Using Telehealth Groups to Combat Loneliness in Older Adults through COVID ‐19

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Abstract

To the Editor: Loneliness has been a growing public health concern for older adults in recent years. It was suggested that almost one‐half of the older adult population will experience chronic periods of loneliness at some point in later life, with about 5% feeling constantly lonely.1, 2 People in later life who isolate from others and feel lonely are at risk for impaired physical health,3 worsening depression,4 and increased cognitive decline.5 Lonely older adults can even put additional burden and strain on family caregivers who dedicate a significant amount of time taking care of their needs. Few group interventions have been developed and validated to help alleviate loneliness in older adults. One psychosocial intervention that has proven effective and sustainable for this population is called Circle of Friends, an evidence‐based intervention to socialize older adults through interactive activities.6, 7 The group protocol meets 12 times over a 3‐month period, covering themes that connect lonely people including narrative writing, creative arts, and exercise training. Although this has been an effective group intervention for community‐dwelling areas and other communal settings, many older adults may not have the finances, transportation, or family support to get them to sessions in a community group. Several challenges have been noted for older adult interventions to adapt their approach online. Some have barriers to having the appropriate technology or resources to set up telehealth‐type services in their residence. Others may have difficulties with hearing or vision that limits their participation in groups. Incorporating technology innovations into the lives of later life adults is key to help prevent risk of further loneliness. We believed Circle of Friends would be an appropriate choice to move to telehealth, largely due to the mission of improving socialization in one’s community, the ease of conversation in the group, and the flexibility of incorporating activities. With the advent of the coronavirus disease 2019 (COVID‐19) pandemic, we accelerated our development of telehealth to provide social support for older persons at home.8 Through COVID‐19, we recognized the importance of caregiver involvement to help their loved ones get set up for participation in Circle of Friends groups. Facilitators conduct initial calls with both the participant and caregiver over the phone before the start of the group. The telehealth group allows for separate calls and scheduled Zoom meetings to help check in or follow up on topics discussed at sessions. The benefit of a telehealth intervention of Circle of Friends is that participants can now experience independence in participating in some of these activities in their comfort of their residence (Table 1). Narrative writing, creative arts, and strength training/exercises can be done from the comfort of home, and they can play back recordings of sessions to remember group tips and feedback. Table 1 Adapting Circle of Friends Groups from In Person to Telehealth Theme In‐person activities Telehealth activities Creative arts and inspiring activities ‐Visits from or to artists, musicians, or poets ‐Attend cultural events or art exhibitions ‐Group activities such as singing, baking, dancing, or games ‐Create an art piece of collage ‐Bring in guest speakers via video; use chat box for group feedback. Record speakers for playback later. ‐Show pictures of trips or unique places where one has traveled ‐Create a simple at‐home project (with caregiver assistance if needed) Group exercise and health‐themed discussion ‐Nature walks ‐Strength/Balance training ‐Dancing ‐Swimming/Pool gymnastics ‐Yoga/Tai Chi ‐Light exercise/stretching ‐Develop an in‐home routine of exercises (floor or chair), where facilitator can demonstrate these live ‐Share physical therapy/occupational therapy recommendations for exercise and strength building through video Therapeutic writing and sharing/reflecting ‐Writing, sharing, and reflecting on the past, dreams, or other feelings of loneliness ‐Bring in a diary or writings from the previous week ‐Discussions of loneliness, friendship, and other topics ‐Create diaries between sessions either written or on computer ‐Facilitator shows inspirational quotes or passages via video ‐Participants encouraged to blog any experiences in their lives, make interactive use of writing with others. Our hope is that more telehealth and online group interventions can be developed to help connect lonely and isolated older adults during the COVID‐19 situation and beyond. With a heightened risk for the virus returning soon, older adults are skeptical about leaving their homes and engaging with others in public.9 It is vital that healthcare clinicians and researchers continue to find creative ways to reach out to later life adults whose isolation and lonely states may worsen as this pandemic continues. Otherwise, this population is at risk for not only further separation from loved ones but increased physical and mental health conditions over time.

