Maintaining communication in extreme isolation during a COVID-19 pandemic: The importance of the emotional component

Journal Identification = NRP Article Identification = 0629 Date: June 16, 2021 Time: 2:39 pm

doi:10.1684/nrp.2021.0629

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NEUROSCIENCES COGNITIVES ET CLINIQUES

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Rev Neuropsychol

2020 ; 12 (S1) : 40-2

Maintaining communication in extreme

isolation during a COVID-19 pandemic:

The importance of the emotional component ^*

Préserver la communication

en situation d’isolement extrême dans le contexte de pandémie Covid-19 : l’importance

de la composante émotionnelle

Ana Inés Ansaldo Full Professor

Department of Speech Therapy and Audiology, Faculty of Medicine, Université de Montréal

Director, Laboratory of Brain Plasticity, Communication and Aging Centre de recherche de l’Institut universitaire de gériatrie de Montréal, 4545 Queen-Mary Road, Montreal, Quebec, Canada H3W 1W5

<ana.ines.ansaldo@umontreal.ca>

To cite this article: Ansaldo AI. Maintaining communication in extreme isolation during a COVID-19 pandemic: The importance of the emotional component.

Rev Neuropsychol 2020;12(S1):40-2 doi:10.1684/nrp.2021.0629

W

e are living in an unprecedented situation. The COVID-19 pandemic has led many govern- ments to impose physical distancing measures to limit contagion. However, by its very nature, physical distancing also limits social interactions. Humans are a biopsychosocial species [1] and communication is a key part of human nature. The current situation – which could reoccur in the future – prevents access to the fundamental human need of socialization.

Although there is great diversity in trajectories of aging, there have been many concerns regarding the impact of social isolation experienced by older populations, consid- ered to be generally more vulnerable. People residing in long-term care facilities (CHSLDin Quebec andEHPADin France) are among the most isolated of the elderly, often finding themselves in situations of extreme isolation, and often suffer from severe neurocognitive disorders, which affect communication skills. Indeed, communication dis- orders are very common for people living in long-term care settings. They constitute a barrier to care, and have signifi- cant impacts, both on the quality of life of residents and on nursing staff, as well as on caregivers’ burden.

Implementation of physical distancing rules impose new communication challenges, in addition to those already

∗This article is an English language translation of the following article: Ansaldo AI. Préserver la communication en situation d’isolement extrême dans le contexte de pandémie Covid-19 : l’importance de la composante émotionnelle. Rev Neuropsychol 2020 ; 12 (2) : 158-60. doi:10.1684/nrp.2020.0558.

Correspondence:

A.I. Ansaldo

experienced in long-term care facilities. The numerous safety procedures and protective equipment constrain both verbal and non-verbal communication. In addition, the psychological stress induced by the uncertainty that an unprecedented situation generates, among caregivers and residents alike, further contributes to the breakdown in communication. Is it possible to maintain signifi- cant and meaningful communication when the residents’

communication difficulties interact with an unfavorable environmental context resulting from the pandemic?

The objective of this article is to discuss the role of emotional communication in preserving social engagement between long-term care (EHPAD or CHSLD) residents and caregivers experiencing increased communication barriers, in the context of the COVID-19 pandemic.

Human communication: a complex skill and a marker of our species

The term communication comes from the Latin,commu- nicatio, which means to connect, or establish a relationship.

This relational dimension of human communication is a core element of social participation; it precedes and facilitates the development of language and is associated with feelings of well-being, as opposed to social isola- tion. Indeed, our brains seem to be pre-wired to feed on social interaction, so much so that it disposes a complex system, which is phylogenetically constructed and shaped according to our experiences, allowing us to communicate with each other[2]. Complex brain circuits integrate per-

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ceptual, sensorimotor and proprioceptive information and allow the constitution of symbols with semantic, phono- logical and phonetic content. Processing of this content is supported by language-specific brain networks inter- connected with memory, and attentional and executive processing networks. Together, these circuits generate one of the most fascinating human tools, language, a pillar of human communication and an essential element in the establishment of social interactions.

In the context of neurocognitive disease, these complex circuits are gradually and inevitably affected, resulting in the deterioration of language skills, which significantly affects communication abilities. This being said, it is impor- tant to note that communication also relies on considerable non-verbal information, including facial expressions, gestures, posture, tone of voice and interpersonal space.

In people with major neurocognitive disorders, non-verbal communication is generally better preserved than verbal.

Non-verbal communication can therefore become a core communication tool with the progression of the illness. In general, non-verbal communication helps inform commu- nication partners of respective emotional states, even in the advanced stages of the disease [3]. Indeed, sharing emotions constitutes a kind of universal language, which allows us to recognize ourselves as members of the human species[4].

