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Sharon E. Straus and Jennifer Watt | May 22, 2020

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The COVID-19 pandemic has laid bare complex system challenges that prevent us from implementing effective and sustainable solutions to mitigate the spread of COVID-19. Facing the tough decisions to address these challenges requires careful consideration of the risks and benefits of imperfect strategies. The rapid spread of COVID-19 in long-term care homes underscores the gravity of this issue. In Canada, more than 70% of COVID-related deaths are associated with long-term care facilities. While this a shocking statistic, the move to deploy resources into long-term care to slow the spread of COVID-19 also risks unintended consequences for older adults who live alone but require social and health care services. 

In Canada, we have many physically and socially frail older adults who live alone. Physical frailty is the decreased resilience and reserves, which impacts the ability to respond to stressors like falls or flu. When you are frail, minor illnesses can trigger rapid and dramatic deterioration. Socially frail older adults are at risk of losing, or have lost, social networks that provide them with friendship and help them live safely in the community.  The implementation of physical distancing to prevent the spread of COVID-19 has increased the risks associated with social frailty and social isolation amongst older adults who live alone in the community, as isolation is a risk factor for depression, delirium (acute confusion) and functional impairment in older adults.

Many frail older adults are dependent on personal support workers (PSWs) for assistance with bathing, dressing and meal preparation to facilitate their independence in the community. These PSWs may be their only contact with what’s happening outside of their apartment. PSWs are often paid low wages and as they are unable to obtain full-time employment at a single place, many work in multiple settings (e.g. community and long-term care) to earn a living wage. COVID-19 outbreaks in long-term care facilities led to a policy that mandates health care workers work at a single institution resulting in a deployment of PSWs and other healthcare workers from the community into long-term care facilities - placing frail older adults who live alone at risk of neglect.

Social isolation places older adults at risk of physical, psychological and financial abuse. Given the loss of these PSWs, care of the older adult may fall to someone who is unable to provide adequate care. We are living in a time of unprecedented stress and consequently caring for an older adult with cognitive impairment and other comorbidities can put additional stress on even the most well-intentioned caregiver. Caregiver burden is a recognized risk factor for elder abuse. Worse yet, what happens if there is no one (including family) to care for these socially isolated older adults? 

Socially frail older adults are also at risk of inadequate medical care during this time. With the pandemic, physicians have moved to virtual care in response to ministry guidance; unfortunately, many of the frailest older adults do not have access to a computer and thus physicians are forced to rely on telephone calls to complete assessments. While much can be done via telephone it is essential that physicians see these frail patients to observe critical physical findings that are not detected in a telephone conversation. Moreover, the face to face interaction with a clinician can have therapeutic value for the patient.

While our attention is focused on plugging one hole in the dike, we have to be careful that we’re not causing another leak elsewhere. To mitigate some of the risks we have outlined, we encourage the public to reach out to older adults with phone calls and grocery deliveries, amongst other essentials. Regular check-ins with caregivers of older adults to support caregiver wellness are also helpful. Finally, while virtual care can help meet the clinical needs for some patients, it does not meet the needs of socially frail older adults and may further widen health disparities. This pandemic has highlighted that we must beware of unintended consequences and come together as a community to meet the needs of our most vulnerable people.