The Lancet Healthy Longevity

BackgroundResidents of long-term care facilities (LTCFs) have been disproportionately affected during the COVID-19 pandemic. To inform decision-making around interventions, we quantified the SARS-CoV-2 infection risk for residents and the relative contribution of different infection sources. We estimated the force of infection (FOI) experienced by Dutch LTCF residents over time and quantified the contribution of residents, LTCF healthcare workers (HCWs), and the general population. Methods & findingsCase data were obtained by Municipal Health Services as part of the Dutch national surveillance program. During the study period (1 October 2020 to 10 November 2021), testing policies included symptom-based testing, exposure-based testing, and facility-wide serial testing. We used a data augmentation approach to include uncertainty in the timing of infection, while taking account of different testing policies. We constructed a Bayesian generalized linear model to estimate group-specific transmission rate parameters and contributions to the FOI experienced by residents. During the study period 36,877 cases were registered among residents and 19,676 among HCWs. The total daily FOI towards residents was highest in December 2020 (1.7*10-3, 95% CI: 1.5*10-3 - 1.9*10-3) and lowest in June 2021 (1.1*10-5 95%CI: 7.6*10-6 - 1.7*10-5). Resident-directed type-reproduction numbers and FOI declined as COVID-19 vaccination rollout started in residents, HCWs, and the older general population (February-May 2021). Most resident infections in spring and summer 2021 were attributable to infections in the general population. The relative contribution of the general population to the FOI decreased in summer 2021 when vaccination was available population-wide. In October-November 2021, type-reproduction numbers and FOI increased again. We observed an increase in residents susceptibility to infection in this period, which was only partially explained by the emergence of the Delta variant. Sensitivity analyses showed that the temporal trends in relative contributions to the FOI were not impacted by assumptions about immunity build-up among residents, nor by underreporting of infections. ConclusionsCOVID-19 vaccination appears to have been effective in reducing SARS-CoV-2 transmission towards residents, although other factors such as seasonality or non-pharmaceutical interventions may also have contributed to this. This effect seemed to have decreased by autumn 2021, which could be due to waning of immunity or changes in control practices. Our estimates of temporal trends in relative contributions to the FOI in LTCF residents can help target intervention efforts.

BackgroundSARS-CoV-2 has disproportionately affected nursing home (NH) residents. In Ireland, the first NH case of COVID-19 occurred on 16/03/2020. A national point-prevalence testing program of all NH residents and staff took place from 18/04/2020-05/05/2020. AimsTo examine characteristics of NHs across three Community Health Organisations (CHOs) in Ireland, proportions with COVID-19 outbreaks, staff and resident, symptom-profile and resident case-fatality. MethodsForty-five NHs surveyed across three CHOs requesting details on occupancy, size, COVID-19 outbreak, timing of outbreak, total symptomatic/asymptomatic cases, and outcomes for residents from 29/02/2020-22/05/2020. ResultsSurveys were returned from (62.2%, 28/45) of NHs (2043 residents, 2303 beds). Three-quarters (21/28) had COVID-19 outbreaks (1741 residents, 1972 beds). Median time from first case of COVID-19 in Ireland to first case in these NHs was 27.0 days. Resident COVID-19 incidence was (43.9%, 764/1741): laboratory-confirmed (40.1%, 710/1741) with (27.2%, 193/710 asymptomatic), and clinically-suspected (3.1%, 54/1741). Resident case-fatality was (27.6%, 211/764) for combined laboratory-confirmed/clinically-suspected COVID-19. Similar proportions of residents in NH with an "early" outbreak (<28days) versus a later outbreak developed confirmed/suspected COVID-19. A lower proportion of residents in NHs with "early" outbreaks had recovered compared to those with "late" outbreaks (37.4% vs 61.7%; {chi}2=56.9, p<0.001). Among 675 NH staff across twenty-four sites who had confirmed/suspected COVID-19 (23.6%, 159/675) were asymptomatic. There was a significant correlation between the proportion of staff with symptomatic COVID-19 and resident numbers with confirmed/suspected COVID-19 (Spearmans rho=0.81, p<0.001). ConclusionThis study demonstrates COVID-19 impact on NH residents and staff. High infection rates lead to challenges in care provision.

