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

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      , PhD 1 , , PhD 2 , , MB, BCh 3
      Journal of the American Geriatrics Society
      John Wiley & Sons, Inc.

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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

          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

            “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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              Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial.

              Loneliness is a distressing feeling of a lack of satisfying human relationships. It is associated with poor quality of life, impaired health, and increased mortality among older individuals. The study aim was to determine the effects of new psychosocial group rehabilitation on the subjective health, use and costs of health services, and mortality of lonely older individuals. This randomized, controlled trial was performed in seven day care centers. A total of 235 older people (>74 years) suffering from loneliness participated. Intervention was implemented in 15 groups (each with 7-8 participants and 2 professional group leaders) meeting for 3 months altogether 12 times. Group intervention aimed to empower elderly people, and to promote their peer support and social integration. Intervention was based on the effects of closed-group dynamics. The groups had the following activities according to the participants' interests: (a) therapeutic writing and group psychotherapy, (b) group exercise and discussions, and (c) art activities. Group leaders received thorough training and tutoring. Subjective health, use and costs of health services, and mortality were measured. At 2 years, survival was 97% in the intervention group (95% confidence interval [CI], 91-99) and 90% in the control group (95% CI, 85-95) (p = .047). The intervention group showed a significant improvement in subjective health, thus resulting in significantly lower health care costs during the follow-up: the difference between the groups was -943 euro/person per y (95% CI -1955 to -127; p = .039). Psychosocial group rehabilitation was associated with lower mortality and less use of health services.
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                Author and article information

                Contributors
                max.zubatsky@health.slu.edu
                Journal
                J Am Geriatr Soc
                J Am Geriatr Soc
                10.1111/(ISSN)1532-5415
                JGS
                Journal of the American Geriatrics Society
                John Wiley & Sons, Inc. (Hoboken, USA )
                0002-8614
                1532-5415
                22 May 2020
                : 10.1111/jgs.16553
                Affiliations
                [ 1 ] Department of Family and Community Medicine Saint Louis University St. Louis MO USA
                [ 2 ] College for Public Health and Social Justice Saint Louis University St. Louis MO USA
                [ 3 ] Division of Geriatric Medicine Saint Louis University St. Louis MO USA
                Article
                JGS16553
                10.1111/jgs.16553
                7273081
                32392617
                af4e8226-57ae-4ea4-9546-7983af4abfd9
                © 2020 The American Geriatrics Society

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                : 30 April 2020
                : 03 May 2020
                Page count
                Figures: 0, Tables: 1, Pages: 2, Words: 1212
                Categories
                Letter to the Editor
                Letters to the Editor
                Custom metadata
                2.0
                corrected-proof
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.3 mode:remove_FC converted:05.06.2020

                Geriatric medicine
                Geriatric medicine

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