32 Think Piece: “Chronic Loneliness or COVID-19: Which is Worse for Elders?”

Caitlin Dunn

Dr. Hoermann-Elliott

ENG 1023.90

14 February 2021

Cover Letter

      To begin, I appreciated taking the spaced-out approach to writing my think piece that was encouraged by our weekly discussion posts. It was very helpful to focus on the beginning and middle sections of my piece for the first week, which also allowed me to receive feedback early on. Using the feedback I received from the first discussion post, I crafted my ending section and decided on the other elements of my piece during the second week of this assignment. Also, I found it helpful to return to my think piece after a day or two if I was having problems with wording or transitions. Returning to my work after some time had passed allowed me to view my piece with fresh eyes.

From reading multiple think pieces and writing my own, I have learned what the defining characteristics of a think piece are: 1) it is focused on a specific and timely topic that is of personal interest to the author, 2) it incorporates the findings of credible outside sources, and 3) it offers suggestions or advice from the author, typically at the end of the think piece. Also, all of the think pieces I have read incorporated personal narratives, so I knew that was how I should start and end my own piece.

Regarding my piece, I incorporated all of the defining characteristics of other think pieces into my own. For example, I began with a personal narrative of my experience as a nursing assistant. Specifically, I described an encounter I had with a confused resident who was trying to leave the facility to see her children. Obviously, she was unaware that her children were not allowed to see her due to the facility banning in-person visitation. Later, I went on to list all of the ways I have seen both loneliness and COVID-19 hurt my residents. In short, I made it clear that this is a specific topic that I am intimately familiar with. Also, there is no doubt that this topic is timely because at present nursing home residents are still unable to see their families due to the ongoing pandemic.

Next, every paragraph of the middle section of my piece incorporates at least one outside source. The findings of these sources are credible and relevant, for the authors are from the Journal of the American Medical Directors Association, the Journal of the American Geriatrics Society, Public Health Nursing, the Journal of Advanced Nursing, and The New York Times. Additionally, most of my suggestions at the end of my think piece are derived from outside sources.

Finally, I devoted the ending section of my think piece to suggestions and advice. As mentioned previously, most of my suggestions were based on the findings of outside sources. For example, my five bullet points of suggestions were summarizing the findings of Simard and Volicer from the Journal of the American Medical Directors Association. Also, I incorporated my personal experience as a nursing assistant to suggest the use of touch and hobbies to alleviate the loneliness of nursing home residents.

I am most proud of finding a topic that is of enormous relevance in my work as a healthcare provider. Specifically, I am happy that I have had countless experiences with residents that highlight the importance of this issue. It has given me insight into the topic that those without experience do not have. For example, I see how much elders are suffering from loneliness, but I realize there are no simple solutions. No matter what we do, we need to prioritize stopping the spread of this virus.

However, it was also difficult speaking on such a specific topic. There are no academic articles that dismiss the severity of COVID-19 – and if there were, I would not trust them – so I had to narrow my topic even more. Rather than just speak on the danger that COVID-19 poses on elders, I had to find an opposing argument to address. After closely reading some articles, I decided that the opposing argument would be loosening up on the policies that prevent in-person visitation in nursing homes. The article “Nursing Home Residents are Dying of Loneliness” demanded that nursing homes allow in-person visitation as the COVID-19 vaccine rolls out, and this became the opposing argument in my piece. What was most challenging was realizing that both sides of the argument have a lot of truth to them. Yes, it is true that loneliness is killing elders, and it is also true that COVID-19 is killing elders. In the end, I decided that I needed to blend these two arguments and suggest creative ways to reduce the loneliness of elders without putting them at risk for contracting COVID-19, which was not easy.

Chronic Loneliness or COVID-19: Which is Worse for Elders?

     As I turned the corner to check on my residents in the other hall, I saw her: my sweet yet confused resident headed toward the exit, purse in hand. I thought, “Here we go again,” as I hurriedly made my way to stop her from leaving. “Where are you going?” I asked her, disheartened because I knew I was going to have to deliver difficult news – once again. “One of my children is waiting outside to see me,” she confidently replied, even though in-person visitation had been banned by our nursing home for the past nine months.

I answered hesitantly, “Sweetheart, I am afraid your children are not able to come see you today, but let’s bring you back to your room to do something fun.” Defeated, she slowly hobbled back to her room. Once we got to the door, she began to weep. Knowing there was nothing I could say to alleviate her grief, I took her into my arms. I could see chronic loneliness eating away at her, and it left me brokenhearted.

