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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