September 22, 2020
Dr. Paul Holyoke, Director, SE Research Centre
In The Future of Aging, we said, “Throughout a person’s life, they forge communities at various scales comprising family, friends, colleagues, and neighbors. These different groups then come to form the social safety net that individuals rely on for emotional and physical support.” (p.25)
And so we should and must celebrate the value of communities and community relationships for all of us, including those of us who are older, to keep us healthy and well.
The health of one, is the health of everyone
We know that social isolation – the alienation from a community – “has deep consequences for mental and physical health”.[1] We know that our risk of dying from cardiovascular disease, for example, is as much or more influenced by how often we get social support and how we fit into a positive social network as by more traditional factors including obesity, smoking, alcohol consumption, cardiac rehab and physical activity.[2] McGill researcher Donila Bzdok and Oxford researcher Robin Dunbar did an extensive examination of the literature on social distance, and found that friendships and social connections are an indispensable component of good health. They said, “The tighter someone is embedded in a network of friends, the less likely they are to become ill. The higher your social capital, the faster you get better if you fall ill, the quicker you recover from surgery, and the longer you will live.”1
In addition, how you feel affects your friends around you (and their friends), and vice-versa.[3] If you are lonely and it is affecting you negatively, it can also affect those around you. Further, when loneliness from social isolation sets in, a person can become skewed to view contacts and cues from other people in a negative light, which can hinder efforts to turn the loneliness and its impacts around.[4]
Communal living is not one-size-fits-all
The covid-19 pandemic has had significant impacts on communities and has presented some lessons for us in thinking about “community” and its impact on us as we age.
Communal living is generally thought to be a good thing, and we drew attention to it in The Future of Aging: “The social connectedness that comes from communal living is good for us … it improves our mental and physical functioning.” (p.40) We identified co-dwelling for care, safe communal spaces and multi-generational living arrangements as potential solutions to the problem of social isolation that can come with aging.
But we have seen that certain communal living arrangements – though designed at least in part to create “community” – may not be so good for us. In Canada, this has been highlighted in the disproportionate impacts of the pandemic in long-term care or nursing home settings as compared to all other settings.[5]
Protecting long term care “communities” during covid-19
Nathan Stall and colleagues have shown[6] that the risk of covid-19 outbreaks in Ontario was equal across all types of long-term care homes. However, those that were operated by for-profit chains and/or were of an older design – with fewer single or double occupancy rooms and more shared bathrooms – had more sickness and more deaths from covid-19.6 So specific kinds of shared living space don’t create the safe and nurturing community that will benefit us as we age.
But what about all the long-term care homes, regardless of profit orientation and design, and their higher-than-elsewhere risks of negative impacts of the pandemic? Surely they were purposely built to create communities – or they became communities by bringing diverse groups of older adults together while attending to their healthcare related needs. How are these “communities” not healthy?
In Ontario’s response to the pandemic, excellent science-driven emergency public health orders focused on our collective wellbeing. Early on in Ontario’s experience with covid-19, long-term care homes – those purpose-built “communities”—were by emergency-order sealed off from the rest of the world, to protect those inside from those outside. Visitors from outside were prohibited from entering the homes, even those visitors who had visited every single day since their family member or friend had first started to live in the long-term care home. An exception was made for paid caregivers: they were free to enter and leave because someone had to manage the home and care for the residents. They became the only permitted “visitors”.
And then we noticed that the paid caregivers, part of the residents’ community, were also members of other communities – their own families and friends – and other long-term care homes and retirement homes. And these paid caregivers carried with them the potential to transmit the disease. So the “community” in a long-term care home was not simply those who were residents in the buildings, nor, generally, a single “cohort” of paid caregivers! Another emergency public health order endeavoured to define and require that paid caregivers’ “community” could be only one workplace to reduce the risk of “cross-community” transmission.
Communities are people, not places
As for family and friend caregivers, they were permitted to peek through windows and wave at residents safely inside the homes, often also connected by phone. As summer arrived, family and friend caregivers could visit residents outside in short, scheduled, manageable bursts, in an effort to rejuvenate the “communities” the residents had been connected to. More recently, “essential caregivers,” that is, family members and friends who are essential to the wellbeing of long-term care home residents, have been allowed greater access to the homes, under rigorous conditions.
A very communitarian-minded initiative – to stop the spread of covid-19 by closing off long-term care homes – had the effect of severing the residents’ many communities that extended beyond the walls of the homes. Even though we were intent on maintaining the health of residents’ communities, we were transfixed by the bricks and mortar of long term care homes, identifying them as community boundaries that were, incidentally, very easy to reinforce with restrictions: doors were closed and locked. What we did not consider was that place does not define community; it is the interpersonal relationships, so essential to health, that define a person’s community. Slowly, we are recognizing that each resident’s “community” is defined by them and their friends, family and paid caregivers, not by where they are.
What’s next: expanding the “centre” of care
As we rethink the future of aging in light of the experiences with the pandemic, we are well advised to start from the perspective of the person who is aging and their community. We often think of “person-centred care” as responding to an individual’s needs. But that is not enough. We need to think of “person- and family-centred care”, or even “person- and social-network-centred care”. But we need to think beyond where a person eats and sleeps. Overall, whatever we call it, we need to think about, secure, and reinforce a person’s links with their community/communities to support healthy aging.
[1] Danilo Bzdok, Robin I.M. Dunbar. (2020). The Neurobiology of Social Distance. Trends in Cognitive Sciences; 24(9): 717-733. DOI: 10.1016/j.tics.2020.05.016
[2] Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. https://doi.org/10.1371/journal.pmed.1000316
[3] Fowler James H, Christakis Nicholas A. (2008) Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study BMJ; 337:a2338. https://www.bmj.com/content/337/bmj.a2338.long
[4] Cacioppo, J. T., & Hawkley, L. C. (2009). Perceived social isolation and cognition. Trends in Cognitive Sciences; 13(10):447-454. https://www.sciencedirect.com/science/article/abs/pii/S1364661309001478
[5] Canadian Institute for Health Information. (2020). Pandemic Experience in the Long-Term Care Sector: How Does Canada Compare With Other Countries? Ottawa, ON: CIHI.
[6] Nathan M. Stall, Aaron Jones, Kevin A. Brown, Paula A. Rochon, Andrew P. Costa. (2020). For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths. CMAJ;192:E946-55. doi: 10.1503/cmaj.201197; early-released July 22, 2020.
