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Alex Maheux:

With the COVID-19 pandemic evolving at a rapid pace, it’s possible that circumstances may have changed since this interview was originally recorded, and may not accurately represent the current situation.

Hello, and welcome to the Canadian Health Information Podcast. I’m your host, Alex Maheux.

In this program from the Canadian Institute for Health Information, we’ll be taking a look at Canada’s health care systems, with the help of some highly qualified experts. Stay with us to hear more about our health policies and systems and the work being done to promote the health of Canadians.

Our guest today is Dr. Quoc Dinh Nguyen, internist-geriatrician at the Centre hospitalier de l’Université de Montréal. Dr. Nguyen holds a master’s degree in medical education from the Université de Montréal, a master’s degree in public health from Harvard University and is currently completing his PhD in epidemiology at McGill University. Dr. Nguyen divides his time between clinical work and his research on frailty in elderly patients. During the first wave of the pandemic, he was appointed to lead the COVID-19 Expert Panel on Measures for the Elderly.

Keep in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information. So let’s get down to business.

Hello, Dr. Nguyen. Thank you for joining us today.

Dr. Quoc Dinh Nguyen:

Hello. It’s my pleasure.

Alex Maheux:

So, COVID-19 has exposed some of the challenges in Canada’s long-term care system. To kick off our interview, could you briefly comment on where long-term care was before COVID-19, and perhaps how those problems factored into the pandemic?

Dr. Quoc Dinh Nguyen:

Sure. One of the greatest difficulties in working with the elderly, and particularly in long-term care where they are treated, cared for, and where they live, is the immense variability of the elderly. That is, some of them are in good physical condition, some not so good, and some are quite ill. I’d say that in long-term care, it’s unusual to see people who are in good physical condition. If you’re in long-term care, it’s for a reason, usually cognitive or mobility issues. Even with mobility and cognitive issues, we still see considerable variation among residents. It’s much the same with CHSLDs, if we look at long-term care in Quebec, which I know a little better than the rest of Canada. The number 1 concern is variability.

Now, even with that variability, and the fact that we have both small and large CHSLDs, it’s clear that personnel in Quebec and elsewhere was insufficient for the requirements. It’s interesting, because there was a great deal of discussion about CHSLDs, especially during the first wave. Now that we’re basically in the third wave, we hear a lot less about them. It was a hot topic for a while, but all the problems we’ve described and discussed were probably already there 10, 20, maybe even 30 years ago in some cases. So in Quebec, there’s a very good segment on a popular show called Infoman where politicians were discussing CHSLDs, and it sounded like they’re talking about 2020, but really, the quotes were from 1990.

So, to answer your question, I’ll say: One of the challenges is staffing. There has been a major shortage, and there is still a shortage. I also think that another tension within long-term care is that it’s a living environment, a place where people are living on a daily basis, even if they aren’t suffering from acute illness requiring immediate medical treatment. So this concept of a living environment, it’s like a home, it’s where people are, a non-hospital setting.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

At the same time, they’re not in a regular home, as they’re quite ill, either cognitively or in terms of mobility. So that still requires care. How do we navigate and manage both as efficiently as possible? That’s the challenge we face. It was there before, and it’s still there to an even greater degree during this pandemic.

Alex Maheux:

Mm-hm, absolutely. Earlier this year, AV���� released a report on the status of long-term care in terms of COVID-19. The report tracked the progress of COVID-19 over the past year and through the different waves. So, what have we seen in the different waves around the country and, as you said, Quebec is your area of expertise, what do we see specifically in Quebec?

Dr. Quoc Dinh Nguyen:

In fact, what we’ve seen, if you take it to wave zero, meaning there’s no COVID yet. Let’s say we’re somewhere in Canada and Quebec, sometime in February, we’re hearing about COVID, there are probably a few cases, but it’s not on the radar. At wave zero, the focus was on hospital care, or preparing ICU beds...

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

...preparing the hospital beds, and there was very little focus on CHSLDs. I think that’s the first thing that’s extremely important to keep in mind.

Alex Maheux:

Okay.

