Loneliness impacts older persons during hospitalization and may amplify during the social distancing required by the COVID-19 pandemic. The American Geriatrics Society (AGS) CoCare: Hospital Elder Life Program (HELP) aids hospitalized older persons in assuaging feelings of loneliness through structured therapeutic activities and volunteer visits that reduce social isolation for hospitalized older adults. During COVID-19, adaptations of this approach are required. We aim to spread awareness of loneliness as a major public health concern for older adults and ensure that programs like AGS CoCare: HELP are preserved through the pandemic and beyond.
loneliness, COVID-19, SARS-CoV-2, American Geriatrics Society CoCare: Hospital Elder Life Program, HEL
Social isolation and loneliness in older adults have widespread social and public health consequences, and have been recognized as major problems impacting acute and long-term care (Jansson et al., 2017). Social isolation and loneliness can lead to increased rates of cardiovascular events, cognitive impairment, and healthcare utilization (Gerst-Emerson and Jayawardhana, 2015; Sorkin, Rook, and Lu, 2002; Tilvis et al., 2004).
Increasingly, experts are noting feelings of loneliness and isolation in hospitalized elders (Rokach, 2017). Even under normal circumstances, hospitals disrupt daily routine, and typically limit or alter social contact to family, friends, and caregivers. The social isolation, loneliness, and unfamiliarity of the hospital leads many hospitalized older persons to become confused and disoriented, resulting in an increased risk for developing delirium (Day et al., 2012; Kalish, Gillham, and Unwin, 2014).
Delirium is an acute state characterized by inattention, disorientation, and other cognitive disturbances. Delirium occurs most commonly in older persons and can result in poor outcomes, including prolonged hospitalization, increased risk of developing dementia, and death (MacLullich and Hall, 2011; Oh et al., 2017). The terrifying experiences of delirium also can have lasting psychological effects, including flashbacks or haunting memories, which can manifest as post-traumatic stress (Azimi et al., 2015).
During this time of a global pandemic and widespread social distancing, many people are experiencing feelings of loneliness. In particular, older persons are a highly vulnerable population and may find it harder to connect due to lack of usual social contacts, functional limitations, and lack of familiarity with web-based services. Isolation is further magnified during hospitalization, where many older adults now battle an illness alone. Since the advent of COVID-19, increased rates of delirium of up to 70 percent have been described (Helms et al., 2020). Thus, it has become increasingly important to protect the older population, focusing efforts on prioritizing delirium prevention and simultaneously treating loneliness as a key outcome in health and longevity.
CoCare: HELP Focuses on Volunteers
The American Geriatrics Society (AGS) CoCare: HELP program, formerly known as the Hospital Elder Life Program (HELP), exemplifies a model program for optimizing patient care in hospitalized older adults, and has built-in methods to combat loneliness. Since its founding in the early 1990s by article co-author Dr. Sharon Inouye, volunteers and other trained hospital staff serve as integral components of the program’s success.
Proven to prevent delirium, cognitive and functional decline, falls, and other adverse outcomes (such as increased length of stay and hospital costs), AGS CoCare: HELP targets six known delirium risk factors—cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration—and addresses them with specialized protocols performed by clinical staff, and assisted by volunteers (Caplan and Harper, 2007; Inouye et al., 2000; Inouye et al., 1999).
The volunteers provide invaluable assistance in maintaining overall health by providing interventions such as walking or range-of-motion exercises, therapeutic activities, and feeding assistance. Volunteer training in the AGS CoCare: HELP model is extensive, including daylong didactic sessions and thorough shadowing opportunities. Volunteers are observed delivering interventions and must complete competency-based checklists from program staff before they are cleared to work independently.
Also, volunteers undergo repeat observation and competency-based checklists twice yearly, with refresher trainings as needed. Hospital volunteer coordinators and HELP staff select volunteers based on their motivation to help older adults, on reliability, and on commitment. While volunteers come from diverse backgrounds and experiences, a large number of AGS CoCare: HELP sites recruit volunteers from local colleges and universities, drawing on pre-medicine, pre-nursing, and other pre-clinical track students, as well as recruiting from community organizations, hospital nonclinical staff, and volunteer organizations.
‘Isolation is further magnified during hospitalization, where many older adults now battle an illness alone.’
