Jerriann Hance meets with her husband, Danny, on the other side of a window on Monday, April 27, 2020, at the Springs Ranch Memory Care Community in Colorado Springs, Colo. Safe from the COVID-19 virus, loved ones can visit them through the windows in the sunroom. At the beginning of the coronavirus outbreak, Jerriann would take all the precautions and come to have dinner with Danny. Eventually, all in-person visitations were stopped. (Jerilee Bennett/The Gazette via AP)

For 81-year-old Elizabeth Funk, who lives in an assisted living apartment just south of Pittsburgh, Pennsylvania, social distancing has meant being confined to her room.

“At least I get out of the room three times a day to get food,” she said. “I understand that’s not the case for many places; I think that would be even worse.”

During the Covid-19 pandemic, the federal Centers for Disease Control and Prevention recommends restricting all visitation at nursing homes and assisted living facilities, with end-of-life situations among the few exceptions.

While the novel coronavirus results in mild illness for many — and in some cases no symptoms at all — older adults and those with underlying medical conditions are at higher risk for severe complications, including death, according to the CDC. As a result, outbreaks at long-term care facilities have been reported around the country over the last six weeks.

But those protective measures offer new challenges for the residents and the staffs caring for them.

“We know that folks in nursing homes, assisted living — they naturally will feel lonely,” said Teresa Morris, program director for the West Virginia Chapter of the Alzheimer’s Association. “In the middle of this, those feelings are significantly increased.”

Studies have shown loneliness and isolation can increase the risk of dementia, stroke, coronary artery disease and even death, she said.

“While we understand the safety measures of it, [eliminating visitation] really been the hardest part of all this,” said Lisa Haglund, interim chief executive officer of Heritage Ministries, a not-for-profit, faith-based organization that operates skilled nursing, assisted living and independent living facilities in New York, Pennsylvania, Illinois and Washington. “You’ve got to provide an alternative. Otherwise, what keeps people from slipping into depression?”

Going without visitation “changes the whole climate of how people engage with the outside world,” said Dr. Matthew McNabney, associate professor of medicine in the Johns Hopkins University Division of Geriatric Medicine and Gerontology.

Doing so affects residents’ ability to stay mentally engaged, which can manifest in a variety of ways, such as changes to eating and sleeping habits. Having their movements limited by efforts to prevent the spread of infection may discourage a resident from staying active, which can have a negative impact on their overall physical health, he said.

“Some of it’s more subtle, where people are maybe a little more confused,” McNabney said.

Funk lives at the Grand Residence of Upper St. Clair, Pa., where there used to be activities scheduled each day. She used to enjoy getting outside, and taking advantage of group van trips for shopping, luncheons or scenic drives.

Since the Covid-19 outbreak, however, the place has changed.

“I can look out the window and see if it’s sunny, but that’s about it,” she said.

When residents eat, everyone has to sit at their own table to maintain social distance, she said. The staff still tries to have activities, like socially distant bingo and sharing daily jokes.

“They’re trying to think of things to keep us occupied,” Funk said. “It is difficult. I’m used to being alone, sort of.”

Funk’s husband of nearly 60 years, Jim Funk, died in February. At a time when Elizabeth would typically be relying on having family close by to help with that grieving process, they aren’t allowed to visit.

Even so, she still receives several phone calls and video visits from family and grandchildren.

“Still, it’s not the same as physically visiting with someone,” she said. “Psychologically, it’s just knowing that you can’t go any place and no one can come see you. It’s very constricting and frustrating.”

Funk said she occupies her time by reading, playing games on a tablet and looking up songs to listen to.

“I sang in church choirs since I was 12,” she said. “I can’t sing anymore. Sometimes, I’ll think of a song I used to sing that I know all the words to, and I’ll sing it in my head.”

Morris worked as a speech-language pathologist in long-term care environments for 20 years. She recalls efforts to keep residents safe during flu epidemics resulting in some restrictions, but she hasn’t experienced anything along the lines of what many are currently experiencing.