Dr. Quoc Dinh Nguyen:

Moving along, the first cases in British Columbia were in mid-March, then the first cases in Quebec, although we didn’t necessarily know it was COVID, in mid- to late March.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

Now this was the beginning of the first wave. The first wave was probably at its peak, at its height, some time in mid- to late April or early May. We talked about staff shortages, shortages in acute medical care, and it’s clear that COVID, a very serious illness that spreads extremely quickly with an asymptomatic phase, we saw the effects and even the devastation — maybe that word isn’t even strong enough — which COVID could bring during the first wave. In terms of disrupting their daily lives, causing stress for residents, staff and families, as well as serious illnesses and of course deaths — and also, we have to admit, in terms of a lack of proper organization and staff preparedness, since most of the focus during wave zero, before the first wave, was on preparing hospitals.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

So it did take several weeks to develop tests, send reinforcements, especially from the army, develop treatment protocols, and unfortunately, by that time the virus had also infected patients, and affected the most vulnerable, and then there was a drop in the number of cases.

If you look at the first and second waves, and I’ll focus more on Quebec here, we were much better prepared, in general. But if we compare regions of Quebec that were less affected during the first wave, to regions which were more affected, like Montréal and surrounding areas, we saw that preparation in less affected regions wasn’t as effective as during the first wave, because people didn’t have the same experience as in Montréal, which was a very hard-earned experience. But Montréal did acquire that experience during the first wave.

In Quebec, we saw training for infection prevention and control, learning how to wear masks properly, hand washing, quarantining infected people. We saw tests which were a much bigger factor in the second wave than the first, and frankly — there’s a lot of talk about this in Quebec — the arrival of 7,000 orderlies in the fall. This certainly made a big difference for CHSLDs in terms of case numbers and mortality.

It’s also worth noting that doctors are getting better at managing the disease. Of course, we hear all the time about intensive care, and intubation, and medications. The truth is that proper care for the elderly is really basic care like hydration, keeping the patient moving, keeping them stimulated, and they did that better during the second wave than they did during the first wave.

Alex Maheux:

Mm-hm. You mentioned some changes that occurred between the first and second waves for certain regions, which may have contributed to improvements in those regions. We’re now in the third wave. Where do we stand? What can we learn from the first two waves so we can prevent and reduce the strain on Canadian families?

Dr. Quoc Dinh Nguyen:

This is an excellent question and also an interesting one, because the third wave in Ontario, and perhaps the rest of Canada, possibly excluding Manitoba, though please correct me if I’m wrong, I don’t see it as a disaster. If you compare the first and second waves, Quebec and Ontario were very similar in terms of CHSLDs and hospital capacity. Of course, it wasn’t perfect. If you look at fatalities in Ontario and Quebec, you’ll see it’s quite different, but it’s basically the same pandemic, the same epidemic. When we look at the third wave and its progress, Quebec is nowhere near as bad as what is happening in Ontario.

As I said: during the first wave, CHSLDs were heavily involved; in the second wave, it was hospitals; and in the third wave, intensive care was involved, and hospitals in general to some extent. In Quebec, the health care network, which has the most problems, is still kind of a bottleneck, as we say in French.

Alex Maheux:

Mm.

Dr. Quoc Dinh Nguyen:

Intensive care is very important. However, community transmission is high, but not catastrophic. So, we’ve seen lots of cases in certain regions of Quebec, in Chaudière-Appalaches and Outaouais, near Ottawa. During the last week, case numbers in CHSLDs began to rise, but at a much lower ratio than in the first and second waves.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

So, we saw residents who started to get infected. We had the feeling... in Quebec, we decided to administer one dose of the vaccine with a four-month delay for the next dose, even for CHSLDs. So there are still people with more serious illnesses and some deaths, but the reality is that we should never forget, and we forget too easily, that the CHSLD is in our community. So, community transmission is the number 1 risk factor for infection or outbreak in a CHSLD. Now during the third wave, Quebec’s community transmission rate is higher than it was two or three weeks ago, although not catastrophic. So, the best way to protect Canadians in CHSLDs and their families is to keep transmission low. This is sort of the idea in the Atlantic provinces, where they’re doing extremely well, without serious problems in long-term care.

So I mean, that’s something we’ve learned, I would say, somewhere during the first wave, but this may be the critical point here. We have to... with vaccines, it’s... we can allow more community transmission before it breaks out in CHSLDs but still, with extremely high transmission, it is going to be very hard. And again, we’re talking about CHSLDs here, but if you get into private residences for seniors (“RPAs” in French), it’s more or less the same story. There’s a lot of contact between communities and these senior living environments.

