For many of the elderly and their families, the COVID-19 pandemic has been a scary and trying time. A major concern has been the physical health and safety of this vulnerable population. In addition to community infection control measures like social distancing and avoidance of public gatherings to slow the initial spread of the outbreak, public health officials have also endeavored to protect high-risk populations by recommending electronic visits with loved ones, whether they are at private homes, nursing homes, or in the hospital.
However, it has become evident that some groups find it a challenge to socially distance, work from home and isolate. Much of the media’s attention has been on homeless individuals who do not have a safe place to isolate, working parents who must care for their children due to school closures, and domestic workers who face a choice of losing their jobs or breaking COVID-19 protocol and possibly exposing themselves and their families.
But the elderly is another population that has been suffering disproportionately from isolation measures. As author and historian Frank Snowden reminds us, “epidemic diseases are not random events that afflict societies capriciously;” instead, they bring out societies’ specific vulnerabilities, reflecting each society’s “structure, standard of living, and political priorities.” Unfortunately, the elderly are often at the bottom of our societal hierarchy and receive insufficient public attention.
Working with a geriatrician in the inland empire, I have seen firsthand how social distancing measures have affected the health and lives of many elderly patients. One of these patients was a lady I shall call Beatrice. Beatrice was in her late 80s and suffered from dementia for the past 10 years. She had been a resident at an assisted living facility for four years and was relatively stable prior to the pandemic. She struggled with short-term memory and activities of daily living such as bathing, cooking, and managing her medications, but she had a strong connection to her family. Her young grandson was the light of her life and she looked forward to his visits on the weekends. She made a small group of friends at the nursing home and they would sit in the dining room and share stories about their grandchildren.
Unfortunately, the nursing home disallowed visitors after several of their residents became infected with COVID-19. We saw Beatrice every other week on our health checks at her facility. In the first month after the shutdown, Beatrice appeared sullen and withdrawn. She took longer than usual to answer questions, avoided eye contact, and spoke in quiet, short sentences. Her physical health was unchanged, but she was clearly not in her usual state of mind and spirit. Two weeks later, Beatrice’s mood was unchanged, but the nurses had noticed that she lacked the motivation to do tasks she had been able to complete in the past, like dressing herself and cleaning her room. Another two weeks passed, and Beatrice became despondent, incontinent and struggled to communicate with us. Visually it was apparent that she had lost weight, as her eyes appeared sunken and lifeless.
Concerned for her functioning and memory, we conducted a mini-mental status exam – the results were significantly worse than just 6 months earlier. Dementia is a progressive disease and patients are expected to get worse, but the pace at which Beatrice was deteriorating was steeper than the expected course of her disease. We asked the staff whether she received phone calls from her family, and they told us that the family felt they were making her worse by calling since she would cry every time she was on the phone with her daughter. Beatrice was also not able to socialize with her friends at the nursing home since the dining room closed and communal meals had been canceled in lieu of meals delivered to the residents’ rooms.
Two weeks after that, Beatrice was not on our list of residents to see. She had passed away three days earlier from a kidney infection which she was not able to fight in her frail state. She died alone in the hospital, unable to see her beloved daughter and grandson one last time.
Others have noticed the impact of COVID-19 isolation measures on the elderly, as well. Recent studies have chronicled an increase in falls, decrease in strength and body weight, and acceleration of dementia — all contributing to a generalized “failure to thrive” among institutionalized elderly. Unable to see their loved ones, practice their social skills, exercise outdoors, or be stimulated by new experiences, many older patients develop worsening dementia and succumb to depression. This, in turn, raises their risk for hypertension, heart disease and stroke.
Social distancing orders have not only affected elderly people in nursing homes and hospitals, but also those stuck at home. Many individuals over the age of 55 depend on community centers, day care centers, and places of worship for social support and sense of purpose. With these resources closed and family and friends discouraged from visiting, many older people living by themselves are suffering extreme isolation and having trouble caring for themselves. The CDC and other health organizations recommend communicating via technology in lieu of visiting older relatives in person, however, many older people are not as technology literate as their younger counterparts, and there are disparities in who can access and afford these technologies. It has been a fine line to walk between protecting our elders’ physical health and contributing to their emotional and psychological demise.
It is clear that institutions like assisted-living facilities have their residents’ best interest at heart. They have been doing all they can to protect the elderly from becoming infected with COVID-19. Nationwide, nursing home cases of COVID-19 are down 96%, and in California, there were only 1,349 cases reported in March 2021, compared to 33,540 cases in December 2020. Many institutions are starting to allow visitors again, but many elderly Americans’ lives are still far from back to normal. Many of their favorite activities are still inaccessible and they rarely leave their homes out of fear of the virus. It is up to physicians and public health personnel to increase the rollout of the COVID-19 vaccine and reassure elderly patients and their families that re-entering public places with a mask is safe and even healthy for them. The future is looking better but our elderly patients are not out of the woods yet.