OT’s Mental Health Response to the COVID Pandemic: Older Adults

About Me

• Practicing OT since 2006
• Post Professional Doctoral Candidate (May 2021)
• Currently working in a skilled nursing facility (SNF)
• Professional interests
  • End of life OT
  • Wound Care
  • ICU/Critical Care
  • Academia
  • Research
  • Professional writing
• Professional experiences
  • Outpatient
  • SNF
  • Acute care hospital

  • Home health​

Thank you, Dr. Helfrich, for that welcome and introduction, and thank all of you for taking the time to participate in this presentation. I have included a little bit about me, which Dr. Helfrich covered almost everything here, but I wanted to include an introductory slide for those that access this coursework not live with us today.

COVID-19

In the early months of 2020, there was an increased global discussion about a viral infection, originating in China, that was causing a rapid onset of severe respiratory distress, spreading easily, and impacting an unforeseen amount of people in Asia as well as spreading to other parts of the world. In March 2020, the first cases developed in the United States with a quick spread to major cities such as Boston and New York City. Now, it has progressed through the rest of this country. I really wanted to start by giving some basic information about the elderly population and then the elderly population as it relates to COVID-19 and related deaths.

The Elderly Population & COVID-19 Related Deaths

In 2019, the US Census Bureau reported that 54,074,028 people were aged 65 years or older, and that population is what they refer to as the "elderly population." The United Nations reported 703,000,000 people aged 65 years or older globally. I thought it was very important to include these statistics to give you an idea of the number of people that I am referring to during this presentation. The Center for Disease Control reports that eight out of 10 COVID-19 deaths reported in the United States have occurred in adults aged 65 years or older, and the total U.S. COVID related deaths as of today, and this is updated information from the CDC website this morning is 249,670 people. It is important to convey the gravity of the situation, particularly for the elderly population. I think it is also important that we understand this to be able to anticipate the further deterioration of the mental health of the elderly as this pandemic continues.

Mental Health Conditions That Impact the Elderly

• Anxiety
• Depression
• Paranoia
• Dementia
• Schizophrenia
• Bipolar
• Psychosis
• Self-isolation/isolative behaviors
• Mania
• Delirium
• Panic Attacks
• Loneliness
• PTSD
• Suicidal Ideation
• Hallucinations
  • Visual
  • Auditory

I wanted to bring forth some of the mental health conditions that impact the elderly, and this is not a limited list. These are the ones that I have seen in my practice. 

Negative Impact of COVID-19 for the Older Adult

• Continuous coverage of the pandemic on all media outlets. 
• Increased conversation among family, friends, medical professionals, caregivers, and strangers (in the community) about the virus.
• Increased panic among elders about:
• Securing food/paper goods
  • Securing medications
  • Securing safe caregivers
  • Securing safe rides
  • Upcoming appointments/surgeries/procedures   ​
• Quarantining/Social Distancing
• Travel restrictions
• Fear of the unknown
• Loss of loved ones due to the virus
• The stigma around contracting the virus
• Loss of daily habits and routines (occupational deprivation)
• Exacerbation of mental health conditions

Khan et al., 2020

There are many negative impacts of COVID-19. The list above focuses on the negative impacts of COVID-19 for all, but especially for older adults. The continuous coverage of the pandemic on all media outlets is overwhelming. An article was published by the "Annals of King Edward Medical University" titled "The Corona Conundrum: A Shadow Pandemic of Mental Health Concerns." This article speaks to vulnerable populations including the elderly. It highlights that there is an increasing concern for the mental well-being of vulnerable populations, and universally it is in jeopardy. There is a concern that the constant 24/7 reporting of the pandemic on the majority of news networks, unverified updates on social media, as well as just the general overflow of statistics and opinions have ensured that this pandemic remains at the forefront of collective consciousness whether we want it there or not.

This article also points out that limited access to mental health services is a primary concern in light of COVID-19. Changes in routine, which we will get at later in this presentation, lead to major upsets in the elderly as they are more susceptible to stress and the emotional response brought on by this pandemic. This can result in relapses or exacerbations in people with pre-existing psychiatric conditions of all ages, but specifically for the older adult. Nursing homes are becoming hot spots for outbreaks. Besides, more families are stepping into caregiving roles, and this puts an additional strain on the family dynamic.

The increased conversations among family, friends, medical providers, caregivers, and strangers in the community, whether at the post office or the grocery store, about the virus really has affected the older adult. There is a sense of increased panic about securing food and paper goods, medications, safe caregivers, rides for appointments, surgeries, and procedures. I know that for myself there was a great deal of panic about getting enough food and paper products at the beginning with things shutting down. It was stressful for me. I cannot imagine how stressful it is for an older adult living in the community. They are worried about securing their medications that they know they need to take to stay alive. They also need to secure safe caregivers, especially people that live in the home environment, and have people coming in and out of their homes regularly to provide assistance as well as people that live in institutionalized settings that require assistance.

Securing rides is always something that elderly people worry about even in normal times. Many do not drive, and the public transportation system scheduling is reduced. How are they going to get from point A to point B? They have concerns about getting to the doctor, and many do not know how to use telehealth. People have expressed concerns about surgeries or procedures being canceled or rescheduled and the overall negative impact that has on their life.

Quarantining and social distancing have been difficult for the older adult. We all like to interact with each other. Many older adults cannot be near their friends or family members. This can increase their sense of depression or anxiety. Seeing family or friends may be the only thing an older adult has to look forward to all year.

