COVID-19 and respiratory syncytial virus cases are increasing, and the height of influenza season is on the horizon, but older adults and long-term care staff members are entering the first virus season in which vaccines are available for all three viruses responsible for the most hospitalizations.

The Centers for Disease Control and Prevention Office of Readiness and Response laid out the agency’s recommendations for flu, COVID-19 and RSV vaccines for older adults during a clinician outreach and communication activity call on Tuesday.

Influenza vaccines

Flu vaccination is recommended for everyone aged more than 6 months. Studies show older adults account for 54% to 70% of flu-related hospitalizations and 71% to 85% of flu-related deaths, said Lisa Grohskopf, MD, MPH, medical officer of the influenza division of the CDC’s National Center for Immunization and Respiratory Diseases.

This year, recommendations were updated regarding vaccine composition for 2023-2024, and changes were made to recommendations for people allergic to eggs.

Specifically, preferred vaccinations for older adults include the standard-dose adjuvanted or high-dose inactivated quadrivalent vaccines, or the recombinant quadrivalent vaccine — the latter being the only preferred vaccine that is not egg-based.

Experts also recommend flu vaccines in September or late fall due to the potential waning of immunity. The updated recommendations also indicate that individuals with egg allergy should be treated no differently than other recipients of any other vaccine, with no additional safety measures required. 

COVID-19 vaccines

Although the burden of COVID-19 varies by age and underlying conditions, older adults and those who have multiple underlying conditions have the highest risk of severe outcomes. Megan Wallace, DrPH, MPH, a CDC epidemiologist, said that the number of COVID cases is lower than at previous points in the pandemic, but experts continue to see thousands of hospitalizations and hundreds of deaths weekly from the virus, particularly in those 75 and older.

Vaccination with the updated COVID-19 vaccine is recommended, according to the CDC, because vaccine and infection-induced immunity wanes and because new variants continue to emerge, suggesting that susceptibility remains and may increase over time. Millions of COVID-19 vaccines have been administered over three years, proving their safety profile, Wallace added.

Key changes to the 2023-2024 mRNA vaccine recommendations include that anyone aged five or more years receive a single dose regardless of prior vaccination history, although additional doses may be recommended in the future based on epidemiology and vaccine effectiveness.

Under general best practice guidelines for immunization, routine administration of all age-appropriate doses of vaccines — COVID-19, flu and RSV — simultaneously is recommended if no contraindications exist at the time of vaccination. 

This year’s COVID-19 vaccines are the first to be available directly from the manufacturers as part of the commercial market rather than through the federal government. 

RSV vaccines

Although RSV is a familiar viral infection, Amadea Britton, MD/SM, medical officer of the CDC’s Coronavirus and Other Respiratory Viruses Division, said that it is an important cause of respiratory illness in older adults.

Older adults typically account for 60,000 to 160,000 RSV-related hospitalizations annually, and 6,000 to 10,000 deaths. Chronic underlying conditions are associated with increased risk of severe RSV disease, along with living in a senior living community or nursing home, frailty and advanced age.

In June, the CDC signed off on a recommendation from the Advisory Committee on Immunization Practices for a single dose of RSV vaccines for older adults. Studies found the vaccines to be generally well-tolerated, with common side effects similar to other vaccines, including pain at injection site, fatigue, headache, muscle pain and joint pain.

The ACIP and CDC recommend that adults aged 60 or more years receive a single dose of the RSV vaccine using shared clinical decision-making with their healthcare provider. RSV vaccination should be administered as soon as the vaccine is offered each summer. 

Vaccine hesitancy

Talking about vaccines can be a challenge, said Joellen Wolicki, BSN, RN, a nurse educator with the National Center for Immunization and Respiratory Diseases. 

“The biggest challenge is, knowledge does not equal behavior,” she said. “And it matters who the message is coming from and how it’s communicated.”

A broad range of socio-psychological determinants contribute to vaccine hesitancy, including attitudes, past experiences, trust, social norms, moral values and world views, Wolicki said.