ImportanceEcological and observational studies have shown a protective association between herpes zoster (HZ) vaccination and dementia risk, yet many had methodological limitations or examined the live HZ vaccine that is no longer available in the US. Improved access to linked electronic health records for patients receiving post-acute care and long-term care permit robust comparisons of dementia risk in adults eligible to receive the recombinant HZ vaccine. ObjectiveEmulate a randomized trial in observational data to estimate the association of the recombinant HZ vaccine (RZV) with incident dementia risk among older adults newly admitted for post-acute or long-term care in nursing homes (NHs). DesignRetrospective cohort study with target trial emulation and the clone censor approach. SettingU.S. NHs that use PointClickCare as their electronic health record. ParticipantsIndividuals who were admitted to a NH between 01/01/2017-12/31/2022; Medicare fee-for-service beneficiaries; did not have prevalent dementia; and eligible to receive RZV as of admission. ExposuresReceive one or more RZV doses within one year of admission vs. do not receive any RZV over four years of follow-up. ResultsWe identified 509,926 eligible NH residents (mean age 79 years; 36% men). Among those alive, uncensored, and without dementia at 12 months of follow-up, 8,843 received one or more doses of RZV. Receipt of RZV within one year of NH admission was associated with a 5.8% lower absolute risk (95%CI: -3.9% to -7.5%) of newly diagnosed dementia over four years (risk ratio [RR] = 0.76 [95%CI: 0.69-0.84]; cumulative incidence in 1+ RZV vs. no RZV: 18.8% vs. 24.6%). Associations were smaller in men (RR=0.82 [95%CI: 0.68-1.01]) and those with prior live HZ vaccination (RR=0.86 [95%CI: 0.65-1.09]). Bias analyses based on two negative control outcomes (NCOs) attenuated, but did not fully explain, the main effect of RZV on dementia risk (bias-adjusted RR = 0.82 [wellness visit NCO] and RR = 0.88 [hip fracture NCO]). Conclusions and RelevanceAdministering RZV within 1 year of NH admission may reduce dementia risk. As RZV uptake was low overall, new NH residents would benefit from increased RZV vaccination uptake. KEY POINTSO_ST_ABSQuestionC_ST_ABSDoes the recombinant herpes zoster vaccine (RZV) reduce dementia risk among older adults? FindingsIn this cohort and trial emulation study of 509,926 patients newly admitted to skilled nursing or long-term care, we found that [&ge;]1 RZV dose within a year was associated with a 24% relative and 6% absolute reduction in 4-year dementia risk. Effects were robust to bias analyses and were stronger in women and those without prior vaccination with the live HZ vaccine. MeaningUsing causal inference methods, this observational study provides evidence that some cases of dementia may be prevented through vaccination with RZV.

BACKGROUNDAlzheimers disease and other dementias are progressive neurodegenerative disorders with profound impacts on cognitive function. There is a shortage of economic evidence relating to the impact Alzheimers disease on healthcare costs and quality-adjusted life-years (QALYs). METHODSWe employed two study designs to model the association between Alzheimers disease and healthcare costs and QALYs. We first estimated conventional multivariable models of the association between Alzheimers disease and these core economic outcomes. However, these types of model may be confounded by diseases, processes, or traits that independently affect Alzheimers disease and either or both of healthcare costs and QALYs. We therefore also explored a complementary approach using germline genetic variation as instrumental variables in a Mendelian randomization analysis. We used single nucleotide polymorphisms (SNPs) identified in recent genome-wide association studies of Alzheimers disease as instruments. We studied outcome data on inpatient hospital costs and QALYs in the UK Biobank cohort. RESULTSData from up to 310,838 individuals were analyzed. N=55 cases of Alzheimers disease were reported at or before recruitment into UK Biobank. A further N=284 incident cases were identified over follow-up. Multivariable observational analysis of the prevalent cases suggested significant impacts on costs ({pound}1,140 in cases, 95% Confidence Interval (CI): {pound}825 to {pound}1,456) and QALYs (-25%, 95% CI: -28% to -21%). Mendelian randomization estimates were very imprecise for costs ({pound}3,082, 95% CI: -{pound}7,183 to {pound}13,348) and QALYs (-32%, 95% CI: -149% to 85%), likely due to the small proportion of variance (0.9%) explained in Alzheimers disease status by the most predictive set of SNPs. IMPLICATIONSConventional multivariable models suggested important impacts of Alzheimers disease on inpatient hospital costs and QALYs, although this finding was based on very few cases which may have included instances of early-onset dementia. Mendelian randomization was very imprecise. Larger GWAS of clinical cases, improved understanding of the architecture of the disease, and the follow-up of cohorts until old age and death will help overcome these challenges.

BackgroundThe COVID-19 pandemic created novel challenges for staff working in the adult social care sector, however its impact on staff working relationships within facilities is unclear. The aim of this study is to explore the effect the pandemic had on staff working relationships. MethodSecondary analysis of data collected in semi-structured, qualitative interviews with LTCF staff. Twenty-four participants working in eight LTCFs in England were recruited to discuss their experiences of working in a LTCF during the COVID-19 pandemic. Thematic analysis was used to explore the impact of the pandemic on staff working relationships. ResultsSeven themes were identified, these were a) a shared commitment to providing care to residents, b) strengthening working relationships between staff members, c) adapting to novel and changing roles, d) working as an incentive for socialisation, e) leadership by example, f) recruitment and retraining of new staff, and g) divisions between furloughed and attending LTCF staff. DiscussionThe findings show that within the challenges that the pandemic created for LTCFs, staff members reported improved staff working relationships, characteristics by strengthened bonds between staff, improvements in team working and developing new approaches to resident care. However, furloughed and newly recruited staff members were, at times, excluded from these developments. Further research is needed to explore how improvements to staff working relationships can be replicated and sustained prior to future pandemics, and the supportive effect these may have on quality of care and staff mental health and wellbeing.