There is a great fear of the unknown for all of us that is exacerbated in the older adult. Life, in general, is a little scarier as we get older when we start to require more help with different things.

Loss of a loved one due to the virus is another negative impact. Parents are burying their children, and older adults burying their grandchildren. There is a multitude of circumstances that coincide with loss because of this pandemic.

There is also a stigma around contracting the virus. This can definitely be seen in the skilled nursing facility setting when somebody comes down with it. There may be a lot of talk between employees and other residents about people that have the virus.

Lastly, there is a significant loss of daily habits and routines resulting in occupational deprivation, and we will get into that in future slides. This can also exacerbate mental health conditions related to all the aforementioned points.

Supporting Older Americans Act of 2020

• Older Americans Act (OAA) of 1965 – U.S. federal law addressing community-based needs of older adults. 
• Multiple reauthorizations and amendments, most recent March 2020.
• “One of the most relevant revisions to the OAA is recognition of the important negative effects that social isolation and loneliness can have on the health and well-being of older adults” (p. 2).

Marfeo, 2020

The Supporting Older Americans Act of 2020 is an amended act from The Older Americans Act of 1965. This is a federal law that addresses the community-based needs of older adults. There have been multiple reauthorizations and amendments, most recently in March of this year. In an article that was written about the Supporting Older Americans Act with relation to COVID-19 and the mental health of the elderly, the quote on the bottom I thought was the most important, "One of the most relevant revisions to the OAA is recognition of the important negative effects that social isolation and loneliness can have on the health and well-being of older adults."

Occupational Deprivation

• “A structural restriction on participation in meaningful occupations” (Darawsheh, 2019).
• “Negatively affects a person’s sense of occupational choice and demeans the person’s power” (Darawsheh, 2019).
• “A state of preclusion from engagement in occupations of necessity and/or meaning due to factors that stand outside the immediate control of the individual” (Whiteford et al., 2020; Whiteford, 2000)

I want to talk a bit about occupational deprivation. There are a few different definitions of this. In one article I read it is described as a structural restriction on participation in meaningful occupations. It is negatively affecting a person's sense of occupational choice and can demean a person's power. This third definition, which is one that I really like, is "a state of preclusion from engagement in occupations of necessity and/or meaning due to factors that stand outside the immediate control of the individual." I think that third definition or description of occupational deprivation really sums up what is going on globally with all of us, but impacts the elderly population a lot harder than it does those of us that are under the age of 65 or those of us that are not considered vulnerable.

OT’s Role in the COVID-19 Pandemic

Beth's Personal Experiences of the Pandemic in a SNF

• ​Shift from OT to nursing caregiver due to staffing issues.
• Constant concern about having adequate PPE.
• Constantly worrying about exposure in light of multiple positive cases, and need to work on different units.
• Inability to address the occupational needs / mental health needs due to the shift in role.
• High-stress environment, disorganized at times.
• Adapting to changing regulations without succinct communication.
• The physical, mental, and emotional impact of the head to toe PPE with minimal breaks for 8+ hour days for months.

I want to talk now about the role of OT in the COVID-19 pandemic. I also want to talk about my experiences as an OT in a skilled nursing facility during the COVID-19 pandemic. I felt like it was very important to be able to convey that this was my experience. I know that it is not everybody's experience, but I think others have gone through what I have gone through and am continuing to go through, and I think it is important to verbalize this and put it out in the open.

There was a major shift from being an OT to being a nursing caregiver because of staffing issues. I worked day, evening, and overnight shifts working as a nursing aide, not as an occupational therapist. There was also constant concern about having adequate PPE. The skilled nursing facility that I work in was poorly prepared, as were many other healthcare providers and facilities, in having adequate PPE. I was constantly worried about exposure in light of multiple positive cases.

I was unable to address the occupational and mental health needs of the clients, specifically where I work, because of the shift in this role. When I was working as a CNA, I was not able to address the deterioration of my client's mental health and/or physical health.

It is a high-stress environment and is disorganized at times. I think that others can relate to this. It was difficult to adapt to changing regulations without succinct communication. Regulations and safety protocols were changing. In my facility, there was not great communication.

There is also a physical, mental, and emotional impact of being head to toe in PPE with minimal breaks for 8+ hours a day for months on end. This really affected me. I definitely experienced a lot of anxiety initially with the introduction of the masks and head to toe hazmat suits. The huge about of perspiration and an inability to communicate have been really difficult.

This is me on the left in the group shot (Figure 1). You can also see me at my desk in head to toe gear. On the bottom is a picture is my face at the end of a 10 hour day. You can see the broken blood vessels and bruises.

Figure 1. Images of the author in PPE.

Hardest Aspects of Being an OT During COVID-19 in a SNF

• Being asked to “shut off” the clinical side of myself and work as a CNA.
• Restrictions initially in working with the COVID-19 + client to address issues such as social isolation and occupational deprivation.
• Dealing with the fact that the mental health and well being of clients was/is overlooked, and not a priority.
• Witnessing those at EOL pass unexpectedly without loved ones, or the opportunity to prepare for death.
• Witnessing the deterioration of the mental health and well being of clients, and not being able to address it immediately.
• Feeling helpless.

One of the hardest aspects of being an occupational therapist during COVID-19 was being asked to shut off the clinical side of myself and work as a CNA. The mental health and wellbeing of clients were overlooked during this time as it was not a priority, and that is still happening right now. There are still major staffing issues in my building, and our ability to address mental health is not high up on the totem pole.

