Marsha Pallanck used to be a social butterfly in her Carmichael assisted living facility. Her best friend Kathy Midgley, who lives in Rocklin, says she was so busy, it was hard to get her on the phone.
“She’d play bingo after dinner and at about 7:10 that was the best time to reach her,” Midgley said. “Because otherwise she wasn’t in her room except to go brush her teeth and then go to the next activity.”
But Aegis Living Carmichael cancelled bingo and other social events due to COVID-19. So Pallanck started passing the time on a chair in her doorway.
“And she just sits there and looks out, and when people go by, ‘Hi! How are ya?’”
Most California facilities are asking residents to stay in their rooms. They’re also canceling visiting hours, group dining, and anything that could put vulnerable seniors at risk of infection. More than 250 of the state’s 1200 skilled nursing facilities have had a COVID-19 outbreak.
Many people with a loved one in a facility are concerned about the toll this isolation period is taking. Experts and advocates say as senior care homes take steps to prevent disease, they also need to find ways to help residents connect with each other, and with the outside world.
Donna Jensen, a social worker in Sacramento State’s gerontology department, said without support, seniors might become overwhelmed or depressed by news about coronavirus.
“For those who might already be on a borderline of ‘why am I here? I’m just a burden on people,’ those messages might just be worsening the issues they’re dealing with,” she said. “The ways people have coped or kept themselves healthy, all those things have changed.”
‘Out of Control’
Midgley and Pallanck met 15 years ago, in a local widowers’ group. They started grabbing coffee after meetings, and the friendship stuck.
Now 71 and 74, the two continue to provide support for one another. When Pallanck was diagnosed with Alzheimer’s disease a few years ago and became unable to function independently, Midgley looked at assisted living communities for her friend.
She was thrilled, but not surprised, that Pallanck immediately fit in at Aegis Living Carmichael.
“She’s very sweet, and she listens carefully,” Midgley said. “She trusts everybody, and everybody who meets her loves her.”
But now, Midgley says Pallanck’s usual spark is fading, along with her memory.
It started with confusion on the phone. Pallanck would put the phone down during a call, only to cry out minutes later because she’d lost the receiver. She keeps asking why she’s stuck inside, no matter how many times Midgley explains it.
Then last week, Pallanck began hallucinating that she was leaving her room to help other residents. Midgley brought her to the hospital, and doctors recommended a medication change.
“The isolation has really caused her Alzheimer’s to spiral out of control,” Midgley said.
Because Pallanck left her assisted living facility, she now has to be in total quarantine for 14 days. That means no walks in the courtyard, and the door to the room stays closed.
“She’s really, really stuck in her room, and very confused,” Midgley said a few days after the hospital visit. “She’s called me twice already today thinking that she’s in the wrong room and asking when she can go back home again. It’s been pretty difficult.”
A Staffing Issue
There is a huge quality spectrum in California’s elder care system, ranging from run-down nursing homes to upscale senior living communities. The industry has a long history of low staffing levels and high turnover, which makes it difficult to give residents one-on-one care.
Jensen at Sacramento State said facilities are now scrambling to meet basic needs such as meals and medication, which doesn’t leave much time for mental health.
“The residents need care - and not just physical care, they need psychological care,” she said. “Yet the best of times it’s difficult to fully staff the skilled nursing communities and assisted living communities, so I think this hardship has kind of tipped the tide.”
There are two main types of homes. Skilled nursing facilities offer supportive services such as medication and hygiene help, and typically receive payment from Medi-Cal and Medicare. The state also oversees “continuing care retirement communities,” like the one Pallanck is in, which focus on independent living and often require an entrance fee.
A 2018 state audit found that inadequate regulation of skilled nursing facilities has led to negative quality measures, such as infection outbreaks, abuse and more residents being in physical restraints.
With nursing home doors closed to the public, advocates worry oversight will go out the window.
“The disaster that is happening in nursing homes is not surprising at all; nobody’s there to watch,” said Patricia McGinnis, director of California Advocates For Nursing Home Reform. “It’s been absolutely traumatic both for the residents and the family members of those residents.”
A trade association called the California Association of Health Facilities said in a statement that the COVID-19 outbreaks are not due to “inattentiveness or lapses in nursing homes,” and instead pointed to the “vicious nature of the virus and its unique threat to older adults with underlying health conditions.”
The association did note that the lack of staffing, personal protective equipment and testing has contributed to the disease’s spread.
“As the pandemic progresses, it is clear we need to shift the focus and deploy county, state and federal resources to the skilled nursing sector,” wrote CEO Craig Cornett in a press statement. “County and state assistance remains necessary to address staffing shortages resulting from worker exposure to COVID-19.”
Jeffrey Chico Ravago, a certified nursing assistant at a nursing home in Contra Costa County, said the pandemic has put additional strain on workers.
“Day shift is a fast-paced job, and if you’re short it’s harder,” he said “You have to do everything, shower, feed them twice, get them dressed and everything … It’s really stressful.”