Alex Maheux:

Mm-hm. I’d also like to talk about something else in the AV���� report, regarding non-COVID health problems in long-term care. There’s been a lot of coverage of COVID cases and deaths, but for example, there are fewer doctor visits, fewer transfers to hospitals, even for palliative care, which could have had very serious consequences for some patients. What do you think about COVID’s impact on non-COVID-related issues during this pandemic? Can you talk a little bit about that?

Dr. Quoc Dinh Nguyen:

Absolutely. COVID is just one of the many illnesses or difficulties that seniors face, especially for those in CHSLDs.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

The AV���� report clearly shows the impact on care provided to people in CHSLDs and on their ability to perform basic functions, such as their ability to walk, their capacity to use their brain. There’s a great French term for this, le “déconditionnement des aînés,” which means that someone, usually an elderly person, who wants to maintain their functions will need to follow a routine. In other words, if someone usually, I don’t know, plays bingo, the classic cliché, she should continue to play bingo in order to stay active. If she goes to the dining room, she needs to keep going to the dining room. But these activities are lost, so there is some deconditioning. On top of that, as you and I both mentioned, there is less of a prioritization of CHSLD care as compared to hospital care. The AV���� report is very interesting, we see where broken hips or fractures in general, I think, were being transferred as often as normal. For that, it’ s pretty clear that for CHSLD caregivers, that’s not something you can treat well in long-term care. Normally, after surgery, you probably need x-rays.

Alex Maheux:

Mm-hm. Exactly.

Dr. Quoc Dinh Nguyen:

All the others, like pneumonia, pain and others, had a net decrease in transfers, which definitely had an impact. We often tend to think of long-term care as something different from hospital care, and that’s true, but it’s also part of a continuum. Health care in Canada, in Quebec, has to deal with the continuum of the elderly, from very frail to less frail. Sometimes, we really have to ask ourselves the question: Why do we prioritize hospitals so much, and what’s the real impact on the elderly?

Alex Maheux:

Mm-hm. You’ve talked a lot about illnesses resulting from COVID, but not related to COVID. Something we’ve been hearing a lot about on the news is the emotional stress caused by the pandemic. In terms of the emotional and mental health of the residents, how did it affect long-term care?

Dr. Quoc Dinh Nguyen:

Well, pretty much as you would expect.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

How can I express this in the way that makes the most sense? With COVID, we all found it extremely difficult as citizens, as individuals, as humans, to be unable to see our friends, our family, to do our normal activities.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

I can tell you that, health care workers at least, they’ve continued to work. So, that’s an achievement, but I’d say it’s one thing to make all those sacrifices and to be able to understand why we have to make those sacrifices. It’s quite another, when you’re in a CHSLD, with cognitive impairments, not being able to understand exactly why all these sacrifices are necessary.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

The whole concept of agency, of controlling your own destiny, is far less prevalent in CHSLDs, especially during COVID. I should also add that family caregivers... and it’s interesting, because in Quebec, family caregivers were allowed to come and visit again quite quickly, compared to Ontario.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

But losing contact with loved ones, for the elderly and even, honestly, for caregivers, that wasn’t easy and, for the caregivers themselves, of course, they’re also worrying about what’s going on. There’s also something to consider. COVID is a pandemic. Pandemic means all people and demographics. It’s not just all people, but all aspects of life that are affected, and it’s going to take several years to understand all the implications, and maybe try to gradually straighten them out.

Alex Maheux:

Mm-hm. Obviously this is an extremely difficult field right now. How are you dealing with this situation? How are you doing?

Dr. Quoc Dinh Nguyen:

I’d put it this way: personally, I still have some balance. I definitely think it’s rough for nurses, you can see that we’re missing a lot, a lot of them.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

Then maybe the orderlies, the all releases, who are out in the field. What’s missing isn’t doctors. I’d call them the heroes, or heroines, I should say, the champions. A lot of it is the nurses and then the orderlies. They’re the ones that were imposed on, they had to act as advocates for the elderly. I think that when this happened, everyone’s attention was focused on the elderly, on the CHSLDs, but it seems that this is less and less the case.