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COVID-19 and the consequences of isolating the elderly

Richard A. Armitage, Laura Nellums (2020)

As countries are affected by coronavirus disease 2019 (COVID-19), the elderly population will soon be told to self-isolate for “a very long time” in the UK, and elsewhere. 1 This attempt to shield the over-70s, and thereby protect over-burdened health systems, comes as worldwide countries enforce lockdowns, curfews, and social isolation to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, it is well known that social isolation among older adults is a “serious public health concern” because of their heightened risk of cardiovascular, autoimmune, neurocognitive, and mental health problems. 2 Santini and colleagues 3 recently demonstrated that social disconnection puts older adults at greater risk of depression and anxiety. If health ministers instruct elderly people to remain home, have groceries and vital medications delivered, and avoid social contact with family and friends, urgent action is needed to mitigate the mental and physical health consequences. Self-isolation will disproportionately affect elderly individuals whose only social contact is out of the home, such as at daycare venues, community centres, and places of worship. Those who do not have close family or friends, and rely on the support of voluntary services or social care, could be placed at additional risk, along with those who are already lonely, isolated, or secluded. Online technologies could be harnessed to provide social support networks and a sense of belonging, 4 although there might be disparities in access to or literacy in digital resources. Interventions could simply involve more frequent telephone contact with significant others, close family and friends, voluntary organisations, or health-care professionals, or community outreach projects providing peer support throughout the enforced isolation. Beyond this, cognitive behavioural therapies could be delivered online to decrease loneliness and improve mental wellbeing. 5 Isolating the elderly might reduce transmission, which is most important to delay the peak in cases, and minimise the spread to high-risk groups. However, adherence to isolation strategies is likely to decrease over time. Such mitigation measures must be effectively timed to prevent transmission, but avoid increasing the morbidity of COVID-19 associated with affective disorders. This effect will be felt greatest in more disadvantaged and marginalised populations, which should be urgently targeted for the implementation of preventive strategies.

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COVID-19 and Older Adult

John E. Morley, B Vellas (2020)

“There is a significant probability of a large scale and lethal modern day pandemic occurring in our lifetimes.” ~Bill Gates Since the great plague and cholera epidemics that occurred before the twentieth century, there have been a number of other pandemics starting with the Spanish Flu in 1918. In December, 2019, a new coronavirus, now recognized as COVID-19, began to cause respiratory illness in Wuhan, China. The epidemic began in a fish market and is most similar to snake, pangolin, horseshoe crab, and bat corona viruses. In humans it is spread by respiratory droplets. It can remain alive on plastic surfaces for over 72 hours. It is spread by respiratory droplets. At the Shattuck lecture in Boston in 2018. Bill Gates called for a “clear road map for a comprehensive pandemic preparedness and response system (1).”Since the great plague and cholera epidemics that occurred before the twentieth century, there have been a number of other pandemics starting with the Spanish Flu in 1918. In December, 2019, a new coronavirus, now recognized as COVID-19, began to cause respiratory illness in Wuhan, China. The epidemic began in a fish market and is most similar to snake, pangolin, horseshoe crab, and bat corona viruses. In humans it is spread by respiratory droplets. It can remain alive on plastic surfaces for over 72 hours. It is spread by respiratory droplets. At the Shattuck lecture in Boston in 2018. Bill Gates called for a “clear road map for a comprehensive pandemic preparedness and response system (1).” COVID-19 presents with nasal secretions, cough, dyspnea, fever, myalgia and occasionally diarrhea. Around 15% may go on to develop acute respiratory distress syndrome for 5 days, but may last up to 14 days. Viral shedding may last up to 37 days. Over 95% of hospitalized patients have abnormal chest computed tomography (2). On CT, ground glass opacities with a