COVID-19 in older people with cognitive impairment in Latin America

The COVID-19 pandemic in Latin America and Caribbean countries (LACs) has failed to capture the attention and attract the resources necessary to control it. The wrenching choice between public health and economic welfare that has polarised political debate in the USA and Europe is starker in LACs, where older people and people with dementia are especially susceptible. We want to raise awareness about this grave situation.

The population in LACs tripled between 1950 and 2000. Although LAC populations are still young compared with the USA and western Europe, the rate of ageing is among the highest in the world.¹ This pattern of ageing is seen in nearly every country in the region,² with a shift in dependant populations from young children to older relatives.² Conditions such as obesity, hypertension, diabetes, and elevated cholesterol, which increase the risk of mortality from COVID-19, have become more prevalent.

The first patient with confirmed COVID-19 was diagnosed in February, 2020 (a 61-year-old man in São Paulo, Brazil). In a few weeks, Brazil surged into the top ranks of the most affected countries. Peru quickly closed its borders in March, 2020, and imposed rigorous quarantine measures. However, 4 months later, Peru now has the second highest number of confirmed cases in LACs. Chile, which also implemented control measures, is third highest among LACs. The public health conditions in these countries are complex and pose unique challenges; one underlying explanation for the surge in cases might be a large informal economy, in which workers need to leave their house every day to clean other households or to stand, for instance, at crowded traffic corners to sell their goods or shine shoes. According to the World Economic Forum, about 55% of all workers in LACs toil in the informal economy,³ which amounts to nearly 140 million people. Physical distancing in the informal economy can be tantamount to starvation.

Other explanations point to economic inequality and inadequate public health systems⁴ but fail to mention the near absence of long-term care facilities and programmes for the cognitively impaired. Dementia care differs from standard medical care in that caring for dementia must involve support for daily activities. Few long-term care centres exist in LACs. Millions populate densely packed favelas or barrios, in which large families often share a single room, and many find moving a grandparent to a nursing home inconceivable. However, older people cannot be quarantined within crowded living quarters, where they can be exposed to young asymptomatic carriers, and older people who live alone struggle to access care without risking contact with infected individuals (figure ). Extended families that ordinarily create a protective environment and provide informal care⁵ can engender environments that increase mental health problems and domestic abuse.⁶

Figure.

An elderly man walks through a district in Lima, Peru, that is heavily infected with COVID-19

Alejandro, who is 83 years old and has arthrosis, using his walker through a crowded market in San Juan de Lurigancho, a heavily COVID-19-infected district in Lima, Peru. Alejandro lives alone and goes out to get food and medicines. He has symptoms associated with depression and cognitive decline but has no access to neurological care. Photo and testimony courtesy of Alexander Kornhuber and Maritza Pintado Caipa.

The situation with professional health workers provides little solace. Weak health-care systems have contributed to the already enormous toll in mortality in health-care workers. For instance, with 20% of over 11 000 health workers in Mexico ill with COVID-19—one of the highest rates in the world—hospital staffing is exiguous.⁷ Many hospitals in LACs have inadequate protective equipment and there is scarce support for health-care workers who become sick.⁸

Barriers to telemedicine, such as restricted internet access, cause additional complications,⁴ with around 40% of hospitals not providing remote consultations.⁸ Certainly, LACs are far from uniform, and some cities with stronger health systems and resources might be able to meet the needs of people with dementia better than others. Here, we put forth an urgent plea for an international coalition to address issues related to dementia care in LACs. Regional cooperation and shared experience cannot be ignored in these difficult times. Brain health diplomacy, potentially led by multiregional non-governmental organisations devoted to dementia, in partnership with local institutions should coordinate an action plan.