Safety Guidelines for Visiting the Elderly

Hi, everyone. I'm Dr. John Whyte, Chief Medical Officer at WebMD. And you're watching "Coronavirus in Context." Everyone's talking about the holidays and what can and can't we do with our elderly loved ones. So to help provide some insights, I've asked Dr. Eric De Jonge, he's chief of geriatrics at Capital Caring Health. Dr. De Jonge, thanks for joining me.

Thanks for being here.

Let's start off with, what's the impact of loneliness and isolation? What are you seeing with your elderly patients?

So here at Capital Caring Health, I work a lot with elders, particularly those who are alone at home. And what we find over the last eight months, John, is that they're very vulnerable to the isolation. They lose access to medical care, they lose access to in-person affection and intimacy from others.

And the results of that are a real profound, almost epidemic parallel to COVID-19-- a sadness, worsening depression. We see a lot of weight loss, especially in the assisted living and nursing home environment because eating is a social activity, especially for folks who have dementia or memory impairment. And so they literally just eat less because they don't have anyone there to eat with them. So that loss of companionship, physical affection, and medical care has led to a real decline in a lot of our most frail elders.

And how are you addressing it? Because everyone is suggesting, for the most part, that we keep our distance, literally, from loved ones who are elderly. Is there an in-between from daily contact versus none at all for seven, eight months?

Yeah, very much. I actually think after the first month or two, where we were just really trying hard to protect people, especially in the nursing homes where there was so much tragedy-- there is very much a middle ground. It's a dilemma, because there's no zero risk option. It's not a zero risk to see people, but it also is not a zero risk to leave people isolated.

So I think if you follow a lot of the basic precautions, we can open up a little bit and have closer contact with our loved ones. For example, we can minimize the risks by having small groups, wear your masks indoors, maintain some physical distance, and use the hand hygiene. Those are the basics. But that can be done safely.

So, Dr. De Jonge, can you hug or kiss an elderly loved one? Is that safe?

Right. So there is no zero risk behaviors, John. But I actually have been seeing a lot of literature, actually, that brief hugs are reasonably safe. And there's some key steps you can do to hug relatively safely. Number one, it should be brief.

You turn heads with masks when you hug. And the kind of aerosol and kind of contagious experts say, hold your breath. So brief, turn to the side, wear masks, and hugs are reasonably safe. I think kissing is a different issue. That should only be done, I would say, within an intimate bubble of people who that you're with.

But I think the value of some physical affection outweighs the relatively low risk. That means you maintain your distance and wear your masks the rest of the time when you're with that loved one. But the way COVID-19 is transmitted is prolonged contact indoors that's unprotected. And if you address all of those issues, my family, with my mom and with grandparents, have encouraged brief, safe hugs.

Now, what's happening with visitor policies at either assisted living facilities, retirement communities, hospice? Are we starting to see those open up? A lot of people have concerns even about visiting whether or not they're open. Do you expect there to be a liberalization of visitation policies in the next few months?

Actually, even CDC has started to recommend some liberalization, again with clear safety precautions. There's several key factors to liberalizing an assisted living or a nursing home. You need to think about the positivity rate in the community. If it's a very high rate, then people are less likely to have visitors.

But you can minimize the risks with, again, wearing masks, briefer visits, outdoors whenever possible. But I actually think that the protection measures that we are using in the health care environment, which have been quite successful once you have good PPE, can be applied. And I would say that the loss of affection and companionship right now needs to be addressed with some opening of some of those rules.

A lot of areas of the country really aren't going to be able to have these visits outside-- or these gatherings outside. It's just going to be too cold, and we also don't want to subject our elderly loved ones to another problem. What about the idea of one should consider getting tested for COVID prior to visiting a loved one, whether it's in some type of retirement home or if they're still residing in their own home and you want to go visit them?

Right. So testing has its limitations. If you get a test within two or three days before visiting a loved one, that can help some with reassurance. But as we've seen from the events at the White House and other places around the country, testing is not the answer. The answer really is taking precautions when you're in the presence of that person and following those public health guidelines.

Getting a test two or three days before might be a little reassuring, but I don't take that to the bank, because tests can be false positives or false negatives. And also something can happen in the two or three days that you're waiting for that result.

I mean, you could, in theory, get a test that's a PCR test as opposed to a rapid test-- the PCR tests are more accurate-- a couple of days beforehand if you can get those results in time, and then make sure you continue to practice those public health measures before you go. Other folks are talking about kids are going to come back from college, lots of generations are going to be in one household. How does that impact the holidays coming-- Thanksgiving, Christmas, and the other holidays around that time-- how do we plan for them?