BackgroundWe investigated six London care homes experiencing a COVID-19 outbreak and found very high rates of SARS-CoV-2 infection among residents and staff. Here we report follow-up serological analysis in these care homes five weeks later. MethodsResidents and staff had a convalescent blood sample for SARS-CoV-2 antibody levels and neutralising antibodies by SARS-COV-2 RT-PCR five weeks after the primary COVID-19 outbreak investigation. ResultsOf the 518 residents and staff in the initial investigation, 208/241 (86.3%) surviving residents and 186/254 (73.2%) staff underwent serological testing. Almost all SARS-CoV-2 RT-PCR positive residents and staff were antibody positive five weeks later, whether symptomatic (residents 35/35, 100%; staff, 22/22, 100%) or asymptomatic (residents 32/33, 97.0%; staff 21/22, 95.1%). Symptomatic but SARS-CoV-2 RT-PCR negative residents and staff also had high seropositivity rates (residents 23/27, 85.2%; staff 18/21, 85.7%), as did asymptomatic RT-PCR negative individuals (residents 62/92, 67.3%; staff 95/143, 66.4%). Neutralising antibody was present in 118/132 (89.4%) seropositive individuals and was not associated with age or symptoms. Ten residents (10/108, 9.3%) remained RT-PCR positive, but with lower RT-PCR cycle threshold values; all 7 tested were seropositive. New infections were detected in three residents and one staff member. ConclusionsRT-PCR testing for SARS-CoV-2 significantly underestimates the true extent of an outbreak in institutional settings. Elderly frail residents and younger healthier staff were equally able to mount robust and neutralizing antibody responses to SARS-CoV-2. More than two-thirds of residents and staff members had detectable antibodies against SARS-CoV-2 irrespective of their nasal swab RT-PCR positivity or symptoms status.

PurposeThe emergence of antibiotic-resistant bacteria represents a considerable threat to human health, particularly for vulnerable populations such as those living in residential aged care. However, antimicrobial resistance (AMR) carriage and modes of transmission remain incompletely understood. The Generating evidence on antimicrobial Resistance in the Aged Care Environment (GRACE) study was established to determine principal risk factors of AMR carriage and transmission in residential aged care facilities (RACF). ParticipantsBetween March 2019 and March 2020, 279 participants were recruited from five South Australian RACFs. The median age was 88.6 years, the median period in residence was 681 days, and 71.7% were female. A dementia diagnosis was recorded in 54.5% and more than two thirds had moderate to severe cognitive impairment (68.8%). Sixty-one percent had received at least one course of antibiotics in the 12 months prior to enrolment. Findings to dateTo investigate the representation of the GRACE cohort to Australians in residential aged care, its characteristics were compared to a subset of the historical cohort of the Registry of Senior Australians (ROSA). This included 142,923 individuals who were permanent residents of RACFs on June 30th, 2017. GRACE and ROSA cohorts were similar in age, sex, and duration of residential care, prevalence of health conditions, and recorded dementia diagnoses. Differences were observed in care requirements and antibiotic exposure (both higher for GRACE participants). GRACE participants had fewer hospital visits compared to the ROSA cohort, and a smaller proportion were prescribed psycholeptic medications. Future plansParticipant and built environment metagenomes will be used to determine microbiome and resistome characteristics. Individual and facility risk exposures will be aligned with metagenomic data to identify principal determinants for AMR carriage. Ultimately, this analysis will inform measures aimed at reducing the emergence and spread of antibiotic resistant pathogens in this high-risk population. Strengths and limitations of this studyO_LIThe GRACE study captured a diverse array of data; demographics, medications, personal and medical care, RACF management practices, as well as oropharyngeal, intestinal, and environmental metagenomic data, allowing detailed analysis of exposure-resistome relationships. C_LIO_LIA high rate of participant recruitment (75% of eligible residents) was achieved, representing the spectrum of resident characteristics and care needs. This included a representative proportion of individuals with moderate or severe cognitive impairment. C_LIO_LIThe main limitation of this cohort resulted from the early cessation of recruitment, due to stringent facility access regulations resulting from the COVID-19 pandemic. While a high recruitment rate partially compensated in terms of cohort size, we were unable to complete recruitment at our fifth site or begin recruitment at two further sites. C_LIO_LIEthnic and linguistic data was not captured and so could not be compared between cohorts. C_LI

