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SPECIAL COMMUNIQUE April 2020
COVID-19 poses a significant threat to our older
adults across the NSM region. For that reason, the
NSM SGS program has been collaborating with
partners to redesign and mobilize resources to
better support the needs of frail seniors and their
caregivers.
COVID-19 is a Significant Risk The 2016 census indicated NSM was home to
90,615 age 65+. Older adults are at risk for
serious disease due to physiological changes,
compromised
immune systems and
underlying co-
morbidities.
Older adults are the
most vulnerable
COVID-19
population.
On April 2, WHO Europe reported that
globally age 60+ account for 95% of deaths
with a case mortality rate of 15%. Case
mortality data from Italy (JAMA, March 15)
showed 19.7% of those age 80+ who
contracted the disease, died. Its important
to remember only swabbed cases are
counted in these stats.
Global, national and provincial news is
highlighting the impact of COVID-19 on
care facilities. NSM has 26 LTCHs (3,065
beds), 50 registered Retirement Homes
(capacity >4,000 beds) and over 40 more
retirement-home type settings in the region.
COVID-19 screening is based on a core set of
symptoms. Older adults can have an atypical
presentation (i.e. increased falls, increased
confusion, gastrointestinal symptoms, no
fever).
While we focus on COVID-19, older adults will
continue to experience medical issues and
geriatric syndromes (i.e. falls, delirium, etc.)
putting them at risk for ED visits and
hospitalization.
Sweeping shutdowns of programs and services
are lending to significant social isolation.
Hospitals, LTCHs and Retirement Homes have
eliminated visiting and volunteer programs.
Social isolation can increase depression,
anxiety and caregiver burden. For those with
responsive behaviours,
behaviours can escalate.
Social distancing can
mean less support from
usual caregivers. As a
result, it may take longer
to identify changes in
medical/functional/
cognitive status and/or the senior may have
less access to necessary food, supplies and/or
medication.
While many pharmacies are delivering
medication, food security has been identified
as an issue of concern in some areas. Some
cannot find needed items. Some cannot
access designated shopping hours or get
grocery delivery slots. Others are too high risk
to leave their homes.
Focus on Older Adults This special communique is focused on
highlighting the needs of NSM older adults and
their caregivers, the great work underway across
the region, available resources and opportunities
for collaboration. Together, partners and
communities WILL make a difference.
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
OLDER ADULTS & COVID-19
Clinical Services
NSM SGS Service Changes The NSM SGS program has made
changes to our clinical services. Some
were planned and others implemented
to provide better support to older adults,
caregivers and NSM partners during this period.
Planned Changes
As of April 1, 2020 the NSM SGS program provides
specialized geriatric mental health consultation
services to support both responsive behaviours
AND serious mental illness.
Waypoint’s Community Consultation Service -
Geriatric Psychiatry (CCS-GP; formerly GPOT) is
now part of the NSM SGS program. CCS-GP is
working alongside our existing BSS team, with
all CCS-GP staff now part of our team,
including Dr. Geoff Daniel.
Dr. Katie Bingham, geriatric psychiatrist, has
joined our team providing virtual support 2.5
days/wk to the Couchiching and Muskoka
regions. Dr. Daniel will focus on Barrie, North
Simcoe and South Georgian Bay.
Our geriatric mental health services can now
all be accessed via the NSM SGS referral form.
SGS clinicians will work with the referral source
to involve the right service.
With these changes we will continue to improve
care coordination, communication, quality of
care and make better use of system resources.
COVID-19 Support
To better support our NSM partners, we have:
Revised the NSM SGS referral form for ease of
completion.
Revised our referral criteria to focus on higher-
risk geriatric syndromes to better support
hospital flow, reduce unnecessary ED visits
and support LTCHs and RHs.
We continue to offer the following consultation
services virtually:
Geriatric Mental Health Services - for
responsive behaviours and serious mental
illness. Of note, a BSS staff member remains in
most NSM LTCHs.
Geriatric Medicine – while Geriatrician falls
clinics have been cancelled, the team
remains available for consultation.
GeriMedRisk
NSM Geriatric Physician Specialists eConsult
Group (via OTN)
Complex Case Resolution
Partnering to Support NSM Recognizing that #WeAreAllInThisTogether, the
NSM SGS program has collaborated with partners
to support older adults and their caregivers:
Distributed a press release and follow-up
Rogers interview focused on COVID-19 and
older adults, including atypical symptoms.