The CDC recommends that healthcare providers give a strong recommendation for vaccination using the presumptive approach, which assumes that someone will choose to get vaccinated. In some cases, motivational interviewing — collaborative communication to guide people toward change or action — might be more effective. Studies using motivational interviewing with vaccination decisions showed increased intent to vaccinate and improved vaccination rates, Wolicki said.

Fully immersive virtual reality is an emerging and promising therapeutic tool to manage psychosocial disorders in older adults, according to the results of a new study.

French researchers assessed the effectiveness of 360-degree immersive virtual reality videos on the well-being of older adults with or without cognitive impairments. They also looked at cybersickness and attitudes toward the emerging technology.

Their findings, published in the April issue of JAMDA, the journal of AMDA–The Society for Post-Acute and Long-Term Care Medicine, found the technology becoming increasingly accessible, affordable and easy to use, with virtual environments that allow users to experience a personalized, immersive 360-degree environment that stimulates an emotional response.

“Our results show that VR 360-degree is a promising technology because it seems that benefits can be observed after only a few sessions,” the authors explained. “Qualitative data analysis showed that older adults found the experience enjoyable, realistic and to generate positive emotions to them.”

A review of 10 studies involving 524 older adults aged 68 to 87 who lived in residential care communities or the community at large examined the effects of virtual reality on anxiety, apathy, loneliness, depression, social engagement, quality of life and emotions. Although rare, they also found side effects associated with virtual reality disorientation, including motion sickness, dizziness, vertigo, eye strain, headache and blurred vision. 

The content of the VR environment, they said, is crucial to optimizing the potential positive effects on well-being. They found that even short-term exposure to natural settings — woods, parks, beaches — can result in positive feelings and reduced negative emotions in older adults with or without cognitive impairment. 

“These findings have been particularly relevant during the ongoing COVID pandemic, in which VR has provided a unique opportunity to enable older adults with age-related impairments to escape from their often confined realities and be transported to interesting, stimulating, calming and enjoyable places,” the authors concluded.

They encouraged researchers to partner with the industry to develop new virtual reality applications for personalized content for older adults.

Virtual reality as an insurance benefit

Earlier this year, MyndVR, which provides virtual reality experiences for senior living residents and other older adults, announced a partnership with specialty managed care organization AgeWell New York to offer VR therapy sessions to nursing homes residents as part of AgeWell’s CareWell I-SNP plan. (The offering is not available to assisted living residents yet, but coverage is planned for next year.)

AgeWell is the first insurance company to cover VR as a supplemental benefit under Medicare Advantage. 

MyndVR also is looking to expand coverage of its VR technology through a coalition called DigitalTherapyNOW.org. The group of academic and industry partners is working to educate lawmakers to support passage of the Access to Prescription Digital Therapeutics Act, which was originally introduced in March 2022. If passed, the bill would formally recognize digital therapeutics at a federal level.

Focusing on older adults’ mental and physical capacities could be more effective than disease management in promoting healthy aging, according to the results of a new study.

Researchers from Peking University in Beijing conducted a literature review of 53 studies and found that most looked at intrinsic capacity — the composite of all physical and mental capacities in an individual — in depth. The intrinsic capacity framework considers cognition, mobility, psychological, vitality and sensory functions — a potential target for senior living providers and other long-term care providers already incorporating wellness into their community programming and offerings.

Older adults often have multiple health conditions that, when controlled, have little effect on their activities of daily living, the authors noted. That fact, they said, makes research focusing on the intrinsic capacity and functional abilities of older adults more meaningful. Their results were published in the March issue of JAMDA, the journal of AMDA–The Society for Post-Acute and Long-Term Care Medicine.

A focus on IC is more effective

“Although diseases/deficits remain the current focus of health services for older adults, evidence suggests that focusing on IC of older adults is more effective than prioritizing health management for chronic diseases,” the authors wrote. “This suggests that older adults’ capacity may be an appropriate target and entry point for health interventions.”

