Caring for older patients in a pandemic

Equipping home care and nursing home staff with more clinical skills and using telemedicine allow the frail elderly to be cared for where they live and not be hospitalised

I was greeted by the incessant call of an elderly woman when I entered the ward that isolated patients at risk of Covid-19 while they were awaiting their test results.

Crying out in a jumbled assortment of Cantonese and Malay, I could make out the "tolong" (help me in Malay) and "awe see" (clear bowels in Cantonese).

As I moved in closer, she pulled me towards her and clamoured to be brought to the toilet. I noticed she had already soiled herself but, nonetheless, transferred her to a commode with the help of my colleague and wheeled her to the toilet.

She repeatedly pleaded to go home and I assured her that she could as soon as she was well. She suffered from a previous stroke and dementia, and had presented to the hospital with diarrhoea. She had a slight fever and acknowledged having a cough when asked. Given the protean manifestations of Covid-19, gastrointestinal symptoms should be considered too. She was hence admitted as a Covid-19 suspect patient and would be discharged if she tested negative twice.

By now, a nurse had come to assist me but she continued to hold me tightly, refusing to let me go, perhaps because I spoke Cantonese and understood her. She implored me to discharge her as she failed to understand why she needed to be in the hospital. I managed to assuage her distress after I convinced her I would call her family to take her home. As I turned away from her, I wondered if we could do more for mentally and physically frail patients like her in these challenging times.

The recent surge in Covid-19 patients has required hospitals to repurpose some wards to house Covid-19 positives and suspects, redeploy staff to accommodate new workflows and implement strict infection control measures such as cohorting and isolating patients to minimise the risk of cross-infection. These measures, which are necessary to cope with a new disease of pandemic proportions, also call for greater attention to frail seniors who need help in their daily needs.

Admitting her to test for Covid-19 is fitting in these pandemic times. Furthermore, older people with persistent diarrhoea have a heightened risk of dehydration, consequent kidney failure and cardiovascular instability, which need to be monitored closely.

But vulnerable seniors may experience limited freedom and mobility, and increased confusion, in unfamiliar hospital wards. Those with dementia and physical disabilities also require more individualised care.

On a usual day, these patients get by with additional attention from staff, having family caregivers and domestic helpers to assist in their care, and volunteers who provide companionship and engage them in pleasurable activities.

However, in these pandemic times when manpower is lean and visitors or volunteers are not permitted, we have to be mindful of the risk of functional decline in frail seniors.

What solutions can we work towards for these vulnerable seniors during pandemic times?

Importantly, ensuring that seniors have access to adequate medical and nursing care at home would allow them to avoid unnecessary hospital episodes. Home care capacity in Singapore has been progressively upscaled in recent years to better meet the needs of frail seniors with multiple chronic illnesses.

Broadening the capabilities of home care to include acute conditions may help seniors reduce hospitalisation and save costs. Uncomplicated infections - for example, cellulitis (skin infection) and urinary tract infections - in clinically stable patients can potentially be treated at home under the watchful eyes of family members and medical professionals who visit regularly and monitor the patient's progress via medical devices and telephone calls.

However, in these pandemic times when manpower is lean and visitors or volunteers are not permitted, we have to be mindful of the risk of functional decline in frail seniors.

Other conditions, including uncomplicated head injuries, acute gout attacks and even mild heart failure, can likewise be managed with the patient at home.

In addition, initiatives that facilitate hospital discharge, such as the early discharge programme in Khoo Teck Puat Hospital, allow patients to continue to receive medical treatment at home after a short hospital stay. A pandemic provides the impetus for the "hospital-at-home" model of care to be advanced further to care for vulnerable seniors in the comfort and familiarity of their own homes. These benefits can be reaped even beyond pandemic times.

Seniors residing in nursing homes are often admitted to acute hospitals when they become ill. Extending the capabilities of nursing homes to manage acute and sub-acute medical illnesses, where appropriate, can allow some nursing home residents to be cared for in-house even when new ailments arise.

A fine example is the gericare@north programme whereby staff in nursing homes are trained in the fundamentals of clinical medicine, including physical examination and the use of a stethoscope.

Empowered with enhanced clinical skills, these staff can act as a bridge between hospital specialists and nursing home residents to help care for the residents without the need for hospital stays.

Nursing homes under this initiative leverage on videoconferencing technology via a telegeriatrics platform for elderly residents to seek treatment remotely from geriatric medicine specialists.

Vulnerable seniors may experience limited freedom and mobility, and increased confusion, in unfamiliar hospital wards, says the writer. He adds that those with dementia and physical disabilities also require more individualised care. ST PHOTO: KELVIN CHNG

Palliative care can also be provided under this platform to allow terminally ill patients to receive holistic and dignified end-of-life care in the nursing home. Covid-19 has led to a surge in demand for telemedicine as a means to ensure care continuity from the hospital to the community and even to patients' homes.

As such, the role of telegeriatrics can be expanded even after Covid-19 to support patients cared for in nursing homes and in their own homes where they typically do better unless they are severely ill.

The Cantonese woman tested negative for Covid-19 and was discharged the next day, with her diarrhoea gradually resolving.

However, we can sympathise with her for having to bear with isolation in an unfamiliar space, disrupted sleep and wearing diapers for the first time as an adult.

The cabin crew of Singapore Airlines, recently redeployed as care ambassadors in hospitals, have started to lend their assistance in our wards. The experience has been positive as both patients and staff value their thoughtful and caring attention to the needs of patients. So, while the care ambassadors start as novices in healthcare, we can surely learn the art of client-centredness from them. We hope that it will be a partnership that endures beyond the Covid-19 pandemic.

Similarly, many telemedicine practices being tried out now in homes and nursing home care can continue beyond this pandemic. This way, more of our elderly people can receive medical care at home where they are more likely to be comfortable.

 • Associate Professor Philip Yap is a senior consultant in the department of geriatric medicine at Khoo Teck Puat Hospital.

A version of this article appeared in the print edition of The Straits Times on May 23, 2020, with the headline 'Caring for older patients in a pandemic'. Print Edition | Subscribe