At that time, COVID-19 had not yet entered the long-term care facility where I have worked as a nursing assistant for the past five months. Even though my residents were suffering from severe loneliness, my coworkers and I were at least thankful that we did not have any COVID-19 cases in the building. Sadly, all of that would change in the following months.

Employees slowly began to catch the virus outside of work, and eventually they brought it into the facility without knowing they had it. By the time they received the phone call from the facility about their positive test, the damage had already been done. It began to spread like wildfire around my nursing home. Several residents that I personally cared for would end up dying weeks later due to the virus. All of those residents had been in the facility for years, with only one of them being under hospice or end-of-life care. In fact, none of the residents I knew who caught COVID-19 are still in the facility. It is a tragedy that months or years of those residents’ lives were stolen from them because a deadly virus was brought into their home.

Now we are faced with a moral dilemma: do we focus on alleviating the severe loneliness of elders by lifting bans on in-person visitation, or do we keep those bans in place to potentially stop the spread of this deadly virus? In my experience as a nursing assistant, I have seen the damage caused by both loneliness and COVID-19. I have seen residents cry out in frustration due to loneliness. I have seen residents with no desire to go through the day because they do not have their loved ones near. I have seen the emptiness that loneliness has caused in my residents’ faces. I have seen residents give up altogether. For some of them, life is not worth living alone.

I have also seen one of my residents be rushed out of her room to the COVID-19 unit. That was the last time I saw her. I have seen our facility’s Chaplain exchanging final words with a woman with COVID-19, who died shortly after. I have seen the faces of grieving residents who used to endure quarantine with a roommate, but then their roommate died of COVID-19. Now where their roommate once laid is an empty bed with a “Welcome to Good Samaritan Denton Village” card on it to greet the next admittee.

All things considered, COVID-19 is the primary cause of the heartache felt by elders during this time. Yes, loneliness is a specific cause of this heartache, but the entire reason why elders cannot see their loved ones right now is because of this virus. The longer the virus is around, the longer elders will be isolated. Although chronic loneliness poses a severe threat to elders’ health, we need to remain strict on in-person visitation policies to put a stop to the spread of the coronavirus. That way, hopefully, fewer elders end up dying like my dear residents.

To start off, we need to remind ourselves of the danger COVID-19 poses in long-term care facilities. The Editorial Board for The New York Times, a group of journalists whose opinions are backed by research, reported that “more than 35 percent of Coronavirus deaths in the United States have been linked to nursing homes and other long-term care facilities” as of December 29, 2020. Similarly, Rossana Lau-Ng, Lisa Caruso, and Thomas Perls published research in the Journal of the American Geriatrics Society stating that “as of May 28, 2020, 26 states had 50% or more of their coronavirus disease 2019 deaths occur in long-term care facilities.” Clearly, elders in nursing homes have been the main target of the coronavirus since the very beginning of this pandemic.

Further, it is not just residents in the United States that have been affected by COVID-19 in such a dreadful way. In addition to researching COVID-19 deaths in the United States, Lau-Ng and her colleagues found that other countries with large numbers of long-term care facilities are also experiencing a greater than 50% rate of their COVID-19 deaths within those facilities. In fact, “the World Health Organization estimates that half of COVID-19 deaths in Europe and the Baltics are among their 4.1 million long-term care facility residents” (Lau-Ng et al. 1895).

Considering these statistics, it makes sense why nursing home residents have not had much, if any, contact with the outside world. They are evidently more susceptible to the virus, and therefore they need to be protected. Those with the Journal of the American Geriatrics Society agree, saying that “as states begin to open up their communities and economies, long-term care facilities will need to be treated differently as COVID-19 appears to have a much stronger hold on these facilities than elsewhere” (Lau-Ng et al. 1895). This is so important because “long-term care facilities have a high density of people with a combination of the strongest risk factors for COVID-19-associated severe illness and death: old age and multiple morbidities” (Lau-Ng et al. 1895).

Since elders in nursing homes are especially vulnerable to COVID-19, it was vital to ban in-person visitation for the time being. Healthcare professionals agree, saying that “given the high mortality of COVID-19 within nursing homes, suspension of nonessential services and visitation was the right decision” (Cocuzzo et al. 2750). In support of this sentiment, Lau-Ng and her colleagues described the significant causes of transmission of the Coronavirus to and within nursing homes:

The “Achilles heel” of these and other defenses is the high prevalence of asymptomatic transmission of SARS‐CoV‐2. Asymptomatic carriers include social visitors, as well as laboratory phlebotomists, intravenous line nurses, and radiology technicians, who travel from nursing home to nursing home and have direct contact with residents. Fomites, such as a technician’s clothing or X‐ray equipment, can be potential vectors for SARS‐CoV‐2 (Lau-Ng et al. 1897).

