COVID-19 and residential care facilities: issues and concerns identi ﬁ ed by the international network prevention of elder abuse (INPEA)

Purpose – The COVID-19 pandemic has affected the physical, psychological, social and financial health of older persons. On this subject, the United Nations published a policy brief on the impact of COVID-19 on older persons in May 2020. In line with this, the purpose of this general review is to address three issues affecting older persons living in residential care facilities: protective measures implemented to block the virus’ entry, the typesofmistreatmentmostfrequentlyexperiencedandthenecessitytopromoteanddefendtherightsofthesepersons. Design/methodology/approach – The design of this study is based on input gathered since the end of April during meetings of the International Network for the Prevention of Elder Abuse (INPEA) and the resultsofa July survey ofits members. Findings – The survey results indicate variability in the implementation of protective measures in different countries and the significant presence of mistreatment and violation of the rights of older persons. Three major issues demand attention: ageism, systemic and managerial problems and the effects of implemented measures. All these prompt the INPEA to once again plea for the adoption of an internationalconvention ofhumanrightsofolderpersons. Originality/value – To our knowledge, this is the first article sharing the views of the INPEA from a global perspective inthe contextofCOVID-19.


Introduction
Since March 2020, when the World Health Organization (WHO) declared the COVID-19 outbreak a "pandemic" (WHO, 2020a), the international community has mobilised to find a solution to this socio-sanitary crisis without precedent in the 21st century. This commitment includes the promotion of prevention measures, the development of a vaccine and the scientific documentation of the medical, social and economic repercussions of this virus (WHO, 2020b).
Global data indicate that older persons, once infected by the virus, are the most severely affected and the most at risk of dying (United Nations (UN), 2020a).The direct and indirect consequences of the virus have the potential to be disastrous on many levels and to various degrees in each country. The UN Secretary-General stated as follows: Beyond its immediate health impact, the pandemic is putting older people at greater risk of poverty, discrimination and isolation. It is likely to have a particularly devastating impact on older people in developing countries (UN, 2020b).
(Information about the authors can be found at the end of this article.) Created in 1997, the International Network for the Prevention of Elder Abuse (INPEA), an UN-recognised non-governmental organization, has members from all continents. As an active member of the Open-ended Working Group on Ageing for the Purpose of Strengthening the Protection of the Human Rights of Older Persons (UN, 2020c), the INPEA is involved in promoting and advocating the rights of older persons all around the world. Since 23 April, 2020, the INPEA has been holding weekly or biweekly virtual meetings of members and friends addressing the mistreatment of older persons in the pandemic context. During these meetings, shared preoccupations concerning residential care facilities (RCF) emerged. This general review puts forth the principal concerns of the INPEA members towards the mistreatment and rights violations of older persons in RCF.

Methodology
Our points are substantiated by two sources. First, the results are derived from an anonymous survey of members of the INPEA that was conducted in July, at their request, by the Research Chair on Mistreatment of Older Adults (RCMOA). A total of 19 INPEA members from 16 countries completed it [1], including at least one member per continent (RCMOA, 2020). The respondents came from both high-and low-income countries. Without painting an exhaustive portrait of the situation, the survey nevertheless revealed concerns. Second, the discussion is a synthesis of audio recordings and notes taken during the INPEA meetings since April. Particular attention was given to the July 16 meeting attended by 56 members and friends, wherein the survey results and the subject matter of this article were discussed. Participation in the meetings was done on a voluntary basis, and all participants were aware that the meetings were recorded. The audio recordings are publicly available on the INPEA website (www.inpea.net/).

Measures to protect older persons
Preventive measures to protect older persons living in RCF were implemented in 11 of the 16 countries represented. Some of these were restrictive, such as preventing older persons from going out, total or partial lockdown in their rooms or apartments and physical distancing. Other measures were exceptional, such as additional financial support, mandatory swabbing of staff before assuming duties or military troops compensating for the lack of health workers. Of the respondents who reported specific measures, more than half stated that their implementation was slow (47.1%) or very slow (5.9%).
Respondents were asked to comment on their "country's leadership ability to make the right decisions to manage this crisis in regard to older adults living in residential facilities". Their reported degree of confidence may be qualified as mixed. Respondents said they were "very confident" (26.3%), "somewhat confident" (26.3%), "not so confident" (26.3%) or "not confident at all" (21.1%). None reported being "extremely confident". Commenting on the adequacy of staffing and equipment availability in RCF during the crisis, more than half of the respondents (52.6%) said it was "poor" or "very poor".

Types of mistreatment and media coverage
At the time of the survey, there was not much aggregated data available on the types of mistreatment perpetrated in RCF during the pandemic. Nonetheless, almost half of the respondents (47.4%) were aware of examples of mistreatment covered in the media: cases of abandonment, negligence as well as, physical, material and psychological mistreatment (RCMOA, 2020). Respondents also commented on which types of mistreatment they thought would likely occur in RCF in this context. All reported psychological abuse as likely. The potential for neglect (73.7%), financial (47.4%), and physical abuse (42.1%) was also noted. A smaller number (10.5%) signaled the prohibition of visits by family members as a form of social mistreatment, which is not a recognized type in the WHO definition of elder abuse.