BackgroundRegular exercise and community engagement may slow the rate of function loss for people with dementia. However, the evidence is uncertain regarding the cost-effectiveness and social return on investment (SROI) of home exercise with community referral for people with dementia. This study aimed to compare the social value generated from the in-person PrAISED programme delivered before March 2020 with a blended PrAISED programme delivered after March 2020. MethodsSROI analysis was conducted alongside a randomised controlled trial (RCT). Of 205 patient participants and their carers who completed cost data, 61 completed an in-person programme before March 2020. Due to COVID-19 pandemic restrictions, 144 patient participants completed a blended programme consisting of a combination of in-person visits, phone calls and video conferencing with multidisciplinary team (MDT) members. SROI analysis compared in-person and blended delivery formats. Five relevant and material outcomes were identified: three outcomes for patient participants (fear of falling, health-related quality of life, and social connection); one outcome for carer participants (carer strain index), and one outcome for the NHS (health service resource use). Data were collected at baseline and a 12-month follow-up. ResultsThe in-person PrAISED programme generated SROI ratios ranging from {pound}0.58 to {pound}2.33 for every {pound}1 invested. In-person PrAISED patient participants gained social value from improved health-related quality of life, social connection, and less fear of falling. In-person PrAISED carer participants acquired social value from less carer strain. The NHS gained benefit from less health care service resource use. However, the blended PrAISED programme generated lower SROI ratios ranging from a negative ratio to {pound}0.08: {pound}1. ConclusionCompared with the blended programme, the PrAISED in-person programme generated higher SROI ratios for people with early dementia. During the COVID-19 pandemic and its restrictions, a blended delivery of the programme and the curtailment of community activities resulted in lower SROI ratios during this period. An in-person PrAISED intervention with community referral is likely to provide better value for money than a blended one with limited community referral, despite the greater costs of the former. Trial registrationISRCTN15320670

BackgroundNursing homes have become the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada. Previous research demonstrates that for-profit nursing homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than non-profit homes. MethodsWe conducted a retrospective cohort study of all nursing homes in Ontario, Canada from March 29-May 20, 2020 using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between nursing home profit status (for-profit, non-profit or municipal) and nursing home COVID-19 outbreaks, COVID-19 outbreak sizes, and COVID-19 resident deaths. ResultsThe analysis included all 623 Ontario nursing homes, of which 360 (57.7%) were for-profit, 162 (26.0%) were non-profit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) COVID-19 nursing home outbreaks involving 5218 residents (mean of 27.5 {+/-} 41.3 residents per home), resulting in 1452 deaths (mean of 7.6 {+/-} 12.7 residents per home) with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak was associated with the incidence of COVID-19 in the health region surrounding a nursing home (adjusted odds ratio [aOR], 1.94; 95% confidence interval [CI] 1.23-3.09) and number of beds (aOR, 1.40; 95% CI 1.20-1.63), but not profit status. For-profit status was associated with both the size of a nursing home outbreak (adjusted risk ratio [aRR], 1.96; 95% CI 1.26-3.05) and the number of resident deaths (aRR, 1.78; 95% CI 1.03-3.07), compared to non-profit homes. These associations were mediated by a higher prevalence of older nursing home design standards in for-profit homes. Interpretation: For-profit status is associated with the size of a COVID-19 nursing home outbreak and the number of resident deaths, but not the likelihood of outbreaks. Differences between for profit and non-profit homes are largely explained by older design standards, which should be a focus of infection control efforts and future policy.

IntroductionDementia is becoming increasingly prevalent in the UK. Older adults from black and south Asian communities have a higher risk for dementia due to an increased prevalence of dementia specific risk factors such as hypertension, diabetes, and heart disease. Deprivation has also been linked to an increased risk of dementia. Ethnic minority and lower socioeconomic groups are underrepresented in dementia research. The aim of this study was to explore factors influencing diversity in dementia and rehabilitation research within the context of the Promoting Activity, Independence, and Stability in Early Dementia (PrAISED) randomised controlled trial (RCT). MethodsWe conducted an exploratory sequential mixed methods study to explore disparities in socioeconomic and ethnic diversity between the PrAISED RCT population and recruitment pathways used in one study site (Nottinghamshire) and compared these with regional and national data. We aimed to collate and summarise data available on ethnicity and deprivation for recruitment/referral pathways (Nottinghamshire site) and the PrAISED cohort (all sites). Additionally, we interviewed healthcare professionals (n=2), researchers (n=2) and members of black and south Asian communities (n=4) to explore barriers to participating in research for people with dementia. ResultsUnder 2% of the overall PrAISED RCT sample (across all sites) were from a non-white ethnic minority background and a third of participants lived in areas with the least deprivation. Referrals to memory assessment services in Nottinghamshire included people from diverse socioeconomic backgrounds, with 7.3% being from non-white ethnic minority communities. Through interviews, several barriers to healthcare, research and rehabilitation were identified. Healthcare barriers included lack of awareness of dementia, mistrust, stigma, fear, and lack of culturally appropriate services. Research barriers included recruitment routes, awareness of research, language, and recruiter beliefs. Barriers to rehabilitation research included a lack of use of culturally appropriate language, more culturally specific barriers, and lack of representation. ConclusionParticipants recruited to the PrAISED RCT were mainly white and socioeconomically privileged. Data recording and access around ethnicity is still inconsistent, making it difficult to ascertain at which point services and research become inaccessible for people from underserved communities. Future research needs to work with these communities to develop innovative solutions to overcome the barriers identified in this study and to put recommendations made into practice.

