As the weeks and months have dragged on and as the public becomes increasingly anxious about basic issues in our society, it is increasingly important to sort out reality from perception. The outbreak in Campbellton is disturbing, aggravating, and disappointing. It illustrates clearly that the best laid plans often can get sidetracked by undisciplined behavior.
Nationally and internationally, the attention has turned to Long Term Care and legitimately so. Chris Selley, in his National Post article of May 27, “Shameful Nursing Home Report Shows How Canada’s Lockdown Strategy Went Wrong”. In the article he refers to recent reports from the federal government, Ryerson University’s Institute on Ageing that make it clear that the Covid-19 risk is very high amongst those of us over 60 who live in long-term care.
Based on analysis, his conclusion is that “Canadians who aren’t elderly or in long-term care homes have faced a risk of death that’s no worse than the 2009 H1N1 outbreak.” His article goes on to underscore that the vast majority of people infected by the virus do, in fact, survive and do well.
So why are issues relative to long term care so important with this infection? We have made the point in previous columns that the virus is particularly serious for persons with compromised immune systems. Immune systems become compromised by the presence of frailty and co-morbidities such as Dementia, obesity, elevated blood pressure, Parkinson’s, and many others common to the senior population.
Persons live in long-term care for these very reasons, that is, they tend to have at least one and usually 3-4 challenging health conditions that seriously compromise their resistance to any contagious infection. As pointed out in a recent column, when these good people are cared for in facilities in which air circulation is not great, rooms are small, multiple persons occupy a small room, and cleaning may not be top standard, there is an immediate opportunity for high risk.
In 1992, the government of New Brunswick introduced the Single-Entry Point program for seniors that meant that only those with serious frailty were admitted to nursing homes while others were absorbed into home care or special care. This meant that seniors with a high Frailty index got to nursing home which has increased the complexity of care, for the most part.
If the staff pandemic training or numbers of staff are inadequate, then the risk is exacerbated. The reason they are living in a facility is that they are reliant on help from staff for some of the basic essentials of life, be it hygiene, nutrition, mobilization, emotional support and more.
What does not seem to be understood either by policy-makers, health authorities, or the general public is that managing persons in homes, small and large, that have these characteristics is so very different from managing sick people in hospital. In hospitals, particularly in New Brunswick, the ratio of nursing staff to patients, even in long term care units, tends to be 4 to 5 times the staffing levels that are approved for nursing homes, for instance. And Special Care Homes, due to the normal functioning of them, require only intermittent consultation perhaps with an Extramural Nurse.
Not only do nursing homes have a fraction of the nursing staff available in hospitals but their support staff, while superb and dedicated personnel, tend to be not so many as you find in hospital either.
When you superimpose on this situation the high ratio of persons with Dementia or other cognitive challenges, you have a formula for disaster unless managed with great care.
What are the practical issues of managing persons with Dementia under these conditions? The short memory that typifies mid-level dementia is a large challenge. Instructions and directions given now can, and mostly are, forgotten 5 minutes later. You can instruct a resident in terms of hygiene or social distancing or what to touch or not to touch and 3-5 minutes later you need to repeat it all over again.
Often, persons with dementia are frightened by a staff person wearing a mask. As kind and caring as the staff person may be, the mask can be a symbol of something very evil to a person with dementia. This can have significant behavior ramifications.
And for those without dementia, residents have told us that they see the mask as creating a barrier to relationship. It is supposed to be a barrier to transmission of disease, but when a frail elder cannot see the smile on the face of the person giving care, the atmosphere can, in fact, be challenging.
Other residents, particularly those with hearing impairments, express the difficulty in communication with a “masked caregiver” and, when asked, revealed that with their hearing impairment they need to be able to see expression and read lips to aid in communication.
Persons with Dementia often tend to wander and many times the wandering takes them into the rooms of other people, taking a nap on someone else’s bed. Dining usually takes place in groups, as it would at home, where relationships are formed that are normally helpful in the care of persons with Dementia. Then to create social distancing there is the need to break up these social dining patterns which creates its own set of problems. Imagine not being able to have breakfast with your kids in your own home for weeks on end!
Then sometimes persons with Dementia, when not managed properly, can develop aggressive behavior patterns. Sometimes such behavior patterns might be as simple as irritability or agitation. But other times, depending on the presence of things that can trigger behavior, serious aggression and even violence can take place.
Frail elders often are impacted by even minor illnesses in an exaggerated way. Something very minor illness can cause other complications including a major fall. In dealing with frail elders, falls can and often do lead to death.
Cleaning routines in health care are always a huge concern, exacerbated during times of outbreak. On March 23, 2012, W-5 showed a documentary in which they examined cleaning routines in hospitals. Now understand: hospitals tend to have much better insight into cleanliness and hygiene than any other facility; presumably emphasis on infection control has been part of the accreditation and basic funding mechanisms for decades and they all have had generous “in-service training capacity” compared to long term care.
But the documentary showed, using blue light techniques, how recently “cleaned” hand rails and surfaces still harbored deadly bacteria, probable contributors to communicable disease. Those who paid attention to the documentary, and many related training tools, have learned that cleaning in health care facilities needs much discipline, awareness, training, use of proper equipment and supplies.
Much more so in long term care facilities due to the fact that residents, mostly with mobility limitations, use the full force and depth of hand rails and other surfaces to support mobility.
A proper Dementia Strategy linked to a proper Long-Term Care Strategy would and should embrace all of these considerations and much more. So, by the next pandemic, perhaps the long-term care sector can be spared the agony and grief experienced with Covid-19. But that will require informed political will.
Ken McGeorge is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News. His email address is firstname.lastname@example.org
Ken McGeorge, BS,DHA,CHE is a career health care executive based in Fredericton, NB, Canada.