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

And then, you know, everybody said, oh, this is really going to change things, this pandemic. But the truth is, unless we keep pushing, I’m not convinced things are going to change, because again, when the hospitals overflow, all the attention goes to the ICU and then acute care. So, I wouldn’t say I’m defeatist or pessimistic, but we need a certain amount of introspection and hindsight to say: Well, we’ve been through this, it was hard, it’s still hard. But will we really be able to learn all the lessons, so that in the end, everyone’s sacrifices and difficulties will be a net positive, that the pandemic will be more positive than negative?

Alex Maheux:

Mm-hm.

Dr. Quoc Dinh Nguyen:

I think it’s going to take a lot of work. And if somebody asks me how I feel? I feel like I have mixture of responsibility to do better next time, without really being able to say: OK, all right, it’s all behind us, we can move on. It’s a kind of in-between feeling.

Alex Maheux:

You’ve mentioned that you want to do better in the future, as a researcher and as a doctor. I think you’re the perfect person to address this next question. What does the future hold? And how can we protect our elderly, specifically long-term care and CHSLD residents?

Dr. Quoc Dinh Nguyen:

That’s a big question, it’s a question...

Alex Maheux:

Yes.

Dr. Quoc Dinh Nguyen:

...that’s fundamentally important, because one geriatrician, Ken Rockwood, from Dalhousie, often says that the seniors we’re seeing right now aren’t even the baby boomers. It’s the parents or older baby boomers that we’re seeing in CHSLDs. So when it comes to the baby boomers, the requirements for elder care, long-term care in particular, are going to be much more intense and so much bigger. So obviously, we have to ask ourselves this question: How can we improve things?

The number 1 problem, and I think Quebec has begun to address this a little bit, is the workforce. We can optimize and find the best, you know, Toyota method or ways to do more with the same people but the truth is, because the number of seniors is growing so rapidly, we need more people to help them and there’s no way to avoid that. I think that means more staff.

After that, I’d say that we probably need to train them better as well. When I think about the medical training I’m familiar with, there’s probably not enough time spent on geriatric issues. However, the elderly, 65 and over, occupy maybe 50% of the beds, even though they’re certainly not 50% of the population. But we don’t spend enough time on delirium, depression, dementia, mobility disorders. So, in medicine and nursing and for orderlies, if we train staff to do a better job of caring for the elderly, we can do more with the same number of people.

Beyond that, I think there’s also the organizational aspect. I’ve said from the beginning, maybe five times now, that hospitals are prioritized too often. One of the problems is that we tend to compartmentalize care. Hospitals are one thing, CHSLDs are another. I’ll optimize my hospital, but it’s often at the expense of CHSLDs, and we saw that with COVID. Patients were sent from hospitals to the CHSLDs, and that led to outbreaks. So it’s a matter of seeing seniors across the entire continuum and optimizing the entire continuum, not just one of the compartments.

I also think that technology definitely has to be part of the solution. We’re doing amazing things with technology, artificial intelligence, but very little of it has to do with the elderly. So a combination of staffing, training, technology and everything organizational, to do a better job of working out the interfaces between CHSLDs, long-term care and acute-care hospitals.

Alex Maheux:

Mm-hm. Finally, I have to ask: Have you thought about what care will be like when you’re elderly, and what your future will be in your later years?

Dr. Quoc Dinh Nguyen:

Well, I have decades to think about that.

Alex Maheux:

<laughs>

Dr. Quoc Dinh Nguyen:

But I’d tell you something like: You have to understand a massive demographic trend is set to take place in the next 20, 30 years. And in 20, 30 years, I won’t even be that old yet. Somehow, if we do it right, I’ll benefit from all the sacrifices that people have made before me. And then I can give you an example: this pandemic, if we do it right, we’re going to learn a lot of valuable lessons. Maybe in five years, well, we’ll have other success stories that we can learn from and implement. If we don’t implement them, well, we’ll hit a wall, it’ll be very difficult, but I think we’ll find other solutions.

So, I am hopeful that in the next 20, 30 years, there will be a huge expansion of care for the elderly, so that in maybe 50 years, when I really need it, it might be really good.

Alex Maheux:

You mentioned having hope. And I’ll also join you in having hope. Thank you again, Dr. Nguyen, for being with us today, and also for all your incredible work in the field.

Dr. Quoc Dinh Nguyen:

It’s my pleasure. Thank you so much for having me and for talking about seniors.

<End of recording>

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