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Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine "booster" doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Older nursing home residents make up the population at greatest risk of morbidity and mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. No studies have examined the determinants of long-term antibody responses post vaccination in this group., Design: Longitudinal cohort study., Setting and Participants: Residents from 5 nursing homes assessed before vaccination, and 5 weeks and 6 months post vaccination, with the BNT162b2 messenger RNA SARS-CoV-2 vaccine., Methods: Comprehensive clinical assessment was performed, including assessment for comorbidity, frailty, and SARS-CoV-2 infection history. Serum nucleocapsid and anti-spike receptor binding domain (RBD) antibodies were analyzed at all timepoints. An in vitro angiotensin-converting enzyme (ACE2) receptor-spike RBD neutralization assay assessed serum neutralization capacity., Results: Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%; 39 of 86) had evidence of previous SARS-CoV-2 infection. All participants demonstrated a significant antibody response to vaccination at 5 weeks and a significant decline in this response by 6 months. SARS-CoV-2 infection history was the strongest predictor of antibody titer (log-transformed) at both 5 weeks [β: 3.00; 95% confidence interval (CI): 2.32-3.70; P < .001] and 6 months (β: 3.59; 95% CI: 2.89-4.28; P < .001). Independent of SARS-CoV-2 infection history, both age in years (β: -0.05; 95% CI: -0.08 to -0.02; P < .001) and frailty (β: -0.22; 95% CI: -0.33 to -0.11; P < .001) were associated with a significantly lower antibody titer at 6 months. Anti-spike antibody titers at both 5 weeks and 6 months significantly correlated with in vitro neutralization capacity., Conclusions and Implications: In older nursing home residents, SARS-CoV-2 infection history was the strongest predictor of anti-spike antibody titers at 6 months, whereas age and frailty were independently associated with lower titers at 6 months. Antibody titers significantly correlated with in vitro neutralization capacity. Although older SARS-CoV-2 naïve nursing home residents may be particularly vulnerable to breakthrough SARS-CoV-2 infection, the relationship between antibody titers, SARS-CoV-2 infection, and clinical outcomes remains to be fully elucidated in this vulnerable population., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Benzodiazepines and related drugs (BDZRs) have been associated with an increased risk of Alzheimer's disease (AD) in later life. Despite this, it remains unclear whether ongoing BDZR use may further accelerate cognitive decline in those diagnosed with mild to moderate AD., Design: This study was embedded within NILVAD, a randomized controlled trial of nilvadipine in mild to moderate AD. Cognition was measured at baseline and 18 months using the Alzheimer Disease Assessment Scale, Cognitive Subsection (ADAS-Cog). We assessed predictors of long-term BDZR use and analyzed the effect of ongoing BDZR use on ADAS-Cog scores at 18 months. Additionally, the impact of BDZR use on adverse events, incident delirium, and falls over 18-month follow-up was assessed adjusting for relevant covariates., Setting and Participants: 448 participants with mild to moderate AD recruited from 23 academic centers in 9 European countries., Results: Overall, 14% (62/448) were prescribed an ongoing BDZR for the study duration. Increasing total number of (non-BDZR) medications was associated with a greater likelihood of BDZR prescription (odds ratio 1.16, 95% confidence interval 1.05-1.29). At 18 months, BDZR use was not associated with greater cognitive decline on the ADAS-Cog controlling for baseline ADAS-Cog scores, age, gender, study arm, and other clinical covariates (β = 1.62, -1.34 to 4.56). However, ongoing BDZR use was associated with a greater likelihood of adverse events [incidence rate ratio (IRR) 1.19, 1.05-1.34], incident delirium (IRR 2.31, 1.45-3.68), and falls (IRR 1.66, 1.02-2.65) over 18 months that persisted after robust adjustment for covariates., Conclusions and Implications: This study found no effect of ongoing BDZR use on ADAS-Cog scores in those with mild to moderate AD over 18 months. However, ongoing use of these medications was associated with an increased risk of adverse events, delirium, and falls. Thus, BDZR use should be avoided where possible and deprescribing interventions should be encouraged in older adults with AD., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Late life depression (LLD), defined as depressive illness in people aged 60 years or older, is more complex than depression presenting in earlier life, with different clinical features and a poorer response to therapy. Different biological factors underlie LLD and hypotension may be an important modifiable risk factor. The aim of this systematic review is to clarify the relationship between hypotension and LLD., Methods: A systematic search was conducted in PubMed and Embase for articles published up to December 31, 2015. Key search terms were "depression," "depressive disorder," "hypotension," and "blood pressure." Studies were included if they were published as a primary research paper in a peer-reviewed journal, involved participants with a mean age of 60 years or more, and examined the relationship between hypotension and depression., Results: The initial combined search retrieved 2268 nonduplicate articles. Of these, 116 full texts were assessed for eligibility, of which 19 were included in this systematic review. Nine cross-sectional studies examined the association between hypotension and LLD, with 8/9 indicating a positive association between the 2. Five cross-sectional studies examined the relationship between orthostatic hypotension (OH) and LLD, with each study finding a positive association between the 2. Five longitudinal studies examined the relationship between hypotension and LLD, with discordant findings between studies. There were no longitudinal studies examining the relationship between OH and LLD., Discussion: This systematic review found that cross-sectional studies demonstrated a consistent relationship between hypotension and LLD, but longitudinal data to date is less consistent, with discordant findings. There are several methodological limitations of published longitudinal data that may explain these differences, including differences in age at enrollment, depression and blood pressure assessment, and controlling for covariates. Further longitudinal studies to clarify the role of these potentially modifiable factors in the development of this complex illness are essential., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The Beers (2012) criteria and the screening tool of older persons' potentially inappropriate prescriptions (STOPP) criteria are often used to identify potentially inappropriate medication (PIM) use in elderly patients. The aim of this study is to determine the prevalence of PIM use in nursing home residents (NHRs) aged ≥65 years presenting to the Emergency Department (ED); to compare the Beers and STOPP criteria and to identify the potential role of PIMs in ED attendances., Setting: The ED of an urban tertiary referral hospital., Participants: Acutely unwell long-term care NHRs seeking medical assistance at the ED., Design and Measurements: This is a retrospective cohort study. Demographic and clinical data were retrieved from the ED electronic record system, from the clinical records, and transfer letters for all NHRs who attended the ED in 2011. Beers 2012 and STOPP criteria were used to identify PIMs., Results: Of 195 NHRs identified, 165 were included. The mean age (±standard deviation) was 82.5 (±7.7) years; 110 (66.7%) were female and 157 (95.2%) were prescribed at least 1 PIM by either criterion. One hundred forty patients (84.8%) received a PIM according to STOPP criteria and 147 (89.1%) according to the Beers criteria. In the majority of patients (148; 89.7%), there was a difference in the medications Beers and STOPP identified as inappropriate. Fifty patients (30.3%) were considered to have a link between their attendance at ED and the PIM prescribed when assessed subjectively. Objective assessment using the WHO-UMC criteria found 7 (4.2%) had a 'probable' link and 45 (27.3%) a 'possible' link., Conclusions: These results show a high rate of PIM prescribing in this cohort. The use of criteria such as Beers and STOPP may be a useful guide for physicians coordinating the long-term care of NHRs and may have the potential to reduce attendances at ED.