What are the ways that long-term care homes can improve the psycho-social well-being of residents in the context of pandemic restrictions?

Summary

The following is a short summary of the available evidence on the ways that long-term care homes can support the psycho-social well-being of residents in the context of the COVID-19 pandemic restrictions. Three reviews, two single studies, one national guidance, one municipal guidance, one professional guidance, one commentary, one editorial, and one book were identified to answer this question and were used in this REAL Summary.  For additional information about each of the sources, see the Table below.

A commentary on  ‘Age and ageism in COVID-19’: Elderly mental health-care vulnerabilities and needs (June 2020) notes that various mental-health issues are expected to surge in the months following the pandemic, with a significant proportion of them being in the elderly population [10]. The authors also note that loneliness is a risk factor for depression and cognitive disorders (especially when chronic), and is associated with a lack of physical activity and decreased immunity [10]. A single study on The technological advancements to address elderly loneliness during COVID-19 (September 2020) raises the concern for poorer people who experience greater impact of the pandemic (i.e., greater risk of COVID-19 exposure due to employment, reduced access to healthcare, and worse healthcare outcomes) and increased degree of loneliness (i.e., due to technological accessibility issues while self-isolating) [9]. 
 
To increase psycho-social wellbeing among the elderly population while maintaining physical distancing, a combination of strategies is recommended. According to guidance from Ottawa Public Health, Protecting Your Mental Health: What you can do as an older adult?, and several resources, older adults should try to: 1) do crossword puzzles, sudoku or puzzles; 2) read books or newspapers; 3) write or journal thoughts, stories, lists or poems; 4) draw, paint or colour; 5) watch documentaries, television, movies or listen to music; 6) meditate, practice gratitude or pray; 7) call or videoconference family or friends; 8) knit, sew or try needlepoint; 9) stretch or do exercises designed for older adults; 10) declutter your room or home; 11) try to maintain as normal of a schedule as possible; and 12) stay connected to clinical services and support through telehealth wherever possible [4-7,9,10]. Having residents sort items such as buttons or cards and thanking them for completing these tasks may help residents feel they are needed [11]. A review on the titled, Consideration of the Psychological and Mental Health of the Elderly during COVID-19, (November 2020) suggests that the elderly should pay attention to their psychosocial health, social health, and physical health during the pandemic [2]. The authors recommend the following to promote psychological and mental well-being of seniors: 1) refraining from reading, watching or listening to news about the pandemic; 2) doing yoga or meditation; 3) maintaining contact with family and friends; 4) maintaining regular activities; 5) maintaining daily schedule and exercise pattern; and 6) maintaining a healthy and balanced diet [2]. 
 
A review entitled 15 Smartphone Apps for Older Adults to Use While in Isolation During the COVID-19 Pandemic (April 2020) describes how mobile technology such as applications (apps) can help older adults stay connected to loved ones, maintain mobility, help to supplement and substitute in-person care, and link older adults to resources that encourage physical and mental well-being [1]. The importance of social connection for long-term care (LTC) residents was identified in the Social Connection in Long-Term Care Homes scoping review (November 2020) which notes that good social connection (i.e., quantified by social networks, social engagement and disengagement, perceived isolation, etc.) possibly associated with better mental health outcomes of LTC residents [3]. However, the study titled Technological advancements to address elderly loneliness: practical considerations and community resilience implications for COVID-19 pandemic (September 2020) suggests that technology-based interventions are ineffective if the elderly do not know how to use them, do not want to use them or are not able to obtain them [9]. Hence, implementation of technologies to mitigate lack of social connections should consider factors that affect loneliness such as economic status, living arrangements, familial ties, and accompanying health conditions [9]. In addition to communication using technology, the Government of Canada also recommends communication through the window of a resident’s room, for example, having family members show signs or sing, and by encouraging families to send cards or letters [4,8]. If family members are unavailable, other ways of connecting with LTC residents is by recruiting volunteers to call residents and through offering Simulated Presence Therapy [11].  
 
Furthermore, the book Psychological First Aid Field Operation Guide for Nursing Homes (February 2019) suggests that all LTC staff should be trained to use Psychological First Aid techniques to increase the likelihood that appropriate mental health interventions will be provided to any residents or staff in need [7]. A news article emphasized the need to monitor the psychological state of nursing home residents [12]. It recommends assessing subtle signs of change in mental health status of residents, offering emotional support to all residents not just those with a prior mental health history, and to pay special attention to residents who have a history of mental health illness or trauma [12]. The study, Clinical and ethical recommendations for decision-making in nursing homes in the context of the COVID-19 crisis, (October, 2020) recommends five criteria for consideration by decision-makers in LTC facilities policies, that incorporate family needs and priorities, involvement and support from the team, and values and preferences of individuals in the nursing home [8].  
 