It has also been difficult watching those at end of life pass away unexpectedly without loved ones or the opportunity to prepare for death. I have been with many people that have passed away during this time. Nobody was allowed to come in as they were not allowing compassion visits for periods of time. It was greatly rewarding to be able to have the opportunity to be with those people during their last moments, but it certainly was and is hard to deal with.

It has also been difficult to witness the deterioration of mental health and wellbeing of clients and not be able to address it immediately. Even though I know that I am giving everything I have to make a difference in people's lives, as most of us do, I still leave with a helpless feeling sometimes. It has been this way for months on end.

Stress and Psychological Consequences Applicable to OT’s and Health Care Workers

• “The wide scope and spread of Coronavirus Disease 2019 (COVID-19) could lead to a true mental health disaster, especially in countries with high caseloads”
• “Health care workers in crises such as the COVID-19 pandemic are under more stress. . . They are exposed not only to infection due to their frequent exposure to infected patients but also to psychological distress, long working hours, fatigue, occupational stigma, and physical violence. . . Exposed to prolonged sources of distress which may exceed their coping skills”
• “Hospital staff and health-care workers are at increased risk of developing psychological and mental health issues during the COVID-19 crisis”

(Zaki et al., 2020)

I want to talk a little bit about stress and the psychological consequences applicable to OTs and healthcare workers. A study was conducted in Saudi Arabia earlier this year aiming to assess mental health changes in healthcare workers. I want to provide some statistics from this study. Clinical depression symptoms were prevalent among the study participants despite 97.6% of participants reporting no previous psychiatric disorders before the quarantine. And, 39% of respondents reported they could not stop imagining catching the infection. It also showed that 23.7% reported feeling helpless. Another 32.5% of participants had an urge to collect data about the pandemic and become obsessive about that. Twenty-five point seven percent avoided watching the news. Finally, sleep was disrupted in about 41% of all the participants.

There are many quotes listed above that capture some of the psychological consequences. I graduated in 2006 with my master's degree. Although I cannot say emphatically that I was never prepared, I do not think I was ever provided education on how to cope with a pandemic. I certainly do not remember the education I may have received. Some people have better abilities to cope than others.

This article also conveyed that hospital staff and healthcare workers are at an increased risk of developing psychological and mental health issues during the COVID-19 crisis. I think it is important to put it out there that we, as occupational therapists, are at risk for developing depression, anxiety, PTSD, sleeplessness, as well as feeling isolated. 

Examples of Older Adult Mental Health Concerns and OT’s Response During the COVID-19 Pandemic

I wanted to give some case study examples about the mental health concerns and OT's response to the COVID-19 pandemic. These case examples are real, the information has been altered to maintain HIPAA privacy laws. These are some of the things that I have experienced. 

Carol

• 106 y/o female
• Dementia
• Hard of hearing
• Anxiety
• COPD
• COVID 19+
• Daily routine
  • Up early and out of bed
  • Dressed
  • Jewelry
  • Hair/Makeup
  • Out of room all day – all meals in the dining room
  • No naps
  • Daily activity participant
  • Multiple family visits throughout the week
  • Maintains social friendships with others

Carol is a 106-year-old long-term care resident that has dementia, is hard of hearing, has anxiety, COPD, and became COVID-19 positive. Carol is always up early and out of bed dressed with jewelry on, and her hair and makeup done. She is typically out of the room all day in the dining room and does not nap. She participates in every daily activity with multiple family visits throughout the week. She also maintains social friendships with those that live on her floor.

• Carol's Mental Health
  • Unable to see caregivers due to PPE
  • Unable to hear caregivers well due to PPE
  • Isolated in the room
  • Not out of bed daily due to staff limitations.
  • No visits - 2nd-floor room, no window visits
  • No socialization
  • Caregivers spending as little time as possible in patients' rooms due to being COVID 19+
  • Experiencing occupational deprivation, anxiety, loneliness, confusion, and depression

I now want to talk about her mental health during the pandemic. She was unable to see or hear caregivers well due to PPE. She was isolated in the room and not out of bed daily due to staff limitations. She required the assistance of two staff with the use of a mechanical lift. As there were only two aides staffed to a unit, it was difficult to provide basic care, get people fed, and get everybody up out of bed, especially when they required more assistance to do so. She was also on the second floor so she could not have any in-person window visits. She had minimal to no socialization outside of caregivers. Caregivers were also spending as little time as possible as she was COVID-19 positive. She experienced occupational deprivation, anxiety, loneliness, and had an onset of confusion and depression. 

• How can OT respond?
  • Establish a cognitively appropriate leisure/relaxation program
  • Assess alternative options for communication with the outside world
  • Develop a temporary new routine in light of restrictions to maintain safety
  • Use of alternative ways to identify caregivers such as writing names on PPE
  • Provide education specific to Carol’s needs to gain a better understanding of what is happening

Some of the things for Carol would be to establish a cognitively appropriate leisure and relaxation program and assess alternative options for communication with the outside world. It would also be important to develop a temporary new routine in light of restrictions to maintain safety. We could also use alternative ways to identify ourselves such as writing our names or affix photographs on the PPE. We could also provide education specific to Carol's needs. This education could then go to nursing, social work, and the medical team as they are seeing the deterioration of Carol's status and may not understand why.

