial. Substantial changes need to be made to protect the very vulnerable LTC population from future pandemics and infectious diseases.

Feasibility of Virtual Reality for Mental Health in Long-Term Care in Rural Populations

Throughout the COVID-19 pandemic, long-term care residents have been disproportionately affected both physically and mentally. Increased restrictions have worsened long-term care residents’ mental health and have increased feelings of isolation and loneliness. This pilot study explores the feasibility of virtual reality (VR) technology used by long-term care residents for mental health in a rural area of southern Illinois. We captured long-term care residents’ thoughts, feelings, and knowledge of VR using a pre-test and post-test design following an educational session introducing VR. Participants were then offered the opportunity to use the technology, with 9 out of the 11 participants watching a 360⁰ video using the VR headset. All participants who tried the VR headset noted that they were more willing to try VR in the future. While no statistically significant changes in mood from before and after the session were found, the results suggest that the use of VR for mental health in long-term care populations is more feasible when paired with an educational session before intervention.

Feasibility of Virtual Reality for Mental Health in Long-Term Care in Rural Populations

Throughout the COVID-19 pandemic, long-term care residents have been disproportionately affected both physically and mentally. Increased restrictions have worsened long-term care residents’ mental health and have increased feelings of isolation and loneliness. This pilot study explores the feasibility of virtual reality (VR) technology used by long-term care residents for mental health in a rural area of southern Illinois. We captured long-term care residents’ thoughts, feelings, and knowledge of VR using a pre-test and post-test design following an educational session introducing VR. Participants were then offered the opportunity to use the technology, with 9 out of the 11 participants watching a 360⁰ video using the VR headset. All participants who tried the VR headset noted that they were more willing to try VR in the future. While no statistically significant changes in mood from before and after the session were found, the results suggest that the use of VR for mental health in long-term care populations is more feasible when paired with an educational session before intervention.

Potential for Drug Interactions and Polypharmacy From Treatment of COVID-19 in Long-Term Care

Potential for Drug Interactions and Polypharmacy From Treatment of COVID-19 in Long-Term Care

Covid-19 and excess mortality in medicare beneficiaries.

We estimated excess mortality in Medicare recipients in the United States with probable and confirmed Covid-19 infections in the general community and amongst residents of long-term care (LTC) facilities. We considered 28,389,098 Medicare and dual-eligible recipients from one year before February 29, 2020 through September 30, 2020, with mortality followed through November 30th, 2020. Probable and confirmed Covid-19 diagnoses, presumably mostly symptomatic, were determined from ICD-10 codes. We developed a Risk Stratification Index (RSI) mortality model which was applied prospectively to establish baseline mortality risk. Excess deaths attributable to Covid-19 were estimated by comparing actual-to-expected deaths based on historical (2017–2019) comparisons and in closely matched concurrent (2020) cohorts with and without Covid-19. Overall, 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. A total of 472,329 confirmed cases were community living and 204,771 were in LTC. Mortality following a probable or confirmed diagnosis in the community increased from an expected incidence of about 4.0% to actual incidence of 7.5%. In long-term care facilities, the corresponding increase was from 20.3% to 24.6%. The absolute increase was therefore similar at 3–4% in the community and in LTC residents. The percentage increase was far greater in the community (89.5%) than among patients in chronic care facilities (21.1%) who had higher baseline risk of mortality. The LTC population without probable or confirmed Covid-19 diagnoses experienced 38,932 excess deaths (34.8%) compared to historical estimates. Limitations in access to Covid-19 testing and disease under-reporting in LTC patients probably were important factors, although social isolation and disruption in usual care presumably also contributed. Remarkably, there were 31,360 (5.4%) fewer deaths than expected in community dwellers without probable or confirmed Covid-19 diagnoses. Disruptions to the healthcare system and avoided medical care were thus apparently offset by other factors, representing overall benefit. The Covid-19 pandemic had marked effects on mortality, but the effects were highly context-dependent.

