To the Editor:
Most older adults with physical or cognitive disabilities require physically close caregiving to perform activities of daily living (ADLs). This presents a unique challenge in this time of physical and social distancing necessitated by the COVID‐19 pandemic. Where is the balance between physically close caregiving and physical distancing at home and in care settings? We survey scenarios by setting and provide preliminary thoughts on caregiving at a physical distance, drawing from public health and telehealth.
Physical distancing must be maintained to minimize unnecessary COVID‐19 exposure between caregivers and disabled individuals living together. Although health agencies recommend reducing exposure through wearing cloth masks outside homes,1 this policy should be extended to inside homes, so members living with disabled individuals wear personal protective equipment (PPE; ie, gloves/masks) during ADLs.
Importantly, partnership between caregivers and clinicians must be supported as an essential step in developing “dementia‐capable healthcare systems.”2 Caregiver training and support forums can move to digital videoconferencing platforms. However, demand for limited programs may exceed supply. Additional funding to memory centers might allow training for caregivers to improve quality of life and minimize unnecessary hospital visits. Training might include assessing orientation and redirecting individuals who become delirious. Studies indicate that educating caregivers improves recognition of delirium and reduces incidence.3 These measures will continue to impact individuals and caregivers beyond COVID‐19.
Modifying existing programs and technology can better serve individuals living alone when caregivers cannot visit regularly. During health emergencies, eligibility for meal assistance and support programs should be expanded. To accommodate for limited resources, services can transition from daily to weekly delivery and from warm meals to frozen/nonperishable food preparation. However, programs should continue to abide by nutritional recommendations and train and screen food handlers, enabling stable food sources during crises.
Physical distancing relies on existing technology for communication and access to healthcare. Disabled individuals must have access to broadband and telephone connections. Hundreds of companies have already signed the “Keep Americans Connected Pledge” to provide 2 months of uninterrupted access to individuals and businesses.4 However, clear pathways must be established for disabled individuals to request and maintain access beyond COVID‐19. Reliable broadband enables individuals and caregivers to set up audio/video communication to promote preparedness and utilize mobile health apps associated with improved outcomes, that is, increased exercise and reduced agitation.5
Long‐term care facility staff may be encouraged to work remotely/reduced hours. Virtual communication is a viable solution for staff, family, caregivers, and residents to check in with disabled individuals. Residents who can communicate might utilize tablets to indicate needs and safety. Although most staff may assist from afar, a subset of staff/caregivers with appropriate PPE should provide direct care for residents, especially those with dementia. Additional resources are already being procured from community collection drives organized by local students.
Disabled residents are at risk for complications during pandemics and may benefit from additional tiers of care. Telehealth is generally gaining financial support, and studies suggest mobile technology is useful for disabled patients.5, 6, 7 Telehealth for care facilities could be driven by clinicians and students, now and beyond. As liaisons, medical students might initiate virtual check‐ins, monitor activity on patient portals/records, and flag pertinent information for onsite staff to address. Subsequently, patients requiring hospitalization could be routed to virtual triage centers staffed by clinicians in training and overseen by self‐quarantined physicians. These activities match medical education initiatives, empowering students to fulfill clinical course credits/requirements.8
Hospitalized individuals with disabilities are at risk for delirium, impacting individual and hospital outcomes.9 Increasing interactions between patients and caregivers significantly reduces delirium duration and mortality.10 As hospitals restrict visitation, accommodations must be made to promote the physical/virtual presence of caregivers. For patients susceptible to delirium, caregivers should physically assist or virtually orient patients via audio/video chats. Additionally, temporary housing for essential providers/caregivers could be obtained from dormitories/apartments left vacant because of distancing.
Onsite care needs may be alleviated by redistributing nonphysical tasks via telehealth.6 Virtual hospital interventions including chart biopsies, history collection, and rounds can be organized by offsite or distant trainees and supervised by self‐quarantined clinicians, older clinicians at risk of complications, or redirected specialty clinicians on a volunteer/need basis.
Overall, caregiving at a distance is challenging. Nevertheless, COVID‐19 serves as an impetus for communication and collaboration between government, healthcare, community, and patient/caregiver groups. We hope the seeds of policy and technology are sown now so that when pandemics arise in a physically distant future, caregivers and providers will be better prepared.
Michael Tran Duong performed the literature review and prepared a draft of the letter with input and feedback from Jason Karlawish. Both authors revised and edited the letter.