The authors concluded that a focus on intrinsic capacity and disease should be balanced to better promote healthy aging in older adults. The discovery of diverse measures of intrinsic capacity also underscores the need for consensus on standardized measurements — many studies in the literature review did not look at sensory capacity — and calculation procedures, they said.

An indicator of health

The World Health Organization recently proposed intrinsic capacity as a multidimensional indicator of health, “accounting for the mental and physical capacity that are crucial to older people to continue doing what they value most,” according to a study in The Lancet.

In that study, the authors concluded that intrinsic capacity represents a unique opportunity for disseminating function-based assessments and integrated care of older adults living in diverse settings and with varying health conditions.

A network of long-term care medical directors and clinicians will develop best practices around COVID-19 treatments and infection prevention guidelines for senior living communities, nursing homes and other congregate care settings in Virginia.

The Virginia Long Term Care Clinician Network is the result of a partnership between Virginia Commonwealth University and the Virginia Department of Health to bring together medical directors and clinicians practicing in long-term care settings. The network is a two-year project being developed and managed by the VCU Division of Geriatric Medicine, VCU’s Virginia Center on Aging and the VCU Department of Gerontology.

Network goals

The goals of the network include developing a consensus-derived COVID-19 treatment algorithm specific to long-term care medicine, disseminating monthly updates focusing on new COVID-19 infection prevention guidelines and treatment options, establishing a monthly forum and creating a central website for network members.

“During the COVID-19 pandemic, the Virginia Long-Term Care Task Force did experience challenges in identifying and communicating with medical directors, physicians and other medical professionals supporting long-term care communities,” Judy Hackler, executive director of the Virginia Assisted Living Association, told McKnight’s Senior Living. “We welcome the creation of the Virginia Long-Term Care Clinician Network and look forward to working with the commonwealth on improving communications with assisted living providers on concerns, programs and opportunities that could better support assisted living providers and the residents they serve.”

The Virginia Health Care Association / Virginica Center for Assisted Living told McKnight’s Senior Living that the network integrates assisted living into the larger conversations happening in the state’s healthcare community. A spokeswoman said that assisted living’s inclusion allows the sector to have access to information and resources for infection prevention and control as a “key part of the care continuum.”

Unified approach

“As COVID-10 variants and new therapeutic options continue to arrive, it is vital that we have a unified approach to connect and engage with this group to be able to better understand the clinical management of COVID-19 for one of our most vulnerable populations,” Lelan Waters, PhD, project director of VCU Center on Aging, said in a statement. 

The network is being funded by an $820,000 grant that was part of $9.9 million the state health department awarded in December to nine organizations across the commonwealth. The network initially was part of the Virginia Long-Term Care Infrastructure Pilot Project, which received funding from the Centers for Disease Control and Prevention through the American Rescue Plan Act of 2021 as part of the Nursing Home & Long-Term Care Facility Strike Team and Infrastructure project.

Christian Bergman, MD, an assistant professor in the VCU Division of Geriatric Medicine and Virginia LTC-CN principal investigator, said that the network will create a collaboration among post-acute and long-term care medicine clinicians who were unified through COVID-19 pandemic.

Building back stronger

“This grant represents an opportunity to learn and build back stronger,” Bergman said in a statement. “We aim to unite clinicians who practice medicine in this challenging work environment while helping some of the most frail members of our community.”

The 580 assisted living communities and 287 nursing homes in the state employ 139 medical directors and up to 600 clinicians. The goal of the project is to create a central mode of communication among those providers through a monthly forum encouraging peer discussions.

Senior living and care providers across the country were among “unwitting” healthcare businesses duped into hiring more than 7,600 nurses with fake credentials due to a $114 million fraud scheme, according to the federal government. 