However, some disagree that nursing homes should continue to discourage in-person visitation. In the words of the Editorial Board for The New York Times, “strict prohibitions on visits are taking an unnecessary toll on patients, particularly those with dementia who rely on routines and familiar faces to ground them.” While it is true that the ban on in-person visitation has contributed significantly to residents’ loneliness, the ban was definitely necessary. Why would nursing homes maintain this ban on visitors if the Coronavirus was no longer a threat? As the previous statistics have shown, COVID-19 is still rampant among nursing homes, and these facilities should not become lax on their policies.

Even though I disagree with the notion that nursing homes should lighten up on their policies regarding visitors, it is important to address how damaging chronic loneliness is for residents. In their argument in support of in-person visitation, the opinion journalists for The New York Times reported that “chronic loneliness increases the odds of an early death by about 20 percent.” Similarly, “social isolation because of the coronavirus in nursing homes has increased depression, weight loss and other forms of physical deterioration” (“Nursing Home Patients”).

Furthermore, healthcare professionals from the Journal of the American Medical Directors Association described the devastating effects of loneliness:

[These effects] include increased risk of depression, alcoholism, suicidal thoughts, aggressive behaviors, anxiety, and impulsivity. Some studies found that loneliness is also [a] risk factor for cognitive decline and progression of Alzheimer’s disease, recurrent stroke, obesity, elevated blood pressure, and mortality. Lonely older people may be burdened by more symptoms before death and may be exposed to more intense end-of-life care compared with non-lonely people. (Simard & Volicer 966)

Many people, like the journalists with The New York Times, feel that it is more important to solve elders’ loneliness than to focus on stopping the spread of the Coronavirus with whatever means necessary. They think that nursing homes are not doing enough to address residents’ chronic loneliness. In fact, writers with the Journal of Advanced Nursing argued that “some residents have been socially isolated for over 3 months due to COVID‐19 outbreaks, spending all day and every meal trapped alone in their rooms; held hostage by ill‐conceived policies” (Chu et al. 2456). To them, “such policies are out of touch with the needs of residents and are causing emotional distress” (Chu et al. 2456). Although healthcare providers could be doing more to improve the mental health of residents, one has to realize that nursing homes are trying to do all they can to prevent a deadly virus from infecting their residents and potentially killing them.

The point of my argument is not to invalidate the loneliness experienced by elders. As a primary caretaker, I know how lonely elders are right now, and I have seen the effects of loneliness with my own eyes. That being said, I realize that the longer the virus is rampant, the longer residents will be socially isolated. Therefore, I think our best course of action is to do whatever it takes to stop the spread of this virus, but at the same time we need to think of creative alternatives to in-person visitation that will alleviate the loneliness of residents.

There are many ways that we, as healthcare providers, can alleviate the loneliness of elders in nursing homes without having in-person visitors. Simard and Volicer with the Journal of the American Medical Directors Association offered the following suggestions that are easy to implement and can decrease the loneliness of residents:

• Ask both residents and staff if they would like to wear name tags that can be easily read, for a lot of the time residents cannot read the tiny print on employee badges. The name tag would have the name the resident or staff member would like to be addressed by. This would help staff and residents form connections with each other.
• Ask family members to purchase a personal computer or iPad for their loved one in the long-term care facility to help them stay connected. One of my residents has an iPad, and he loves to FaceTime his wife with it. He is so much more happy when he can see his wife’s face versus when he can only hear her voice. If all residents had access to that technology, they would feel much closer to their loved ones.
• Have family members call their loved one at least once a day. Perhaps one family member could be designated to call their loved one to say, “Good morning,” and another one could call in the evening to say, “Good night.” This may bring back some sense of normalcy to the resident, and they would feel like their loved ones are still involved in their day.
• Family members can do a “window visit” outside of their loved one’s room. I see this at work all of the time. Just this past weekend one of my residents got to see her daughter and infant granddaughter outside her room, and I have never seen her so happy. This is perhaps one of the best alternatives to in-person visitation, for only a window separates the resident from their loved ones.
• Encourage families and members in the community to send letters to nursing home residents. I can assure you that residents love getting letters. One of my residents refused to let go of a card her family had sent her, for she was so attached to it. Every single one of my residents have letters from their family on their bedside table, and they love to look at them. It is a physical reminder that their family is there for them, even though they can’t be there in person.