In the context of dementia, sharing emotions may become the primary approach to establish and maintain communication [5]. More precisely, predominantly non- verbal exchanges focused on sharing emotions allow for both phatic and informative communication and reduces the risk of social isolation [6]. In addition, sharing emo- tions is fertile ground for the expression of empathy, an essential component for maintaining communication [7].

Hence, empathy represents the basis for sharing and joint attention, which is one of the precursors of communication.

In summary, in the context of dementia, sharing emotions and generating empathy helps maintain the communication bond and decreases the risk of isolation.

Communication in a long-term care environment in the context of a pandemic

In order to better understand the effects of the pandemic on communication in long-term care settings, our team is working with caregivers in the field at two CHSLD:

the Institut universitaire de gériatrie de Montréal and Manoir-de-Verdun, both of which are affiliated with the CIUSSS-du-Centre-Sud-de-l’Île-de-Montréal, in Québec, Canada. Together with caregivers on the ground, we have identified the main barriers to communication in the context of the pandemic. The research team has developed an intervention that has potential to sustain communication with residents in CHSLD, who are experiencing extreme

isolation resulting from severe physical distancing and protection measures to limit the spread of COVID-19.

In particular, there is a general consensus about the negative impact of masks and visors on communication, which are considered among the main communication barriers in CHSLD/EHPAD. Thus, masks and visors interfere with the perception of non-verbal cues of communication, and they reduce voice volume up to 20%. Communication partners are deprived of non-verbal elements of communi- cation, such as mouth, gaze and forehead expressions, all of which are essential for proper decoding of verbal and non-verbal components of the message. The emotional content of the message then becomes much less obvious.

Body language is also affected by the equipment and the discomfort it generates, and patients are only touched using protective gloves. Members of the staff are difficult to recognize, which can contribute to restlessness and agitation[8], further aggravating isolation. Moreover, lack of staff and the increased burden imposed by the situation, reduces the mental availability of caregivers, which further compromises the quality of communication, and increases the risk of isolation for the resident. This occurs in a context where the patient is already suffering from extreme isolation due to the lack of contact with family members.

In such a demanding situation, teams on the ground report that communication easily becomes strictly limited to what is required for the administration of care.

In summary, the changes imposed by COVID-19 on both the communication environment and communication partners interact with the resident’s communication and cognitive difficulties, which further accelerates communi- cation breakdown.

The emotional component

of communication to counteract extreme isolation in the context of a pandemic

Various studies[11, 12]have shown that the emotional life of people with dementia is generally preserved. At the same time, these studies highlight the importance of sharing positive emotional experiences to maintain the commu- nication bond [12]. Indeed, the unconscious and largely automatic nature of emotions would make them more resis- tant to the cognitive decline that characterizes dementia.

From a theoretical perspective, emotional contagion is con- sidered as a precursor of representative (language) and meta-representative interactions (i.e. attribution of mental states,i.e.theory of mind)[7]. Moreover, emotional expe- rience is constructed both individually and culturally, and as such, it represents a component of identity. According to recent dementia research, communication based on sharing emotions contributes to reducing the risk of depersonaliza- tion, which may result in dehumanization, and even more so in a context of extreme social isolation. In short, shar- ing positive emotions promotes communication between

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caregivers and people with dementia, by promoting empa- thy and contributing to social engagement in a long-term care setting[8].

These theoretical constructs inspired the development of COMPAs (Communication Proche-Aidants), a tablet application bringing together audiovisual content in a secured space. The objective of the application is to evoke positive emotions between the person with dementia and their communication partner[9, 10]. These shared positive emotions trigger, what is called person-centered emotional communication. COMPAs has been implemented at the Bruchési long-term care center of the CIUSSS-du-Centre- Sud-de-l’Île-de-Montréal for roughly one year. More recently, it has been also implemented at Saint-Victor Centre Hortillons, a long-term care facility at the Centre hospitalier universitaire d’Amiens Picardie, in France. Its use has allowed significant improvements in communi- cation between residents and caregivers. Data collected show improved quality of life in residents and caregivers, and an improvement in measures of professional accom- plishment. COMPAs has also made it possible to facilitate group communication between the residents themselves.

Families and staff have thus found an effective and turnkey solution to establish meaningful and pleasant communi- cation with their loved ones, with fewer communication breakdowns, in part resulting from shared knowledge using COMPAs tools.

COMPAs will now be used in various long-term care facilities in Montreal affected by the COVID-19 pandemic.

To do so, COMPAs will be coupled with a digital video- conferencing application (Zoom) to allow families and residents to communicate remotely despite extreme iso- lation. Remote training will be offered to families and caregivers, to help offset the deleterious impacts of physical distancing using emotional communication strategies and COMPAs tools. It is expected that person-centered emo- tional communication supported by COMPAs will reduce social isolation and preserve communication between residents, families and caregivers despite the constraints imposed by the pandemic.

Conflict of interest None.

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