The Department of Justice announced federal charges last week against 25 nursing school recruiters, owners and managers for a wire fraud scheme that created an illegal licensing and employment shortcut for aspiring nurses. Dubbed “Operation Nightingale,” the investigation resulted in search warrants in five states: Delaware, New York, New Jersey, Texas and Florida.

“What is disturbing about this investigation is that there are over 7,600 people around the country with fraudulent nursing credentials who are potentially in critical healthcare roles treating patients,” Special Agent in Charge Chad Yarbrough with the FBI Miami office said in a statement.

SNFs, assisted living, home care

According to three unsealed indictments from a South Florida federal grand jury and two informations filed by federal prosecutors, the scheme involved the sale of fraudulent nursing degree diplomas and transcripts from accredited Florida-based nursing schools for an average of $15,000 each. The “bogus diplomas” and transcripts qualified individuals to sit for the national nursing board exam and obtain licenses and jobs as registered nurses and licensed practical/vocational nurses in various states.

The overall scheme involved three now-closed South Florida-based nursing schools: Siena College and Sacred Heart International Institute in Broward County, and Palm Beach School of Nursing in Palm Beach County.

According to a grand jury indictment, the Palm Beach School of Nursing is accused of providing fake diplomas and transcripts to seven “co-conspirators” between April 2016 and July 2021 for associate nursing or LPN degrees. 

Those individuals, the Justice Department said, used those fake credentials to obtain employment in various states at “unwitting” healthcare providers throughout the country, including the New Jersey assisted living community; skilled nursing facilities in Ohio, New Jersey and New York; and a New York rehabilitation facility, a New York US Department of Veterans Affairs medical center, and a Massachusetts home health facility.

Similarly, an information and an indictment revealed that Siena College allegedly sold 2,016 fraudulent diplomas and educations transcripts from Nov. 17, 2018, through October 2021, falsely representing that the “students” had completed the necessary courses and clinical training to obtain nursing degrees that led to employment by “various unwitting healthcare providers throughout the country,” including a Georgia hospital and a Maryland Veterans Affairs medical center.

And according to an information, Sacred Heart International Institute from November 2020 through July 2021 sold 588 false and fraudulent diplomas and educational transcripts. According to an indictment, the school provided LPN credentials that allowed individuals to obtain employment at various healthcare providers throughout the country, including two Texas skilled nursing facilities and a Texas home health facility.

Defendants face 20 years

The charging documents allege that the charged individuals solicited and recruited accomplices seeking nursing credentials to obtain employment as an RN or LPN/VN in the healthcare field, created and distributed false and fraudulent diplomas and transcripts, used the fraudulent documents to obtain employment, concealed the use of those fraudulent documents to obtain employment and used the proceeds of the fraud for their personal use and benefit.

Each defendant faces up to 20 years in prison.

“Not only is this a public safety concern, it also tarnishes the reputation of nurses who actually complete the demanding clinical and course work required to obtain their professional licenses and employment,” US Attorney for the Southern District of Florida Markenzy Lapointe said in a statement. He added that a “fraud scheme like this erodes public trust in our healthcare system.”

In a study published in Innovation in Aging, the journal of the Gerontological Society of America, discussed earlier this month in the Annals of Long-Term Care, researchers examined decision-making related to administering as-needed antipsychotic medications to assisted living/residential care residents who had a diagnosis of dementia or cognitive impairment. The study looked at decision drivers among direct care workers, nurses, administrators and consulting pharmacists.

Researchers conducted semi-structured interviews among 11 direct care staff members, licensed nurses, administrators/executive directors and pharmacists between May and August 2021. They found that decisions to administer antipsychotic medications involved attitudes, underlying morality and perceived expertise. 

Direct care staff members, the researchers found, are guided by rules, training and resident needs, whereas those not involved in the day-to-day care of residents are guided by professional standards, training and an awareness of the challenges presented by some behaviors.

Practice implications

The study raises practice and policy implications for the senior living setting, the study authors said.

“Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective, extending beyond direct care staff passing antipsychotic medications to residents,” study researchers concluded. 