Mary

• 80 y/o female
• Lives alone, no family; HCP/POA is her attorney
• Functioning at home with engrained routines in place.
• Baseline dementia with paranoia-- doesn’t allow help at home
• Multiple calls to 911 over a span of 3-4 days regarding her television being “controlled by someone else”
• Transfer to the ER after the last call then transferred to the SNF
• OUTCOME
  • Remained in the facility for 1 month in isolation
  • Unable to return to her home, transitioned to ALF
  • Further progression of dementia and paranoia likely in part due to media coverage of COVID-19

Here is an example of media overexposure with Mary. Mary is an 80-year-old female who lived alone, had no family, and was functional at home with very deeply ingrained routines in place. She had baseline dementia and paranoia and did not allow for help at home. She was functional in her home, but it was not the best situation.

• Mary's Mental Health
  • Multiple calls to 911 related to thinking that someone was controlling her television (paranoia)
  • All of her channels on basic cable were showing COVID-19 coverage (dementia)
  • Trigger: Bodies being placed in refrigerated trucks/caregivers in PPE
  • Worsening anxiety, paranoia, depression, and confusion
  • Lack of comprehension of the global pandemic
  • Constant concern about ending up in a refrigerated truck
  • Poor sleeping/eating habits

In Mary's case, there were multiple calls to 911 from her over a span of three to four days regarding her television being controlled by somebody else with the last 911 call prompting a transfer to the emergency room by EMS, and then to the skilled nursing facility where I work. She remained in the facility for a month in isolation and was unable to return to her home. She transitioned to an assisted living facility due to the further progression of her dementia and paranoia, likely in part due to media coverage of COVID-19.

Mary had basic cable at home, and when she called 911 multiple times thinking that someone was controlling her television, this was her paranoia setting in. All of her channels on her plan were CBS, NBC, ABC, and a few other news channels, and they were all showing coverage of COVID-19. As Mary has dementia, I do not believe that she recognized that all of the channels were showing the same stuff. This was a trigger for her, especially seeing bodies being placed in refrigerated trucks. This was covered on almost every news outlet. Besides the refrigerated trucks showing up outside of hospitals as makeshift morgues, these news stations also covered caregivers in PPE on a constant loop. As a result, she had worsening anxiety, paranoia, depression, and confusion. What Mary did not understand is that as she was switching through different channels, she was seeing the same things because this was all that was being covered. Instead, she thought that somebody was controlling her cable, and that is why she was calling 911 to get somebody to fix her remote control and/or her television. She really demonstrated a lack of comprehension of this global pandemic. She also was constantly concerned about ending up in a refrigerated truck, and this induced poor sleep and eating habits. This rendered her dehydrated and with a UTI by the time she got to the hospital.

• How can OT respond?
  • Identification of triggers, and provide education to caregivers about reducing triggers when possible
  • Establishment of activities that the patient can successfully engage in through building rapport and use of standardized cognitive assessments
  • Validate feelings of paranoia, anxiety, depression, panic, and likely PTSD; Therapeutic use of self
  • Assess abilities to retain, process, and respond to new information to help guide Mary through this life transition that wasn’t planned
  • Create a plan of care for functional maintenance.

The identification of the triggers and providing education to caregivers about the reduction of the triggers whenever possible are very important. I told the aides that when they checked on Mary to make sure that the news was not on. I also established some activities that she could successfully engage in by building a rapport and using standardized cognitive assessments. I thought it was important to validate her feelings of paranoia, anxiety, depression, panic, and likely PTSD by using a therapeutic use of self. As human beings, we need to be relatable to each other, especially as OTs taking care of the elderly. I told her that I shared some of the same concerns so that she did not feel so awkward or isolated. It was also important to assess her abilities to retain processes and help her to respond to new information to guide her through this life transition. As she was transferring to assisted living, I helped her to create a plan of care for functional maintenance as she was relatively independent and able to complete self-care related activities. Her paranoia, depression, and subsequent muscle weakness from UTI and the medical things going on, made it a little difficult for her at that time, but I fully expected her to resume these activities.

Jane

• 80 y/o female
• Dementia, anxiety, paranoia.
• Fearful and anxious with change.
• Follows a daily routine with continual redirection.
• Ambulatory at walker level.
• Spends time walking the halls, and sitting with peers in common areas.
• Requires ongoing redirection during activities.
• Requires ongoing assurance of safety.
• Responds well to tactile input such as a back rub or hug.

Jane is an 80-year-old female, long-term care resident with dementia, anxiety, and paranoia at baseline. She is typically fearful and anxious with change, whether it is a new nurse, a new aide, or a new roommate. She follows a daily routine with continual redirection. She was ambulatory at the walker level, spent a lot of time walking in the halls and sitting with peers in common areas, and required a lot of ongoing redirection and reassurance during activities for safety. She responded really well to tactile sensory input such as a back rub, a hug, or holding her hand,

• Jane's Mental Health
  • Extreme difficulty in following isolation protocols
  • Expressed fear of not knowing who was caring for her due to PPE
  • Increased anxiety (crying and hyperventilation)
  • Multiple falls
  • Wandering/intrusive behaviors
  • Reduced appetite
  • Unable to tolerate trials of a face covering to allow for out of room time
  • Significantly reduced sensory stimulation, leading to agitation during care
  • Expression of hopelessness and suicidal ideation

As the restrictions started coming in with COVID, she really deteriorated. She had extreme difficulty in following isolation protocols. She was constantly out of her room, and it was very hard to get her to understand that the isolation was for her safety. She expressed fear of not knowing who was caring for her because of the PPE. She demonstrated increased anxiety with crying and hyperventilating. She sustained multiple falls over a few months and often wandered and became intrusive, which negatively affected other residents. Her appetite was reduced. She was not able to tolerate trials of face coverings to allow for time spent out of the room when that was allowed. She had significantly reduced sensory stimulation leading to a lot of agitation during basic hygiene and care. She expressed feelings of hopelessness and expressed suicidal ideation, although never with a plan. She would often say, "I just want to die. I just want to kill myself." This was a huge change in her mental health.

