“They talk about social distancing. My wife had a stroke and needs constant care. My son stays abroad and is stranded. My daily help has stopped coming, and even on repeated requests the care providing agency is not able to provide an alternative due to the lockdown. I need to do every single work. Now you tell me doctor, what type of distancing can I practice!”
This is a telephonic conversation I recently had with a patient’s husband. The context was COVID-19, as it mostly is these day with patients. He said this when I pointed him to the World Health Organization’s three-pronged strategy (social distancing, hand and respiratory hygiene)1. Telephonic health-care has become the norm with India experiencing the world’s largest lockdown intended to break the chain of the novel coronavirus.
The lockdown was necessary but sudden, and no one was adequately prepared, least so the elderly. Since the beginning of lockdown on 25 March 2020, similar conversations with elderly patients have become routine. Ironically, they are as vulnerable to the virus as to the isolation needed to contain it. As COVID-19 cases continue to soar around the world, the physical and psycho-social health of our senior citizens needs urgent attention, now more than ever before.
Age and Ageism: The two common vulnerabilities
The causative agent of COVID-19, novel coronavirus SARS-CoV-2 is definitely less fatal than its earlier congeners (Severe Acute Respiratory Syndrome or SARS and Middle East Respiratory Syndrome or MERS), but much more contagious with increased human to human transmission risk2. Some studies suggest that the viability of the virus in aerosol and various surfaces is also one of the reasons for this3. A majority of infections are mild, but few have pneumonia and Acute Respiratory Distress Syndrome (ARDS), which can eventually lead to mortality. Also, the severity and fatality of the infection is higher in the elderly, immunosuppressed and people with pre-existing respiratory illnesses, chronic medical problems as well as under-detection of symptoms4.
The elderly are at a unique risk of all these vulnerabilities together.
During the first wave of infection in China, 20 per cent of deaths were among people above the age of 605. The Chinese Centre for Disease Control and Prevention has reported a fatality rate of 3.6 percent among 60-69 year olds which can rise up to 20 percent in those above 80 years6. Similar findings have been reported from Italy, Spain, South Korea, Iran, and the United States7. In old age, there can be mortalities even without the involvement of the lungs but due to non-specific multi organ failure and septicaemia5.
An age-wise comparative study among hospitalised cases of COVID-19 also shows that the elderly group (above 55 years) had increased duration of hospital stay, delayed clinical recovery, increased lung involvement, faster progression of the illness and eventually increased fatalities7. The need for mechanical ventilation and oxygen therapy was doubled in the elderly age-group and their blood also showed decreased lymphocytes and C-reactive protein, both of which are markers of adequate immune response to the virus. Issues with mobility, chronic uncontrolled illnesses (like diabetes, hypertension, pneumonitis, osteoarthritis and cognitive decline), multiple medications and increased need for hospitalisations due to various other factors further increase the susceptibility of the elderly.
The COVID-19 pandemic has brought to sharp focus some of these vulnerabilities of the elderly:
1. Frailty (the age-related sum-total biological and psycho-social vulnerability of the individual) that is related to movement restriction, malnutrition and poor immunity8.
2. Loneliness, neglect, isolation and poor nutrition (more so in old-care care homes and institutionalised setups).
3. Sensory problems (difficulties in vision, hearing) that can prevent them from taking adequate precautions.
4. Chronic illness, use of multiple medicines (polypharmacy), increased health-care need and physical support.
5. Impaired cognitive abilities (memory, processing speed, thinking and language) that worsen with age, can prevent them from comprehending and adhering to precautionary instructions. People affected with dementia might have behavioural problems and wandering tendencies that can add to challenges of keeping them isolated at times of such outbreak.
6. Social distancing might not always be possible (multiple people of various specialities involved in their care, including domestic help for those who stay alone).
7. Elderly might not be aware and updated with authentic information related to infection, amidst misinformation spread through a variety of modes.
8. Less testing and consequently less detection can risk them to be asymptomatic carriers.
9. Existential issues of ‘what after me’ and ‘what about by family’ due to the fear of death.
10. Psycho-social vulnerability, especially at times of lockdown and quarantine: loneliness, anxiety and uncertainty can give rise to depressive disorders, insomnia and chronic stress. Grief and bereavement due to loss or distancing from their loved ones can be major and prolonged. They are also at increased risk for post-traumatic stress syndrome, if the stress is prolonged. Alarmingly, suicide risk is also two to three times more in the elderly population and is often under-reported
9.The elderly also suffer due to the prevalent stigma of ageism. In general, the elderly are marginalised even though traditionally humans are taught to respect and take care of the older generation, the innate fear of ‘ageing’, ‘losing vitality’ and death have made ‘ageism’ a prevalent ‘social evil’. Society equates ageing with loss of ‘charm and beauty’ and of youth that many times trigger old-age abuse. Such stigma and abuse can flare up during an outbreak which has an age-specific vulnerability10.