About half (49%) of the nation’s assisted living/residential care residents have a diagnosis of Alzheimer’s disease or related dementia, and more than 70% of those residents experience behaviors that include aggression, agitation, anxiety, delusions, hallucinations and sleeplessness, the researchers said. Chronic or severe behaviors have implications for resident quality of life, family and caregiver burden, and care transitions, they noted.

Off-label use

In the early 2000s, studies showed that off-label use of antipsychotic medications in older adults living with dementia was associated with a higher risk of early mortality, leading the US Food and Drug Administration to issue a “black box” warning on use of antipsychotic use in older adults.

Although through the National Partnership for Quality Dementia Care the Centers for Medicaid & Medicare Services developed quality improvement efforts related to the use of those medications in nursing homes, evidence is lacking about antipsychotic medication use in assisted living/residential care facilities, staff training and use of nonpharmaceutical interventions, and potential discrimination against older adults whose behaviors are deemed “challenging,” the study authors said.

Accreditation

Reducing the off-label use of antipsychotics in assisted living communities has been an industry goal.

The Joint Commission’s assisted living accreditation program, launched in 2021, includes it as part of its performance measures. And the National Center for Assisted Living’s Quality Initiative also considers antipsychotic medication use among its criteria. 

The study was supported through a private donation to the Portland State University Foundation to support students studying gerontology.

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As the country enters the fourth year of dealing with COVID-19, the federal government is offering its assistance on testing access, vaccines and guidance on antiviral treatments, according to White House COVID-19 Response Coordinator Ashish Jha, MD, MPH.

“At this point, our job in the administration is to make sure we provide as much support as we can and that vaccines and treatments remain free,” Jha said Wednesday during a LeadingAge membership call. “We know it’s not enough.”

Jha said the administration is open to “all of the above” strategies to ensure that vulnerable populations, including long-term care residents, are protected from COVID-19. 

“It’s been a long, difficult, painful three years,” Jha said. “We’ve made so much progress, but the virus is still around and continuing to make people ill.”

The challenge, he said, is that the virus continues to evolve, meaning that immunity can wane and leave people susceptible to illness. The bivalent booster released in the fall, he said, was the first major upgrade to the COVID-19 vaccine and provides protection against serious illness. All older adults, as well as individuals with comorbidities, should receive the bivalent vaccine, Jha said.

Assistance from QIOs

Assisted living communities and nursing homes also can seek assistance from quality improvement organizations, or QIOs, which the Centers for Medicare & Medicaid Services tasked with improving bivalent booster update and access to therapeutics for long-term care residents, Jha said. QIOs are available to provide technical assistance to organize vaccine clinics, provide information and answer questions about vaccines and therapeutics, and identify and access supplies, he said.

“At this point, we want to ensure there are no barriers to vaccination,” Jha said.

Among other federal strategies to increase vaccination rates among long-term care residents and staff, the Centers for Disease Control and Prevention is creating COVID-19 vaccine sub-provider agreements to allow long-term care facilities not directly enrolled as providers in the CDC COVID-19 Vaccination Program to access vaccine doses through pharmacy providers. 

Alternate vaccine providers

The CDC also is working with long-term care facilities and partners to consider alternative vaccine providers — emergency medical technicians and others — to provide onsite vaccinations. In addition, the agency is working with state health officials to develop “strike team” efforts in long-term care facilities.

Last month, the White House released a COVID-19 Winter Preparedness Plan to help long-term care facilities manage the virus. The playbook focuses on three areas — improving bivalent booster update, increasing access to COvID-19 testing and treatments, and improving indoor air quality.

The plan called for expanding access to free COVID-19 testing options, including distributing rapid testing kits to long-term care facilities, community health centers, rural health clinics, schools and other locations.

Free tests for Section 202

Free at-home tests also will be distributed at more than 6,500 affordable housing properties operated by the Department of Housing and Urban Development. A new federal Health Partner Order Portal launched recently to enable the bulk ordering of COVID-19 test kits for Section 202 Supportive Housing for the Elderly providers. The almost half a million older adults living in Section 202 affordable senior housing communities — as well as staff members there — can access tests free of charge. 

