Tag Archives: Judith Graham

The New Digital World Can Give Seniors A Hard Time

Family gatherings on Zoom and FaceTime. Online orders from grocery stores and pharmacies. Telehealth appointments with physicians.

These have been lifesavers for many older adults staying at home during the coronavirus pandemic. But an unprecedented shift to virtual interactions has a downside: Large numbers of seniors are unable to participate.

Among them are older adults with dementia (14% of those 71 and older), hearing loss (nearly two-thirds of those 70 and older) and impaired vision (13.5% of those 65 and older), who can have a hard time using digital devices and programs designed without their needs in mind. (Think small icons, difficult-to-read typefaces, inadequate captioning among the hurdles.)

Many older adults with limited financial resources also may not be able to afford devices or the associated internet service fees. (Half of seniors living alone and 23% of those in two-person households are unable to afford basic necessities.) Others are not adept at using technology and lack the assistance to learn.

During the pandemic, which has hit older adults especially hard, this divide between technology “haves” and “have-nots” has serious consequences.

Older adults in the “haves” group have more access to virtual social interactions and telehealth services, and more opportunities to secure essential supplies online. Meanwhile, the “have-nots” are at greater risk of social isolation, forgoing medical care and being without food or other necessary items.

Dr. Charlotte Yeh, chief medical officer for AARP Services, observed difficulties associated with technology this year when trying to remotely teach her 92-year-old father how to use an iPhone. She lives in Boston; her father lives in Pittsburgh.

Yeh’s mother had always handled communication for the couple, but she was in a nursing home after being hospitalized for pneumonia. Because of the pandemic, the home had closed to visitors. To talk to her and other family members, Yeh’s father had to resort to technology.

But various impairments got in the way: Yeh’s father is blind in one eye, with severe hearing loss and a cochlear implant, and he had trouble hearing conversations over the iPhone. And it was more difficult than Yeh expected to find an easy-to-use iPhone app that accurately translates speech into captions.

Often, family members would try to arrange Zoom meetings. For these, Yeh’s father used a computer but still had problems because he could not read the very small captions on Zoom. A tech-savvy granddaughter solved that problem by connecting a tablet with a separate transcription program.

When Yeh’s mother, who was 90, came home in early April, physicians treating her for metastatic lung cancer wanted to arrange telehealth visits. But this could not occur via cellphone (the screen was too small) or her computer (too hard to move it around). Physicians could examine lesions around the older woman’s mouth only when a tablet was held at just the right angle, with a phone’s flashlight aimed at it for extra light.

“It was like a three-ring circus,” Yeh said. Her family had the resources needed to solve these problems; many do not, she noted. Yeh’s mother passed away in July; her father is now living alone, making him more dependent on technology than ever.

When SCAN Health Plan, a Medicare Advantage plan with 215,000 members in California, surveyed its most vulnerable members after the pandemic hit, it discovered that about one-third did not have access to the technology needed for a telehealth appointment. The Centers for Medicare & Medicaid Services had expanded the use of telehealth in March.

Other barriers also stood in the way of serving SCAN’s members remotely. Many people needed translation services, which are difficult to arrange for telehealth visits. “We realized language barriers are a big thing,” said Eve Gelb, SCAN’s senior vice president of health care services.

Nearly 40% of the plan’s members have vision issues that interfere with their ability to use digital devices; 28% have a clinically significant hearing impairment.

“We need to target interventions to help these people,” Gelb said. SCAN is considering sending community health workers into the homes of vulnerable members to help them conduct telehealth visits. Also, it may give members easy-to-use devices, with essential functions already set up, to keep at home, Gelb said.

Landmark Health serves a highly vulnerable group of 42,000 people in 14 states, bringing services into patients’ homes. Its average patient is nearly 80 years old, with eight medical conditions. After the first few weeks of the pandemic, Landmark halted in-person visits to homes because personal protective equipment, or PPE, was in short supply.

Instead, Landmark tried to deliver care remotely. It soon discovered that fewer than 25% of patients had appropriate technology and knew how to use it, according to Nick Loporcaro, the chief executive officer. “Telehealth is not the panacea, especially for this population,” he said.

Landmark plans to experiment with what he calls “facilitated telehealth”: nonmedical staff members bringing devices to patients’ homes and managing telehealth visits. (It now has enough PPE to make this possible.) And it, too, is looking at technology that it can give to members.

One alternative gaining attention is GrandPad, a tablet loaded with senior-friendly apps designed for adults 75 and older. In July, the National PACE Association, whose members run programs providing comprehensive services to frail seniors who live at home, announced a partnership with GrandPad to encourage adoption of this technology.