reticular pattern, a subplural line, fibrotic streaks and an air bronchogram were the most common signs (3). These findings allowed COVID-19 pneumonia to be separated from classical viral pneumonia. From the laboratory point of view lymphocytopenia, elevated C-reactive protein, elevated interleukin-6, elevated lactic dehydrogenase, hypoalbuminemia, a decreased CD8 count increased ferritin and decreased procalcitonin (4). In addition, very high angiotensin II levels were present. Highly elevated d-dimer levels are associated with mortality for people on ventilators. Besides acute respiratory distress syndrome severely ill patients develop myocardial damage and this is associated with increased mortality. Kidney and liver disease also occur. COVID-19 enters the central nervous system and increases inflammatory cytokines which can be expected to lead to delirium. Older people also have an increase in delirium and do not always have an increase in fever. The prevalence of COVID-19 in the community is uncertain as it appears a number of persons may not show symptoms. It would appear that the mortality may be as low as 0.6% (5). It is clear that older persons are at a much higher risk of mortality (about 15%) than younger persons (5). Persons with comorbidity are at an increased risk. It is suggested that the FRAIL screen is used to detect persons at increased risk (6, 7, 8). Persons with hypertension and diabetes mellitus are at increased risk possibly due to alterations in the angiotensin converting enzyme 2 (ACE 2) receptor produced by ACE 1 inhibitors. Primary prevention especially for older persons with comorbidity is social distancing and where possible social isolation. For older persons the problem with social isolation is loneliness (9). Loneliness leads to depression, cognitive dysfunction, disability, cardiovascular disease and increased mortality. Obviously, prevention also requires regular hand washing and cleaning of surfaces. Wearing a mask does not provide protection for the individual. Finally, the first vaccine has just started testing. If it or other vaccines under development mount an adequate antibody response there will be a need to try to rapidly bring it to the general public. It is important to recognize that some persons, like “Typhoid Mary” who spread typhoid fever in the 1910s, may be asymptomatic. Thus, distance must be kept from everybody. At present, while there are no established drugs to treat COVID-19, some are showing promise. Chloroquine phosphate, an anti-malarial, has been shown to be useful in treating COVID-19 pneumonia (10). Remdesivir, an antiviral drug developed to treat Ebola, has been suggested to have positive effects in COVID-19 infected patients with severe respiratory disease (11). These patients developed gastrointestinal symptoms and elevated liver function tests. Some patients with severe COVID-19 disease develop cytokine storm and this may be prevented with toclizumab. Passive infusion of polyclonal plasma antibodies from persons who have had COVID-19 infection has been suggested and monoclonal antibodies to COVID-19 are under development (12). Finally, COVID-19 binds to the soluble portion of the ACE-2 receptor and this seems essential for the virus to enter cells. The possibility of a monoclonal antibody to the soluble portion of the ACE-2 receptor is under consideration. It is uncertain whether stopping the use of ACE 1 inhibitors which increase ACE-2 receptors should be undertaken. However, this may explain the increased virulence of COVID-19 in persons with hypertension and diabetes mellitus. COVID-19 infected patients may do worse if taking ibuprofen, so it is recommended that patients take acetaminophen or paracetamol for fever and pain. In conclusion, COVID-19 represents a major threat to older adults. This is particularly true in older persons with frailty and co-morbidity. Other factors that appear to play a role in the increased severity in older persons are the decline in immune function and alterations in the ACE 2 receptor. There is need for rapid development of a COVID-19 vaccine and its deployment among the population. In the meantime, social distancing, careful hand washing and using antiseptic wipes to clean surfaces and door handles before touching them represent the appropriate preventive measures. During the pandemic it is especially important to isolate older persons in nursing homes and to provide support when nursing home staff need to be quarantined. With good population health approaches, it is expected that the COVID-19 pandemic will be controlled in a relatively short time period.

