The unspoken impact of COVID-19

I remember the last large family gathering I attended; it was January 25, 2020 and we were celebrating the Lunar New Year. We had just finished our family feast and my cousin had won our annual cooking competition! As we started to hand out Red Envelopes to the young children and elderly, we heard on CP24 that “Patient Zero”—the first COVID-19 case in Canada, had been admitted to Sunnybrook Health Sciences Centre. I would have never guessed at the time that I wouldn’t see my cousins, relatives, and extended family for the next two years. Or that this would be one of the last times I would see my uncle before he passed away a year later from cancer. No one could have predicted that we would encounter multiple waves, variants and numerous lockdowns in an attempt to control COVID-19. As a pharmacist working in a geriatric outreach team, I’ve witnessed the impact the pandemic has had on our older adults—from the very frail to those who were managing well before the pandemic. Read: QUIZ: Test your knowledge of chemotherapy treatments and side effects When outbreaks first began to appear in nursing homes in early 2020, we recognized quickly that these individuals experienced a disproportionately high morbidity and mortality from COVID-19 and the conditions associated with it. In an effort to protect these people, we confined them to their rooms with minimal contact, cancelled all social activities and enacted a strict no visitor policy. Retirement residences and senior buildings quickly followed suit; discontinuing group activities, ending congregate dining and again, not allowing visitors. There were no projection models or precedents to alert us to the far-reaching negative consequences that these measures would have on our older adult population. Read: The more meat, the more cancer Essential care suffered Prior to the recent amendments made through the Fixing Long Term Care Act 2021 (replacing the previous 2007 Long Term Care Homes Act), nursing home residents would receive only 2.75 hours of direct care by PSWs or nursing staff. Even before the COVID-19 pandemic, there were many gaps in the long-term care home sector, including severe understaffing, crowded rooms, poor ventilation and the unmet needs of many frail seniors. As such, family members were critical in providing care for long-term care home residents. In restricting these visitors (now recognized as essential caregivers) and compounded by further staffing shortages, horror stories amassed about residents being left in soiled diapers all day long, not being fed and being found in deplorable conditions. In one nursing home, 26 residents reportedly died from dehydration “because of lack of staff to care for them.” In the community, the home care sector did not fare much better. Family members rely on PSWs to assist with personal care, the most challenging of that care being diaper changes and bathing. Many patients would not receive PSW support on the weekends because the agency couldn’t find staff, and seniors would be left in soiled diapers for up to 24 hours or more. Sometimes, the PSWs did not come at the requested time, resulting in the caregiver having to provide personal care. Other times it would be a matter of a different PSW every day, arriving at different times—which is often confusing and disorienting to the older adult with cognitive impairment. The PSW shortage and inconvenient scheduling have long been recurring themes and a source of frustration amongst patients and caregivers. It’s a situation that was further exacerbated by the pandemic. Basic needs With the closure of non-essential businesses (namely restaurants and malls), reduced capacity at grocery stores and pharmacies and the fear of contracting COVID-19, many older adults could no longer easily access meals, groceries, or their medications during periods of lockdowns. Read: Spironolactone not associated with a significant increase in cancer risk To try and mitigate the impact of these lockdowns, our outreach team called each and every person on our caseload to ensure that they had access to groceries, food and medications, prioritizing those who lived alone with lack of social supports. Many people were referred to a COVID-19 Response Team or the Friendly Neighbourhood Hotline—teams of volunteers who can pick-up and deliver groceries or medications to those in need. Referrals to Meals on Wheels also skyrocketed, as many seniors do not cook and actually rely on takeout or the goodwill of family and friends (who stopped visiting due to the fear of COVID-19) for their meals. Although we have yet to see what “normal” will look like, there is still a waitlist for Meals on Wheels and some seniors still have a brittle social support system. Social isolation and rapid cognitive decline When Adult Day Programs shut down, it was a devastating blow for our patients and for geriatric teams nationwide. For those who attended, Adult Day Programs were their means of socialization and provided them with a sense of community. Adult Day Programs are often the first recommendation geriatric teams make to adult caregivers who are experiencing caregiver burnout. As a result of these