Published on Sep 21, 2020

Video Transcript


JOHN WHYTE: You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at Web MD. With all the physical distancing that we've been doing, the social distancing, we've seen increase in loneliness and depression, and it's disproportionately impacting the elderly.

I was reading an article by AARP the other day, and I want to give you the headline. It says, "is extended isolation killing older adults in long-term care." To help provide some insights, I've asked back one of my favorite guests, Dr. Terry Fulmer. She is the president and CEO of the John A. Hartford Foundation. Dr. Fulmer, thanks for joining me.

TERRY FULMER: John, I'm so glad to be with you. This is such an important topic. JOHN WHYTE: You've been a proponent all your life for aging properly, healthy aging. Tell us about the impact that loneliness is having, particularly on the elderly?

TERRY FULMER: John, loneliness is something that's so painful for older people who are isolated in either their homes, their assisted living facilities, nursing homes. And the National Academy of Science, Engineering, and Medicine released a report in February 2020, almost prescient, thinking about social isolation and loneliness in older adults, and their findings were quite stunning.

They found that 40% of older adults note that they are lonely. And that is the subjective sense that you are without friends or feeling alone. And then another almost 25% said that they felt socially isolated. Now, compound this with the COVID-19 pandemic, and you can only imagine what is going on in these settings of care.

JOHN WHYTE: You know, I have some interesting statistics I want to share with our listeners, that isolation and loneliness are associated with a 50% increase in developing dementia, a 32% increase in stroke, a fourfold increase of death among heart failure patients.

And this article talks about a woman's mother, 99, living in assisted living, you know, using a walker, but getting around. And now she talks about she's really in an abyss. She wants to visit her mother, but she's not allowed to, physically.

So where's-- where's the middle ground, recognizing that is-- is it possible to have some loosening of restrictions? How do we decide on a case-by-case basis? I think we're moving away a little from this all or none approach and figuring out how do we balance.

TERRY FULMER: If, um, you live in a rural area, and your county has almost no cases, your Department of Health and your nursing home are going to be making their decisions a little differently than if you're in a dense city, for example. So first of all, it's thinking about the environment in which you live and working with your public health office in your county to say what's safe, what can I do, and what do we know.

Because we do know that it's the contagion around you that's so dangerous. If your county has no cases, and you've not traveled at all, could you go and see your daughter? Well, I think that's something to negotiate.

I also think that people have been very creative about coming to the windows-- we've seen these pictures-- and-- and doing dance recitals outside the windows of people who are in facilities. And the way in which concerts have been held, for example.

So the other thing we know is that-- setting up a communication plan. We have a lot of-- we have a big family. And so we-- we sort of have a strategy about whose day it is to be in touch. And, um, we're all sending cards and letters and greetings. And Aunt Rita is 92, and she just learned Facebook.

And this has been a-- just remarkable for her. And it's a whole new window for her. So I think thinking of all the strategies that are appropriate, that are acceptable to that older person, is what we must do now.

JOHN WHYTE: For those that have loved ones in assisted living and nursing homes, do you need to start engaging more with the professionals there or talking about what could be potential, you know, changes to-- to systems? We've been hearing more about hospitals allowing visitors in, you know, more frequently than they were before. We saw that in terms of live births. Really kind of balance the-- the competing demands of trying to have infection control and at the same time recognizing the impact of loneliness, depression, its role in mental health, and then ultimately, its role in a person's physical health.

TERRY FULMER: Right. So John, you know that our foundation is very keen on thinking about age-friendly health systems. And that system starts wherever you are, whether it's the nursing home or the assisted living facility or your own kitchen. So what we think about in our age-friendly health system approach is our-- our essential set. And those are the four M's.

So we start with what matters to the older person. And if what matters to them is making sure that they have a virtual conversation with a family member every single day, then the assisted living facility or the nursing home nurses do everything in their capacity to try to respect that. I have seen heroic actions and-- and extremely gifted, talented nurses, nursing assistants, physical therapists doing everything they know how to be creative, to keep those older individuals connected. And that's what matters.

The other elements of our for M's are mentation. So you mentioned that. With social isolation comes an increased risk of depression, dementia, delirium. Very, very serious issues. And so thinking about mentation and really following that.

If an older person starts speaking differently than they usually do, if they're missing their dates, if they are missing their names, and that's a new change, you really want to alert your physician or primary care person to say something's changing. The next one is medications.

JOHN WHYTE: Yeah, and people have been talking about that. Because we do want to take that seriously. I want to underscore that point. If people are starting to see a difference, mention that earlier.

As you've talked about, maybe, you know, their speech pattern or their-- you know, their awareness of, you know, the day is different than it was before. So-- so that's good. So let's go through the four M's, which you and I are-- are big fans of. I know I am as well. So. We have what matters, mentation--

TERRY FULMER: Medications. And so with COVID and with the changes and with the isolation, and what if an older person hasn't been eating, and there's weight loss? That could mean that medications are now too strong for them. And so we have to be monitoring each of these physical changes with cognitive changes, but asking yourselves, can we deprescribe anything that this person is taking right now. Is there anything that might have been OK that could now be harmful?

