Letter to the editor: Staying True to the Calling of Geriatric Medicine Amid the Waves of COVID-19.

Dear Editor,

We read with sadness the challenging state of affairs in geriatric medicine amid the COVID-19 pandemic in Italy (1) and wish to express our solidarity as fellow geriatricians working in the tertiary hospital. To date, Singapore has more than 2500 confirmed patients with COVID-19 (2) with the numbers still rising and no discernible horizon.

In our hospital, we too are beginning to feel the strain as over half our wards are now dedicated to caring for patients suspected of or positive for COVID-19; only two wards remain under specialist geriatric care. We have also suspended in-patient geriatric service streams such as the emergency department geriatric service, hip fracture unit, frailty unit, delirium/dementia service and geriatric surgery team. Ambulatory outpatient visits have been reduced by 70% while home and community-based services also have been limited to essential services as stipulated by our local health ministry (3).

We have had to find new ways to deliver specialist geriatric care across settings and to secure care continuity. In the wards, specialist geriatric consults continue to be provided while the hip fracture pathway is adopted despite the absence of cohort beds. As delirium and/or dementia feature prominently with a prevalence of ≥20% in our hospitalized patients, the knowledge and skills needed to provide appropriate care are usually imparted through an in-house training programme. During these COVID-19 times, an e-learning curriculum with self-assessment MCQs was devised. The enhanced care protocol is encapsulated by the acronym KNOW our VIPS NEEDS BEST. KNOW entails getting to know the patient as a person (e.g. his or her interests, preferences, routines), VIPS captures the philosophy of person-centred care (4), NEEDS expresses how person-centred care is operationalized while BES3T summarises the essentials of comprehensive geriatric assessment and care. (Table 1) We hope that web-based learning can be an expedient way to empower more staff with the requisite skills to care for these cognitively and physically frail older patients who are highly vulnerable to the harms of hospitalization, especially in these trying times. We are privileged to have the cabin crew from the airline industry redeployed as care ambassadors in our wards, and they will likewise benefit from this learning these salient skills in eldercare (5).

Table 1

The enhanced care protocol with the acronym KNOW our VIPS NEEDS BES3T

V	Value (respect)
I	Individual, Identity
P	Perspective
S	Social (relational)
N	Normalize
E	Engage
E	Emancipate
D	Dignify
S	Simplify (slow)
B	Bladder, Bowel, Brain
E	Energy, Electrolytes, Environment
S	Sight, Sound, Smile
S	Sip, Stand, Sway
S	Sleep, Skin, Strain
T	Tubes, Tablets, Teeth

For the past ten years, our team has been leveraging on technology to provide telegeriatrics to nursing homes and primary care providers. (6) With the first cluster of COVID-19 nursing home residents (7) recently reported and a no-visitor rule for all residential care facilities subsequently imposed, this means of providing medical input has become all the more pertinent. Moreover, 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 patients’ homes. We have now expanded the scope to provide teleconsultations with patients, often mediated through their children, to reduce the need for clinics visits. It is also used to lend support to our nurses making home visits to discuss patient care plans and facilitate meetings involving multiple service providers caring for the same group of patients under our hospital-community integrated care network (8). Care continuity is also enabled through the telegeratrics platform for patients discharged from the hospital to follow-up on outstanding issues and as a means for patients to access us should problems arise.

As of Apr 7, “circuit-break” measures, have been implemented to limit the spread of COVID-19 (9). Community-based programmes, including daycare centres and centre-based rehabilitation, senior befriending and other home-based intervention programmes for seniors have thus been suspended. The negative impact of social isolation on the mental and physical health of older persons is well recognized and also evidenced in a local study (10). Therefore, counselling and befriending services have had to resort to telephone calls in a bid to secure the continued wellbeing of their beneficiaries. Volunteers have also stepped up efforts to reach out to older people living alone to emphasize hygiene and safe distancing measures and at the same time identify those who require additional help (11). Technology can likewise be relevant to provide evidence-based interventions such as cognitive stimulation therapy (12) through the internet. The multi-component web-based cognitive engagement programme run by our local Chinese media, Zaobao, is a case in point. (13) Besides, we are also positive that our collaboration on the House of Memories app (14) with the National Heritage Board and Liverpool museums can help provide meaningful engagement for seniors while they are isolated in their homes.

Even as we cherish the hope that this pandemic will fizzle out soon, may our efforts to innovate and stay true to the calling of geriatric medicine serve our older patients well as we ride out COVID-19 together.