Auditors have urged the California Department of Public Health, which regulates these facilities, to reform the system. By 2030, estimates show that one fifth of Californians will be seniors.
“This is not a short-term issue that we can put a bandaid on and get through,” Jensen said. “We need to look at some long-term, system-wide issues…and a lot of it honestly comes around funding.”
Staying Connected
Midgley’s conversations with Pallanck are hit or miss these days. Sometimes they can have a long chat about the news, their hair, what books they’re reading. Other times Pallanck seems distant and shaky.
When Midgley gets worried about what’s going on, she calls the staff at Aegis Living Carmichael to get more information. But she misses their weekly lunches.
“It’s been really frustrating to hear her frustration and her confusion and not be able to rush in and fix it,” she said. “I’m not a person that likes to feel powerless.”
The assisted living community sends Migley regular email updates with photos. Pallanck doesn’t do well with technology, but other residents have the option to video chat their families.
Chuck Schuringa, general manager of Aegis Living Carmichael, said they acquired five tablets at the start of the pandemic so they could help their 71 residents stay in touch with one another and with their loved ones.
“That’s been really critical for a lot of our family members,” he said. “I’ve facilitated a lot of those calls myself. Sometimes - well not sometimes, most of the time - they need a little help. But we’re happy to do it and we have the staffing to be able to facilitate that.”
But many nursing homes are not making the effort to keep families informed of what’s going on in the facility, said McGinnis with the advocacy organization. She’s been hearing from people all over the state who are blocked from visiting loved ones and can’t seem to connect with them at all.
“Family members don’t know what’s going on,” she said. “We’re getting calls about, ‘how can I get to see my mother? I think she’s dying’.”
Most facilities are making exceptions to allow people who are dying to see their families. Some homes are letting loved ones to talk to residents through a glass window, though not all facilities are set up to accommodate that.
McGinnis thinks seniors should be allowed to have one visitor each, which is the policy many hospitals are using for children in inpatient units, laboring mothers and adults undergoing surgery.
If nothing else, she thinks they can do more on the technology front.
“I talk to my granddaughter in Los Angeles every day,” she said. “Why can’t we do that in nursing homes?”
Most skilled nursing facilities didn’t have tablets and iPhones on hand before the pandemic, said DeAnn Walters, director of clinical affairs for the trade association.
“Obviously, the cost is quite high,” she said. “But residents are receiving donations, staff are providing some of their own devices so residents can use them. I highly encourage communities to band together to support residents in nursing homes and provide them with tablets so that we can enhance the lives of the residents.”
‘The Right Direction’
Lots of organizations are putting their heads together on ways to help seniors in nursing homes and skilled living facilities stay afloat.
On Wednesdays, a group of Sacramento-area volunteers gets in their cars and drives around to senior facilities with cheerful signs, costumes and decorations. They call it a “kindness parade”. Some senior homes have introduced robotic pets to combat social isolation.
Jensen of Sacramento State says there’s a key difference between being isolated and being lonely, and the latter is a much bigger problem. While lots of seniors do fine on their own, others are prone to chronic loneliness, which can be a major risk factor for suicide. It’s also been shown to reduce immune function.
To combat loneliness, loved ones should try to help the seniors in their lives find productive activities, such as crafts, virtual museum tours or reading, instead of passive ones such as watching TV, Jensen said.
“As we are trying to help our friends, our loved ones, our community members, being able to be creative in how we help engage others and help them find meaning and purpose in their lives is really important,” she said.
Physical activity is also crucial, she said.
Ravago, the certified nursing assistant, says staff are doing their best to look out for residents’ mental health.
“We’re all like their family member who takes care of them,” he said. “We talk to them, we’re friends with them. Sometimes we’ll play dominoes. We reassure them that you have someone to talk to.”
The LeadingAge California Foundation, which advocates for the state’s older adults, is using $2.6 million in state grant money to bring new software to 60 California nursing homes. The virtual program includes exercise videos, therapy, memory training, puzzles and virtual travel. The Alzheimer’s Foundation of America is offering free virtual classes for seniors, as well as online support groups for caregivers. Sacramento State gerontology students are using state grants to reach out to older, isolated adults to check on their wellbeing.
When the lockdown started, Midgley says she sent an email to all of Pallanck’s friends outside the facility and asked them to reach out.
“And I said ‘call her! You can get her in her room anytime now! Or send her a card or something to let her know you’re thinking of her’,’” she said.
She’s also been encouraging Pallanck to read and color, but the response is less enthusiastic than it used to be.
“She really needs to have a one-on-one,” Midgley said. “She has a desk with a light and everything where she can do something like that, but she just needs someone to get her pointed in the right direction, and that’s just not available right now.”
For the time being, Midgley’s doing the one thing that she’s sure makes Pallanck happy: a weekly delivery of candy and cookies to the assisted living facility’s front door.
“She has a real sweet tooth,” she said. “She loves Annabelle’s rocky road and York peppermint patties, and Rollo’s.”
She says she’ll keep calling Pallanck as often as she can, until they can reunite in person.