Circulated information to local Assessment
Centre teams (atypical symptoms in older
adults, tips for nasal and throat swabs in
people with cognitive impairment)
Gathered and forwarded information around
available community services to 211.
Enlisted HCC support in doing wellness checks
on older adults receiving HCC care without a
local primary care provider.
Encouraged follow-up calls to older adults
visiting Assessment Centres. This is occurring in
Barrie, Couchiching and Muskoka. All referrals
for follow-up in Couchiching come through
SGS and are directed to local resources.
Modified/distributed a provincial telephone
screening tool which is being used in full or
part by some NSM partners . For information
on the tool contact the NSM SGS office.
Leading weekly partner huddles in Barrie and
Muskoka to share information and discuss
opportunities for collaboration.
Distributed a press release and follow-up
Rogers interview around advance care
planning, in alignment with messaging from
local hospice palliative care partners.
Advocated for a system-wide approach to
supporting older adults in LTCHs and RHs.
In partnership with OSMH, developed an
orientation plan to support staff transitioning to
support LTCHs and RHs.
Developed Friendly Visiting Guidelines and an
Activity Toolkit to help address social isolation
(see pg.3).
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
NSM SGS - COVID-19 - APRIL 2020 Page 2
Social Isolation & Loneliness By Allyson Jayaweera, PRC
As clinicians, we identify social isolation
but how often do we assess loneliness?
Social isolation occurs when individuals
have few interactions with people. Social
isolation itself does not impact health, but it can
increase one’s chance of experiencing loneliness
and depression. Loneliness is the disconnect
between someone’s desired and actual social
relationships, which results in an emotional and
physical response. It is a subjective feeling. It is
often unrelated to the number of connections a
person has with some feeling lonely even in a
crowd or when many social connections exist.
Loneliness and social isolation can affect physical
health, mental health and contribute to
functional decline. One in five Canadians,
experience some degree of loneliness and this
may be higher for those age 85+. Loneliness can
have a direct impact on health outcomes and
has been equated to being as detrimental to
one’s health as smoking 15 cigarettes a day.
While there are many risk factors that contribute
to social isolation and loneliness, the most
significant now is the restrictions imposed to stop
the spread of COVID-19. Clinicians are in a
unique position to assess, identify and offer
support for loneliness. Although it may take more
creativity, there are many strategies to remain
socially engaged. Some recommendations
include: developing a new daily routine,
connecting virtually for visits and previously
attended activities (e.g. church), and exploring
online options (e.g. cards games, crosswords,
etc.). It is important to remember that practicing
social distancing does not mean someone needs
to experience social isolation. It is also important
to remember that any support provided must be
done in consultation with the older adult and his/
her caregivers. Source: RGP of Toronto. (2019). The SF7 Toolkit.
Retrieved from https://www.rgptoronto.ca/resources/.
Wellness Checks & Friendly Visiting Many older adults connected to services are
receiving wellness checks from their providers.
Some organizations are offering friendly visiting
calls. Both are great supports for interested older
adults. There are, however, a few things to
appreciate. Some older adults are overwhelmed
by the volume of calls they are receiving. As such,
it is important to ask (1) whether the individual
wants to receive calls and (2) about the desired
frequency of calls. Some are not answering calls
as they do not recognize the number of the caller.
Some are very thankful for the calls as it provides
contact and reduces social isolation.
Available Resources If you are interested in further information and/
or team education about social isolation and
loneliness contact the NSM SGS program.
We have developed Friendly Visiting
Guidelines (available upon request from the
NSM SGS office) for interested organizations
which include strategies to promote the safety
of both the older adult and the caller.
We have created an Activity Toolkit with
virtual links and activity ideas for older adults,
their caregivers, LTCHs, Retirement Homes
(RHs).
We engaged an expert Recreation Therapist
to connect with recreation teams from NSM
LTCHs and RHs for support and to facilitate the
sharing of ideas.
The Regional Geriatric Program of Toronto’s
Senior Friendly 7 toolkit includes a section on
social engagement that addresses social
isolation, loneliness and social engagement.