ObjectivesDetermine individual level risk factors for care home residents testing positive for SARS-CoV-2. Study DesignLongitudinal observational cohort study using individual-level linked data. SettingCare home residents in Wales (United Kingdom) between 1st September 2020 and 1st May 2021. Participants14,786 older care home residents (aged 65+). Our dataset consisted of 2,613,341 individual-level daily observations within 697 care homes. MethodsWe estimated odds ratios (ORs [95% confidence interval]) using multilevel logistic regression models. Our outcome of interest was a positive SARS-CoV-2 polymerase chain reaction (PCR) test. We included time dependent covariates for the estimated community positive test rate of COVID-19, hospital admissions, and vaccination status. Additional covariates were included for age, positive PCR tests prior to the study, sex, frailty (using the hospital frailty risk score), and specialist care home services. ResultsThe multivariable logistic regression model indicated an increase in age (OR 1.01 [1.00,1.01] per year of age), community positive test rate (OR 1.13 [1.12,1.13] per percent increase in positive test rate), hospital inpatients (OR 7.40 [6.54,8.36]), and residents in care homes with non-specialist dementia care (OR 1.42 [1.01,1.99]) had an increased odds of a positive test. Having a positive test prior to the observation period (OR 0.58 [0.49,0.68]) and either one or two doses of a vaccine (0.21 [0.17,0.25] and 0.05 [0.02,0.09] respectively) were associated with a decreased odds of a positive test. ConclusionsOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable. Furthermore, minimising potential COVID-19 infection for care home residents admitted to hospital should be prioritised. SUMMARY BOXESO_ST_ABSSection 1: What is already known on this topicC_ST_ABSO_LICare home residents are at a high risk of COVID-19 infection, but existing literature has mainly focussed on excess mortality rather than infection risk. C_LIO_LIIn our study we were able to investigate associations between COVID-19 infections and the community positive test rate of COVID-19, the vaccination status of care home residents, hospital admissions, and frailty. C_LI Section 2: What this study addsO_LIOur study suggests an increased community positive test rate and hospital inpatients had an increased likelihood of a positive SARS-CoV-2 polymerase chain reaction test, whilst one or two doses of vaccination indicated a decreased chance of a positive test. C_LIO_LIOur findings suggest care providers need to stay vigilant despite the vaccination rollout, and extra precautions should be taken when caring for the most vulnerable, especially in a hospital setting. C_LI

ObjectivesThe aim of this study was to develop a comprehensive economic evaluation of the Integrated Cognitive Assessment (ICA) tool compared with standard cognitive tests when used for dementia screening in primary care and for initial patient triage in memory clinics. MethodsICA was compared with standard of care comprising a mixture of cognitive assessment tools over a lifetime horizon and employing the UK health and social care perspective. The model combined a decision tree to capture the initial outcomes of the cognitive testing with a Markov structure that estimated long-term outcomes of people with dementia. Quality of life outcomes were quantified using quality-adjusted life years (QALYs). Both costs and QALYs were discounted at 3.5% per annum and cost-effectiveness was assessed using a threshold of {pound}20,000 per QALY gained. ResultsICA dominated standard cognitive assessment tools in both the primary care and memory clinic settings. Introduction of the ICA tool was estimated to result in a lifetime cost saving of approximately {pound}147 and {pound}283 per person in primary care and memory clinics, respectively. QALY gains associated with early diagnosis were modest (0.0019 in primary care and 0.0035 in memory clinic). The net monetary benefit of ICA introduction was estimated at {pound}184 in the primary care and {pound}368 in the memory clinic settings. ConclusionsIntroduction of ICA as a tool to screen primary care patients for dementia and perform initial triage in memory clinics could be cost saving to the UK public health and social care payer.