“Everyone is scrambling to move to this new remote care model and looking for options,” said Scott Lien, co-founder and chief executive officer of the company, which is headquartered in Orange County, California.

PACE Southeast Michigan purchased 125 GrandPads for highly vulnerable members after closing five centers in March where seniors receive services. The devices have been “remarkably successful” in facilitating video-streamed social and telehealth interactions and allowing nurses and social workers to address emerging needs, said Roger Anderson, senior director of operational support and innovation.

Another alternative is technology from iN2L (an acronym for It’s Never Too Late), a company that specializes in serving people with dementia. In Florida, under a new program sponsored by the state’s Department of Elder Affairs, iN2L tablets loaded with dementia-specific content have been distributed to 300 nursing homes and assisted living centers.

The goal is to help seniors with cognitive impairment connect virtually with friends and family and engage in online activities that ease social isolation, said Sam Fazio, senior director of quality care and psychosocial research at the Alzheimer’s Association, a partner in the effort. But because of budget constraints, only two tablets are being sent to each long-term care community.

Families report it can be difficult to schedule adequate time with loved ones when only a few devices are available. This happened to Maitely Weismann’s 77-year-old mother after she moved into a short-staffed Los Angeles memory care facility in March. After seeing how hard it was to connect, Weismann, who lives in Los Angeles, gave her mother an iPad and hired an aide to ensure that mother and daughter were able to talk each night.

Without the aide’s assistance, Weismann’s mother would end up accidentally pausing the video or turning off the device. “She probably wanted to reach out and touch me, and when she touched the screen it would go blank and she’d panic,” Weismann said.

What’s needed going forward? Laurie Orlov, founder of the blog Aging in Place Technology Watch, said nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services — something that many lack.

“We need to enable Zoom get-togethers. We need the ability to put voice technology in individual rooms, so people can access Amazon Alexa or Google products,” she said. “We need more group activities that enable multiple residents to communicate with each other virtually. And we need vendors to bundle connectivity, devices, training and service in packages designed for older adults.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

What Does Recovery From Covid19 Look Like?

Reports of recovery from serious illness caused by the coronavirus have been trickling in from around the world.

Physicians are swapping anecdotes on social media: a 38-year-old man who went home after three weeks at the Cleveland Clinic, including 10 days in intensive care. A 93-year-old woman in New Orleans whose breathing tube was removed, successfully, after three days. A patient at Massachusetts General Hospital who was taken off a ventilator after five days and was doing well.

“Patients are definitely recovering from Covid-19 ARDS [acute respiratory distress syndrome] and coming off vents,” Dr. Theodore “Jack” Iwashyna, a professor of pulmonary and critical care medicine at the University of Michigan, wrote on Twitter recently.

But the outlook for older adults, who account for a disproportionate share of critically ill COVID-19 patients, is not encouraging. Advanced age is associated with significantly worse outcomes for older patients, and even those who survive are unlikely to return to their previous level of functioning.

According to a new study in The Lancet based on data from China, the overall death rate for people diagnosed with coronavirus is 1.4%. But that rises to 4% for those in their 60s, 8.6% for people in their 70s and 13.4% for those age 80 and older.

How often do people who are critically ill recover? According to a report from Britain out last week, of 775 patients with COVID-19 admitted to critical care, 79 died, 86 survived and were discharged to another location, and 609 were still being treated in critical care, with uncertain futures. Experts note this is preliminary data, before a surge of patients expected over the next several weeks.

According to a just-published small study of 24 critically ill COVID-19 patients treated in Seattle hospitals, 50% died within 18 days. (Four of the 12 who died had a do-not-resuscitate order in place.) Of those who survived, three remained on ventilators in intensive care units, four left the ICU but stayed in the hospital, and five were discharged home. The study appeared in the New England Journal of Medicine.

What does recovery from COVID-19 look like? I asked Dr. Kenneth Lyn-Kew, an associate professor of pulmonology and critical care medicine at National Jewish Health in Denver, named the No.1 respiratory hospital in the nation last year by U.S. News & World Report. Our conversation has been edited for length and clarity.

Q: What’s known about recovery?

It’s helpful to think about mild, moderate and severe disease. Most people, upwards of 80%, will have mild symptoms. Their recovery typically takes a couple of weeks. They might feel horrible, profoundly fatigued, with muscle aches, a bad cough, a fever and chest discomfort. Then, that goes away. Also, there are some people who never have symptoms, who never even know they had it.

Q: What about people with moderate illness?