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 3 NSM SGS - COVID-19 - APRIL 2020
Advance Care Planning
Despite all our best planning, there is the
reality that older adults in NSM who
contract COVID-19 may not survive. To
further challenge things, hospitals, LTCHs and RHs
have eliminated visiting. While exceptions are
being made in extenuating circumstances, there
may be cases where older adults may not have
their families or support system with them in their
last days or at their time of death.
Advance care planning should be considered at
all times, but it is especially important now.
Having a plan will ensure a person’s wishes are
carried out even if loved ones can’t be there at
the end. “We understand this is a difficult time.
You need to ensure you have completed
advance care planning by having conversations
now and not during personal crisis,” explains Kelly
Hubbard, Executive Director of Hospice Simcoe.
The Process Advance Care Planning is a process of reflection
and communication with two important steps.
First, an individual must identify who they wish to
have as their Substitute Decision Maker (SDM).
The 1996 Health Care Consent Act does define a
hierarchy of SDMs. Should an individual choose
to have someone that does not align with the
hierarchy then there is a need to define a Power
of Attorney for Personal Care. An SDM must be
willing and able to make health decisions on the
individual’s behalf, be willing to honour the
individual’s wishes, be at least 16 years of age
and be available when required.
The second step is to have a conversation with
the SDM to ensure there is an understanding of
the individual’s wishes, values, beliefs as well as
healthcare choices. It is always important to
consider things like treatment/care decisions,
admission/transfers to hospital or care facilities
and code status decisions. At this time it would
also be important to consider things like ICU
transfers and ventilator use.
Advance care planning conversations can be
difficult. Taking the time needed, allowing
emotions to come through and using moments
of silence for reflection are all good strategies to
consider during the conversation. If it is a difficult
to start the conversation think about using
personal examples or examples from the news
to open the discussion.
Available Resources To support difficult conversations and
planning, the North Simcoe Muskoka Hospice
Palliative Care Network has a toolkit that is
updated weekly with resources.
Speak Up Ontario has resources and toolkits
for providers and the public.
For anyone in the region who needs help with
grief, a regional bereavement support line
has been established, connecting
communities to resources in local areas -
(705) 325-7871.
There are also great local hospice resources
always available to provide support:
NSM Hospice Palliative Care Network
Hospice Georgian Triangle
(Collingwood)
Hospice Huntsville
Hospice Huronia (Penetanguishene)
Hospice Muskoka
Hospice Orillia; and,
Hospice Simcoe (Barrie).
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 4 NSM SGS - COVID-19 - APRIL 2020
Caregiver Stress
The current environment is difficult and is
placing increased stress on some of our
caregivers. Caregiver stress should be
included as part of all initial and regular
assessments, keeping in mind that there are likely
four key groups of individuals at increased risk:
Existing caregivers whose social support
network has been reduced, including those
who have stopped in-home services.
Family members who are now working from
home and needing to provide more support.
Individuals unable to visit their loved ones due
to social distancing and visiting restrictions.
Individuals who have taken loved ones out of
care facilities to provide care at home.
A caregiver’s perception of stress translates into
their sense of burden and, if not addressed, can
lead to burn-out. Various tools are available to
assess caregiver stress (i.e. Caregiver Burden
Scale, Zarit Burden Interview). While valuable,
they may not be practical in this environment.
Instead, consider asking about symptoms
considered reflective of stress: trouble sleeping,
decreased appetite, loss of interest in usual
activities, decreased mood, irritability and
physical changes (i.e. weight gain/loss). It is also
important to ask whether there has been any
recent increase in substances use like alcohol.
If caregiver stress is identified, providers should
work with the caregiver to identify the stressors,
identify interventions and provide ongoing follow
-up to evaluate effectiveness:
Provide information and link the caregiver
with appropriate resources and supports (i.e.
support groups, Social Work support)
Encourage the caregiver to draw on existing
supports to build a support network.
Work with the caregiver to set realistic
personal and caregiver goals.
Consider possible stressors and put strategies
in place to get ahead of them (i.e. NSM SGS
Activity Toolkit or decision making tool by the
Ottawa Hospital/ University of Ottawa/
National Institute of Aging for caregivers
considering taking loved ones home from
care facilities)
Elder Abuse Health care providers must be aware that
an increase in caregiver stress is
associated with an increased risk for elder
abuse. Elder abuse is defined by the
World Health Organization as “a single, or
repeated act, or lack of appropriate action,
occurring within any relationship where there is
an expectation of trust which causes harm or
distress to an older person.”