The Experience of Family Members in Long-Term Care Facilities During the SARS COV2 (COVID-19) Pandemic

In-person visits are one form of care support offered by family members for residents in a Long-term Care Facility (LTCF). Family member visitation may extend to close social relationships with the residential care staff, which can be important in managing care. The long-term care population has been significantly impacted by a high number of SARS-COV2 (Covid-19) cases in morbidity and mortality but, in-person visits were limited due the public health concern. This study aimed to describe the experience of family members of persons in LTCFs during the Covid-19 pandemic. We used an online survey of 34 questions. Forty-six family members were recruited through online caregiver support platforms, and 22 completed the survey. Average participant age was 57. Majority were female with high-moderate (M=3.48) Kessler psychological distress scores. Participants reported less frequent communication with their family members in LTCFs. Difficult to reach nursing staff, who were the primary contact, was a concern. Their preferred means of communication was the telephone followed by window visits; residents preference remained for in-person visits followed by telephone. Participants described a decrease in relationship closeness with staff and a decrease in confidence in the quality of care. These results, limited by sample size, offer a beginning insight into the importance of communication between the family member and nursing staff, including the contact frequency. Structural disparities such as LTCF nursing staff levels may partly explain these deficits in supporting families during the Covid-19 pandemic. Opportunities to support family members remain a needed focus of long-term care reforms.

Fluctuating Decision-Making in People with Mental Illness

Fluctuating Decision-Making in People with Mental Illness

Pain-related health care costs for long-term care residents

BackgroundWe tested for differences in direct health care costs among long-term care (LTC) residents age 65 and older with clinically significant pain (CSP) and with no pain or non-daily mild pain (NP/NDMP). We are not aware of any other large scale investigation that examined the cost of pain in LTC environments.MethodsPopulation-based administrative health data from Saskatchewan, Canada for 2004 to 2015 were used to compare direct health care costs for CSP and NP/NDMP groups up to one year after admission to LTC. Total accumulated costs for hospitalization, physician services, LTC, and prescription drugs were calculated in 2015 Canadian dollars. Group differences were tested using generalized linear models with generalized estimating equations.ResultsAmongst 24,870 LTC residents, 8289 (33.3%) were censored due to death or discharge in the 365-day study observation period. Of the 16,581 (66.7%) observed residents, 5683 (34.3%) had CSP at admission. Residents (66.3% female) had a mean age of 85 years (SD = 7.4). The mean annual total direct health care cost per resident was higher among the CSP group (CAD $8063) than the NP/NDMP group (CAD $6455). This difference was found even after including LTC costs, and for each cost component (i.e., CSP residents had higher hospitalization, physician, and prescription drug costs). Similar results were obtained after controlling for demographics, comorbidities, physical and cognitive impairment, prior health care costs, and facility characteristics.ConclusionThe higher costs incurred by CSP residents compared to NP/NDMP residents are likely underestimated because pain problems are often missed in residents with dementia, who comprise a large portion of the LTC population. Improved pain care can reduce such costs and improve quality of life.

Dementia-Friendly "Design": Impact on COVID-19 Death Rates in Long-Term Care Facilities Around the World.

Persons with dementia (PWD) make up a large portion of the long-term care (LTC) population the world over. Before a global pandemic swept the world, governments and healthcare providers struggled with how to best care for this unique population. One of the greatest challenges is a PWD's tendency to "walk with purpose" and exhibit unsafe wayfinding and elopement, which places them at risk of falls and injury. Past solutions included increased use of restraints and pharmacological interventions, but these have fallen out of favor over the years and are not optimal. These challenges put enormous strain on staff and caregivers, who are often poorly trained in dementia care, underpaid, overworked, and overstressed. PWD are impacted by these stresses, and unmet needs in LTC places an even greater stress on them and increases their risks of morbidity and mortality. The physical design of their environments contributes to the problem. Old, institutionalized buildings have poor lighting, poor ventilation, long dead-end hallways, poor visual cues, lack of home-like décor, shared bedrooms and bathrooms, and are often dense and overcrowded. These design elements contribute to the four 'A's' of dementia: apathy, anxiety, agitation, and aggression, and they also contributed to the rapid spread of COVID-19 in these facilities the world over. In this review, we present current "dementia friendly" design models in the home, community, and LTC, and argue how they could have saved lives during the pandemic and reduced the stresses on both the dementia resident and the caregiver/staff.