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Effects of social isolation on a long-term care resident with dementia and depression during the COVID-19 pandemic

The older population and medically frail persons are at higher risk of severe infections and death from coronavirus disease 2019 (COVID-19). Long-term care (LTC) facilities are encouraged to take various actions to safeguard residents and reduce the spread of COVID-19 including by restricting visitors, which leads to isolation. The imposed isolation undermines the autonomy of older adults living in LTC facilities, especially those with dementia, and the isolation from loved ones can worsen cognition and depression. The purpose of this case report is to highlight isolation practices implemented to reduce the spread of COVID-19 in an LTC facility, which increased the social isolation and worsened cognition and depression in a resident with dementia and depression. Because many residents of LTC facilities have dementia, this case is an example of the need for interventions to support the mental health of persons living in LTC facilities during the COVID-19 pandemic.


Introduction
In the US, more than 5 million cases of coronavirus disease 2019 (COVID-19) and more than 169,000 COVID-19Àassociated deaths were reported as of August 20, 2020. 1 The older population and medically frail persons are at greater risk of severe infections and of death from COVID-19. 2 In a long-term care (LTC) facility in King County, Washington, 56.8% of residents with COVID-19 were hospitalized and 27.2% died from February 27, 2020, through March 9, 2020, according to a report from the Centers for Disease Control and Prevention. 3 LTC facilities are encouraged to safeguard residents in various ways, including by restricting visitors, 3 which leads to isolation. Many persons with dementia reside in LTC facilities, and they are often unable to understand why isolation during the pandemic is needed. 4 Isolation from loved ones for those with dementia can worsen cognition and depression. 5 The purpose of this case report is to highlight isolation practices implemented in an LTC facility to reduce the spread of COVID-19, the ramifications of the consequent social isolation, including worsening cognition and depression in a resident with dementia and depression, and some possible evidence-based solutions that could be implemented by advanced practice nurses (APNs).

Case report
An 87-year-old woman residing in an LTC facility was isolated from family because of restrictions resulting from COVID-19. Her medical history included vascular dementia, weight loss, multiple cardioembolic strokes, heart failure, dysphagia and aspiration pneumonia, pulmonary embolism (she was taking chronic anticoagulants), atrial fibrillation, hypertension, hypothyroidism, neuropathic pain, and osteoarthritis. She had become depressed after a stroke, which was appropriately treated with a selective serotonin reuptake inhibitor (SSRI) and an a-2 antagonist.
Before the COVID-19 pandemic and quarantine at her LTC facility, her family visited daily, sometimes multiple family members, multiple times. Because of a mandatory quarantine imposed to protect the LTC residents from COVID-19, the frequent visits from her family stopped. The staff initiated virtual visits, telephone calls, and window visits to help compensate for lack of in-person visits. Despite having the virtual contacts with her family, the resident's depression and cognition worsened. She became less engaged with nursing staff. She stopped eating well because of lack of appetite. She lost 14.4 pounds in 6 months and said that she would be "better off not living." To help with the depression and cognition, the resident's medications, including her SSRI and a-2 antagonist, were adjusted, and she was prescribed psychotherapy with a licensed independent clinical social worker. The gabapentin dosage she was taking for neuropathy was decreased to limit the possibility of sedative effects. The levothyroxine dosage she was taking for hypothyroidism was also decreased to help with the weight loss, after verifying that her levels of thyroid stimulating hormone were within reference ranges, and she was given nutritional supplements. Despite medically appropriate care, her cognition and depression continued to worsen, and she continued to lose weight.
Over 4 months, her scores on the Patient Health Questionaire-9, which screens for depression, increased from 5 (27 possible) to 12, or from mild to moderate depression. Additionally, her scores from the Brief Interview for Mental Status worsened over 7 months from 11 (15 possible) to 9 then to 0, or from mild cognitive impairment to severe cognitive impairment.
After 5 months, the family asked for an exception to the no-visitor policy because of their concern and distress about their loved one's worsening health and mental status, and quality of life. The request was denied. The resident continued to ask for her family and stated how much she missed them. Unfortunately, after approximately 6 months of isolation, she suffered a hemorrhagic stroke, and her prognosis was poor. At the time of this writing, her loved ones were contemplating hospice care.

Comment
Isolating residents of LTC facilities has been needed during the pandemic to protect their health and to reduce the spread of COVID-19; however, their autonomy has been severely impacted. 6 Staff at LTC facilities are distressed by the potential negative effects of isolating residents and also the negative consequences of not isolating effectively for best infection control. 4 The case reported herein describes the family's emotional distress of watching their loved one decline in their absence, and despite increasing contactless interactions with her family, her depression and cognition worsened. The ethical perspective during the COVID-19 pandemic is to protect the population as a whole, including those in LTC facilities. The special needs, such as continued social interaction with loved ones, of those with dementia residing at LTC facilities have been recognized, but interventions to meet these needs continue to be lacking. In this case, the safety of all the residents in the LTC facility outweighed the benefit to this 1 resident.
Alternative ways to connect LTC residents to family and friends have been described and include virtual and other forms of technology, such as phone calls, video calls, and social media. 6 However, for the resident described herein, window visits and increased communication through these other forms of technology did not help to improve her depression. Isolation contributed to her worsening depression and exacerbation of her dementia.
The case reported herein highlights the opportunity for APNs to collaborate with LTC facilities and government agencies. APNs are in a unique position to advocate for vulnerable residents in LTC facilities. During the COVID-19 pandemic and in the future, APNs can work with local government agencies to help obtain proper supplies of various types of personal protective equipment (PPE). APNs can also partner with LTC facilities to advocate for increased frequency of face-to-face family visits undertaken with appropriate safeguards, including PPE, in place. In some states, such as Minnesota, PPE is provided by state funding and could be given to families as well as practioners. When facility-provided PPE is not available, families would need to provide their own masks, which are now widely available at reasonable prices, of a type specified by the LTC facility. As in other health care institutions, instruction on proper use could be given by the APN to caregivers and families of those residents in LTC facilities, who may not be trained in how to ensure compliance to specific guidelines, as well as to family members.
In conclusion, isolation is an important means to protect LTC residents from COVID-19, but it can negatively affect their mental health, especially those with dementia. APNs need to ensure that all possible measures are taken to improve outcomes in this vulnerable population. Interventions should include optimizing medical management and employing strategies to leverage technology to enhance virtual communication and increasing opportunities that facilitate more window visits. Additionally, structured in-person visits utilizing PPE such as gloves, gowns, masks, and social distancing could be implemented. During the remainder of the COVID-19 pandemic and beyond, new and innovative interventions need to be developed that will increase the number of quality interactions between residents and families. APNs are in an optimal position to make the types of changes that will protect the physical and mental health of residents of LTC facilities.