Doctors are calling it “confinement syndrome.” Like those in solitary, some seniors in long-term care homes, cut off from loved ones because of COVID-19 restrictions, have had to grapple with severe physical, cognitive and mental health decline and depression.
Ninety-year-old Nancy Russell’s choice to go through a medically assisted death last month rather than face a winter of isolation is a stark illustration of the devastating toll pandemic restrictions can have on seniors. But some doctors and caregivers say there are ways to protect both the physical and mental health of the elderly, pointing to examples at home and in countries like the Netherlands where both have been managed successfully.
“We’ve learned a lot more -- the fact that there can be such a degree of collateral damage by simply isolating people to this extent,” said Dr. Samir Sinha, the director of geriatrics at Mount Sinai Hospital, who has long been advocating for a better balance between restrictions and the well-being of residents.
“We know in many other jurisdictions, they’ve been able to find that balance, but in many parts of Canada, we haven’t. And that’s had enormous consequences on the quality of life and wellbeing of residents.”
When the pandemic was declared in March, long-term care homes in many parts of the world went into immediate lockdown, cutting seniors off from visits with family and friends. For many, this meant meals taken in their rooms instead of dining halls with friends, group activities cancelled, and socialization restricted.
In Canada, thousands of seniors still died, with many places insufficiently prepared for the dramatic and sudden changes. The mental health decline among some seniors from the isolation compounded the catastrophe nursing homes were already contending with.
Dr. Wilco Achterberg, a professor of institutional and elderly care medicine at Leiden University Medical Center in the Netherlands says “never again” should there be a blanket ban on visitation.
He believes this policy could create more victims than it can save lives.
“We studied the effects of the visitor’s ban,” he said. “We saw that some residents have less behavioral problems, so that quietness for some residents was good, but we also saw that for many residents, there was a kind of loneliness that was terrible for them.”
Residents became apathetic when the activities were halted, but became less so when they re-incorporated them even if they had to be modified for distancing.
The Netherlands halted its ban on visitors to nursing homes in May, he said, and introduced a program that allowed for training and scheduled visitations for both visitors and residents. Family caregivers were taught how to properly put on PPE and how to practice good infection prevention and control protocols.
These changes not only helped residents sleep and eat better, but was also comforting for staff and family members.
It was difficult in the beginning, when little was understood about the disease and its impact, but now we know more and can do better, Achterberg said, adding that infection rates in the Netherlands did not decelerate with the ban.
“It’s a very complicated period of time in which we see that making good policy, weighing quality of life and weighing the benefits of visiting, but also the risk of visiting, is very complicated and should be done locally.”
Chester Village, a not-for-profit home in Toronto, Ontario is one care facility that found that balance. They never cancelled activities, avoided an outbreak, and worked quickly to bring some normalcy back to the residence, while staying vigilant against COVID-19. The facility had one resident who was infected and has since recovered, and staff members who tested positive through the community, but no transmissions.
Activities at Chester Village never stopped, said Chief Executive Cynthia Marinelli, they changed from a large group event of 50 to 60 residents in their village hall, to small, localized activities. The intimacy of doing some of the activities with a small group was actually more meaningful, she added.
“We really had to look at how we were meeting the emotional and social well-being of our residents,” said Marinelli. Communication with family members was an important part of that effort.
“Sometimes, it was just a matter of the resident only ate the food the family made, or only ate if the family was here. And so we welcome those families back, but again, in a very safe manner.”
This meant complying with getting tested, wearing PPE, and understanding the necessary safety protocols they had to follow. Having over 100 families coming to visit on a weekly basis, some several times a week was challenging resource-wise, Marinelli said, but families welcomed it, adding that it was something staff felt was important for residents.
“I think people can find a safe way to do it … It's worked for us. You know, it does take a lot of effort and a lot of time … but I think it can be done in a safe manner,” said Marinelli.
“At the end of the day they got to see their families. We welcomed families back early, especially for those residents who needed the emotional support.”
Canada's National Institute on Aging has issued guidelines urging a balanced approach to COVID-19 precautions, while maintaining quality of life. But in too many instances, residents remain isolated.
Sinha, who is involved with the institute said Ontario eventually adopted the guidelines in September, as did Prince Edward Island, but most regions across Canada have not fully implemented its recommendations on how to maintain both the physical and mental health of seniors.
“What really pains me to see is that jurisdictions that are still saying, ‘No, no, no, we can't afford to have anybody die. This is for their well-being.’ Well, the evidence doesn't actually support what a lot of these jurisdictions are doing and what we do know is actually this is causing a lot of unnecessary harm,” said Sinha.
“I hear stories of people saying, I’d just rather die. I've had my patients say that, when their family caregivers share those stories with me. My heart breaks just as theirs does as well because you can tell someone's given up, and someone really feels at that point, the only option they have -- or the only right that they have to exercise -- is the right to end their life early ... when it truly isn't.”