Another way we can help elders feel less lonely is to encourage them to revisit long-forgotten hobbies or discover new ones. According to Meredith Troutman-Jordan and Donna Kazemi with Public Health Nursing, this “is another way to exercise the brain and encourage mental well-being.” Specifically, they found that “new experiences promote brain plasticity and enhance brain reserve [as well as] the development of new dendrites” (Troutman-Jordan & Kazemi 638). Examples of hobbies elders could take up include writing, gardening, painting, and drawing. For residents that have limited mobility, staff could encourage residents to sing and play instruments together in the hall. My skilled nursing unit did this by having residents sing Christmas songs while playing hand-held percussion instruments, and everyone was smiling and laughing the entire time.

Finally, we cannot underestimate the power of touch. Every time I interact with a resident or even walk past them in the hall, I make it a point to touch them in a comforting manner. I have one resident who has recently started reaching for my hands to hold every time I enter his room, and this shows that residents have a need for touch. Brianna Cocuzzo, Algevis Wrench, and Chasity O’Malley with the Journal of the American Geriatrics Society understand this need for therapeutic touch and believe it should be encouraged in every long-term care facility. They state:

In a study in the United Kingdom, patients and primary care physicians were asked what constitutes patient‐centered communication. All patients and most doctors felt human therapeutic, rather than procedural, touch was critical. Physicians specifically mentioned older adults, stating, “Older people respond to, or seem to benefit from, skin to skin . . . just holding hands while you talk about how they are feeling.” Therefore, training on human touch will be beneficial during the pandemic when there is a pervasive fear of human touch and could permanently reform nursing home operations in the future, especially for residents who do not have visitors (Cocuzzo et al. 2750).

In the end, we need to recognize that our residents are suffering from loneliness, and it is our job to intervene. Even though I couldn’t let my sweet yet confused resident leave the building to see her children, I was able to offer her a hug she desperately needed. Also, over the following months some staff members encouraged her to take up puzzle-solving, and she is evidently much happier because of her new hobby. Additionally, I now realize how much she appreciates physical touch, so I make sure to give her a comforting rub on the back everytime I see her. Long story short, we need to devote ourselves to learning the social and emotional needs of our residents, and we have to take it upon ourselves to provide that companionship they are missing.

Caitlin Dunn is a student at Texas Woman’s University studying Nursing and Applied Psychology. She has been a nursing assistant for the past five months, so she is familiar with the experiences of nursing home residents during the pandemic. She is particularly passionate about alleviating the loneliness of elders while also protecting them from the novel Coronavirus.

Works Cited

Butterfield, Chalmers. Elderly Woman. 28 Nov. 2006.

Chu, Charlene H., et al. “Competing Crises: COVID‐19 Countermeasures and Social Isolation among Older Adults in Long‐Term Care.” Journal of Advanced Nursing, vol. 76, no. 10, 30 July 2020, pp. 2456–2459., doi:10.1111/jan.14467.

Cocuzzo, Brianna, et al. “Balancing Protection from COVID‐19 and the Need for Human Touch in Nursing Homes.” Journal of the American Geriatrics Society, vol. 68, no. 12, Dec. 2020, pp. 2749–2751., doi:10.1111/jgs.16861.

Lau‐Ng, Rossana, et al. “COVID‐19 Deaths in Long‐Term Care Facilities: A Critical Piece of the Pandemic Puzzle.” Journal of the American Geriatrics Society, vol. 68, no. 9, 20 Sept. 2020, pp. 1895–1898., doi:10.1111/jgs.16669.

“Nursing Home Patients Are Dying of Loneliness.” The New York Times, 29 Dec. 2020, www.nytimes.com/2020/12/29/opinion/coronavirus-nursing-homes.html.

Simard, Joyce, and Ladislav Volicer. “Loneliness and Isolation in Long-Term Care and the COVID-19 Pandemic.” Journal of the American Medical Directors Association, vol. 21, no. 7, 7 May 2020, pp. 966–967., doi:10.1016/j.jamda.2020.05.006.

Troutman‐Jordan, Meredith, and Donna M. Kazemi. “COVID‐19’s Impact on the Mental Health of Older Adults: Increase in Isolation, Depression, and Suicide Risk. An Urgent Call for Action.” Public Health Nursing, vol. 37, no. 5, 28 July 2020, pp. 637–638., doi:10.1111/phn.12774.