Author: Reliant Communications

The novel coronavirus and resulting pandemic have altered our lives in many ways. The combination of  isolation, physical and social distancing, as well as an economic crisis have all impacted our personal and professional lives. Juggling the ever-changing responsibilities during a healthcare emergency may be overwhelming. The lack of social connections with family and friends as well as in-person visits with your patients can lead clinicians to feelings of loneliness and isolation. Now consider the impact that continued social distancing and isolation may have on the residents and patients within our long-term care facilities. In some instances, isolation of residents has been ongoing for the entirety of the pandemic, entering nearly 6 months!

Prior to this healthcare emergency, a 2019 University of Michigan study on healthy aging noted that 34% of adults aged 50-80 years reported feeling lonely. This current period of social isolation will only exacerbate the number of adults feeling disconnected and lonely and disproportionately affect the elderly population, especially those whose primary social contacts were within their long-term care facility. Furthermore, according to the National Academics of Sciences, Engineering, and Medicine, “Seniors who are experiencing social isolation or loneliness may face a higher risk for mortality, heart disease, and depression.”

As experts on communication, SLPs know the value and need for social interaction for the mental health and well-being of our patients. We are a major factor in the identification of patient needs and educating patients and caregivers on appropriate and personalized techniques to improve and maintain cognitive, speech-language, and executive functioning. We can start by educating on the importance of social interaction and modeling how to achieve this safely during the pandemic.

In the absence of cognitive stimulation and routine, patients may have trouble maintaining prior levels of cognition. We can encourage and educate on the use of daily orientation techniques and maintaining daily routines – targeting problem solving, reasoning, memory, and sequencing during morning and evening self-care routines. Engage with each patient on a personal level and encourage all caregivers to do the same. Provide insight to caregivers on personal preferences that may enhance engagement.

Socialization and purpose play a critical role in feelings of self-worth and success in everyday life. Encourage the use of personal electronic devices. Provide education on increasing socialization through communication and social media. Encourage residents to write letters to family or “neighbors” within the facility. Foster conversation between residents and caregivers during meals and invite family or friends to “dine” with residents via videoconferencing.

Incorporate training on personalized “home” exercise programs to give purpose and focus to each resident’s day. Develop exercises that capitalize on the routines the resident has already established, such as oral motor exercises and/or breathing exercises during a TV commercial break.

As we evolve as professionals during a pandemic, we must continue to protect and advocate for our most vulnerable residents. With the continuation of the healthcare emergency there is a fine line between protecting those that are medically fragile from this virus while continuing to encourage and promote socialization that is vital to their well-being. As visitor restrictions are lessened we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care, and by supporting the facility and promoting each caregivers’ strengths as well as educating in areas of opportunity we are creating a more understanding and supportive environment for our residents.  

https://www.asha.org/Practice/Connecting-Audiologists-and-Speech-Language-Pathologists-With-Mental-Health-Resources/

https://time.com/5833681/loneliness-covid-19/

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

As we all have become acutely aware of, COVID-19 and the response to the pandemic have resulted in adverse outcomes to residents of skilled nursing and long-term care facilities. These adverse outcomes range from reduced physical function, including decreased muscle strength and endurance, to cognitive and psychosocial impairments, including delirium, neurological dysfunction, depression, and occupational deprivation. In combination, these symptoms paint a clear picture for the need of occupational therapy (OT) intervention. As OT practitioners, we must identify and champion our unique role in not only the physical rehabilitation of our patients but also in their psychological well-being.

According to the American Journal of Occupational Therapy’s (AJOT) OT Practice Framework, our profession, in its fullest sense, is facilitating achieved “health, well-being, and participation in life through engagement in occupation.” We identify the areas of occupation that our residents value, consider their context, and recognize the unique performance patterns and skills that affect the individual’s ability to engage and participate. This is clearly a client-centered, holistic process—one that considers physical function, cognition, and psychosocial impairments that may be impacted. Who better to address the wide range of outcomes that have resulted with our residents in skilled nursing and long-term care facilities?

