‘Age and ageism in COVID-19’: Elderly mental health-care vulnerabilities and needs

Dear Editor,

The last three months have marked the emergence of a global health threat that has taken the world by its knees. The Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 has crippled the public health, economy and the daily lives of billions. Originating in Wuhan, China it took around a month to be declared as a ‘public health emergency of international concern’ and thereafter less than two months to erupt into a pandemic. With more than three million affected so far and around 1.5 lakhs succumbing to this outbreak, the countries have locked down national and international borders to contain it (WHO Situation Report, as on 17 April 2020). At many areas the lockdown has been sudden, though necessary, contributing to the already built up mass hysteria, panic, uncertainty and anxiety. Pandemics like this are not merely biological phenomena. They affect society at a large, having long-lasting psycho-social implications, many of which tends to outlast the pandemic itself Even though the virus is considered to be global public health problem, certain sections of the society are at a clearly defined and increased risk. One such section are the senior citizens. Amidst all the chaos of the ongoing crisis, certain sections of the population like the elderly are as vulnerable to the virus as to the psychological effects of the pandemic and the situations put in place to control it. As the number of COVID-19 cases keep increasing in the world, it is time that we pay increased attention to the mental health of our senior citizens, besides their physical susceptibility to the ongoing infection. Additional care and support will be necessary to take care of their overall well-being.

1. The vulnerability of ‘age and ageism’

COVID-19 has been postulated to be less fatal than its earlier congeners like Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), caused by the same family of viruses. However, the SARS-CoV-2 is much more contagious with an increased human-human transmission (Lai et al., 2020). Though majority of the cases are mild, few can progress to pneumonia and consequently Acute Respiratory Distress Syndrome (ARDS), which can eventually lead to mortality. This severity and fatality have been found to be higher in the elderly, immunosuppressed, socially impoverished, people with pre-existing respiratory conditions and chronic medical comorbidities: all of which can be predisposing risk factors at an increased age (Novel, 2020). The geriatric age-group already has unique physical, psycho-social and environmental vulnerabilities, owing to the frailty, which is conceptualized as a sum-total susceptibility to the physicological and psycho-social attributes associated with age. During the first wave of the outbreak in China, 20 percent of deaths were above 60 years of age (Wu and McGoogan, 2020). Based on The Chinese Centre for Disease Control and Prevention data, the fatality rate among 60–69 years old is around 3.6 percent, which increases to 18 percent above 80 years (Lai et al., 2020). This is also correlated with the viral load and virulence, and similar data has been reported from the worst affected countries like South Korea, Iran, Spain, Italy and the United States (Rothan and Byrareddy, 2020). Also, age is an independent mediating factor between mortality due to COVID-19 and non-pulmonary involvement, as non-specific multi-organ dysfunction syndrome (MODS) and septicemia are common in the geriatric population. An age-wise comparative study by Liu et al. (2020) showed that patients of COVID-19 above 55 years had three times increased mortality. They also had increased hospitalization, delayed clinical recovery, increased pulmonary involvement, faster disease progression, and comorbidities of diabetes, hypertension, history of cerebro-vascular accident (CVA) and chronic obstructive pulmonary disease (COPD). The need for mechanical ventilation and oxygen therapy were double in them and their blood showed decreased lymphocytes, C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): all of which are markers of inflammatory response to the virus. Further issues in elderly are the sensory problems, polypharmacy, impaired cognitive abilities and increased visit to health-care facilities, which can serve as additional burden in case of any infectious disease. Neglect, loneliness, isolation, depression, anxiety and abuse are the associated evils especially at times of social distancing practiced during present times. This can be more problematic in the institutionalized elderly (example: those in old-age care homes). The distancing and hygiene measures might not be adequate in all of these places.