Specific aspect of rights violation
In an open-ended question, participants revealed a series of rights violations such as ageism, loss of dignity, civil rights denial, barring of family visitors, poor management, no boundary between "cold" and "hot" zones, lack of staffing and equipment, suspension of medical treatment and lack of information given to family members. These elements will be explored further in the following discussion.

Discussion
Three major themes emerged from the survey and discussions on RCF: ageism, systemic and managerial problems and effects of implemented measures.
Examples of ageism abound, many of which demonstrate the invisibility of older persons. In some countries, authorities delayed or never revealed the levels of COVID-19 infected older persons or related deaths, neither by age group nor by residential setting. In France, public health authorities were slow to record the number of fatalities in RCF, whereas in Great Britain and Peru, the numbers were never recorded. Also, in certain countries, the COVID-19 excess mortality among older persons was presented as the natural order of things, a form of quasi-natural selection. As opposed to the rapid response in hospitals to handle infected persons, many members noted a slowness or an absence of preparation in RCF.
Here is a comment, published in March 2020, in the USA: Political leaders need to put the looming crisis in LTCF front. The danger of hospitals becoming overwhelmed is increasingly widely recognized. But we have heard little or no discussion of the LTCF population by the President or his team. LTCF residences should be priority sites for COVID-19 testing and PPE. (Gardner et al., 2020, p. 4) Ethical issues arose from this lack of readiness. In countries such as Italy, Spain and Sweden, the limited resources pushed doctors to prioritise younger patients when it came to the attribution of ventilators and beds in intensive care units, sometimes at the cost of an older adult's life (Popescu and Marcoci, 2020).
These diverse manifestations of ageism raise the question of the value given to the voices of older persons: were their views solicited? If so, were they listened to and taken into consideration? Even in Malta, where no COVID-19 deaths were reported in RCF, the balance between the voices of older persons and others was a concern.
The pandemic evidenced several issues linked to the quality of health and social services in RCF, many of a systemic and managerial nature. According to some members, these preexisting deficiencies were amplified in this situation. Firstly, RCF regulations may vary considerably according to country and type of facility (public, private for-profit, private nonprofit). As indicated by one member from India, the number of facilities is growing, and some are of questionable quality. Therefore, considerations emerge with regards to who is accountable for the quality of health care and other services and how the delivery of not only basic physical needs (food, hydration, hygiene) but also other needs are ensured. Secondly, in several locations, staffing was insufficient, poorly trained, even untrained, and ignorant of infection control. Protective and other medical equipment were missing, putting staff and residents at high risk of contamination. One Canadian member, living in an RCF, also described the adverse effects of physical activity cancellations on their muscle tone and balance. These issues indicate a lack of human and technical resources arising from systemic problems and governance. Finally, the pandemic revealed the power imbalance between the RCF, residents and their families, and the lack of attention given to the needs of older persons.
In addition, governmental responses to the pandemic had some unintended effects on the living conditions in RCF. In general, several members underlined that the initial, strictly medical response to the problem in large part obscured social health determinants. While impinging on older persons' fundamental rights such as the right to security, liberty and privacy, the implemented measures did not safeguard RCF from the virus. Indeed, only a few countries succeeded (notably Australia and Malta). Rather than being propagated by family members or personal caregivers, the virus was transmitted by employees, who often worked in precarious conditions (Peisah et al., 2020). On the other hand, members described a lack of basic healthcare where, for example, hygiene care was limited to the occasional sponge or towel bath. The harmful effects of closing RCF to family members and residents' obligation to remain cloistered were psychologically and socially numerous. Moreover, one member from Africa described the fear engendered in residents with cognitive impairment, unable to recognise loved ones wearing personal protective equipment. One member from Israel published this statement: However, the current policy of full isolation, regardless of the differences in health and functioning of the residents, might cause full and for some fatal isolation. The implications are that a large number of older residents, who even in normal times many of them feel handicapped and isolated, suffer now so much more -Isn't it violation of rights and infringement of quality of life? (Lowenstein, 2020, p. 89)

Conclusion
Since March 2020, extraordinary discussions within the INPEA have reinforced the idea that an international charter of the rights of older persons needs to be swiftly adopted. It is anticipated that this convention would address the importance of advance directives in health and social services, the rights of older persons in RCF and their families, respect for the decisional capabilities of older persons, and much more. Such a convention would constitute an incentive to the establishment of minimum standards and remove older persons from the shadows.
This sharing of experiences offers ways to ensure the acknowledgement and promotion of the rights of older persons that include: RCF regulation, taking into account the selfexpressed needs of older persons or, in cases of inaptitude, their representatives, promotion of ingenious means to preserve older persons' contact with their loved ones, etc. Knowing that the pandemic may continue for an indefinite period, we must quickly benefit from past and current praxeological knowledge and experiences.