Competing crises: COVID‐19 countermeasures and social isolation among older adults in long‐term care

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 morbidity – particularly 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-minute long, outdoors, physically distanced while wearing personal protective equipment (PPE), and the visitor needed to attest to 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 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 well-being 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). Such isolation increases the risk of cardiovascular disease, obesity, and stroke (Tomás, Pinazo-Hernandis, Oliver, Donio-Bellegarde, & Tomás-Aguirre, 2019) and correlates with anxiety, depression, and cognitive decline (Barbosa Neves, Sanders, & Kokanović, 2019; Hernández-Ascanio et al., 2020). Frail older adults and those with cognitive deficits may also depend on caregivers for their activities of daily living (ADLs), orientation and safety (Steinman et al., 2020). While social isolation has become ubiquitous for older adults during the COVID-19 pandemic, its experience is simultaneously unique to each person (Machielse, 2015). It generates a positive feedback loop, magnifying and being magnified by a multitude of chronic conditions (Barbosa Neves et al., 2019; Kirkevold, Moyle, Wilkinson, Meyer, & Hauge, 2013; Wong, Chau, Fang, & Woo, 2017). While correlation does not indicate causation, the relationship between social isolation and medical illness suggests that the dangers of social isolation pose a significant counterweight to the threat of COVID-19. Our society must confront 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 resident – highlighting 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-centred design approaches would be suitable 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. Our current broad strokes approach assumes the priorities of older adults to be largely homogeneous 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 residents and their families should have the latitude to make autonomous decisions concerning theirwell-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 with each solution, as well as establishing a care plan that is centred on the physical and psychosocial well-being of the resident. Additionally, it is a clinical reality that residents will likely experience their end of life in LTC. 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). 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 LTC facilities alone, barred from visits. Dying alone has become a hallmark of COVID-19. Some final moments are immortalized on social media with screenshots of video calls capturing the grief, pain, and trauma of close family watching their loved ones pass. These are deeply disturbing scenarios 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 health policy reform and investment into LTC, ensuring homes can effectively respond to outbreaks while meeting the physical and psychosocial needs of residents. Furthermore, this pandemic is an opportunity for nurses in LTC to refocus care on the resident and reintroduce person-centred care into countermeasures. Nurse can lead the innovation in LTC to address key issues, especially in anticipation for a 'second wave'. This means welcoming and advocating for innovation, user-friendly digital technologies that promote connections to loved ones, and leveraging their close relationships with residents to advocate for more person-centred 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 facilities. 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-centred care in LTC facilities. CC: Conceptualization, Writing, Reviewing and Editing, and Supervision. SDW: Writing, Reviewing, and Editing. CD: Conceptualization, Writing, Reviewing, and Editing. None The authors have no conflicts of interests to declare. CC is funded by the Alzheimer Society of Canada New Investigator Award. No funding to declare.

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