Management of Dementia Related Behaviors During COVID: Second Virginia Nursing Home Clinician Survey, March 2022

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

Management of Dementia Related Behaviors During COVID: Second Virginia Nursing Home Clinician Survey, March 2022

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

Thought-provoking trends from the second Virginia nursing home clinician survey included that rural clinicians reported increases in use of antipsychotics and sedating antidepressants more often than their urban and suburban colleagues (p=0.053 for both). Eighty-five percent of respondents stated that the lack of family and volunteers, as well as staffing changes, made dementia management more difficult. Of concern, only 19% of clinicians stated that their facilities offered support for their pandemic related stress, and only 12% reported reduced administrative burdens to help with the challenges of nursing home dementia care.

These are preliminary findings from a March 2022 survey of Virginia nursing home clinicians funded by the Virginia Center on Aging, ARDRAF 22-2. Below please find a summary followed by a brief commentary.

PRELIMINARY QUANTITATIVE FINDINGS among respondents (n=42)

For dementia behavioral symptoms:

·       26% (11/42) reported an increase in use of second generation antipsychotics

o   44% Rural (8/18)

o   12.5% Urban/suburban (3/24)

o   P=0.53

·       50% (21) reported an increase in use of antidepressants

o   50% Rural (9/18)

o   50% Urban/suburban (12/24)

·       28.6% (12) reported an increase in use of sedating antidepressants

o   44% Rural (8/18)

o   16.7% Urban/suburban (4/24)

o   P=0.53

·       14.3% (6) reported an increase in use of mood stabilizers

No significant differences in reported medication use between:

·       Geriatric and psychiatric subspecialists and clinicians without subspecialty

·       Facilities with low versus higher percentages of minority residents

*However, there may not have been enough respondents to show such differences.

Reported helpful for dementia management during the pandemic:

·       81% (34/42) Safe family/volunteer visits

·       71.4% (30/42) Vaccinating staff

·       71.4% (30/42) Residents socializing more with other residents

·       69.0% (29/42) Vaccinating residents

·       4.8% (2/42) None of the above

Other significant findings:

·       85.6% (36/42) reported periodic staff absences made dementia management more difficult

·       85.6% (36/42) reported family/volunteer absences made dementia management more difficult

·       19.0% (8/42) reported support for clinicians to assist with pandemic stress and burnout

·       11.9% (5/42) reported pandemic easing of administrative tasks to lessen work/stress for clinicians

Selected quotes from respondents who volunteered additional information: (n=17)

·       The pandemic created so many challenges that facilities struggled to manage, and in some cases left direct care staff on their own to "figure it out" while working under directive that pandemic could not have any impact on ability to provide care.

·       Poor management response to LTC staff stress

·       The way the residents were cut off from their families and isolated was in humane (sic). I have had more residents die from heartbreak or worsen clinically from such then any pandemic related illness. Their fear of our masked faces, again heartbreaking

·       Worsened staffing, especially those skilled in managing residents with dementia.

·       Observed global declines in patients with dementia not associated with personal COVID infection during isolation due to COVID facility outbreaks, also associated with weight loss, loss of ADL ability, and skin breakdown. Also a corresponding increase in hospice referrals.

·       Other residents (w/o dementia) were also negatively impacted by the increased symptoms of residents with dementia. Calling out/yelling while residents were confined to their rooms was a big problem.

To contribute your experience to this important work, the link to the most recent survey version is available here: Click Here for Survey!

Commentary

The findings above are from an ongoing study led by Drs. Kerns and Winter to evaluate the impact of the pandemic on nursing home dementia care and outcomes. They hypothesized that the intense strain and pressure of the pandemic have functioned as a stress test on Commonwealth nursing facilities, unmasking and exacerbating existing dysfunctional processes and gaps in care. Since the start of the pandemic, they have described an increase in all dementia related behavioral symptoms along with functional losses that are likely to be irreversible.

Decreased availability of employed and voluntary staffing, as well as family and community supports, has decreased the availability of all non-drug interventions for dementia. Conversely, the use of risky drugs for dementia symptoms has dramatically increased. Ominously, there appears to be an increasing separation of the ‘have’s and the have-nots,’ with the greatest negative pandemic impacts noted for resource-poor facilities in vulnerable communities, notably rural, with lower social determinants of health. On the other hand, this crisis has not been without its victories. Beyond the personal heroism of staff, families, and residents, pandemic stressors have forced innovation in the treatment of dementia symptoms with increased resident involvement in each other’s care, creative engagement strategies that are consistent with social-distancing protocols, and an increased reliance on family and community resources.

Alarming for clinicians as well as staff is the lack of physical, administrative, and emotional support offered by nursing facilities. As noted above, some facilities ‘…left direct care staff on their own to "figure it out" while working under directive that pandemic could not have any impact on ability to provide care.’ Many have published advice regarding steps to mitigate pandemics and similar crises in the future. Policy makers need to put procedures in place to support patient care by supporting clinicians, staff, and facilities in practical ways delineated by this and similar studies.

For the last decade, Drs. J. William Kerns and Jonathan Winter, faculty at the VCU-Shenandoah Family Practice Residency in Front Royal Virginia, with the assistance of the VCU Department of Family Medicine and Population Health, have been investigating issues surrounding the use of risky psychiatric medications in nursing homes. Intriguing findings of their work include the description of significant barriers to the use of non-pharmacologic alternatives to medications that do not exist for drugs. They believe that optimal dementia care will not occur until non-pharmacologic therapies for dementia symptoms are as available, affordable, and accessible as drugs.