2. Impact on the mental health and well-being

The uncertainty and fear of the pandemic can have increased effect on the minds of the aged, as they are aware of their vulnerability. The fear of death stays lost in the existential fear of losing their loved ones and guilt of possibly being the carriers of the infection. This can lead to significant 'what after me' issues and self-neglect, which can in turn lead to non-compliance to the prescribed standards of precautions. Due to generation limitations and sensory and cognitive deficits, they may be unaware of the updates related to the COVID-19 situation making them easy targets of misinformation and inadequate precautionary measures are followed. The bulk of 'information overload' that has essentially converted COVID-19 into a digital 'infodemic' can be extremely counter-productive, especially for those staying alone, increasing health-anxiety, somatization, apprehension and fear. The effects of the quarantine can be paramount leading to loneliness, physical distancing from their loved ones, grief, anxiety and chronic stress that can have long-standing psychological effects. Preliminary research so far has shown increased incidence of depressive disorders, complex post-traumatic stress (PTSD) and adjustment reactions in the elderly (Banerjee, 2020). Furthermore, increased suicidal ideations and attempts consequent to stress, on the background of the already existing suicidality risk in the elderly, is an added concern. Any form of stress is associated with decrease in immunity, that can compound the already weakened physiological defence-systems in the elderly Also, under-reporting of the psychiatric symptoms has also been observed during the COVID-19 pandemic in a recent study done in elderly (Armitage and Nellums, 2020). This leads to under-detection of symptoms, faulty treatment and increased prevalence of them being asymptomatic carriers. All these factors can have an overall detrimental effect on public health, as the neglected elderly can serve as vulnerable 'hidden pockets' of viral load that can contribute to increased infection spread. Many of the seniors are living alone, where basic living amenities are a regular problem due to lack of travel options and scarce domestic help during the lockdown. Loneliness is a potent risk factor for depression and cognitive disorders, especially when chronic and associated with lack of physical activity (Aylaz et al., 2012). Many elderlies might not be well-versed with technology leading to increased emotional distancing in absence of even digital contact with the families. Added to that, is the social stigma of ageism magnified by this outbreak that can lead to marginalization, segregation, abuse and increased institutionalization. This can hamper the autonomy and self-dignity that are important in resilience for any age group. Our preliminary experience in our tertiary mental health centre, shows increased reports of abuse and polarization of the senior citizens. This involves both acts of omission and commission, and are often unintentional in an attempt to preserve their well-being. This however restricts their mobility, independence and has negative effects on their autonomy and mental state.

3. Caring for the elderly: the way forward

Families and care givers need to be holistically involved in the care of the elderly, with increased sensitivity to their mental health. Stake-holders and policy-makers at all levels need to take a collective responsibility to decrease the Knowledge-Attitude-Practice (KAP) gap associated with elderly mental health-care during such pandemics. Few measures that can be undertaken to ensure their psychological well-being are:

• 1Ensuring the adequate three-pronged precautionary measures as suggested by WHO (social distancing, hand and respiratory hygiene). They need to be explained about the needful in simple and relevant terms. Security is the first step to ensure mental peace and quality of life.
• 2Social connectedness with their loved ones is essential together with social integration. They need to be involved in decision-making at familial levels, during times of such crisis.
• 3Providing adequate emotional support is vital to those living alone. Ensuring their basic needs, safety and dignity will help them to stay free from stress and fight loneliness, more so in lockdown situations. Their doubts need to be addressed periodically to allay the pandemic-related anxiety. Public-private partnerships can help increasing their access to basic requirements during the lockdown.
• 4Tele-facilities for health care consultations are better rather than physical access. That decreases the physical health risks and reduces fear. All elective surgeries (like hernia, cataract, knee-replacement, etc.) are best avoided.
• 5‘Digital screen time’ is better reduced, more so for the elderly to prevent misinformation and panic. They need to be updated about the COVID-19 situation and the necessary measures in a relevant manner. Vivid data and unnecessary statistics are better avoided.
• 6Those in day-care or old-age homes might need special care. Preventing overcrowding, encouraging physical activity, enhancing family support and ensuring nutrition are vital for their overall well-being. Abuse can be increased in such situations and need to be prevented and identified at the earliest. Abuse identification and prevention need sensitization among th general population and physicians alike, and is unfortunately often neglected amongst other priorities during a pandemic.
• 7Self-medication can be fatal (especially with drugs like hydroxychloroquine) and needs to be avoided at all costs. Professional advice is mandatory before any prescription refill.
• 8Various elder-friendly helplines exist specific to various countries both for telephonic counselling as well as food or essential deliveries at home. They need to be made aware of the same and seeking mental health care, if in need, should be actively encouraged. The elderly might have unique requirements in terms of technology-handling, communication and accessibility which need to be kept in mind while designing the digital helplines and tele-consultations
• 9The families and caregivers need to be sensitive to the increased needs of those with pre-existing disorders like dementia, depression and other neurological disorders. Suicide prevention using ‘gate-keeper awareness’ approach should be the top priority.
• 10Autonomy, respect and dignity needs to be preserved for the geriatric population, especially during the quarantined COVID-19 situation. Taking care of them is important, but what is more vital is their active involvement in decision making.

The seniors might be frail due to age, but they are definitely not weak. Their resilience can be noteworthy, if adequately cared for. It is high time that the pandemic-related policies and legislation in various countries are made more senior-friendly. The WHO and Centre for Disease Control and Prevention (CDC) have updated data related to geriatric-care during the pandemic. Besides their physical health burden, their psycho-social needs are also vital to be protected for their well-being and healthy survival. This is just the starting phase of the crisis. It is expected that in the post-pandemic months, there will be a surge in various mental-health issues, and a significant proportion of them might be the elderly. Preparedness to deal with this is necessary. Integrating them into this struggle against the unprecedented outbreak, can help us learn from their hope and wisdom for a better post-pandemic aftermath.

Financial disclosure

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Declaration of Competing Interest

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