Section 202 providers can register and order between 45,000 and 90,000 tests to be delivered weekly for residents, staff and community partners, according to Linda Couch, LeadingAge vice president of housing policy.

Portal across care settings

LeadingAge also set up a portal to allow provider across all care settings to apply for free COVID-19 test kits. The application is available to both members and nonmembers.

A handout, “Why Residents Should Get the Bivalent Booster,” designed to help long-term care staff members discuss the value of the bivalent booster with residents, was released late last month by the American Health Care Association/National Center for Assisted Living.

Getting the updated bivalent COVID-19 booster is the single most important thing that older adults can do to protect their health, White House COVID-19 Response Coordinator Ashish Jha, MD, MPH, said Friday during a White House virtual town hall on COVID-19 vaccinations.

Residents in long-term care settings should be offered COVID-19 vaccines, he added, but if they are not, he recommended that families arrange for their loved ones to get vaccinated.

Older adults or anyone at elevated risk who becomes infected should pursue treatments, Jha added.

“Getting treated is critical,” he said. “There are so many good treatments now. They’re widely available. They’re free.”

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, also advocated that family members and friends of residents get tested before visiting older adults who live in long-term care settings, to provide an extra layer of protection for everyone.

Don’t wait

In fact, during the town hall, the nation’s leading COVID-19 experts had a singular message on vaccination: “Don’t wait.”

Jha and Fauci were joined by first lady Jill Biden and AARP CEO Jo Ann Jenkins to address the importance of Americans — particularly older adults — receiving the updated COVID-19 vaccine.

“The most important thing you can do to prepare for your holidays is to get your updated COVID vaccine,” Biden said. “It offers the best protection for you and your family against the version of the virus we’re facing today.”

Jha said the virus has evolved over the past two years. Although the first vaccine targeted the original virus, today’s virus is “very different,” he said. He also noted that immunity can wane over time, requiring everyone to stay up to date on their vaccinations and boosters.

“In the same way as we’ve seen waning immunity against COVID, getting that updated bivalent vaccine is the single most important  thing you can do to make sure your immunity is up to date and you can fight the virus that’s out there,” Jha said. 

Other vaccines, such as ones for measles and polio, provide long-lasting immunity that can continue for decades or a lifetime, Fauci said.

“Unfortunately, that’s not the case with COVID, so we’ve got to keep up with that virus and keep up with the waning immunity; when we do that we’re going to wind up being safe,” he said. “You’ve got to keep your body defenses up to date.”

Timing important

For those who are infected with the virus, Jha explained, the immune system revs up and creates some immunity benefit. He recommended waiting three months after infection before getting another vaccine, to further build up protection.

With influenza ramping up across the country, Fauci said that it’s “very appropriate” to mix flu shots and COVID vaccines in one visit.

“It’s one and done. It’s very easy,” Jha said. “Your immune system is very good and able to handle two vaccines at once.”

Combining a COVID-19 vaccine with a shingles (herpes zoster) vaccine, however, is another story. Although immunologically it’s fine, Jha said the combination could cause a “significant reaction” in the form of “a lot of aches.” Fauci recommended spacing the two vaccines out by two to three weeks from one another.

COVID will continue into the future

Jha said he’s sympathetic to the fact that everyone is “a little tired of this virus.” The good news, he added, is that COVID-19 does not have the same effect on the lives of Americans as it did two years ago, or even last year, due to vaccines and new treatments.

“COVID is going to continue to be around for a long time,” he said, adding that it “need not be” disruptive. “We can get on with our lives. We can do the things that matter to us if we do certain things: keep updated on vaccination and get treated if you have an infection.”

Uncertainty remains around whether new vaccines will be necessary in the future, but Jha said that it’s possible — maybe even likely — that a new COVID vaccine will be necessary next fall in the same way that flu vaccines are necessary each year.

