Coronavirus Disrupts Routine for Dementia Patients” includes quotes from Element Care’s physician Dr. Eric Reines. [Lynn Daily Item]

She used to see her daughter and grandson every Sunday, go to church, and even help cook dinner that night if it was a recipe she is familiar with. But there are no more visits, no more church, and no more trips to places like the grocery store due to the pandemic of COVID-19.

Lynn resident Sam is his wife’s caretaker. She suffers from Alzheimer’s disease and the resulting dementia, but, under usual circumstances, the couple maintains a sense of normalcy by having a routine. Sam did not wish to identify himself or his wife by name.

“It’s not so much that routine helps her memory, it’s more that it gives her joy, a sense that there are people that come see her and care,” Sam said.

Sam said his wife has barely left the house since the coronavirus outbreak, and he has minimized his trips out of the home because he’s worried about getting them both sick in their old age. He has made lots of phone calls to friends and family, and always gets his wife on the phone, but it’s not the same as the frequent in-person visits.

“She asks (where her daughter is), and she asks when she’s coming,” Sam said. “It’s sad to hear, and there’s no sense in saying, ‘I’m sorry, we don’t know when she’s coming back.’”

A lack of regular communication has been the most difficult of the COVID-19 pandemic for his wife, Sam said, and the rest of their days haven’t been that different than normal. They wake up around the same time each day, and do things in a very specific order. They get dressed, then eat breakfast sitting in the same seats they do every day, with the television always on in the background.

“It can get tough trying to figure out what the rest of the day is like. We are watching a lot on TV,” he said.

Dr. Eric Reines is a physician with the nonprofit healthcare organization Element Care, which serves the elderly throughout Essex County and northeastern Middlesex County, with four offices in Lynn, and other locations in Beverly, Gloucester, Lowell, and Methuen. Reines has provided geriatric care to dementia patients at their homes, at Element Care offices, and at nursing homes during his past 12 years with the organization, and said having a normal routine is critically important.

“Right now, it’s rough. It’s a heartbreaking situation,” said Reines.

Element Care’s day care services are closed right now, and visitors are not allowed at its nursing homes, except in extreme situations such as end-of-life visits. And, for the many seniors with dementia who are confined to their homes right now, they can’t have visitors like children and grandchildren to brighten their days.

“The biggest thing is family and loved ones can’t visit. We try to set up ways to Facetime or Zoom or Skype between people with dementia and their families,” Reines said. “Sometimes families will visit just to knock and wave through a window, but, on a case-by-case basis, sometimes that can be more upsetting than no visit at all.”

Reines said people with dementia may not understand why they haven’t been visited. It’s also difficult that caregivers are getting sick, and strangers will have to fill in, confusing dementia patients. For those with very poor memory, doctors may even suggest that caregivers tell a white lie.

“If the memory is bad enough, you can tell them, ‘They were just here yesterday, they can visit tomorrow,’” Reines said. “I don’t like to tell white lies, but sometimes that’s the better part of the battle.”

People with dementia staying inside are being given activities like watching TV, doing puzzles, and playing word games. Objects that are familiar to them, or pictures, can be helpful in keeping a small sense of familiarity in their lives, Reines said.

“Some (people) are getting listless, just lying in bed, depressed,” Reines said. “Some insist on getting more upset if they are being held back.”

Reines said “it’s not worth the fight” if a person with dementia gets extremely upset and needs to go out for a walk. He added they should be wearing masks, and even gloves and goggles — that can be confusing as well — and staying 6 feet from others.

“Really, routine is important. If whatever part of routine is something you can still maintain, do that,” he said.

There are so many “unknowns” when it comes to COVID-19, Reines said, and that also applies to dementia patients. It’s unknown how long the pandemic will last before their routines may resume, and it’s unknown if they will be affected long-term by the current lack of normalcy.

Making sure that people with dementia are as comfortable as possible, while also minimizing the possibility of them getting sick, is about all that can be done.

The Changing Face of Aging Well [Merrimack Valley Magazine]

The Changing Face of Aging Well

Today’s baby boomers think differently than earlier generations about what it means to age well. They want to remain independent, stay mentally and physically fit and maintain a wide array of interests. At the same time, achieving optimal health is no easy task for many of them, especially for those on fixed incomes who are challenged by the high cost of health care. 

