








key: cord-344818-ms2edk3w
authors: Chu, Charlene H.; Donato‐Woodger, Simon; Dainton, Christopher J.
title: Competing Crises: COVID‐19 Countermeasures and Social Isolation among Older Adults in Long Term Care
date: 2020-07-09
journal: J Adv Nurs
DOI: 10.1111/jan.14467
sha: 
doc_id: 344818
cord_uid: ms2edk3w

While debate over the appropriate scope and goals of COVID‐19 lockdowns has raged, all public health agencies have been clear on one matter: older adults have the highest rates of mortality (Comas‐Herrera et al., 2020) and should be isolated (Public Health Agency of Canada, 2020). Older adults and individuals with complex health conditions are most vulnerable to the virus. Yet, social isolation contributes to the onset and intensifies depression, feelings of despair and, in older adults with dementia, further cognitive decline.

While debate over the appropriate scope and goals of COVID-19 lockdowns has raged, all public health agencies have been clear on one matter: older adults have the highest rates of mortality (Comas-Herrera et al., 2020) and should be isolated (Public Health Agency of Canada, 2020). Older adults and individuals with complex health conditions are most vulnerable to the virus. Yet, social isolation contributes to the onset and intensifies depression, feelings of despair and, in older adults with dementia, further cognitive decline.

Older adults living in long-term care (LTC) facilities comprise 79% of the COVID-19 death toll in Canada (Rothan & Byrareddy, 2020; Walsh & Semeniuk, 2020) . While our failure to protect long-term care (LTC) facilities has been made apparent both by this high mortality and a shocking recent Canadian Armed Forces Report (Mialkowski, 2020) , the singular focus on mortality has overshadowed any attention to morbidityparticularly the effects of physical distancing on health, quality of life and autonomy. Annual mortality in LTC facilities exceeds 25%, approaching 50% in some jurisdictions (Tanuseputro et al., 2015) . This suggests that if physical distancing measures are extended for months or years until either herd immunity or a vaccination, a shocking proportion of LTC residents are likely to die under a "new normal" of isolation that few would choose.

Many in Canada were deeply troubled by the recent news of family members being turned away from the windows of Ontario LTC facilities as they attempted to visit loved ones while respecting physical distancing recommendations (Pringle, 2020). Equally troubling stories have emerged detailing the challenges that LTC residents have faced including restrictions on visitors and volunteers, elimination of the interactions residents enjoyed with their families (Armitage & Nellums, 2020; Gardner, States, & Bagley, 2020) and limitations on physical and social activities (Bains, 2020; Flint, Bingham, & Iaboni, 2020; Harden, 2020; Kingdon, 2020; Liebermen, 2020; Steinman, Perry, & Perissinotto, 2020; United Nations, 2020) . Recent changes to LTC visitation policies allow loved ones to visit in-person but continue to be overly restrictive: visits could only be 30-minutes long, outdoors, physically distanced while wearing personal protective equipment (PPE) and the visitor needed to present a COVID-19 negative test (Ontario Ministry of Long-Term Care, 2020). The impracticalities of such visits are obvious: spouses of residents are often older adults themselves and face mobility challenges getting tested, residents have hearing and vision loss making communicating during a physically distanced visit outdoors challenging and covering visitor faces with masks is not helpful or comforting for

This article is protected by copyright. All rights reserved residents with memory loss. Some residents have been socially isolated for over 3-months due to COVID-19 outbreaks, spending all day and every meal trapped alone in their rooms; held hostage by ill conceived policies (Bercovici, 2020) . Such policies are out of touch with the needs of residents and are causing emotional distress.

Given the World Health Organization's holistic definition of health (WHO, 2020) and the impact of social isolation on the psychosocial wellbeing of older adults, any public health response is morally obligated to mitigate the impact of isolation as a policy consequence. Social isolation is defined as an objective lack of a social network, relates to loneliness (the subjective, negative experience that results from social isolation) and a lack of meaningful, supportive relationships with family and friends (Hernández-Ascanio et al., 2020). More older adults living alone as the population ages (National Seniors Council, 2017), contributing to a social isolation epidemic among older adults long before physical distancing became a key policy priority.

Before the COVID-19 pandemic, approximately 50% of Canadians over the age of 80 reported feelings of loneliness, particularly those with physical or mental illness, cognitive deficits, members of marginalized groups and those experiencing life transitions such as loss of employment, a spouse, or access to a vehicle. Those most at risk for social isolation face the greatest number of barriers to support (National Seniors Council, 2013 , 2017 . 

This article is protected by copyright. All rights reserved the toll and trauma that COVID-19 countermeasures have taken on older adults residing in LTC facilities and their families.

The public has generated several solutions to increase the quality of life for older adults during the pandemic. These include the use of mobile devices to engage remotely with older adults. Teleconferencing applications such as Skype, Facetime, or Zoom (Canadian Frailty Network, 2020a; Klein, 2020; Lorinc, 2020), allowing users to interact virtually. Conventional telephone calls and written letters provide a familiar form of communication (Holtby, 2020 ) that can remind older adults of their support network (Canadian Frailty Network, 2020b; Ireland, 2020). Written letter campaigns have emerged to combat the isolation experienced by many older adults during the crisis (Field, 2020) and before it (Harris, 2020) . In these campaigns, strangers write letters to LTC residents, including photographs, poetry and uplifting messages, to remind them that they are valued.