Don’t put loved ones at risk

Fauci said that his takeaway for those who are not up to date on their vaccinations is not to wait. 

“If you wait, you put yourself at risk,” he said. “We’re entering the colder months of late fall and early winter. We’re all going to congregate with family and friends for the holidays. Get vaccinated now.”

Jha said that the nation is at a point in the pandemic where it is important to gather and spend time with family. And it is possible to do that by staying updated on vaccinations, getting the new bivalent vaccine, getting treated for infections and using testing, he said.

“There are so many things we can do now to make sure that the things we have missed out on the last two years, we don’t have to miss out on them again,” Jha said. “It’s up to us, and it’s really important that we take this opportunity to do the things that will protect ourselves and our families.”

Improving indoor air quality is key to reducing the toll that respiratory viruses are taking on vulnerable older adults. But current regulations are “simply out of date” and don’t consider airborne pathogens, experts say.

Speaking last week during a LeadingAge membership call, Natalie Kopp, an adviser on the White House COVID-19 Response Team, said that almost all COVID-19 infections occurred indoors, usually in poorly ventilated spaces. Improving and increasing ventilation and filtration in the air, she said, can dramatically reduce the burden of COVID-19 as well as decrease the transmission of flu and respiratory syncytial virus.

To elevate the topic in people’s minds, the White House hosted a Summit on Indoor Air Quality in October, bringing together experts in public health, education and the private sector to discuss the future of indoor air quality investment.

“We have to bring the burden of respiratory pathogens down,” Ashish Jha, MD, the White House COVID-19 response coordinator, said during the event. “And the single biggest structural change that we can make as a society is to do for indoor air quality what we’ve done for water quality. We need healthy buildings because we need healthy communities.”

Kopp added that many Americans don’t know that much about indoor air quality or its effects on society.

“We really want to elevate this as a key mitigation strategy,” she said. “But we also recognize that it can mean energy efficiency and other positive health effects to people in our building stock in the US.”

Improvement pledge

To generate buy-in, the White House in March launched the Clean Air in Buildings Challenge, calling on building owners and operators to improve ventilation and filtration systems that can improve indoor air quality. Senior living communities and other long-term care facilities, as well as other businesses and schools, can sign a pledge and receive a digital “badge” to display on their websites and social media. 

“Signing the pledge makes you look at your building, what your organization is doing on this topic,” Kopp said. “The goal is to lift up and reward institutions making changes. We want to show the nation there is leadership in this area.” 

Where to start

Many experts in the field of indoor air quality can provide guidance on improving ventilation and filtration, Kopp said. Providers don’t normally look at HVAC systems from the perspective of airborne pathogens, she said, so an outside expert can perform an initial inspection and provide a checklist of steps to take to focus on the health benefits of the system.

“The most impactful thing you can do is ensure your HVAC system is running as intended,” Kopp said, adding that doing so means scheduling a deep inspection and regular maintenance.

She encouraged operators on a budget to look for simple things, such as portable air cleaners, with a good track record and evidence of effectiveness and being cost-effective. The main factor to look for when choosing an air cleaner is HEPA, or high efficiency particulate air unit. She also discouraged buying units that use bipolar ionization, citing little research on its safety and effectiveness and the fact that such units generate ozone, a known lung irritant.

Senior living communities and other long-term care facilities also are eligible for grants to improve HVAC systems, as well as other ventilation and filtration improvements. The Biden administration provided $350 billion for state and local governments through the American Rescue Plan to address those and other pandemic-related infection control efforts. 

Adopting indoor air quality regulations

The end goal for the federal government, Kopp said, is to adopt regulations similar to those that govern safe drinking water. She pointed to a recent study from the Lancet COVID-19 Commission’s Task Force on Safe Work, Safe School, and Safe Travel. The group of experts examined air ventilation, filtration and disinfection to reduce the transmission risk of airborne infectious diseases inside buildings. 