BackgroundThe COVID-19 pandemic significantly increased the number of deaths within LTCFs globally. Restrictions around visitation and social distancing were common, however, research conducted during the pandemic demonstrates that these policies impacted the ways in which end of life care was delivered in LTCFs. AimThis paper aims to understand the experiences of LTCF staff in providing end of life care in the UK and explores the barriers and facilitators to doing so in the context of policies issued by the government at the time. MethodsData from semi-structured interviews conducted with 24 LTCF staff working across eight LTCFs in the north-west of England were analysed. Qualitative interviews were conducted with LTCF staff members, exploring their experiences of working in adult social care during the COVID-19 pandemic. Themes related to providing end of life care during this time were identified and analysed using thematic analysis. FindingsThematic analysis identified four key themes including: discrepancies in following COVID-19 UK government guidelines including visitation at end of life as an exception; the influence of staffing on delivering end of life care; utilising technology to substitute physical presence at end of life visits; and the emotional impact of delivering end of life care under COVID-19 restrictions. ConclusionsThe findings demonstrate the numerous challenges care staff experienced when delivering end of life care during the COVID-19 pandemic in terms of the practicalities of managing resident deaths, facilitating visitation and the associated impact on emotional wellbeing. Ensuring that all LTCF staff are trained to recognise end of life care, in the event of a future pandemic, will better equip LTCFs. In addition, it is paramount that the government provide consistent guidance on managing family contact at end of life, while taking into account the impact of implementing such guidance on the mental and emotional wellbeing of LTCF staff members.

BackgroundUrinary tract infections (UTIs) are a leading cause of hospitalisation in people living with dementia (PLWD), making accurate detection and prompt treatment essential in this vulnerable population. MethodsThis retrospective longitudinal cohort study assessed the concordance between self-reported symptoms, urine colony counts >10{square} CFU/mL, dipstick results positive for leukocytes and/or nitrites, and urinary IL-8 levels in identifying UTIs among PLWD. The study included 78 community-dwelling individuals aged over 50 with a confirmed dementia diagnosis, recruited from cohorts established by the Surrey and Borders Partnership NHS Foundation Trust and the Hammersmith & Fulham Partnership Primary Care Network between late 2019 and 2023. ResultsUTI frequency among PLWD was highly variable, with some individuals experiencing recurrent infections whilst others had none throughout the study period. The microbial taxa identified were consistent with those seen in other populations. There was no clear concordance between self-reported symptoms and laboratory indicators of UTI. However, dipstick-positive results correlated with urine samples showing >10{square} CFU/mL of a single colony morphology growth and elevated IL-8 concentrations. ConclusionsUrinary dipstick tests for nitrites and leukocytes may serve as a practical screening tool for UTIs in PLWD, particularly in individuals unable to reliably report symptoms. However, future research is needed to evaluate the clinical impact of this diagnostic approach on outcomes such as hospitalisation rates, delirium incidence, and antibiotic resistance and stewardship in this vulnerable population.

BackgroundThe effectiveness of exercise interventions to improve activities of daily living function in people with dementia is inconclusive. This study aimed to assess the long-term cost-effectiveness of the PrAISED intervention from a National Health Service (NHS) perspective. MethodThis novel robust economic analysis used a Markov model to evaluate the incremental cost-effectiveness ratio (ICER) over a lifetime horizon of 15 years for a cohort of patients. Sensitivity analyses were conducted to investigate the uncertainty and robustness of high-impacting parameters and results. ResultsThis study included 365 adults, aged 65 years and above with 183 and 182 randomised to the PrAISED and standard care groups respectively. The PrAISED intervention had mean per-patient cost of {pound}60,465 for the PrAISED arm and {pound}54,604 for standard care. The Praised intervention gained an incremental QALYs of 0.05 resulting in an ICER of {pound}129,614 per QALY. The sensitivity analysis of the intervention cost varied the ICER value between {pound}68,173 and {pound}191,054/QALY. To achieve the recommended NICE willingness to pay threshold value of less than {pound}30,000/QALYs would require the intervention cost to be reduced from {pound}1,236 (current cost) to {pound}263 to break even and be cost-effective. The sensitivity analyses revealed that there was a 40% probability of standard care dominating the PrAISED treatment. ConclusionsAlthough the PrAISED intervention was a low-cost intervention, it did not produce a cost-effective intervention in this analysis. The flexibility of the PrAISED program to adapt to government policy during the COVID-19 pandemic was positive. Trial registrationISRCTN15320670

ObjectivesTo describe the point prevalence of SARS-CoV-2 in care homes reporting low numbers of cases of COVID-19. DesignA cross-sectional study of care homes, ascertaining perceived disease burden using interviews with care home managers and SARS-CoV-2 RNA detection in residents and staff using nose and throat swabbing. Setting15 Care homes in Essex, United Kingdom, all of which had reported either zero or one case of COVID-19 to the Health Protection Team. Participants912 residents and staff of care homes were tested. Residents were eligible to be tested regardless of symptoms. Main outcome measureDetection of SARS-CoV-2 in residents and staff. ResultsIn the 15 care homes studied, SARS-CoV-2 was detected in 23 (5.2%) of 441 residents. Of these 23, 21/23 (91%) were asymptomatic as reported by the care home managers. SARS-CoV-2 was detected in 8/471 (1.7%) of staff. This differs from that in residents (p=0.003). ConclusionsThe studys findings suggest that symptoms, as reported by care home managers, are an insensitive method of defining the extent of SARS-CoV-2 infection in nursing homes. Viral detection from residents is more common than from staff. Microbiological screening is a more sensitive method for defining the extent of SARS-CoV-2 in care homes than managerial reporting of resident symptoms.