Many boomers and other older adults ponder, “How do I continue being me and doing the things that I love when my income drops, my network gets smaller and many health care options are beyond my means?” says Bruce Jankowitz, director of marketing at Element Care, a nonprofit organization that provides health care to low-income adults 55 and older in the Merrimack Valley through its Program of All-Inclusive Care for the Elderly (PACE). “Today’s older adults want the best of both worlds,” continues Jankowitz, “[They want] health care that helps them to stay independent and live in their homes and communities for as long as possible and cool activities so they can continue to do the things they love.”   

Over the last few years, Element Care has used the PACE model to address the changing needs and expectations of its clients. Participants joining the program have access to services that help them stay active. For example, participants can receive avatar home companions — electronic pets such as virtual cats or dogs that operate on a 4G network. These electronic pets play games with their owners, provide reminders to exercise and take medications and allow 24/7 monitoring for signs of distress.

“About 25% [of participants] are using the new technology,” Jankowitz says. “From keeping them happy and active to reminding them to take their medication, Element Care is adapting to a new generation of boomers.”

Element Care’s other programs include cooking classes; the PACE Olympics; Latino music, dancing, dominoes and food in Lowell and Methuen; and special events for the Cambodian New Year including past performances by the Angkor Dance Troupe. 

“The paradigm for aging well is changing and Element Care continues to innovate to engage older adults of all ages and cultures,” says Jankowitz. This commitment to innovation is on display at the PACE Element Care wellness center on Central Street in Lowell and at Ingalls Court in Methuen. There, an entire team of clinical and social service professionals proactively manage the health care of their participants. Element Care provides everything they need to age well, including primary, specialty, hospital and dental care; physical and occupational therapy; transportation to all medical appointments; and hosting activities that address the changing needs of older adults. There are no monthly premiums, copays or out-of-pocket expenses for those who qualify for Medicare and MassHealth. Medicare only and private pay options are also available.

There are other challenges that face boomers at any income level. Their generation faces an epidemic of obesity and diabetes. Alzheimer’s and dementia rates are skyrocketing. Increased traffic congestion in our area can make it feel as though the roads are less safe (although this isn’t necessarily clear from the data). And who knows what changes to our health care system will create unforeseen consequences as more and more boomers head into retirement?

Still, what matters most is that boomers seem unwilling to accept the old stereotypes about what it means to live and thrive in life’s later decades. How they, and we as a society work together to facilitate this process is a challenge we avoid facing at our own peril

Direct care workers are key to prompt action for long-term care patients with sepsis

[Betsy Lehman Center for Patient Safety]
Eric J. Reines, M.D.,is a practicing internist at Element Care in Lynn, Massachusetts. He specializes in geriatric medicine and sees patients enrolled in the Massachusetts Program of All-inclusive Care for the Elderly (PACE)The goal of PACE is to allow eligible patients who would otherwise need to live in skilled nursing facilities to remain in their homes and receive needed medical, social, recreational and wellness services. Dr. Reines serves as an advisor to the Massachusetts Medical Society’s Committee on Geriatric Medicine and on the Steering Committee that developed recommendations and toolkits recently released by the Massachusetts Sepsis Consortium.
The Betsy Lehman Center: Thanks to you and others, the Massachusetts Sepsis Consortium has developed recommendations for sepsis prevention and early recognition in post-acute care. There is now a great deal of focus on preventing and recognizing COVID-19. When it comes to long term health care settings, in what ways do the two concerns align?Dr. Reines: Indeed, there is synergy between practices to address both sepsis and COVID-19. The basic premise for people in long term care — the elderly, disabled or younger patients with multiple diseases — is to do all you can to prevent them from getting infections, such as influenza, pneumonia, pertussis and certainly COVID-19, on top of the health problems they already face. Everyone should take advantage of available vaccines and practice good health habits: washing our hands and coughing into our elbow, for example. Remember that sepsis is the body’s overreaction to infection. It’s not an infection itself, but avoiding infection also helps prevent sepsis.

Prevention is best; you want to do everything you can to avoid giving infections to people who are already ill.