Right, so same kind of general guidelines. You have to really think hard about where those kids are coming from. If they're coming from a high hot spot zone, I would be much more cautious about having them interact with elders. And we should point out that the risk of this disease in elders exponentially increases with every decade.

So age 50 to 64, there might be a 30 times rate of death compared to a young person in their 20s. By the time you're 85-plus, it might be more like 700 or 800 times the risk of death.

How do we balance, though, that Dr. De Jonge? Because we started off by talking about the issues of loneliness and isolation. And many of those folks are in their 70s and their 80s. How do we balance, then, the idea of some type of interaction other than virtual in balancing those competing risks? Are you saying that maybe over 80, it's a no-go-- just trying to think, how do we provide practical advice?

Yes, I think the practical advice-- even though the risk is higher with those folks over 80, John, I actually still think that you can have relatively safe interactions, even with grandkids, if you make sure that when they come, they're coming from a relatively less high rate of area. If they're coming from the highest rate area in the country, I would probably be careful about interaction with someone in their 80s. But almost everyone else with masking, with physical distancing, with less prolonged contact, I think you can do that with relatively low risk, although it's never going to be zero.

What's the recommended size of gathering that you've been talking about to people? Is it 10, 20? Does it depend on the size of the house or the area that's holding the gathering?

Well, in terms of numbers, my general recommendation is 10 or less. Because I think once you get 10, 20, 30 people, it's hard to control the relative risk of having one person in that group who might have asymptomatic COVID-19. So I would say smaller gatherings, less than 10, are probably safer. It's really hard to manage the risk when you get into larger gatherings.

Larger rooms with good ventilation-- doesn't have to be outdoors in the freezing cold, but trying to make sure that there's circulation and ventilation. And then not having prolonged, unmasked time-- so prolonged, close contact where you're unmasked is a higher risk.

And if we do end up doing a virtual visit, either because of issues of distance or what have you, how do we make a good virtual visit? Is there a regularity that we should be doing every week, every few days to try to help combat those feelings of isolation and loneliness?

One thought that I've heard from a family recently was to have a large screen. And there's ways you can click your laptop or your phone into a large screen, and people can almost look life size on the TV in the room with you. So that's a nice, I think, way to enhance the experience. Making sure you have good audio and good Wi-Fi connectivity. I think it's hard to convert a virtual experience to in-person. But if you're really worried about somebody's risk in the group, those are the ideas that I've heard.

Should we be trying to do connections with elderly loved ones at least once a week?

I think the old fashioned phone can be almost as good as video. Sometimes the video is harder for elderly folks to manage or concentrate on. So the habit I am in with my own mom is to talk three or four times a week by phone. Once a week, we do a video. It's the frequency of the contact, but also finding someone locally who can give some in-person love and affection to that person.

I do think that frequency matters. If we never do virtual visits and then on Thanksgiving and other holidays, that's when we want to do it, it can make it much harder. I think we need to get to build in that experience as well as familiarity with the technology. Sometimes we forget it can take a little longer when you're older. And I don't think we're always doing that. Wouldn't you agree?

Right. I think one silver lining all of this is to recognize how vulnerable these folks are and how much they love to have frequent contact with their loved ones. I hear a lot from my patients that they desperately miss their grandchildren. And why should they have a will to live if they can't see their grandkids? So some way of connecting that elderly person with their grandkids can be some of the most joyful moments that person has in their short life.

So maybe a limited physical visit, some type of virtual visit-- any other strategies or ideas to share?

I just saw one recently, an article about physical contact. That if you, again, wear masks and are limited, have the grandparent kiss the child from the back. Kiss them in the back of their head so they're not breathing on each other. And some limited physical contact-- hugs around the waist are much safer than hugs unmasked face to face. So finding a way to have some physical affection kind of makes life worth living. And I think you can find ways to lessen the risk.

And what about bringing them into the household if they're not already living in the same household for a holiday gathering? Just let's remind everyone again what those safeguards are.

Right. So there's a lot of growing literature, both in the health care environments, but also on airplanes, for example, that constant masking with physical distance renders an environment quite safe. So I think an indoor gathering with a small number of people-- say, 5 to 10 people-- with masking and reasonable distance is not zero, but it's quite safe for the benefits of having that love and time together.

Well, Dr. De Jonge, I want to thank you for sharing your insights. Thank you for all the work that you're doing with elderly patients across the region. And we'll look forward to checking in with you as we think up some new ideas as well to address these feelings of loneliness and isolation.

Thanks, John. Enjoy the holidays.

And thank you for watching "Coronavirus in Context."