BackgroundDisease-modifying therapies (DMTs) for Alzheimers disease, including lecanemab and donanemab, have received regulatory approval in multiple jurisdictions. These therapies require complex diagnostic workup and safety monitoring, raising significant budget impact concerns for healthcare payers. No budget impact analysis specific to Ireland or comparable small European healthcare systems has been published. ObjectiveTo estimate the 5-year budget impact of introducing DMTs for early-stage Alzheimers disease in Ireland from the Health Service Executive (HSE) payer perspective. MethodsA budget impact model was developed following International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines. The model incorporated Irish epidemiological data, published drug prices, and healthcare resource utilisation estimates. Three treatment uptake scenarios (conservative, base case, optimistic) were modelled over a 5-year time horizon. Sensitivity analyses examined parameter uncertainty. ResultsFrom an estimated eligible population of 11,568 individuals with early-stage Alzheimers disease, annual budget impact in Year 5 ranged from {euro}12.8 million (conservative: 3% uptake) to {euro}89.6 million (optimistic: 20% uptake), with a base case estimate of {euro}35.8 million (8% uptake). Cumulative 5-year budget impact ranged from {euro}32.0 million to {euro}224.0 million. Drug acquisition costs represented 61% of total expenditure, with diagnostic and monitoring costs comprising 24% and 15%, respectively. Sensitivity analysis identified drug price, eligible population size, and treatment uptake as the most influential parameters. ConclusionsIntroduction of DMTs for Alzheimers disease will have a substantial but manageable budget impact on the Irish healthcare system, contingent on treatment uptake rates constrained by diagnostic capacity. Strategic investment in diagnostic infrastructure, phased implementation, and negotiated drug pricing could mitigate budgetary pressures while enabling patient access to these novel therapies. Key Points for Decision MakersO_LIThis is the first budget impact analysis of disease-modifying therapies (DMTs) for Alzheimers disease specific to Ireland, a small European healthcare system with constrained diagnostic capacity. C_LIO_LIAnnual budget impact ranges from {euro}12.8 million (conservative scenario) to {euro}89.6 million (optimistic scenario) in Year 5, representing 0.05% to 0.33% of the total Health Service Executive budget. C_LIO_LIDrug acquisition costs account for 58-65% of total expenditure, with diagnostic workup and safety monitoring comprising substantial ancillary costs. C_LIO_LIPhased implementation aligned with diagnostic infrastructure expansion could enable budget-neutral introduction through efficiency gains in dementia care pathways. C_LI

BackgroundThe COVID-19 pandemic adversely impacted health professionals mental health and emotional wellbeing, however less research has examined the impact of the pandemic on LTCF staff. There is limited research on the emotional wellbeing of adult social care staff, particularly within the context of the government guidance and restrictions. This study aims to explore the impact of the COVID-19 pandemic on the mental health and emotional wellbeing of LTCF staff in England. MethodsSemi-structured, qualitative interviews with 24 staff members working in eight LTCFs based in the north-west of England. Data was collected initially to explore experiences of staff members working in LTCFs during the COVID-19 pandemic, and a secondary analysis of the data focused on mental health and emotional wellbeing was conducted using thematic analysis. FindingsFive central themes were conceptualised: burnout and trauma (including initial impact on mental health and long-lasting effects on mental health); efforts to cope (passive coping strategies and active coping strategies); positive impacts on staff wellbeing (including building resilience and preserving the routine of daily life); impact on personal/home life (including protecting ones family, changing family relationships, and less work/life balance); and availability of support (including informal support and support from external services). ConclusionsThe COVID-19 pandemic had a predominantly negative impact on LTCF staffs emotional wellbeing, partly due to a lack of external support and appreciation. This impact continues to affect many LTCF staff who have not been able to access useful or appropriate support. This research highlights the importance of developing organisational resilience within such facilities and supporting LTCF staff to emotionally cope with the challenges of future pandemics.