• How can OT respond?
  • Validate Jane’s feelings, allow for self-expression, and provide emotional/sensory support
  • Establishment of a new routine with assistance to follow it
  • Use standardized cognitive assessments to create cognitively appropriate activities that can be completed with setup, and/or frequent check-ins
  • Education nursing/social work caregivers about the potential for patients to elicit negative behaviors due to change of daily routine
  • Reach out to family members and facilitate video or phone contact

OT's response to somebody like this is to validate feelings. I allowed her to express herself and provided emotional and sensory support. I think a lot of times when we are dealing with the elderly and they say negative things, we want to make it better for them. However, part of that process is to allow them to express themselves and validate those feelings. Establishment of a new routine with assistance to follow it was difficult in this case. Using standardized cognitive assessments to create a cognitively appropriate activities program that could be completed with set up or frequent check-ins could be one intervention idea. We could also provide education to nursing and social work about the potential for the patient to elicit negative behaviors due to the change in the daily routine. I do not believe that everybody thinks the same way that OTs do about occupational deprivation and the importance of having routines. Disturbances in these routines can really cause a shift in the well-being of an older person. It would also be good to reach out to family members and facilitate video or phone contact in these cases. In fact, Jane at one time thought that all of her family was dead because they were not coming. Facilitating some form of communication between Jane and the outside world would really be helpful.

Edward and Pam

• Edward
  • 72 y/o male with multiple hospitalizations, cirrhosis of the liver due to ETOH, portal vein thrombosis, +tobacco use, anemia, on TPN
  • On the short-term unit, bed bound, dependent for care. Under hospice care
  • Was previously living with his wife of 30+ years who was his primary caretaker
  • Passed away alone
• Pam
  • Unable to enter the building due to COVID-19 restrictions
  • Elderly herself, frail, and visiting her husband from a window in the cold (March)
  • Unable to have a compassion visit
  • Unable to be with her spouse when he passed away

This is the last case study for this section about Edward and Pam. Edward is a 72-year-old male with multiple hospitalizations, cirrhosis of his liver due to ETOH, portal vein thrombosis, tobacco use, anemia, and on TPN. He was admitted to our short-term unit while bed-bound, dependent for care, and was under hospice care. Before this, he was living with his wife of over 30 years who was his primary caretaker. Edward, unfortunately, passed away without his family there. His wife Pam was unable to enter the building due to restrictions. She is elderly herself, frail, and was visiting her husband from a window in the cold as this was in March. She was unable to have a compassionate visit granted to her, and she was unable to be with her spouse when he passed away.

• Their mental health
  • Edward
    • Anxious
    • Agitated
    • Disengaged
    • Fearful
    • Heartbroken
    • Lonely
    • Scared
    • Loss of his identity, specifically as a spouse
  • Pam
    • Heartbroken
    • Helpless
    • Scared
    • Frustrated
    • Worried
    • Feelings like she is at fault
    • Feeling like she failed her husband
    • Unable to say goodbye

I wanted to kind of give a side-by-side view of their mental health. They experienced a lot of similar feelings. Edward was really connected to his wife, and it is not the same through a glass window. Pam felt somehow that this was her fault, and she was not able to say goodbye to him. 

• How can OT respond to a situation like this?
  • Provide intervention specific to increasing the patient's abilities to interact with his spouse
  • Collaborate with the hospice agency to meet occupational needs at the EOL
  • Work with administrative personnel to create a way to complete a safe compassion visit in light of COVID-19 safety protocols
  • Provide Pam with education regarding Edwards condition/status to promote her involvement, engage in alternate means of communication
  • Educate facility caregivers about the situation, determine how to best meet the needs of this family

Increasing the patient's ability to interact with his spouse was really difficult during this time, but there are always ways to improve communication with loved ones. It would be important for the OT to collaborate with the hospice agency to meet the occupational needs at end of life and work with the administrative personnel in the building to create ways to complete a safe compassion visit in light of COVID-19 safety protocols. What I have found is that the administration is really worried about the spread and is often not open to this, but I think with persistence it can happen. We could also provide Pam with education regarding Edward's condition and status to promote her involvement and engage in alternative means of communication.

The Impact of Our Mental Health on the Elderly

I want to talk about the impact of our mental health on the elderly.

The OTR/OTA & COVID-19

• Anxious in general – global pandemic.
• Worried about ourselves and vulnerable family/ friends.
• Anxious about PPE availability.
• Increase in + cases = increase in stress.
• Sudden onset of client deaths.
• Productivity in a fluid, changing, limiting situation.
• Treatment restrictions.
• Resistance with continued client advocacy for OT.
• COVID-19 BURNOUT

This is a little bit about my perception of the OTR and OTA and COVID-19. This is based again on my experiences and the experiences of my colleagues and what we have gone through together. We are all pretty anxious in general. This is a global pandemic, and many of us have kids and vulnerable loved ones. We are worried about ourselves and anxious about PPE availability. This was a real thing for me and my colleagues.

An increase in positive cases equals an increase in stress. Things are quickly changing and without good communication. The sudden onset of client deaths was really hard. Productivity in a fluid, changing, and limiting situation was difficult. There was a period of time that the company I worked for was not really looking at productivity, but that did not last forever. Thus, trying to be productive in a fluid situation is very hard and stressful.