“With that, you typically see increased agitation,” Morris said. “You may see increased confusion because their [schedule] has been disrupted. I really can’t even imagine what our caregivers are going through right now.”

McNabney said family members can help with long-term care residents’ isolation, for example, “not just maintaining telephone contact but maybe intensifying it.” When communicating with a family member in long-term care, he suggested people focus on the positive by saying things like “We’re getting through this. We’re going to make it.”

He also suggested emphasizing looking forward to the next in-person visit.

“I think we can all be overwhelmed with the news and statistics,” McNabney said. “It can take on its own momentum, and it can spiral in a negative way.”

McNabney recommends family members and staff communicate and brainstorm ways to convey positive messages to residents. Perhaps, they can send items that can be passed along once sanitized. Or, he said, a staff member can point to a picture of a relative when delivering a message from them.

At some facilities, it’s possible for residents to interact with family members through a closed window. People in different communities have made signs with positive messages to share with long-term care residents from outside.

Apps like Zoom and FaceTime can be used for interaction between families and residents. Residents with cognitive issues may need a little preparation if they are using the technology for the first time, McNabney said.

There may be added challenges for residents who have some level of dementia, with routines interrupted and staff members clad in protective equipment that may look more like a character out of a science fiction movie than a caregiver.

“When you’re prone to have some thoughts that maybe aren’t based in reality … it can feed right into that,” McNabney said.

He suggested using stickers or some other embellishment to make the equipment look less intimidating. He also noted that carrying a picture of the staff member out of their gear — to reassure a resident that it’s still the same individual they usually see — could help, too.

Senior Suites at St. Clair Commons has a large tablet they use for residents to have video chats in the privacy of their rooms, said Joette Martin, administrative assistant at the assisted living facility in St. Clairsville, Ohio. Relatives can submit pictures to the facility’s website, which staff will print out and give to residents.

Residents are allowed out of their rooms, Martin said. They’ve been given masks and instructed to maintain six feet of social distance, which has not been a problem.

“We do have residents that will come out to read the paper, just to have four different walls around them,” she said.

Activities have been adapted, with bingo and games of chair volleyball or kickball held in the halls. Special treats like ice cream sundaes and root beer floats are offered to provide some variety and excitement, while maintaining as much human interaction as possible, Martin said.

“You just want to make sure that they know, just like everybody, that you’re not alone,” she said.

On April 24, Senior Suites threw a surprise party for resident Charles Phillips’ 100th birthday, with a parade of classic cars, fire trucks, snow plows and more. A number of residents went outside to watch it, with chalk on the sidewalk marking off six-foot intervals where they could stand.

Heritage Ministries has established a COVID task force to come up with ways to prevent infection, relying in part on the experiences of its staff in Seattle. Washington was an early epicenter of the pandemic in the United States, but so far, Heritage’s facility there – and all of its skilled nursing and assisted living units – have not reported any positive cases, Haglund said.

There have been four cases and two Covid-19-related deaths at an independent living facility in Buffalo, N.Y.,, where regulations are not as strict, she said.

In addition to building units specifically for patients who are suspected of having or eventually do test positive for the virus, Heritage is spending time and money on ways to help residents deal with increased isolation, Haglund said. For example, they’ve bought equipment to help residents do exercises in their rooms that were previously done in group sessions that are now canceled.

“We … actually went out and purchased a whole new slew of technology to make sure we can really up our game,” Haglund said.

At some facilities, residents are brought to their doorways, while music is played on overhead speakers and residents try to identify the song.

“So the whole hallway’s lined, but they’re six feet apart,” Haglund said.

At a three-story independent living facility in Seattle, residents walked onto their balconies and joined together in singing hymns recently, she said.

“As much as this has been scary, we’ve also seen the very best in people,” Haglund said.

McNabney said it’s also important to show concern and appreciation for long-term care staff. Some have been cast in a negative light because of outbreaks at facilities, but he said most are “doing the best they can with the most vulnerable people in our society.

“This thing came upon us so fiercely and quickly,” he said. “If we can try to keep the morale of the staff up, it’s really going to have a positive impact on our residents.”