December 2020
Dying of Loneliness?
Marv was an 83 YO man who lived in a long-term care facility. His family visited at least weekly. Moreover, staff assisted in weekly video calls to his family. In addition to having chronic comorbidities of cognitive impairment and profound hearing loss, Marv contracted and survived COVID-19 infection in April. After this illness, he began to decline. He was eating less and interacting with staff less. Staff members from multiple disciplines continued to try and keep up with phone calls to family. As his condition worsened, family was able to come in to talk about how best to move forward.

At this visit, Marv began to sit up straighter, interact verbally and he attended to conversation in the room. Further, he ate his entire lunch with enthusiasm. After this visit, he again quickly lapsed into poor appetite and general inanition. One month prior to his eventual death in November, he was hospitalized for change in mental status and unstable vital signs. He was found to be septic from urinary source. He again survived this illness. On the day he was transferred back to the facility, the family was able to say that, if Marv were able to, he would say that he didn’t have any quality of life. They made the decision to allow Marv to die a natural death.

As PA-LTC professionals, we hear this kind of story more often than we’d like. Now, in the time of pandemic, long-term care facilities are being much more attentive to preventing transmission of infection. This is to the point that the only people a resident might see are their nursing team and potentially the person who cleans their room. Every staff member caring for them wears a mask. Their room door is kept closed and they might not be able to leave it. If they DO leave their room, it is with a face mask.

In the facility where Marv lived, staff has noticed that even after the most stringent restrictions were eased, other residents were much less likely to leave their room or to participate in activities.
In 2010, AARP conducted a survey of adults 45 and older and found that 35% of adults age 45 and older are lonely. This percentage ranges from 43% of persons 45-49 to 25% of persons 70 and older. In this survey, protective factors were one or more supportive people in their life, higher income, and marital status. 1

There have been studies in the past that show that social isolation, or the lack of social connections, puts older persons at risk for premature mortality and functional decline, especially those over age 60. 2

Another study, based on the data from the Health and Retirement Study, showed that loneliness was associated with an increased risk of death. During the six year follow up on these persons, the hazard ratio for mortality was 1.70. Other effects of loneliness were ADL decline (24.8% lonely vs 12.5% not lonely), difficulty with upper extremity tasks (41.5% lonely vs 28.3% not lonely), and difficulty with stair climbing (40.8% lonely vs. 27.9% not lonely). 3 This study found that loneliness shows a harmful effect for all-cause mortality and this effect is slightly stronger in men (HR 1.22). 4

Would Marv have declined and died in this manner anyway? How does this affect clinical practice? Can we safely add protective factors against loneliness in congregate settings?

I worry that there are more questions than answers.

Are you able to address this in your facility? How are you dealing with the loneliness of residents?

Please feel free to share your thoughts on this articles on the PALTC Practitioners' Forum. Here's how to join and access the Forum.

Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
[1] Loneliness Among Older Adults; A National Survey of Adults 45+, AARP, September 2010.
[2] Holt-Lunstad J,Smith TB,Baker M,Harris T, Stephenson D. Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Perspectives on Psychological Science. 2015; 10(2): 227-237.
[3] Perissinotto CM, Stijacic Cenzer I, Covinsky K. Loneliness in Older Persons: A Predictor of Functional Decline and Death. Archives of Internal Medicine. 2012;172(14):1078-1083.
[4] Rico-Uribe L, Caballero F, Martin-Maria N, Cabello M, Ayuso-Mateos J, Miret M. Association of loneliness with all-cause mortality: A Meta-analysis. PLOS ONE. 13(1):e0190033, 2018
CMS Cut to Primary Care Services in Nursing Facilities/Assisted Living/Home Health by Nearly 10 Percent is Unconscionable
Columbia, MD – AMDA – The Society for Post-Acute and Long-Term Care Medicine strongly opposes policy the Centers for Medicare & Medicaid Services (CMS) finalized on December 1, 2020, to cut payments for evaluation and management (E&M) services in nursing facilities, assisted living, and home health by nearly 10% effective January 1, 2021.

Physicians, nurse practitioners, physician assistants, and occupational/physical therapists who practice in these settings have put themselves at the highest risk caring for patients who have been the hardest hit by the COVID-19 pandemic. These clinicians face incredible physical and mental hardship, as many are forced to isolate from their families and suffer the consequences of contracting the virus themselves. Cutting these services at this time is simply unconscionable.

There are upwards of 50,000 unique visits billed to Medicare in the nursing home alone—that number grows significantly when assisted living and home health are included. Upwards of 17,000 clinicians practice exclusively in the nursing facility setting. Such cuts will force these practices to make hard choices that likely will lead to the worsening of an already crippling clinical workforce crisis for our nation’s most vulnerable citizens.

As a consequence, veterans, frail older Americans, disabled individuals, and many others may not have access to adequate care. Many will end up being re-hospitalized, which will impose significant additional costs to Medicare, reversing the significant progress made on reducing re-hospitalizations, and only serve to erode the quality of life and quality of care for these patients and residents. When combined with the fact that family members, who normally serve as an integral part of the care team, are restricted from seeing their loved ones, we must more than ever rely on our front line clinical caregivers to provide care and to communicate with families on the care being provided.

“It is inexplicable, in light of the surging COVID-19 crisis, that CMS has chosen to impose this drastic cut on the very clinicians who, at great risk to themselves and their families, have been battling this deadly virus at ground zero for the past 9 months,” said Society Executive Director Christopher E. Laxton, CAE. “Far from offering support and encouragement to our dedicated practitioners, this instead delivers a wound that may very well prove to be unsustainable—with tragic consequences for our nation’s nursing home residents and their families.”

Given the urgency of this matter, the Society is actively working with Congress on legislation that would suspend budget neutrality requirements that result in this cut. We urge Congress to act immediately to prevent cuts so that our seniors can continue to receive the care they deserve.

Please follow the “Take Action” link below to contact your members of Congress and ask them to waive the budget neutrality requirements stipulated in Section 1848(c)(2) of the Social Security Act before the final E/M code proposal is implemented on January 1, 2021.

If your have an questions, please contact Alex Bardakh at abardakh@paltc.org
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Under the best of circumstances, working in a nursing home can be a physically and emotionally demanding job. This past year, under the unprecedented circumstances of the COVID-19 pandemic, highlighted the dedication, compassion, and innovation of our PALTC workforce, caring for our most vulnerable population.

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