While such solutions are helpful, many older adults either lack the access to remote communication; most LTC facilities have a limited number of iPads to share between residents, constraining their access to their loved ones. Another problem is that many LTC residents lack the dexterity to hold a tablet steady. Family members end up looking at the ceiling, instead of the face of their loved one (CBC News, 2020) . Many older adults also lack the technical proficiency to use such devices (Klein, 2020), particularly those with limited cognition (Bains, 2020). Some homes have hired more staff solely to help residents make video calls rather than purchasing tablets for every residenthighlighting a patchwork solution to the real problem of technology that is not well-designed for older adult users. There is room for innovation and improvement. In particular, making technology easier to use and understand for older adults. User-centered design approaches would besuitable to generate technology focused on the needs of older adults and healthcare providers in LTC. The need for innovative collaboration between researchers, developers, older adults and their family members has never been made more clear than during this pandemic.

This article is protected by copyright. All rights reserved Our current broad strokes approach assumes the priorities of older adults to be largely homogenous and views LTC residents as passive recipients of care, without any particular desires or preferences. That view is paternalistic and antithetical to a person-centred approach that is so central to nursing. Implicit to this discussion is the recognition that older adults are valued by their loved ones and community.

We must not value incautiously quantity of life over quality of life. Little attention has been paid to autonomy and individual acceptance of risk. Any pandemic response must balance these risks and recognize that morbidity may be as important as mortality. In this case, it means calculating if and when patients and their families should have the latitude to make autonomous decisions concerning their well-being. In absence of allowing residents the dignity of choice, there are widespread reports of increased suicide rates and of residents preferring death over isolation in their rooms, referring to their treatment as being "held like a prisoner" (Aronson, 2020). LTC facilities must collaborate with residents and families to ideate creative solutions and help them understand the risks associated, to establish a care plan that is centered on the physical and psychosocial wellbeing of the resident.

Additionally, it is a clinical reality that residents will likely experience the end of life in long-term care. Thus, the questions surrounding quality and manner of death are intensely important ones. Dignity should be paramount when older adults must experience the end of their lives in hospitals and care facilities alone, barred from visits. The unknown duration of isolation means that over one-third of LTC residents could die without seeing their loved ones for months or even years (Jayaraman and Joseph 2013). This deeply disturbing scenario is a concept which should deeply trouble most of us and is not what residents, families, or staff want.

Nurses are the primary clinicians responsible for leading and coordinating care in LTC facilities referred to as "ground zero" of COVID-19 (Barnett & Grabowski, 2020) . From a policy perspective, nurses are advocating for more staffing and appropriate resources to be diverted into LTC (Registered Nurses' Association of Ontario, 2020). This advocacy should come as no surprise as nurses have been always been revolutionaries during times of infectious diseases for which there were no effective medical interventions. Nurses can prepare for future outbreaks by organizing and advocating for reform and investment into LTC, ensuring homes can effectively respond to outbreaks while meeting the physical and psychosocial needs of residents. Further, this pandemic is an opportunity for LTC nurses to refocus care on the resident and reintroduce

This article is protected by copyright. All rights reserved person-centered care into countermeasures. This means welcoming innovation, user-friendly digital technologies that promote connections to loved ones and leveraging their close relationships with residents to advocate for more person-centered policies. Policy makers and nurse leaders need to enable nurses to work to the top of their scope of practice in LTC and provide the resources to support nurses working in their full capacity.

COVID-19 countermeasures like physical distancing involves a balance of risks for older adults living in LTC facillities. The COVID-19 epidemic has upended many assumptions about the safety, health and well-being of older adults and revealed numerous areas for collaboration, innovation and improvement. Within this crisis lies an opportunity for nurses to start a deeper conversation about autonomy and values and how to restore person-centered care in LTC facilities.

Halifax group starts letter-writing initiative for seniors facing loneliness amid COVID-19 pandemic -Halifax | Globalnews.ca

Effect of COVID-19 on the Mental Health Care of Older People in Canada

The Coronavirus and the Risks to the Elderly in Long-Term Care

Harden: COVID-19 -ask seniors to stay home

Help For Canadian Seniors' Loneliness Comes Via Ontario University Students | HuffPost Canada

Effectiveness of a multicomponent intervention to reduce social isolation and loneliness in communitydwelling elders: A randomized clinical trial. study protocol

How to help seniors feel less isolated | New Trail

How to help seniors get through the COVID-19 pandemic | CBC Radio

Physical distancing: How to slow the spread of COVID-19 -Canada

RNAO Calls for Immediate Action in Response to the Canadian Armed Forces' LTC report with Minister Fullerton's

The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak

Meeting the Care Needs of Older Adults Isolated at Home During the COVID-19 Pandemic

Development of a community's self-efficacy scale for preventing social isolation among community-dwelling older people (Mimamori Scale)

Hospitalization and Mortality Rates in Long-Term Care Facilities: Does For-Profit Status Matter?

Loneliness and social support: Differential predictive power on depression and satisfaction in senior citizens

Accepted Article This article is protected by copyright. All rights reserved United Nations

Long-term care connected to 79 per cent of COVID-19 deaths in Canada -The Globe and Mail. The Globe and Mail

World Health Organization: Basic Documents forty-ninth edition

Illuminating the psychological experience of elderly loneliness from a societal perspective: A qualitative study of alienation between older people and society

The authors have no conflicts of interests to declare. This article is protected by copyright. All rights reserved

Editorial note: Editorials are opinion pieces. This piece has not been subject to peer review and the opinions expressed are those of the authors.