closures, new and/or worsening responsive behaviours would emerge due to under-stimulation and disorientation at home, as these seniors did not understand what was happening around the world and why they weren’t able to attend the program to see their friends. They would also experience worsening memory or a decline in function due to social isolation and lack of stimulation. Read: Bladder Cancer Canada addresses resolution of BCG shortage for bladder cancer Adult caregivers now often had to work from home, watch mom/dad with said responsive behaviours (e.g. wandering, exit seeking, agitation) and oversee remote learning for their children. While some Day Programs have now resumed in-person programming, many are still offered at reduced capacity. As such, there is a long waitlist for those waiting to return, and when they do, they will not be able to go as often. Although some of these Day Programs did transition to virtual programming, most of these older adults have cognitive, hearing, vision deficits and/or low digital literacy which prevent them from fully engaging or accessing virtual sessions. Some adult caregivers and patients expressed that they were experiencing major social isolation, as they previously went to the mall for walks on a daily basis or met up for dinner with friends regularly. In February 2022, one patient confided to me that he hadn’t seen his daughter since Christmas and that we were his first visitors since then. Since the start of the pandemic, our team has received an increasing number of referrals for seniors who were previously cognitively intact and functionally independent but who have experienced a rapid cognitive and/or physical decline as a result of the pandemic and social isolation. Vaccine inequity The launch of mass vaccination really brought cultural competency (or lack thereof) to the forefront. As someone who is “tech-savvy,” even I had difficulty booking appointments for myself and my family. You had to be both fluent in English or French and be digitally competent in order to navigate the confusing vaccine websites. The conundrum was that patients in those areas that had a higher number of cases (e.g. Scarborough) were the ones that were unable to access the vaccines because of these challenges. Many required the assistance of others to book the vaccines and transportation had to be arranged as well. The production of language-specific materials and mass immunization clinics in certain neighbourhoods were essential in increasing vaccination rates in these populations. Read: Long lasting cell treatment cured leukemia patients: doctors Final thoughts The good news is that there are now policies in place to ensure that essential caregivers will always be allowed in nursing homes, regardless of whether or not there is an outbreak. The Canadian Coalition for Seniors Mental Health and the Canadian Association of Geriatric Psychiatry came out with a Position Statement for Mental Health Care in Long-Term Care During COVID-19 stating that infection control measures intended to reduce the spread of infectious diseases must also balance the impact of these measures on the quality of life and dignity of LTC residents. However, I believe this statement should be expanded to include the quality of life and dignity of all Canadians. The COVID-19 pandemic is the proverbial straw that broke the camel’s back—shedding a light on all the cracks in our healthcare system that need to be addressed. Maslow’s hierarchy of needs include: physiological, safety, love and belonging, esteem and self-actualization. For older adults especially, a sense of belonging is vital in order to feel that they are living a purposeful life. Being alive isn’t the same as living, and I wonder when the next pandemic comes, how can we do better? How can we physically distance and remain social at the same time? How can we protect our loved ones without isolating them and removing their sense of purpose? While many things are outside of our realm of influence, I hope we each make the decision to recognize the complex needs and challenges that our patients experience. As pharmacists, we have been indispensable during this pandemic. While addressing medical issues is important, I hope we can further elevate our practice so that we can help our patients continue to live their lives with purpose and meaning. They are more than just their vaccinations and medications. Read: Study examines opportunistic salpingectomy as tool to reduce ovarian cancer risk Janet Chong-Lee is a licensed pharmacist practicing in Toronto, Ontario. She currently works as the consultant pharmacist for the Carefirst Geriatric Assessment & Intervention Network (GAIN) Clinic. She is also a Board Certified Geriatric Pharmacist, Certified Diabetes Educator, Culinary Nutrition Expert, Holistic Weight Loss Expert, Fitness and Nutrition Expert, and Health Coach residing in Toronto, Ontario. She has a strong passion and interest in the power of food (culinary and therapeutic nutrition) to reverse metabolic disease and to improve and maintain health. For more information, visit janetchonglee.com.

The unspoken impact of COVID-19

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