Elder abuse can come in many forms - physical,
psychological /emotional, financial or sexual.
Elder abuse also includes neglect. Neglect can
be intentional or unintentional in nature and is
characterized as not meeting someone’s basic
needs. Examples can include: denying access
to necessary services; leaving someone alone
when that is not safe; not assisting with activities
of daily living when assistance is required.
The Elder Abuse Prevention Ontario website has
great information and resources for older adults,
caregivers and health care providers about
abuse and prevention . There is also a Seniors
Safety Line (1-866-299-1011) available for anyone
to call. It is free and operates 24/7 with trained
counsellors available for support.
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 5 NSM SGS - COVID-19 - APRIL 2020
Supporting Our Providers
The Reality of Care COVID-19 will have a lasting impact on
our health care providers (Wave 4 - see
pg. 7). Providers today are facing
unimaginable situations: providing end
-of-life care in the absence of families; making
decisions around allocation of limited resources;
providing care in settings like LTCHs and RHs
where people (who are like family) are dying in
large numbers; providing care to critically-ill
people knowing that on some days best efforts
will not be enough; caring for colleagues who
have contracted the disease and, in some
cases, supporting them in their final days and
hours. All this comes on top of the daily concern
for personal safety and safety of those at home.
People will respond to this reality in different
ways. Some will be overwhelmed by the trauma
and grief; in the end, experiencing PTSD and/or
choosing to leave their chosen jobs/professions.
Others will rise and push forward knowing that,
together, we can make a difference. What is
certain is that providers of today will never see or
deliver health care in the same way again.
Caring for Our Providers It is imperative that we acknowledge the reality
of our new environment. We can not pretend
everyone is fine. We must make the time and
take the effort to support providers and teams.
UNICEF posted an inter-agency paper
addressing the mental health and psychosocial
aspects of COVID-19. “Intervention 5”, page 15
of the paper, focuses on supporting providers
and offers some considerations for all providers:
It is normal to feel stressed in this environment.
Some may not feel they are doing a good
enough job; others may feel overwhelmed by
the demands. For some, stress can be useful
as it keeps them going and gives purpose.
Managing stress and psychosocial wellbeing
is as important as managing physical health.
It is important to take care of basic needs
(nutrition, rest, physical activity, social
engagement) and put coping strategies in
place (consider strategies that have been
successful in the past).
Turn to colleagues, leaders or other trusted
people for support. These individuals may be
having similar experiences.
Watch for signs of worsening stress - mood,
irritability, anxiety, fatigue, trouble sleeping,
decreased appetite, unexplained physical
complaints (i.e. body pain, stomach aches).
Chronic stress can affect mental wellbeing
and how one engages at home and at work.
It is important to remember, stress can affect
people even after the situation improves.
Considerations for leaders:
Monitor staff wellbeing and open lines of
communication; in particular, monitoring
those with known stressors or with limited
social supports.
Provide timely, good quality communication.
Provide a regular forum that allows staff to
ask questions and promotes peer-support.
Within available capacity, ensure staff have
time for rest and recuperation.
Leaders can provide support through regular
team meetings and communication. Think
about providing updates, shout-outs (recognize
great work by individuals and teams) and
sharing messages of hope (i.e. good news story,
heartfelt thank you). If capacity exists, consider
complimenting this with team education on
topics like mindfulness, coping/resiliency and
clinical topics relevant to staff practice in this
environment. Team challenges may also be a
way to bring light and fun into the environment
and provide a brief distraction from the reality.
Available Resources Employee Assistance Programs.
Relevant support groups, services, programs.
Waypoint’s new regional resource for health
care, LTC and residential care workers, and
first responders dealing with mental health
challenges during COVID-19. *Contact Info:
705-549-3181 ext. 2308 or see the Waypoint
website for more information.
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 6 NSM SGS - COVID-19 - APRIL 2020
What Should We Focus On Now?
While we deal with the urgent and
immediate needs associated with the
pandemic, health care needs of older
adults and their caregivers continue
today as they did yesterday and the day before.
In truth, it is amazing to think that amid this crisis
we have capacity in our system (for now). We
have achieved today what we have been
unable to achieve historically
- large numbers of available
hospital beds, quieter than
usual EDs, virtual visits. etc.
