We know how the Covid-19 pandemic has killed older people. We are still learning about its other effects on older adults. The picture is complex and often difficult to look at.
A new study by Michael Barnett of the Harvard TH Chan School of Public Health and colleagues (paywall) finds that nursing home residents with active cases of Covid-19 not only died frequently but during their lifetime experienced greater functional decline, weight loss, and depression compared to pre-pandemic times. Perhaps most surprisingly, the study found that even in nursing homes where no cases of Covid-19 were identified, residents lost more weight and were more depressed during the worst of the pandemic.
The study published in Journal of the American Medical Association (JAMA), two other important outcomes: hospital visits to reject Among residents of all facilities studied, whether or not they had an outbreak of Covid-19. And in facilities without Covid-19, deaths have also decreased.
While this study did not attempt to answer why all of this happened, it does include some informed speculation. There are many important lessons that policy makers, nursing home operators, and consumers can learn from the results.
The costs of social isolation
The authors reviewed Medicare claims data and a clinical assessment for residents of a skilled nursing facility called the Minimum Data Set (MDS) for 2020, the first year of the pandemic. They then compared their findings with the pre-pandemic years of 2018 and 2019. The study sample included nearly 1 million long-term care residents (short-stay and post-acute patients were excluded).
We’ve known about the costs of social isolation among the elderly for a while. The new findings confirm widespread anecdotal evidence of an increase in depression, a 2020 survey of nursing home residents, and a narrower 2021 study by research firm Mathematica.
The new study found that residents in Covid-19 positive facilities lost an average of 3.1 pounds more than they did before the pandemic. The proportion of the population with increasing depression increased from about 27 percent to 32.5 percent. Even in facilities without an outbreak of Covid-19, residents lost an average of 1.8 pounds more and the proportion of people with major depression increased to 30.2%.
The authors suggest one of the main reasons: to close nursing homes and other long-term care facilities mandated by the Trump administration. Banning visitors, including family members, and requiring patients and residents to eat alone in their rooms, may reduce the spread of infection and even save some lives. But it had a cost.
Combine the acute shortage of staff and the absence of family members to help provide care and monitor problems and the consequences have been dire for many residents.
Other results are more complex. Before the pandemic, about 2.2 percent of nursing home residents died in a typical month and 3 percent were hospitalized. In facilities with active Covid-19 cases, deaths increased by an average of 1.6 percentage points and hospital admissions decreased by 0.1 percentage points. In facilities where there are no known outbreaks, deaths to reject By 0.15 percentage points, hospitalizations decreased by 0.8 percentage points.
There is no shock from the increase in deaths in facilities with Covid-19. We all know that. But why is the death rate in facilities down with no cases?
The authors suggest one reason: stronger infection control. Before Covid-19, viruses such as seasonal flu often resulted in death in nursing homes. But strong infection control during the pandemic may have reduced the incidence of these other diseases and led to fewer deaths unrelated to Covid-19.
At first glance, the decrease in the number of hospitalizations seems counterintuitive as well. But facilities — and families — may have been more reluctant to send residents to tax-burdened hospitals.
As the authors note, this finding may have important policy implications: it suggests that there may be less benefit from hospitalization for residents of nursing homes than some have thought. And if true, it supports efforts to reduce unnecessary hospitalizations for these frail elderly people.
Lessons next time
A few things to know about the study: Once a facility had a single Covid-19 case, it was grouped with nursing homes with active infection. But because the study relied on Medicare claims, it likely missed cases that never required medical care. Thus, some facilities may have been classified as non-Covid-19 when, in fact, they had active cases.
The study also excluded employee injuries. And it only looked at 2020 data, before vaccines and before Omicron came out. One final problem: How reliable will MDS data be during 2020, when filling out forms may be a low priority for exhausted nursing home employees?
However, this important study provides new evidence that while lockdowns have reduced the risk of infection, they can come at a significant cost. When the next pandemic hits, can we find ways to prevent its spread in long-term care facilities without paying the price of social isolation?