Medication is very important to think about. Deprescribing, titrating, and looking out particular for those medications that can be particularly dangerous for older people. And our final M is mobility. And what could be worse for an older person than being stuck in a room, no matter where they are, stuck in a building.

The-- the opportunity for us to do some check-ins with them and say let's do some physical activity together. Let's do some physical therapy today, together, on camera or by telephone. There are people who don't have Zoom. And so what if you called and said, you know, Mom, I really want to talk about stretches today. Let's do that. And how are you feeling? And how is your balance?

If an older person were to fall and end up with a hip fracture and go to the hospital, well then, you-- we've tripled the threat, right there. So what matters, mentation, medication, mobility, watching those-- watching the interactions of that set, and making sure that we're doing everything we can and not discounting because somebody is in a nursing home. They need mobility more than the rest of us.

JOHN WHYTE: Right. And now is the time where it sounds like we need to make more of an effort. Recognizing it is hard to begin with, but even more so now, during these times. Do-- do you expect visitation policies to change at all in the next few months?

TERRY FULMER: We've seen visitation policies evolve since COVID started, from not recognizing how serious it was to-- and by the way, having even people from the Department of Public Health come in with that-- you know, initially, and being allowed to come in without testing. And now we see that there are COVID wings that are being-- which-- which therefore means that you can socially isolate people who are COVID-free from those with COVID, so that makes it a little safer.

So yes, I do think that everybody is trying really hard to get these uh, uh, visitation principles and priorities loosened, so that people can be with their loved ones. We also know, John, and I was reading this morning, that there is a decrease in the admission rate and in the total number of people who are now in nursing homes. People have, to the degree possible, gone home.

JOHN WHYTE: I was going to ask you about that, that, you know, we talked about that several months ago. What do you think's driving that? Is it-- is it just because it's the fear of COVID? Is it because people are working from home now, so maybe they feel they have more of an opportunity to take care of loved ones, but that might change as they return? What-- what's the driver?

TERRY FULMER: There was documentation by McKnight's this morning saying that there's an overall decrease in people choosing to go to nursing homes, that they are afraid, that they are making alternative arrangements. Most older people, left to their own devices, would much rather stay at home or stay with people who are related to them or dear friends. And so we're seeing that shift, and-- and we need to pay attention to it.

The other thing we saw right during the-- the height of the pandemic was there were fewer elective surgeries. And so people who would normally go to a nursing home because they were recovering and needed rehabilitation from a hip surgery aren't going there. And so we're seeing those changes as well. And we-- we don't know what our new normal is yet.

JOHN WHYTE: Let's be transparent. There have been a lot of deaths, percentage-wise, that have been in nursing homes, versus the general population.


JOHN WHYTE: Um, it seems like we're getting better in terms of controlling the spread, controlling, you know, the morbidity and mortality associated with COVID and nursing homes. But listeners and viewers are worried, and they wonder, is it safe to put their loved one in a nursing home or to keep their loved one in a nursing home. How did they help make that decision, recognizing a lot depends what's going on in the community? But Dr. Fulmer, what advice could you give them, or what resources could you point them to?

TERRY FULMER: Some of the resources available that give us some guidance are the star ratings, for example. And so CMS has star ratings, which talks about the quality and safety of a-- a particular facility. Having said that, we do know that there are four-star, five-star nursing homes that had a disproportionate number of people with COVID because of their surrounding community. So it's a balance.

You should always be talking to your public health office. You should be talking to the administrator of the nursing home and saying, how would you guide me in this moment. Because I can't take-- the fact is some people cannot take care of individuals who have profound dementia, need help going to the bathroom, need help eating their meals. And so it's this balance that has to be re-eva-- re-evaluated on a continuous basis. And it is scary for the public.

JOHN WHYTE: And this all goes to-- to your point about an age-friendly health care system that we've been talking about, or you've been talking about, for a long period of time. Tell our viewers what else the John A. Hartford Foundation is working on and-- and what resources you have available to them.

TERRY FULMER: Oh, I'd love to do that, John. So our-- our mission is to improve care for older adults. We take the science that's generated by the National Institutes of Health and the CDC and others, and we get it into practice in reliable ways. And particularly, we partner with the Institute for Health Care Improvement, the American Hospital Association, the Catholic Health Association, CVS Minute Clinics.

We're looking at all-- all sectors of care in order to make sure that we're improving care for older adults. And you do that not only by creating age-friendly health systems but also by supporting family caregivers. We know we have 40 million family caregivers out there who have been desperate during this pandemic, saying what do I do now? Is this the right approach?

And AARP has done some really nice work trying to give toolkits and support systems, as has LeadingAge and ACL. So there's a lot of organizations out there who are really working hard to support those family caregivers.

JOHN WHYTE: So we're going to put the URL so viewers can see it. And also you are very active on social media. And we'll put your Twitter link up here as well. Dr. Fulmer, I want to thank you for all you're doing for supporting research around age-friendly health care systems, for your advocacy of patients and caregivers, and really, your help in guiding us through this pandemic that we experience once a century.

TERRY FULMER: And we're grateful to WebMD, John, for all you're doing to get the word out and to get the voices of leaders around the country, uh, in front of people. Thank you.

JOHN WHYTE: And I want to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.