A unique feature of the AGS CoCare: HELP program that distinguishes it from “friendly visitor” or other general hospital volunteer activities is that volunteers perform clinical protocols that can prevent adverse outcomes. For example, AGS CoCare: HELP volunteers provide not only a friendly face to hospitalized older adults, but also they orient the patient three times daily and engage in therapeutic activities (such as crossword puzzles, Sudoku, and current-events review) to help prevent cognitive decline.
Visits from volunteers in the program serve a dual-purpose: they prioritize the comfort and emotional well-being of the older adult patient and ensure that patients receive useful clinical interventions. While the majority of patient-volunteer interactions occur while patients are in the hospital, in the AGS CoCare: HELP model, staff and volunteers also ensure patients connect to community supports prior to discharge. All enrolled patients in the HELP program receive individualized discharge planning, including assessment of social and family supports, skilled nursing services, and post-discharge need for assistance with transportation, chores, shopping, and friendly visiting.
Benefits of using volunteers include preventing loneliness in older patients. Volunteers perform interventions with patients multiple times per day, providing unique patient engagement that hospital staff cannot, due to time constraints. In a 2016 study of the program, older adult participants noted that volunteers helped them pass the time and not feel lonely (Steunenberg et al., 2016).
Older Adults Report High Satisfaction with Program
Without the volunteer support, many patients report loneliness due to lack of socialization during hospitalization (Steunenberg et al., 2016). In a 2010 study of AGS CoCare: HELP, the volunteer-based program demonstrated a 95 percent satisfaction rate as measured by surveys distributed to patients and families (Sandhaus et al., 2010).
“I think people are impressed by the compassion and caring feeling that volunteers are able to give,” staff involved with the program have said (SteelFisher et al., 2011). Volunteers provide a friendly face, a chance to reminisce and share stories, and overall, supplement the time and attention that clinical staff provide. Volunteers can lend a listening ear and assuage fear, especially when patients have no visitors or family members. This holds particular importance with delirium, which may have lasting psychological effects.
The program is highly adaptable, even during the time of COVID-19. Many patients experience limited contact to families, visitors, and even clinical staff, due to isolation precautions. Staff wear full personal protective equipment, which can frighten or disorient patients, particularly those who have delirium or dementia. To respond to this “perfect storm” of delirium and loneliness risk factors, the AGS CoCare: HELP program developed a patient toolkit for staff to distribute to patients during their hospitalization, including range-of-motion exercise cards, printed puzzles and therapeutic activities, and nighttime sleep aids (eye masks, ear plugs, non-caffeinated herbal tea, and relaxation exercises).
One unique feature of the AGS CoCare: HELP program is that volunteers perform clinical protocols that can prevent adverse outcomes.
While most other programs have had to limit or fully restrict volunteer engagement at the hospital, the staff at some AGS CoCare: HELP sites provide access to tablets for video calling or pre-recorded messages from family and friends, and offer therapeutic activities and games to patients that suit their interests. Some AGS CoCare: HELP sites are introducing video calling and remote visiting with volunteers. Multiple AGS CoCare: HELP sites have noted that bringing volunteers back into their hospitals (with appropriate PPE and infection-control training) is of utmost priority. While AGS CoCare: HELP is currently exclusive to hospital settings, research and pilot testing is being conducted for HELP in the home and other settings.This is a critical time to battle social isolation in older adults. As a global community, we need to help our older population to combat loneliness during the COVID-19 pandemic, and long after we experience its lingering effects. Healthcare systems can use the AGS CoCare: HELP program to implement strategies such as volunteers to aid hospitalized older patients in combating loneliness, and in times of social distancing, we can rely upon methods such as adapted hospital protocols and virtual visiting. Now is the time to take action against this crisis of loneliness, a feat that will require strong efforts from all of us, across generations, to support the older adults in our communities.
Benjamin K. I. Helfand, MSc, is a doctor of medicine and doctoral degree candidate in the Department of Emergency Medicine, University of Massachusetts Medical School, in Worcester, Massachusetts, and in the departments of Psychiatry and Human Behavior and Neurology, at the Warren Alpert Medical School, Brown University, in Providence, Rhode Island. Margaret Webb is research associate in the Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, in Boston. Sharon K. Inouye, MD, MPH, is director of the Aging Brain Center and Milton and Shirley F. Levy Family Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center in Boston. Sarah L. Gartaganis, MSW, MPH, is a project director in the Aging Brain Center.
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