Frailty and Isolation – Balancing the Risks

To date, 80% of the COVID-19 deaths in Canada occurred in nursing homes, (Canadian Institute for Health Information) and 85% in the US (CDC). In March 2020, the governments of both countries implemented strict “no visitor” policies to protect their older citizens from the threat of this infection.  However, these measures were imposed without much thought being given to the collateral damage it could cause. What does this mean to your frail residents, and what can be done to help?

Frail residents, especially those with cognitive decline or dementia, often become more anxious, angry, stressed, agitated, and withdrawn in isolation.  Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. (Stall, 2020) One impact of note has been weight loss created by isolation, fear of caregivers in PPE, inadequate available staff to help at meals, and the overall change in routine and increased chaos. (Danlivoch 2020)

In May 2020, even as the pandemic continued to rage, the Centers for Medicare & Medicaid Services (CMS) issued guidance allowing nursing homes to reopen if they had no new COVID-19 cases for 28 days,  no shortage of PPE or testing availability, and adequate staffing. To date, very few facilities have met these criteria, and many are calling for more immediate and attainable approaches to allow families to reunite.

Experts Gather to Propose Solutions

With more being published on the physical and psychological damages for frail nursing home residents, American and Canadian experts in geriatric medicine began to recommend ways to reopen nursing homes. An international panel of 21 experts met early this year to develop evidence-based guidance for the reopening of nursing homes. The panel consisted of clinicians, academics, administrators, and patient advocates. They reviewed published reopening guidelines from the CDC, CMS, and 17 US states and conducted focus groups with family members and visitors. From this they identified key recommendations and planning assumptions that focus on family caregivers and visitors rather than essential workers and nursing home staff:

  • Maintain strong infection control precautions
  • Facilitate indoor and outdoor visits
  • Allow limited physical contact with appropriate precautions
  • Assess individual residents’ care preferences and level of risk tolerance
  • Dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes the psychosocial well-being of residents

The detailed guidance for both “Family Caregivers” and “General Visitors” is available at https://www.jamda.com/action/showPdf?pii=S1525-8610%2820%2930663-0

Light at the End of the Tunnel

Re-opening the nursing home to visitors will not be easy and there will be those who criticize the process, no matter how it is accomplished. Finding “the balance between individual resident preferences and the health of the collective” (Bi-National Expert Panel) will not be easy but is necessary to reduce the risks to health and well-being caused by social isolation.

In the meantime, finding creative ways for residents, especially those who are frail and/or cognitive impaired, to visit and engage with family members is not one-size-fits-all. The options include window or outdoor visits, video calls, and specially designed visitations rooms to keep residents and visitors safely separate. At the same time, communication with families is essential to gain their thoughts, concerns, and ideas about visitation and to help them understand what you are doing to keep their loved ones as safe, comfortable, and happy as possible. 

For more information on frailty and best practices in geriatric medicine contact our experts today.