Management of Dementia Related Behaviors During COVID: Third Virginia Nursing Home Clinician Survey, June 2022

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

This survey purposefully focused on current, June 2022, pandemic nursing home care of patients with dementia. Particularly concerning for this later stage of the pandemic, are that of the Virginia nursing home clinicians responding:

1)     Ninety-three percent reported that their facilities expect them to deliver the same level of care no matter what staffing is available to support that care,

2)     Only twenty-one percent stated that their facility offered supports for clinician stress and burnout, and

3)     Twenty-five percent recounted that they felt legally exposed because of their facility’s actions.

Compared to the other surveys:

1)     Vaccinations are not currently affirmed as helping dementia management as much, and

2)     Antidepressants and other medications are still used more often than pre-pandemic for management of dementia symptoms.

There were mixed responses to less PPE:

1)     Most stated that patients not wearing masks assisted dementia care, but others also noted that not wearing masks carried risks for infection/reinfection, and

2)     Responses were varied as to whether less glove wearing, directly touching patients, was beneficial for patient care.

These are preliminary findings from a June 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=28)

Reported helpful for dementia management during the pandemic:

·       71.4% Safe family/volunteer visits

·       28.6% Vaccinations

·       71.4% Residents socializing more with other residents

·       10.7% Technology enabled visits

Clinician Stressors:

·       92.9% reported ‘our facility expects us to provide the same level of care regardless of changes in staff’ in 2022

·       21.4% reported current support for clinicians to assist with pandemic stress and burnout

Contemporaneous use of medications for dementia behavioral symptoms in June 2022 compared to pre-pandemic:

·       14.3% reported increase in use of second-generation antipsychotics

·       53.6% reported increase in use of antidepressants

·       21.4% reported increase in use of sedating antidepressants

·       7.1% reported increase in use of mood stabilizers

Selected quotes from respondents who volunteered additional information: (n=14)

·       Facility staff burnout is taking a toll on providers who are trying to continue to provide good care

·       The feeling 'exposed' is particularly strong at this time.  Many of the new hires had no meaningful 'hands-on' training during their LPN training, and the trainers (4 LPNs) are not that senior or experienced.  Rehab practices have also changed and probably providing less intense therapy.

·       We as private practice physicians are being excluded from NH care

·       We encourage and give residents mask

·       Overall, the benefits are greater for this population than continued masking

·       Community exposure makes the covid rates go up

Commentary:

URGENT ACTION NEEDED

It is urgent that policy makers put procedures in place to support patient care by supporting clinicians, staff, and facilities in practical ways delineated by multiple published studies and editorials of how to improve nursing home care during the pandemic. Unfortunately, to date additional resources have not been forthcoming.

Wave after wave of Omicron sub-variants continues to stress Virginia nursing homes, and dementia management in particular. Risky drug use for dementia symptoms remains significantly increased.

Distressing for responding clinicians is the continued lack of physical, administrative, and emotional support offered by nursing facilities. Almost all facilities are said to expect the same level of care whether or not the facility has adequate nursing and other staff, and a quarter of clinicians responded that they feel legally exposed by their facility.

The findings above are from an ongoing study lead 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 has 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

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.