As we continue to care for our residents who have been affected directly or indirectly by COVID-19, it is imperative that we implement this client-centered, holistic approach. How has the individual’s physical function been affected? Consider implementation of a cardiopulmonary program that includes respiratory strategies, postural control exercises, and exercise prescriptions. To address changes in cognition, complete a standardized cognitive assessment to identify specific processing skills for intervention during activities of daily living. Equally important, and even more important in some cases, are the psychosocial challenges that residents face during the pandemic. As patients are isolated to reduce transmission risks, unintended negative consequences present, including disruption of daily routines and restrictions to leisure and social participation. Recent studies suggest that isolation- associated loneliness has contributed to swift health declines in residents with dementia during the COVID-19 pandemic. Recognize and affirm residents in the challenges they face and use creative technological outlets to enhance participation in meaningful daily activities. Are there opportunities for virtual conferencing with friends or family? Are audio books, online games, or learning modules an option for leisure?

As OT practitioners, we are equipped to meet the tidal wave of challenges that COVID-19 has introduced to residents in skilled nursing and long-term care facilities. The tenets of our profession prepare us to respond to the physical, cognitive, and psychosocial changes that may occur. Though relaxed restrictions to nursing home visitation are on the horizon, the time is now to take hold of our unique, distinct role in facilitating health, well-being and participation in the lives of our residents.   

References:

American Occupational Therapy Association. (in press). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication.

De Biase, S., Cook, L., Skelton, D. A., Witham, M., & Ten Hove, R. (2020). The COVID-19 rehabilitation

pandemic1. Age and ageing, 49(5), 696–700. https://doi.org/10.1093/ageing/afaa118

Gitlow, L., PhD, ATP, FAOTA, OTR/L, Lee, S., OTR/L, Hemraj, R., OTR/L, Sheehan, L., OTD, OTR/L, & Ambroze, G., OTS. (2020). Occupational Therapy and Older Adults: Combating Social Isolation through Technology. PDF. American Occupational Therapy Association.

Lasek, A. (2020, September 18). Dementia mortality skyrockets since lockdowns; CMS loosens visitor restrictions – Clinical Daily News. Retrieved September 18, 2020, from https://www.mcknights.com/news/clinical-news/dementia-mortality-skyrockets-since-lockdowns-cms-loosens-visitor-restrictions/?utm_source=newsletter

For over 100 years, physical therapists have specialized in human movement using skilled interventions to maximize health and function.  During periods of critical illness, such as moderate to severe cases of COVID-19, it is common for patients to experience a loss of physical function which can lead to the development of new impairments or worsening of existing ones.

Long-term recovery from COVID-19 may be complicated by lasting effects due to deconditioning, restrictive lung disease, post intensive care syndrome, or neurological disorders. After 10 days of bed rest healthy older adults may lose up to 2.2 pounds of muscle mass from the legs with 2-5%/day loss of muscle strength.  Recovery of physical function may take an extended period of time with impairments that may persist up to 2 years post infection. 

As practitioners of movement, physical therapists are essential in early mobility during and following a critical illness in order to minimize the effects of immobility.  Through skilled interventions such as functional mobility, balance training, endurance activities, posture training, and strengthening, physical therapists are equipped to help residents achieve their optimal level of function as quickly and effectively as possible.

Along with debility, residents in nursing homes that remain quarantined during the public health emergency face another silent threat: social isolation. Even with the recent relaxation of nursing home visitor guidelines, the effects of social isolation may be long lasting.

Restricted access to family and friends may affect even those who have not contracted the virus itself and may include severe fatigue, anxiety, post-traumatic stress disorder, depression, and cognitive dysfunction. 

The effects of patients remaining in their room, the cessation of communal dining, and restricted access to common areas (i.e. the therapy gym and equipment) pose significant barriers not only to successful intervention and outcomes, but also overall resident well-being. The interdisciplinary team should assess and re-assess situations, analyze tasks, make changes, and consider a holistic plan of care to help reduce the lasting effects of social isolation and provide person-centered, specialized care which emulates Reliant’s motto of Care Matters.

References:

https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf.

https://academic.oup.com/ptj/article/100/9/1458/5862054

https://www.aannet.org/initiatives/choosing-wisely/immobility-ambulation