Evidence

What‘s Trending on Social Media and Media

The Registered Nurses’ Association of Ontario has released three platforms that provide support for long-term care and retirement homes. To help families cope with the impact of the current visiting restrictions within long-term care (LTC) homes, a “Connecting Families” Facebook group was created. This platform provides individuals with a forum to connect and receive support from others in similar situations. To help nurses and other healthcare professionals share experiences and strategies to cope with challenges in LTC homes, a Facebook group called “Sharing and Tackling Emerging Care Issues Together” was created in addition to a “Peer-to-Peer Support” group.  

Organizational Scan

The Ontario Centres for Learning, Research & Innovation in Long-Term Care (LTC) has created a province-based collated list of resources for LTC leaders and team members during COVID-19. These resources focus on the health and well-being of residents and include: A Virtual Visits Toolkit, which aims to help residents stay connected with family and friends during social isolation, and Boredom Busters for LTC, which is a list of resources for recreation professionals to help minimize boredom and loneliness for residents living LTC homes [13].  
  
The Canadian Coalition for Seniors Mental Health provides a list of mental health support lines for seniors in Canada that offer advice, information and counselling services to those in need [14].  
 
The National Initiative for the Care of the Elderly (NICE) offers free the Talk 2 NICE service where social workers provide, by phone, free outreach and brief counselling services for older adults and persons with disabilities [15]. 
 