There were also a lot of treatment restrictions. For example, our gym was closed, and our ability to bring things to people's rooms was reduced. You had to rehabilitate people even in the short term sense without access to equipment and things that you need. It is hard to say if somebody can cook a meal without them physically being in the kitchen. There was also resistance in my experience to client advocacy as the staffing issues were so great.

Example: Abby

• 67 y/o female with early-onset Alzheimer’s Disease – A & O x 1.
• Previous client, admitted due to inability to be cared for at home after domestic violence issue.
• Morbid obesity and OA.
• Assist of 1-bed level ADL’s/toileting.
• Mechanical lift transfers.
• In facility for short term rehab and transition to LTC
• Becomes COVID-19 +.
• Forced to discontinue all rehabilitation.
• Isolated in a room alone with no clothes, no personal items.
• Unrecognizable caregivers due to PPE.
• One of the first + cases in the building.
• Cognition declining, depression/anxiety increasing.

This is a particular case study about a female named Abby. I was restricted from seeing her for OT when she became COVID-19 positive. She is a 67-year-old female with early onset of Alzheimer's, oriented only to herself. She was a previous client of ours in the SNF. She ended up going home and then was not being cared for at home. There was domestic violence going on. She is morbidly obese with serious OA, assist of one at bed level for ADLs and toileting, and a mechanical lift for transfers. She was on the short-term side of rehab with a plan to transition to long-term care. A couple of weeks into her stay, she became positive, and we were forced to discontinue rehabilitation despite valiant efforts to resist that. She was isolated in a room alone with no clothes, no personal items, and she was not able to recognize caregivers due to PPE. She was one of the first cases of positive in the building. Her cognition declined and her depression and anxiety increased. Due to her isolation, everything deteriorated for this client.

• Advocating for Abby
  • Persistence in being able to see Abby to address:
    • Occupational deprivation
    • Isolation
    • Cognition/orientation
    • Human interaction
    • Caregiver education

To advocate for her, I was really persistent about seeing her to address occupational deprivation, isolation, cognition and orientation, human interaction, and to provide caregiver education. Ultimately, because I can be pretty much unrelenting when I feel passionate about something, I was able to see her for some of those issues.

COVID-19 and Burnout

I am sure many of you are experiencing burnout.

• What does it look like?
  • Mental fog
  • Exhaustion
  • Fear of the unknown
  • Increased irritability
  • PPE
  • Anxiety
  • Lack of Sleep
  • Lack of Hydration
  • Lack of relaxation
  • Lack of leisure
  • Increased shift lengths
  • Lack of support

For me, it is a mental fog, exhaustion, and being worried and fearful of the unknown, I get really irritable when I am in PPE, and this has been going on for months. I have had anxiety, a lack of sleep, and poor hydration. I am not really good at relaxing or engaging in leisure activities, especially now in light of all the shutdowns. My shift lengths were anywhere between 10-14 hours.

I did not feel supported as I do not have any family members that are OTs in this type of setting. My husband is a nurse, but he does administrative nursing, so it is different. The separation from friends and family also got to me. I wanted to share with you some personal experiences (Figure 2).

Figure 2. Personal experiences of the presenter. 

This is what I am missing. On the left at the top is baby Roan. Below that is a picture of myself and his mom, my best friend Sam. I was not able to support her through her pregnancy or see Roan. I still have not seen him. The little guy in the middle on the top is my nephew Ben. He lives in Pittsburgh, and below him are his parents, my sister Christina and her husband Brian. I have not been able to see him either. That has been really hard. On the right are my aunt Kathy and uncle Mark. My uncle Mark is currently fighting esophageal cancer, and because of my job, I have not been able to be anywhere near them to support them. It has been tough.

The Mental Health of the Elderly is Impacted by Our Mental Health

• As caregivers under an immense amount of prolonged stress and emotional/physical/mental strain we may be:
  • Short with our clients
  • Frustrated with our clients' inability to understand what is happening
  • Exhausted by their needs when ours are not being met
  • Helpless, unable to give them what they want
  • Unable to meet their needs due to restrictions, or for their safety
  • Sadness for them and the loss of life as they knew it

As caregivers, we are under an immense amount of prolonged stress and emotional, physical, and mental strain. We have the potential to be short with our clients and be frustrated with their inabilities to understand what is happening. We are exhausted by their needs when ours are not being met, not even basic ones. We feel helpless because we cannot give them what they want or feel unable to meet their needs due to restrictions. I really do feel sad for them in the loss of the life that they once knew. This is not to say that it will not ever come back, but for them, they are living this and are having a difficult time thinking ahead.

• Resulting in...
  • Reduced trust between the elderly and their caregivers
  • Elderly feeling isolated, trapped, out of control
  • Increased behaviors, increased falls, decreased function
  • An overwhelming fear of the virus, and the unknown
  • Ultimately, the deterioration of the mental health of the elderly

There is reduced trust between the elderly and their caregivers when they feel that their caregivers are being short with them or are frustrated with them. The elderly feel isolated, trapped, and out of control. There are increased behaviors, falls, and decreased function. There is an overwhelming fear of the virus and the unknown, and ultimately the deterioration of their mental health is what we are faced with.

Call to Action

• Acknowledge and care for our own mental/physical/emotional health.
• Identify clients with deterioration in their mental and physical health and advocate for them.
• Improve understanding of the dynamics of this situation with the elderly at home, or in a more institutionalized setting.
• Use of skills as clinicians to provide innovative intervention.
• Conduct research and analysis.