However, anyone who
understands the system
knows this capacity has
consequences.
To help flatten the curve,
elective or less-urgent
surgeries have been delayed
or cancelled. In addition to
impacting the well-being of
these individuals, the system
will be back-logged when it
re-opens. Services are
operating virtually with
reduced volumes. Virtual care, especially when
provided by phone, makes it difficult to see and
hear what we would during a physical exam.
Usual caregivers may visit less and not pick up on
subtle changes they would have noted before.
Cancellations to congregate programs means
those relying on mental health, respite, caregiver
support, and exercise are going without. Finally,
for fear of contracting COVID-19, people are
waiting longer to seek help when feeling unwell.
A recent graphic showed the health waves of a
pandemic. While the source is unknown
(apologies to the authors as we’re unable to
reference), it lays the foundation for next steps.
Wave 1 focuses on immediate system issues
related to COVID-19 itself and is underway.
Wave 2 is becoming evident as we see those
with urgent non-COVID-19 issues delaying
care. Some older adults requiring medical
attention are avoiding places like emergency
departments (EDs) because they think they
are supposed to (based on current
messaging) or for fear of contracting COVID.
Wave 3 is occurring silently. While many with
chronic conditions are being monitored
remotely, some are not. Couple this with the
loss of regular services and congregate
programs and we will see exacerbations of
clinical conditions, functional decline and
caregiver burn-out.
Wave 4 reflects the society impact, including
the impact on health care providers (see pg.
6) and on social determinants of health.
Key Next Steps
Public communication is required and needs
to focus on: (1) addressing the safety of EDs,
hospitals and primary care settings; AND, (2)
encouraging people to seek medical
attention when required.
Support previously provided for chronic
conditions, including congregate exercise
and support programs, must be re-
established virtually or in some other form.
System planning must begin to consider
rehabilitation; for individuals who contracted
the disease and were critically ill AND for
those who functionally deteriorated as a
result of COVID-19 restrictions.
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 7 NSM SGS - COVID-19 - APRIL 2020
COVID-19 & Medications By Karen Cameron, Pharmacist
The devastation caused by COVID-19
has led to a flurry of research into
prevention and treatment for the novel
coronavirus. To date, no medication has
been reliably proven to be effective in
preventing or treating the virus.
In the community, the most reliable preventative
actions continue to be self-isolation for those with
symptoms, physical distancing and frequent
handwashing. Clinical trials are ongoing to
identify an effective treatment and vaccine
development. For hospitalized patients who are
very ill, supportive care and management of
symptoms is the mainstay of treatment.
Physicians may also be able to access
experimental COVID-19 medications through
clinical trials. Stockpiling medications such as
hydroxychloroquine, should be avoided as it
leads to drug shortages and the lack of
availability of the medication for those that need
it for other chronic medical conditions.
For assistance with optimizing medication,
mental health and co-morbidities in older adults
the GeriMedRisk team remains available for
consultation and education. COVID-19
resources, including drug-related information,
are available to health care providers on the
GeriMedRisk COVID-19 page.
Recognizing Great Work!
We would be remiss if we did not acknowledge
the great work happening in NSM to support
older adults and their caregivers:
NSM first responders and health care
providers who are doing everything possible
to keep our older adults safe, including
transforming the way services are delivered
and partnering with the NSM SGS program!
Essential services in our NSM region like
grocery stores and pharmacies who have
altered hours of operation, processes and
services to better
support older adults
and keep them safe.
Families, friends and
volunteers in our
communities who are
stepping up to keep
an extra eye on our
older adults and
caregivers.
Leaders across NSM in all sectors for finding
ways to collaborate and provide support.
NSM recreation teams in hospitals, long-term
care and retirement homes who are coming
up with creative ways to reduce the social
isolation of older adults in their facilities.
Great partners like our local Alzheimer
Societies, VON Simcoe County and area
hospice programs who have moved services
to virtual platforms to continue to support
older adults and their caregivers.
Last but not least, our own NSM SGS Team for
continuing to move forward in good days
and bad. #bestteamever
#ProtectOurSeniors #LeaveNoOneBehind
#WeAreAllInThisTogether
North Simcoe Muskoka Specialized Geriatric Services
190 Cundles Rd. East, Unit 205 I Phone : 705-417-2192
Page 8 NSM SGS - COVID-19 - APRIL 2020
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