Review of Evidence

Resource	Type/Source of Evidence	Last Updated
15 Smartphone Apps for Older Adults to Use While in Isolation During the COVID-19 Pandemic — Banskota et al.	Review	Methods: apps were found from the App Store, ranked by category and screened for an adequate rating and were found to benefit older adults during the pandemic. A literature review using PubMed and Google Scholar was done to gather more apps.  Mobile technology such as applications (apps) can help older adults stay connected, maintain mobility and link them to resources that encourage physical and mental well-being.   The recommended apps can supplement and substitute in-person care, decrease loneliness and maintain health and independence.   Provides a list of 15 apps for older adults for social networking, telemedicine, prescription management, health and fitness, food and drink and visual and hearing-impairment. Last Updated: April 13, 2020
Consideration of the Psychological and Mental Health of the Elderly during COVID-19: A Theoretical Review — Kunho Lee et al.	Review	For psychosocial health: 1) Refrain from reading, watching or listening to news about the pandemic 2) Do yoga or meditation  For social health: 1) Maintain contact with family and friends 2) Maintain regular activities  For physical health: 1) Maintain daily schedule and exercise pattern 2) Maintain a healthy and balanced diet  Last Updated: November 2, 2020
Social Connection in Long-Term Care Homes: A Scoping Review of Published Research on the Mental Health Impacts and Potential Strategies During COVID-19 — Jennifer Bethell et al.	Scoping Review	Methods: searched MEDLINE, CINAHL, PsycINFO, Scopus, Sociological Abstracts, Embase, Emcare Nursing and AgeLine for papers quantifying social connection among LTC residents.   Review of 133 studies revealed good social connection among long-term care residents was associated with better mental health outcomes.  Using technology to encourage social connection is identified as one of the strategies to mitigate mental health impacts of COVID-19.  Twelve strategies and interventions were identified to adapt to the COVID-19 pandemic including: 1) manage pain; 2) address vision and hearing loss; 3) sleep at night instead of during the day; 4) find opportunities for creative expression; 5) exercise; 6) maintain religious/cultural practices; 7) garden indoors/outdoors; 8) visit pets; 9) use technology to communicate; 10) laugh together; 11) reminisce about events/people/places; and 12) address communication impairments/communicate nonverbally.   Last Updated: November 25, 2020
Interim guidance: Care of residents in long term care homes during the COVID-19 pandemic — Government of Canada	National Guidance	Social interaction and recreational activities should continue where feasible and abiding by public health guidance, dependent on local COVID-19 epidemiology.   If there is an outbreak or residents are infected with COVID-19, activities may be conducted one-on-one or virtually.   If possible, long-term care homes should provide smartphones or tablets to residents (if shared, disinfected between uses) and free internet.  Alternative methods of family contact, e.g., phone or video, communication through the window such as by showing signs or singing and encouraging families to send cards or letters if no one in the household is ill.   Online viewing of religious services is recommended.   Last Updated: July 16, 2020
Things to do While Physical-Distancing — Canadian Coalition for Seniors' Mental Health	Professional Organization	Activities older adults can do to remain social and active while physical-distancing: 1) crossword puzzles, sudoku or puzzles; 2) reading books or newspapers; 3) writing or journaling thoughts, stories, lists or poems; 4) drawing, painting or colouring; 5) watching documentaries, television, movies or listening to music; 6) meditating or practicing gratitude; 7) calling or videoconferencing family or friends; 8) knitting, sewing or trying needlepoint; 9) stretching or doing exercises designed for older adults; 10) decluttering your room or home.   Last Updated: June 15, 2020
Protecting Your Mental Health: What you can do as an older adult? — Ottawa Public Health	Municipal Guidance	Older adults can try using technology to reach out to friends and family.  This resource provides links for adults to learn about their technology, phone numbers to call for emotional and clinical support and technology that is available to connect to the outside world (i.e., access to museums, art galleries, exercise classes, magazine, etc.).  Last Updated: June 15, 2020
Psychological First Aid Field Operation Guide for Nursing Homes, Second Edition — Brown et al.	Book	This book describes how the use of Psychological First Aid techniques in nursing homes is an ideal intervention for staff to learn and use with distressed residents and staff. All nursing home staff should be training to use psychological first aid to increase the likelihood that appropriate mental health interventions are provided for those in need.    This book recommends the following adaptive coping actions to recommend to nursing home residents: 1) getting adequate rest, nutrition and exercise; 2) engaging in positive distracting activities such as hobbies and reading; 3) engaging in meditation or prayer; 4) trying to maintain as normal of a schedule as possible; 5) getting needed information; and 6) keeping a journal or using calming self-talk.   Last Updated: January 31, 2019
Clinical and ethical recommendations for decision-making in nursing homes in the context of the COVID-19 crisis — Jordi Amblàs-Novellas et al.	Single Study	Five criteria to consider for decision-making in nursing homes include person, family, team, territory resources and referral criteria.  Family needs and priorities, involvement and support from the team, and values and preferences of individuals in nursing homes should be considered for decision-making.  Last Updated: October 22, 2020
Technological advancements to address elderly loneliness: practical considerations and community resilience implications for COVID-19 pandemic — Conroy et al.	Single Study	Emerging technologies can help mitigate loneliness in elderly people.   Interventions aimed at mitigating loneliness should consider factors that affect loneliness, such as economic status, living arrangements, familial ties, and accompanying health conditions.  Technology-based interventions are ineffective if the elderly person does not know how to use them, does not want to use them or is unable to obtain them.  Access to smartphones should be considered for disadvantaged people who suffer more from COVID-19 and experience higher degree of loneliness.  Access barrier may be addressed through government or health insurance programs to provide inexpensive technologies to connect virtually with others.  Last Updated: September 7, 2020
‘Age and ageism in COVID-19’: Elderly mental health-care vulnerabilities and needs — Banerjee, Debanjan	Commentary	All forms of stress are associated with decreased immunity.  Loneliness is a potential risk factor for depression and cognitive disorders, especially when chronic and associated with lack of physical activity.  Measures to ensure psychological well-being: 1) maintaining and increasing social connectedness with loved ones; 2) promoting tele-facilities for health care consultation; 3) reducing digital screen time to prevent misinformation and panic; 4) promoting physical activity and ensuring nutrition; and 5) preserving autonomy, respect and dignity among geriatric populations through their active involvement in decision making.   Various mental-health issues are expected to surge in the post-pandemic months with a significant proportion of them might be the elderly.   Last Updated: May 31, 2020
Loneliness and Isolation in Long-term Care and the COVID-19 Pandemic — Simard & Volicier	Editorial	Recommendations that require little or no cost or hiring of additional staff: 1) using name tags that can be easily read to help build connections; 2) having family members or residents to purchase personal computers or iPads for communication; 3) asking families to call in mornings and evenings or recruiting volunteers to call residents; 4) having families come to the window of a resident’s room, urging families to send cards and letters; 5) providing realistic toys such as dogs, cats or dolls to comfort residents with dementia; 6) using Simulated Presence Therapy; and 7) providing activities such as sorting items and thanking residents so that they feel they are needed.  Last Updated: May 7, 2020
Tips to ensure your residents’ mental health needs are met during the COVID-19 pandemic — Lind, Lisa	News Article	Some tips in monitoring the needs of nursing facility residents include assessing the subtle signs of change in the mental health status of residents, offering emotional support to all residents, not just those with a prior mental health history and to pay attention to your residents who have a history or trauma.   Last Updated: May 3, 2020
Supports for LTC Team Members during COVID-19 — Ontario Centres for Learning, Research & Innovation in Long-Term Care	Organizational Scan	Last Updated: June 10, 2020
Mental Health Support Lines for Seniors in Canada — Canadian Coalition for Seniors' Mental Health	Organizational Scan	Last Updated: March 31, 2020
Talk 2 NICE — National Initiative for the Care of the Elderly	Organizational Scan	Last Updated: June 10, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.