Everyday conversations such as “The old are dying more, so you better stay separate, lest you get infected” or “ you need to take more care, or else you might infect others” seem apparently benign but are laden with reproach and stigma. The elderly are prone to chronic bronchitis, obstructive lung disease and common cold leading to chronic cough, sore throat and flu-like symptoms which overlap with those of COVID-19. These can be easily mistaken with COVID-19 leading to social segregation and impaired mental well-being. Overcrowding, neglect and poor self-care in old-age homes are other contributing factors.
Stress impacts immunity and can increase proneness to infections. Autonomy and self-dignity may be hampered during a lockdown further impacting their mood, appetite and sleep11. Many elderly people live alone and are struggling with basic amenities like food, domestic utilities and hygiene along with the lingering fear of the pandemic.
Caring for the elderly in a pandemic
Families and caregivers can use some of these ways to keep the elderly disease-free, spirited and mentally fit:
1. ‘Physical distancing’ rather than social distancing: Regular telephonic contact with them to ensure adequate emotional support. Their daily needs and living requirements need to be optimised.
2. Considering their vulnerability, it is better they avoid going out or meeting too many people. Additional effort is necessary to supervise whether their hand and respiratory hygiene are ensured.
3. It is better to avoid hospital set-ups during the pandemic. Tele-consultations have been started by most places including central Government institutes like NIMHANS (Bengaluru), AIIMS (New Delhi), PGI (Chandigarh) and CMC (Vellore). Emergency services are also open throughout the day, should the need arise.
4. All elective surgeries like cataract, hernia or knee-replacements (unless complicated) are better postponed.
5. A bulk of the pandemic statistics does not mean much to them. However, the elderly have all the rights to remain updated for their own safety. The status of the pandemic and necessary precautions need to be explained in simple terms, especially for those with sensory or cognitive difficulties. ‘Digital screen time’ is better reduced to avoid confusion.
6. Those in isolation or quarantine need special care: telephonic counselling, digital contact with family and ensuring adequate nutrition is vital.
7. Family members need to be sensitive to the early symptoms of COVID-19 and testing if needed should be promptly done. This however, should not give rise to panic, self-isolation and stigma. Medical advice is the best choice for any clarification.
8. The elderly should not be self-medicated with any drug (antivirals, hydroxycholoroquine, any herbal supplement or quick remedies doing the rounds on social media) as preventive or curative strategies for COVID-19. It can be life-threatening. It’s better to seek a physician’s opinion.
9. Psycho-social issues are vital and families need to be sensitive to them. It is natural to be stressed, but signs of excessive panic, depression, sleep problems or suicidality need urgent attention from a qualified mental health professional. Many institutions like NIMHANS and AIIMS have their helplines with round the clock support. The Government of India (MoHFw) helpline also has a timely service and a good web resource for the elderly12.
10. The elderly need to be involved in decision making even in times of crisis. Their rights, self-respect and dignity must be preserved and protected. There could be things to learn from their experience and wisdom.
The WHO and CDC have updated data and precautions for the geriatric during COVID-19. The seniors might be vulnerable and frail due to age, but they are not weak. Their resilience can be amazing, if adequately cared for, and we can all borrow from their strengths. Albert Camus’ famous line “The old can go through every plague”13 should guide us to hold our elderly together, integrating them into our struggle and recovery as we live through these troubled times. That will truly indicate the social evolution of our civilisation.
(Debanjan Banerjee is a geriatric psychiatrist at the National Institute of Mental Health and Neurological Sciences, Bengaluru. He can be reached at Dr.Djan88@gmail.com)
1. Coronavirus disease (COVID-19) Pandemic, WHO (accessed on 3rd April, 2020)
2. Lai, C. C. et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): The epidemic and the challenges. Int. J. Antimicrob. Ag. 55, 105924 (2020) doi: 10.1016/j.ijantimicag.2020.105924
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4. Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi. 41, 145-151 (2020) doi: 10.3760/cma.j.issn.0254-6450.2020.02.003
5. Wu, Z. & McGoogan, J. M. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 323, 1239-1242 (2020) doi: 10.1001/jama.2020.2648
6. Lai, C. C. et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): the epidemic and the challenges. Int. J. Antimicrob. Ag. 105924 (2020) doi: 10.1016/j.ijantimicag.2020.105924
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8. Fried, L. P. et al. Frailty in older adults: Evidence for a phenotype. J. Gerontol. A-Biol. 56, M146-M157 (2020) doi: 10.1093/gerona/56.3.m146
9. Lebret, S. et al. Elderly suicide attempters: Characteristics and outcome. Int. J. of Geriatr. Psych. 21, 1052-1059 (2006) doi: 10.1002/gps.1605
10. Nelson, T D., ed. Ageism: Stereotyping and prejudice against older persons. MIT press (2004)
11. Armitage, R. & Nellums, L. B. COVID-19 and the consequences of isolating the elderly. Lancet Publ. Health (2020) doi: 10.1016/S2468-2667(20)30061-X
12. https://www.mohfw.gov.in/pdf/AdvisoryforElderlyPopulation.pdf (accessed on 3rd April, 2020)
13. Camus, A. The plague. Vintage (2012)