BackgroundCOVID-19 has had large impact on care-home residents internationally. This study systematically examines care-home outbreaks of COVID-19 in a large Scottish health board. MethodsAnalysis of testing, cases and deaths using linked care-home, testing and mortality data for 189 care-homes with 5843 beds in a large Scottish Health Board up to 15/06/20. Findings70 (37.0%) of care-homes experienced a COVID-19 outbreak, 66 of which were in care-homes for older people where care-home size was strongly associated with outbreaks (OR per 20-bed increase 3.50, 95%CI 2.06 to 5.94). There were 852 confirmed cases and 419 COVID-related deaths, 401 (95.7%) of which occurred in care-homes with an outbreak, 16 (3.8%) in hospital, and two in the 119 care-homes without a known outbreak. For non-COVID related deaths, there were 73 excess deaths in care-homes with an outbreak, but no excess deaths in care-homes without an outbreak, and 24 fewer deaths than expected of care-home residents in hospital. A quarter of COVID-19 related cases and deaths occurred in five (2.6%) care-homes, and half in 13 (6.9%) care-homes. InterpretationThe large impact on excess deaths appears to be primarily a direct effect of COVID-19, with cases and deaths are concentrated in a minority of care homes. A key implication is that there is a large pool of susceptible residents if community COVID-19 incidence increases again. Shielding residents from potential sources of infection and rapid action into minimise outbreak size where infection is introduced will be critical in any wave 2. FundingNot externally funded. O_TEXTBOXResearch in context Evidence before this study We searched PubMed and the medRxiv preprint server using terms long-term care, nursing home, care home, or residential care combined with COVID-19 and/or SARS-CoV-2, updated to 25th June. The existing published literature highlights the large impact in care-homes, and that atypical disease presentation, asymptomatic carriage and a presymptomatic infectious period is common in both residents and staff. One living systematic review confirms the international outbreak burden among residents and staff and high but varied international mortality rates. International modelling studies have failed to take account of the care-home environment and context, making estimates informed by general community transmission of infection. Only one peer-reviewed study was identified which evaluated US nursing home characteristics associated with outbreaks, finding associations with larger facility size, urban location, and ethnicity, but no association with quality ratings or ownership. Added value of this study This study reports data for all 189 care homes in one large Scottish health board, where 37% experienced an outbreak of COVID-19, with 95% of outbreaks in care-homes for older people. The number of beds was the only care-home characteristic statistically significantly associated with the presence of an outbreak. One-third of affected care homes had only single cases or short outbreaks, but sustained outbreaks were common, and there was evidence of potential reintroduction of infection in some care-homes with >14 day gaps between confirmed cases. Cases and mortality were heavily concentrated. In care-homes with an outbreak there were 472 excess deaths (12.3% of bed capacity, 3.1 times the average in the previous five years), 85% of which were COVID-19 related. There were only 16 COVID-19 related deaths and 14 other deaths of care-home residents in hospital in the same period, consistent with [~]20 non-COVID excess deaths occurring in care-homes being deaths that would have happened anyway. 99% of the excess deaths and of the COVID-19 related deaths were in care-homes with an outbreak, suggesting that quality and safety of care in the wider care system was not affected. Implications of all the available evidence Outbreak patterns varied considerably and more detailed understanding of why some care homes avoided or controlled outbreaks would allow learning to prepare for wave two. Systematic, regular testing and use of whole genome sequencing will inform understanding of transmission dynamics and future outbreak management. Future research should consider the built environment and organisation of care as other potentially modifiable factors to support infection control. Improving national and local data on the care-home population is a priority both for COVID-19 and for ensuring this vulnerable population receives better care in the future. C_TEXTBOX

BackgroundCare home residents have complex care and support needs, as demonstrated by their vulnerability during the COVID-19 pandemic. There is a perception that the needs of residents have increased, but evidence is limited. We investigated changes in health and functioning of care home residents over two decades in England and Wales. MethodsWe conducted a repeated cross-sectional analysis over a 24-year period (1992-2016), using data from three longitudinal studies, the Cognitive Function and Ageing Studies (CFAS) I and II and English Longitudinal Study of Ageing (ELSA). To adjust for ageing of respondents over time results are presented for the 75-84 age group. ResultsAnalysis of 2,280 observations from 1,745 care home residents demonstrated increases in severe disability (difficulty in at least two from washing, dressing and toileting). The prevalence of severe disability increased from 63% in 1992 to 87% in 2014 (subsequent fall in 2016 although wide confidence intervals). The prevalence of complex multimorbidity (problems in at least three out of six body systems) increased within studies over time, from 33% to 54% in CFAS I/II between 1992 and 2012, and 26% to 54% in ELSA between 2006 and 2016. ConclusionOver two decades, there has been an increase in disability and the complexity of health problems amongst care home residents in England and Wales. A rise in support needs for residents places increasing demands on care home staff and health professionals. This is an important concern for policymakers when considering the impact of COVID-19 infection in care homes. Key pointsO_LICare home residents have complex care and support needs, which has contributed to their vulnerability during the COVID-19 pandemic. C_LIO_LIDespite a perception that the needs of care home residents have increased over time, the epidemiological evidence is limited. C_LIO_LIThis study demonstrates an increase in the level of disability and the complexity of health problems amongst care home residents in England and Wales over two decades. C_LIO_LIThe rise in support needs for care home residents places increasing demands on care home staff and health professionals, and should be an important consideration for policymakers and service commissioners when considering the impact of current and future waves of COVID-19 infection in this setting. C_LI