Because we’re so early into this, we have less information about these patients. Often, they spend a few days in the hospital. People feel more short of breath: Sometimes, an underlying condition like asthma is exacerbated. Typically, they need a bit of oxygen for a few days.

Also, there are patients who have high fevers or severe diarrheal illness with COVID-19. Those patients can get dehydrated and need IV fluids.

There also appears to be a small population of people who can develop myocarditis ― inflammation of the heart. They come in with symptoms that mimic heart attacks.

Q: How long do these patients stay hospitalized?

It can vary. Some people get a little oxygen and IV fluid and leave the hospital after two to three days. Some of these moderate patients start to look a little better, then all of a sudden get a lot worse and decompensate.

Q: What about patients with serious illness?

Many of the sickest patients have acute respiratory distress syndrome [ARDS, a disease that floods the lungs with fluid and deprives people of oxygen]. These are the patients who end up on mechanical ventilators.

Those least likely to recover seem to be frail older patients with other preexisting illnesses such as COPD [chronic obstructive pulmonary disease] or heart disease. But there’s no guarantee that a young person who gets ARDS will recover.

ARDS mortality is usually between 30% and 40%. But if you break that down, people who have ARDS due to trauma — for instance, car accidents ― tend to have lower death rates than people who have ARDS due to infection. For older people, who tend to have more infections, mortality rates are much higher — up to 60%. But this isn’t COVID-specific data. We still have a lot to learn about that.

Q: If someone is sick enough to need ventilation, what’s involved?

People usually need a couple of weeks of mechanical ventilation.

Ventilation is very uncomfortable for many people and they end up on medication to make them more comfortable. For some people, just a bit of medication is enough.

Other people require heavier doses of medications such as narcotics, propofol, benzodiazepines or Precedex [a sedative]. Because they act on your brain, these medications can induce delirium [a sudden, serious alteration in thinking and awareness]. We really try to minimize that because delirium has a significant impact on a person’s recovery.

Being on more medication affects other things also: a patient’s sleep-wake cycle. Their mobility, which can make them weaker. It can slow down their gastrointestinal tract so they don’t tolerate nutrition as well and get suboptimal nutrition. Many of these patients end up having PTSD [post-traumatic stress disorder] and impaired concentration afterwards.

Q: When can someone go off a respirator?

There are three criteria. They have to be awake enough to protect their swallowing mechanism and their airway. They have to have a low enough need for oxygen that I can support that with something else, such as nasal prongs. And they have to be able to clear enough carbon dioxide.

Q: What will a patient look like at the end of those two weeks?

That depends. If we’re able to do everything right, these people are up and walking around with the ventilator. Those patients come out on the other end looking pretty good. Maybe they’ll have some weakness, some weight loss, a little PTSD.

The patients who are sicker and more intolerant of the technology, they tend to come out weak, forgetful, confused, deconditioned, maybe not even able to get out of bed. Sometimes, in spite of our best efforts, they’ll have skin wounds.

Some of these patients have significant lung fibrosis ― scarring of the lungs and reduced lung function. This might be a short-term part of their recovery or it could be long-term.

Q: Are there special considerations for older adults?

Older adults tend to have more preexisting illnesses that put them at more risk for complications. Their immune system is less robust. They’re more prone to secondary infections such as pneumonia in spite of everything we do to prevent that.

Frailty is an important factor as well. If you come in frail and weak, you have less reserve to fight this through.

Q: When are people ready to be discharged?

You can go home on supplemental oxygen if you still need that kind of assistance. But you need to be able to feed yourself and move around or, if you have more disability, have someone to provide that for you.

Some people spend a couple of weeks in the ICU, then two to three days on a medical/surgical ward. Other people take another week or two to regain some strength. Some will go to an acute rehabilitation facility to get rehab three times a day. Others can go to a skilled nursing facility, where they’ll get rehab over a couple of months and then go home.

Q: Who’s unlikely to recover?

That we just don’t know yet. When we sit down after all this and look at everything afterwards, we can pull up those patterns.

In the ideal world, I wish I could predict who would do well and who wouldn’t, so I could talk to them and their family and have an honest conversation.

Q: Are other factors complicating recovery?

With such a high number of sick people, it’s harder to do things to maximize recovery, such as bringing in physical therapy and occupational therapy. People aren’t able to get as much therapy because there are only so many therapists and some hospitals are limiting who can come in.

COVID-19 is really a nasty disease because of its infectiousness. It isolates people from a lot of things they need to get better — perhaps, most importantly, their family, whose support is really critical along with all the other things I’ve talked about here.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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