We know how the Covid-19 pandemic killed older adults. We are still learning about its other effects on seniors. And the picture is both complex and often difficult to look at.
A study by Michael Barnett of the Harvard T. H. Chan School of Public Health and colleagues (paywall) finds that residents of nursing homes with active cases of Covid-19 not only died more frequently but while living suffered greater functional decline, weight loss, and depression, compared to pre-pandemic times. Perhaps more striking, the study found that even in nursing homes with no identified Covid-19 cases, residents lost more weight and were more depressed during the worst of the pandemic.
The study, published in August at the Journal of the American Medical Association (JAMA), had two other important results: Hospital visits declined among residents of all the facilities studied, whether they had Covid-19 outbreaks or not. And in facilities with no Covid-19, deaths declined as well.
While this study did not attempt to answer why all this happened, it includes some informed speculation. And there are several important lessons policymakers, nursing home operators, and consumers can learn from the results.
Costs of social isolation
The authors reviewed Medicare claims data and a clinical assessment of skilled nursing facility residents 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 almost 1 million long-term care residents (it excluded short-stay, post-acute patients).
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We’ve known about the costs of social isolation among older adults for while. And the new results confirm widespread anecdotal evidence of increased depression, a 2020 survey of nursing home residents, and a narrower 2021 study by the research firm Mathematica.
The new study found residents in Covid-19-positive facilities lost an average of 3.1 pounds more than before the pandemic. The share of residents with increased depression increased from about 27% to 32.5%. Even in facilities with no Covid-19 outbreaks, residents lost an average of 1.8 pounds more and the share of those with more serious depression increased to 30.2%.
One key reason, the authors suggest: the Trump Administration-mandated lock-downs of nursing homes and other long-term care facilities. Barring visitors, including family members, and requiring patients and residents to eat alone in their rooms may have reduced the spread of the infection and even saved some lives. But it had a cost.
Combine severe staffing shortages with the absence of family members to both help provide care and keep an eye out for problems and the consequences were severe for many residents.
The other results are more complicated. Before the pandemic, about 2.2% of nursing home residents died in a typical month and 3% were hospitalized. In facilities with active Covid-19 cases, deaths increased by an average of 1.6 percentage points and hospital admissions declined by 0.1 percentage points. In facilities with no known outbreaks, deaths declined by 0.15 percentage points, and hospitalizations fell by about 0.8 percentage points.
No shock that deaths increased in facilities with Covid-19. We all knew that. But why did mortality decline in facilities with no cases?
The authors suggest one reason: More robust infection control. Before Covid-19, viruses such as seasonal flu often led to death in nursing homes. But aggressive infection control during the pandemic may have reduced cases of these other diseases and led to fewer non-Covid-19 deaths.
At first glance, the decline in hospitalizations also seems counter-intuitive. But facilities—and families— may have been more reluctant to send residents to overtaxed hospitals.
As the authors note, this finding may have important policy implications: It suggests that there may be less benefit to hospitalizing nursing home residents than some thought. And, if true, that supports efforts to reduce unnecessary hospitalizations of these frail older adults.
Lessons for next time
A few things to know about the study: As soon as a facility had a single Covid-19 case, it was grouped with those nursing homes with active infections. But because the study relied on Medicare claims, it likely missed cases that never required medical care. Thus, some facilities may have been categorized as non-Covid-19 facilities when they did, in fact, have active cases.
The study also excluded staff infections. And it looked at data from 2020 only, before vaccines and before Omicron surfaced. One last issue: How reliable were the MDS data during 2020, when filling out forms may have been a low priority for overwhelmed nursing home staff?
Still, this important study provides new evidence that while lockdowns may have reduced the risk of infection, they also may have 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?