We have to acknowledge and care for our own mental, physical, and emotional health as caregivers and as OTs. We should identify clients with deterioration in their mental and physical health and advocate for them. We need to improve our understanding of the dynamics of this situation with the elderly at home or in a more institutionalized setting. We need to use our skills as clinicians to provide innovative interventions. All of us here that have lived and practiced through this pandemic have valuable data to share. I encourage you to conduct research and analysis to help facilitate improved calls to action in the future should something like this ever happen again.

I want to thank you for your time, and I want to open up any questions.

Questions and Answers

Where are you currently working? Are you still working with COVID patients?

I am currently working in a skilled nursing facility in Massachusetts, and there have been COVID patients that have come in from the hospital. Typically, patients are tested in the hospital before the transition to our facility, and then they are swabbed at Day Two, Day Seven, and Day 14. Upon anybody's arrival into the facility, whether they are long term or short term, they are isolated for 14 days regardless. Some patients have popped up as positive despite previous negative testing, which kind of solidifies this idea that the incubation period is variable. Right now we do not have any positive patients, but there have been positive employees. The entire building right now is in quarantine, whether the patient is negative, recovered, or naive. We are still feeling the effects of it right now even though we do not have any positive cases in the building.

Is the PPE status getting any better in terms of availability? It seems that we are hearing yes, but the staff is saying not so. It is alarming.

This is a fluid and changing experience. Initially, when this started, we were given masks. Masks were meant to be used for five days unless they were saturated in water or whatever else. We were given paper bags to hold them in. When we had to start wearing more PPE, like clothing coverings and stuff like that, the building went through whatever supply of one-time use stuff, and then that wasn't available. They brought out some hazmat suits, like the blue suits that you saw, and the National Guard dropped things off as well. Then, you were supposed to wear one suit per week. However, suit sizing is not great when you have staff members that are of different heights, weights, widths, and body makeups, I certainly busted through many suits because I bend down and move around. I'm on the floor, and if the suit gets caught on something, it rips. The other problem with that is they got saturated in perspiration. I would take mine off and go outside the building during my lunch break to be free from all of that. However, when I would come back in, the whole thing would still be wet. I was wearing just leggings and tank tops under the suit because I was sweating. I also had skin break down under my armpits and thighs because I'm not a twig. Right now, the facility has purchased multiple washable gowns.

The current requirement is before entering any room you gown up, put on face gear, whether that be goggles or a face shield, and an N95 mask. The recommendation is to have a new N95 mask every two days. You cannot leave the room in the gown, so you have to doff everything if you need to go get something. Then, there is hand hygiene and all that.

I bet your organizational skills have really improved. I used to go into a room and I would forget something and have to leave again. 

It is hard to anticipate what they're going to need. You also do not want to waste things by trying to bring things in. For example, you are not supposed to step in the room to even have a conversation without being fully gowned. There are only so many people that do the laundry, and if you just bring things in, you can't take things out of the room. I asked the administrator a couple of weeks ago what the status was of PPE ordering, and I got a very vague answer so I'm not sure what's going on now. - Yeah.

Is the place that you are working in an urban setting, suburban, or more rural?

It is in a pretty busy suburban area. I live in Springfield which is a bigger city in the western part of the state. The capacity of our building is 254 people.

Do you get regular testing and if so what kind?

The testing depends on the number of positive cases in the building. When COVID wound down for us in the summer and no employees were testing positive, 40% of the employees were getting tested monthly. The residents' testing upon admission was the negative swab in the hospital and then at Day Two, Day Seven, and Day 14. Other residents in the facility were getting tested based on symptomology. The National Guard came in at one point and tested everybody in the building. That was in the long-term care site.

Our testing as staff members depends on the positivity going on in the building. We have had two staff members recently in the past three weeks test positive. Currently, every staff member gets tested every week. I do not know how long that's going to last. We have the choice of up the nose or down the throat. They do it either way, and it depends on what you want. We have an antigen testing machine that the state has provided us that's preliminary. They do not really use it, though, they mostly use it for patients that demonstrate symptoms to try to determine if it's really COVID or something else like RSV, the flu, or a cold. I think that the testing is fluid and it's changing.

If a person has dementia, how are they able to deal with the swab going into the nasal cavity?

The two respiratory therapists in our building are doing the swabbing. It's been a challenge. Often, I do not think they realize that it is happening and cannot react to resist it. If there's somebody that's combative, I think that they give them a break or they go in their mouth. I personally prefer to be swabbed in the back of my throat as opposed to up my nose. I think it would be a great opportunity for respiratory and OT to work together to try to figure out the easiest way to do this that causes the least amount of strain and stress for the patient. However, those are not things that are at the forefront of the administration's mindset. I think it would be really easy to evaluate somebody's abilities to tolerate the introduction of a nasal swab and try to figure out the best way to do it to be able to provide that education, but again that's not where the need is. 

What are some ideas for treatment with limited equipment in these rooms? Do you have a few ideas that you could throw out?

What I do with a client depends on their physical and cognitive abilities. I like to work on functional tasks like making their bed. I can raise the height of the hospital bed all the way up and use it as a table to do different activities. I can also bring certain things in that I can clean. For example, I use an old vacuum cleaner to practice vacuuming and work on dynamic balance, and then I use a bleach wipe between rooms. There have been restrictions with showering and simulating a shower is difficult. I am trying to fight right now to get a microwave on a cart that we can kind of wheel into other people's rooms and sanitize that to be able to do more of hot meal prep. I do a lot of medication management. I have also incorporated a lot of goals about coping strategies. I have been forced to be really creative.