To address COVID-19, nursing facilities must screen all professionals and visitors, if any, for travel history and current illness. At my practice and at PACE sites, we’ve been screening people at the door for flu symptoms every winter season. Prevention is best; you want to do everything you can to avoid giving infections to people who are already ill.The Betsy Lehman Center: There are some overlaps in the symptoms of COVID-19 and sepsis. When educating providers and staff about the need for quick action, is it important to draw distinctions between the two?Dr. Reines: The most important thing we can do is to encourage all caregivers to speak up when they notice changes that may signal infection or sepsis. Elderly patients often do not give the same signs that we see in younger people. It’s critical for direct care workers to be alert to changes in behavior or eating habits, to report what they observe to other clinicians and to feel confident that they’ll be heard. Whether changes signal early sepsis, COVID-19 or a different infection, caregivers who are in close interaction with patients — changing diapers, helping them eat and get dressed — are often the first to know. We must pay attention to our direct care workers who know our patients well, whether they be aides, nurses, family members or close friends; we must value them and listen to them. Changes in behavior may or may not be due to infection or sepsis; that’s up to a clinician to decide after evaluating the patient. The earlier we know there may be a problem, the better.

We must pay attention to our direct care workers who know our patients well, whether they be aides, nurses, family members or close friends; we must value them and listen to them.

The Betsy Lehman Center: Collecting meaningful data on the prevalence and progression of sepsis has proved a challenge in all settings, which can make it more difficult to focus resources on improving sepsis outcomes. Do you have thoughts on ways to underscore the importance of advancing sepsis care?Dr. Reines: I will say again that for patients in long term care it’s most important to recognize a change in condition and then evaluate the patient appropriately. Defining sepsis — which we must do to collect meaningful data — gets technical and arcane, even for physicians. Direct care workers, who play a critical role, don’t need to know how to diagnose and treat sepsis, which evolves along a continuum. It starts with an initial infection — say, in the bladder — that may spread to the kidneys and into the bloodstream. The body’s automatic response is sometimes helpful and sometimes, when uncontrolled, can result in sepsis.Recognizing and responding to signs of change early can help, but in the case of advanced sepsis, not always. It is not always possible to save people, especially if they have serious underlying health problems. There seems to be an acceptance of death when it follows a heart attack or cancer, but not following infection, which brings up another important topic.Everyone and especially those near the end of life should talk with their loved ones about what they would like done when they are not able to make their own decisions. As a physician, I want to be able to make the right decisions for patients and families. It helps to know the patient’s priorities and wishes. We should do everything possible to prevent and treat sepsis and also prepare for the difficult decisions that we sometimes face.The Betsy Lehman Center: You served on the Steering Committee for the Sepsis Consortium that produced the new report, recommendations and toolkit for sepsis identification. What are the most important takeaways from that work for your peers? Where should they start?Dr. Reines: First, I want to acknowledge the Betsy Lehman Center, and our project leader, Lisa Conley, for bringing the Post-Acute Steering Committee together and for polling providers to understand current practices. It’s an important topic, and I’m glad we were able to address it together.I come back again to supporting direct care workers, at home as well as in nursing facilities. They are the ones who will first notice that something is “off.” If they don’t understand the significance of their observations or don’t feel empowered to say something to a nurse or another clinician, we miss an opportunity to address problems early, when we can be most effective.The Betsy Lehman Center: The post-acute care provider community has also faced challenges when it comes to ensuring that all staff members get their annual flu shots. Do you see any signs that the current COVID-19 outbreak is raising greater awareness of the need for vaccination or infection control in general?Dr. Reines: The families and friends of my patients in nursing homes have accepted the order not to visit. This is heartbreaking, but they realize the necessity. All staff at our hospital are required to wear a surgical mask throughout their shift, and this rule may soon come to our nursing homes. The clamor for a vaccine against the coronavirus is making many rethink their objections to the flu vaccine. Regarding flu vaccine, I think we should work to better understand the socioeconomic factors that influence health and help our direct care workforce make good decisions for their own well-being, as well as the health of their family members, coworkers and patients. Long term care facilities are often understaffed, which is a big problem. Direct care workers receive low pay and often not much respect. They may feel they need to work while sick or have trouble accessing childcare during this difficult time. These are societal issues that impact health for everyone.