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Loneliness in Old Age: An Unaddressed Health Problem

M. Berg-Weger, John E. Morley (2020)

“No one should be alone in old age he thought, But it is unavoidable.” —The Old Man and the Sea, Ernest Hemingway Older persons are more likely to live alone and tend to be less socially engaged. There has also been a decline in religious involvement. This has been perceived to result in a “loneliness epidemic.” Declared as a global epidemic by former U.S. Surgeon General Vivek Murthy (1), loneliness and social isolation are reported to occur in approximately one-third or more of older adults with 5% of those often or always feeling lonely (2, 3). Recent U.S.-based research suggests the range is 17% - 57% of persons experience loneliness, a figure that increases for those who have mental and physical health concerns, particularly those with heart disease, depression, anxiety, and dementia (4). Loneliness and social isolation have been shown to significantly impact older adults, both physically and emotionally. Areas of the older adult’s life that can be negatively affected when the individual is experiencing loneliness and/or social isolation are listed in Table 1. The long-term (greater than four years) effects of loneliness and social isolation can be even more devastating, including; Increased blood pressure, depression, weight gain, smoking alcohol/drug use, and alone time (5) and decreased physical activity, cognition, heart health, and sleep, stroke and coronary heart disease, in particular (6). Table 1 Negative Effects Associated with Loneliness • Quality-of-life (7) • Cognition (28, 29) • Subjective health (30) • Stress and depression (31) • Decreased quality of sleep (32) • Disability (33, 34) • Cardiovascular disease (6) • Increased use of health care services (29, 35–37) • Increased mortality (29, 38, 39) • Institutionalization (29) Predictors and risk factors of loneliness and social isolation are numerous, but some may be modifiable. These factors are listed in Table 2 (7–13). Table 2 Risk Factors for Loneliness • Living in rural area—being left behind when other migrate • Poor functional status, particularly in IADLs and cognitive impairment • Widowhood • Being female—may be due to increased expressiveness and value on relationships • Lower income and education—those at higher levels may have more resources/networks • Urinary incontinence • Subjective causes—illness, deaths, lack of friends, losses, etc. • *Depression • *Living alone • *Poorly understood by others • *Wisdom *Stronger predictors than health, functional status or widowhood Management of loneliness requires both medical and social interventions. Persons with decreased hearing including those who hear poorly in noisy groups need to be evaluated for hearing amplifiers or hearing aids. Persons with visual disturbances need to be provided with appropriate vision aids. Persons with dual sensory impairment are at particular risk for loneliness (14). Depression can play a major role in loneliness and needs to be treated either with group behavioral therapy especially when minor depression (dysphoria) and medications or electroconvulsive therapy when major depression (15). Cognitive impairment needs to be assessed and where possible reversible causes need to be treated (16). Persons with moderate dementia should be offered Cognitive Stimulation Therapy (17, 18), an evidence-based, non-pharmacologic individual or group intervention. Developing compassionate social communities are a key approach to dealing with loneliness. Persons who are isolated need to be recognized and attempts made to provide them with social interaction. In this case, transportation represents a major component as well as mobilizing youth and other community volunteers to become friendly visitors (via phone or in-person visits). A variety of group therapies such as laughter therapy, reminiscence therapy, horticulture therapy, exercise and dancing can all reduction loneliness (19). Emotional loneliness requires a different approach. Emotional loneliness is typified by Albert Einstein, who said, “It is strange to be known so universally and yet to be so lonely.” It is clear that for a number of reasons, there are persons in the community who have difficulty making friends. They need coaching in behaviors that will help them make friends and to alter their expectations of friends. These people can suffer loneliness in the presence of multiple social contacts (20). It is important to recognize the role of maladaptive social cognition in loneliness as it needs a different therapeutic approach. Developed by scholars and practitioners at the Central Union for the Welfare of the Aged at Helsinki University in the early 2000s, Circle of Friends© is built on a model of group rehabilitation with the aim being alleviation and prevention of loneliness in older adults (21). The group of approximately eight older adults who have self-identified as being lonely or socially isolated meet 12 times over three months with a facilitator for the purpose of making new friends, feeling less lonely, sharing feelings of loneliness with others: experiencing meaningful things together; and transitioning into a self-supportive group who continues to meet after the initial three months (22). Each session includes three components: 1) Art and inspiring activities with discussion; 2) group exercise and health-themed discussion; and 3) therapeutic writing with sharing and reflecting on issues related to loneliness (23). Evidence for the effectiveness of Circle of Friends© has been reported by the founders of the intervention to suggest that the intervention is well suited for delivery with older adult populations living in the community, adult day centers, and residential facilities. Outcomes for participants encompass physical and emotional health and health care utilization. Specifically, in a two-year post-intervention study, 97% of participants were still living, reported improved subjective health with decreased health care costs and hospitalizations, only 2.5% had dropped out, and 6 of 15 groups were still meeting (24). Similarly, a later study reports 95% of participants no longer feel lonely, 45–85% made new friends, 40% of the groups continued meetings, and feeling of being needed and psychological well-being improved (25, 26). Through the Geriatric Workforce Enhancement Program (GWEP), Circle of friends© is being introduced in the St. Louis, Missouri area. As the first Circle of Friends© groups to launch outside of Finland, two organizations have integrated the intervention into programming for older adults. Both funded through the St. Louis Senior Fund, Circle of Friends© is being offered at the Association for Aging and Developmental Disabilities and through a collaborative partnership between CHIPS (Community Health in Partnership) and the St. Louis Public Housing authority. Both Groups received training during Summer 2019 and launched multiple groups in the fall at locations in senior centers and housing complexes. Groups continue to meet at both agencies with plans to continue this successful intervention to bring older adults together to build new relationships. In addition, a rural hospital in Perry County and the Family Practice program at Saint Louis University are both providing Circle of Friends groups. Our preliminary observations have suggested that the Circle of Friends is an excellent approach to reduce loneliness. Physicians and other health and social service providers tend to be poorly trained and equipped to deal with loneliness (27). Patients are seldom asked about loneliness and providers do not have an approach to treating the “problem.” There is a need to train medical students and residents and other professionals in recognizing loneliness, e.g., ALONE screen (Table 3) and to manage the problem working together with social workers and the community as so aptly stated by Mother Theresa, “Loneliness and the feeling of being unwanted is the most terrible poverty.” Health professionals need to become more aware of the importance of loneliness in older persons. Table 3 ALONE Scale To assess an individual’s perception of being lonely, ask each of the items below using the following rating scale: Yes, Sometimes, No A Are you Attractive (as a friend) to others? Yes___ Sometimes___ No___ L Are you Lonely? Yes___ Sometimes___ No___ O Are you Outgoing/friendly? Yes___ Sometimes___ No___ N Do you feel you have No friends? Yes___ Sometimes___ No___ E Are you Emotionally upset (sad)? Yes___ Sometimes___ No___