Their findings led to recommendations to adopt new noninfectious air delivery rates, or NADRs, for reducing exposure to airborne respiratory infectious diseases — including COVID-19, influenza and RSV — and to improve health.

“Current standards for ventilation are based on bare minimums targets, do not reflect the latest scientific evidence on the multiple benefits of enhanced ventilation and filtration, and are not designed for health or infection control,” the authors concluded. 

Other than in healthcare settings, commercial building guidelines for indoor air quality are not designed to control the transmission of infectious diseases, they noted.

The task force examined a variety of indoor air quality targets and metrics — including air changes per hour, volumetric flow rate per floor and volumetric flow rate per person — as well as various methods of mitigating infectious disease risks, including ventilation with outdoor air, air filtration and air disinfection using germicidal ultraviolet energy.

The group proposed a set of “good, better and best” NADR targets for reducing exposure to airborne respiratory diseases, ranging from four to more than six equivalent air changes per hour. They also noted that the targets are not intended to replace existing ones for healthcare or residential settings. 

In addition to reducing respiratory infection risks, the task force noted that other benefits of its NADR targets would include better cognitive function; improvements in cardiopulmonary health and the prevalence of sick building syndrome symptoms; and asthma control and quality-of-life scores.

The prevalence of dementia in older adults in the United States declined 30% between 2000 and 2016, possibly due to rising education levels, a reduction in smoking and better treatment of cardiovascular risk factors, according to a new study published Monday in the journal Proceedings of the National Academy of Sciences.

Overall, researchers from the nonprofit group the RAND Corp. found the prevalence of dementia had decreased substantially in the U.S. older adult population since 2000, declining from 12.2% of older adults in 2000 to 8.5% in 2016, an almost one-third drop.

Gaps narrow 

The gap in dementia prevalence narrowed between men and women, and inequalities decreased between education, income, and race and ethnicity groups, especially among men.

The prevalence of dementia was higher among women than men over the study period, but differences shrank in that time. Among men, the prevalence of dementia decreased from 10.2% to 7%, whereas decreases were larger among women, dropping from 13.6% to 9.7%.

“The reasons for the decline in the prevalence of dementia are not certain, but this trend is good news for older Americans and the systems that support them,” Peter Hudomiet, the study’s lead author and a RAND economist, stated in a release. “This decline may help reduce the expected strain on families, nursing homes and other support systems as the American population ages.”

The economic cost of dementia was estimated at $200 billion per year in the United States and $600 billion worldwide, making it the most expensive of all medical conditions, according to the authors. In 2021, approximately 6.2 million US adults aged 65 or more years lived with dementia. Because age is the strongest risk factor for dementia, increasing life expectancy is predicted to substantially increase the prevalence of Alzheimer’s disease and related dementias between 50 to 150 million worldwide by 2050, according to the report.

Education a predictor

Researchers found that education is a “very strong” predictor of dementia, and that there was a sizable increase in the average level of education over the study period. Education rates alone explained a 40% reduction in dementia prevalence among men and a 20% reduction among women. The number of college-educated men in the study increased from 21.5% in 2000 to 33.7% in 2016, whereas college education rates for women increased from 12.3% to 23%.

Changes in factors including age, race and ethnicity, as well as cardiovascular risk factors, mattered less in determining the prevalence of dementia. 

The authors stated the results suggest that as education levels continue to rise in the US population in younger generations, the prevalence of dementia would continue to decrease. Changes in age-specific rates of dementia have important implications for projected prevalence and costs, including payments for long-term care by families, insurance companies and the government.

“Closing the education gap across racial and ethnic groups may be a powerful tool to reduce health inequalities in general, and dementia inequalities in particular — an important public health policy goal,” the authors wrote. 

The National Bureau of Economic Research in Cambridge, MA, and Network for Studies on Pensions, Aging and Retirement in the Netherlands contributed to the study, which was supported by a grant from the National Institute on Aging.

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