What codes do you use that are specific to mental health?

I use 97129 and 97130 if I'm working on specific cognitive retraining, anxiety reduction, isolation reduction, and things like that. I have found a lot of older adults are terrified of germs. If we're working on reducing anxiety during a bathroom level ADL and I'm working on coping strategies for being able to organize the activity, set it up, and actually go through it, then I'll bill 97535. If we're trying to figure out a car transfer, that might be 97530. If we're trying to do something with standing balance while incorporating ways to reduce mental health, like Tai Chi, then I'll bill the 97112 code. It requires you to think critically about how you are treating the individual client and really take what you are doing with them physically and cognitively into account when you are determining how to bill for it.

What is an example of how you would document one session when you are working on mental health?

I can give you an example of a situation I had yesterday, and I'll just give you a brief overview of the client. This is a long-term care resident, 67 years old, in a single private room with a schizoaffective disorder of the bipolar type, OCD, anxiety, and depression. We are working on anxiety and social isolation reduction around COVID-19, and we are working on organizing her room as she has hoarding tendencies. We are also working on her being able to be comfortable with showering as she has a very severe fear of germs. This particular patient would rather go for months without a shower than risk showering in a communal shower room, even if I have cleaned it. She is very up and down with her willingness to participate.

We had previously planned what we were going to do the day before, and I went in to see her at the designated time. She was laying in her bed, stiff as a board, eyes closed, and said "I can't deal with it. I'm not doing anything." She was not interested in participating, completely overwhelmed, anxious, and her respiratory rate with just talking with me was like 35. I billed this under 97129 and 97130 because the 97129 code is for 0 to 15 minutes of intervention, and the 97130 code is 16 minutes on. I had to bill both codes because I was in there for 26 minutes.

What I do for her in this particular situation is to keep a very calm tone to my voice. I get down on her level. "This writer approached the patient who was resting in bed in a semi-supine position, eyes closed, easily aroused with this writer's introduction." I also use a lot of patient statements in my documentation. "This writer got eye level with the resident and spoke to the resident about what is going on...". I just document what I see. She was really having a bad day about what was going on in the hallway. She lives in a long-term care unit with dementia patients. It is challenging to keep them in their rooms and to wear masks. When you are very afraid of germs, you feel isolated to your room. I always carry a stress reduction workbook with me when I go see her because sometimes if I can catch her in the mood we do some of those exercises. We talk about mindfulness and controlling our breath support. Instead of letting these anxious feelings take her away, these exercises can help her to recenter herself.

Yesterday I was able to talk her through mindfulness and a visualization activity. It reduced her anxiety, and her respiratory rate by the end was 16. This is how I documented that particular session. I split up my documentation between the two codes to cover the minutes. I started the documentation under 97129. and I finished it under 97130. We really did not do anything specific towards organizing her room or working with the hygiene in the shower, but we did focus on the reduction and acknowledgment of the anxiety. I validated how she felt. "This writer validated the patient's expressions of frustration and anxiety. This writer provided an opportunity for the patient to participate in mindfulness and verbal visualization activity." I also report that she was able to follow it with X amount of accuracy, et cetera.

How are you handling stress in this situation, you and your co-workers? Do you have some tips to handle stress?

I am blessed with the coworkers that I have right now in this particular work environment. I do not know how we all would have gotten through it without each other. That being said, we have each other. I like to print out funny memes and tape them to the bathroom door. I really try to maintain as much optimism as I can. I think we validate each other's concerns. Three people in my department got COVID, two of which were in the hospital for an extended period of time. I felt horrible for them. We have all stuck together and supported each other through difficulties with the administration in the building, the PPE availability, and the disorganization and poor communication.

You had to step up and be a CNA during the height of everything. As an OT that would be really hard to separate and to be able to do that, but obviously you had to do it because it was called for, so can you just wrap up and talk about that?

I have been in OT for 14 years, and I have had my share of things that were very difficult to see. The majority of my career was spent in South Florida in the Miami Fort Lauderdale area. Until this time, I never really felt defeated in my career. I walked into work on a Sunday, and I was one of two aides on the memory care unit for 44 people. The day shift requires breakfast and lunch, and all the care that goes in between. This was at the beginning of the pandemic where I was wearing the blue hazmat suit that you saw in the photos. I felt defeated in that I could not provide basic human care, never mind switching gears from an OT to a CNA. There were 12 people on my assignment that needed to be fed. I left crying that day, and I still feel horrible about that experience. Although I know it was out of my control, it is difficult for me to go in there and consider an ADL as the face, under the arms, and in between the legs. There is oral hygiene, hair hygiene, and just being able to bathe yourself. It takes longer whether you are doing it for somebody or not. I found it to be very difficult to shift and change gears and not allow somebody to have the opportunity to go on the toilet to go to the bathroom because it takes more time. It is hard for me to justify doing something for somebody that could do it for themselves in a different way because of a staffing shortage, and that was really the hardest part for me. Plus, it is back-breaking work. CNAs are extremely overworked and underpaid and provide care that most of us as OTs consider appropriate, you cannot do it as one person, even with only 12 people on your assignment. That experience was very humbling.

These are the references I used for your review, and this is my email, and I would welcome and appreciate anybody contacting me. If anybody just wants to vent about their experiences, I welcome that. Part of being an OT for me is being able to network with other OTs globally and within the United States, and anything that we can do to support each other. Thank you all for your time and your thoughtful questions.

References

Available in the handout.