Challenges and Opportunities of Elderly Care during COVID-19 Era

INTRODUCTION

The coronavirus disease 2019 (COVID-19) has taught us many lessons during this devastating pandemic since its inception in December 2019. Most of us especially the elderly population (60 years and above) suffered a lot due to COVID-19 and its consequences such as loss of life, economic loss, and loss of positive mental health. The COVID-19 pandemic has brought about exceptional fear and anxiety, especially among the elderly population.¹

The elderly population revolves around social connection more compared to younger generations and they were deprived of this socialism due to the sudden pandemic and subsequent lockdown. India like other countries has also implemented a whole country lockdown and advocated for social distancing measures to prevent the spread of COVID-19 in elderly people. With senility, the immune system becomes weak which makes the elderly more vulnerable to developing severe COVID compared to the younger generation. The elderly are already struggling with lifestyle diseases such as hypertension, heart disease, diabetes mellitus, and cancer. Recoveries in the elderly usually take time and complications arise in the presence of comorbidities. They also have to deal with mental health problems such as anxiety and depression due to their isolation, the burden of household costs, and periodic medical checkups.²

Globally, the elderly constitute about 11.5% of the total population of 7 billion.³ By 2050, the number of elderly is projected to reach 2 billion marks. The elderly population in India accounted for 7.4% of the total population in 2001, and 8.6% (104 million) in 2011, and has been projected to increase to 19% by the year 2050. At the end of the century, the elderly will constitute nearly 34% of the total population in the country.¹ There are nearly 138 million elderly persons in India in 2021 comprising 67 million males and 71 million females according to the Report of the Technical Group on Population Projections for India and States 2011–2036.⁴

Routine healthcare facilities cannot deal with the growing burden of the elderly population to mitigate their challenges such as different non-communicable diseases, mental health problems, and social issues. Rigorous and extensive training of young Indian Medical Graduates in geriatric care, home nursing is now of utmost importance. The government should assist Nongovernmental Organizations and other agencies financially to provide affordable and accessible health care to the elderly population smoothly.¹

ELDERLY POPULATION VULNERABILITY AND MORTALITY DUE TO COVID-19

In India, elderly people suffer from dual medical problems, that is, both communicable as well as non-communicable diseases. It is estimated that one out of two elderly in India suffers from at least one chronic disease such as diabetes mellitus, dyslipidemia, hypertension, chronic obstructive pulmonary disease, thyroid disorders, and heart diseases which require life-long medication. This is further complicated by impairment of special sensory functions such as vision and hearing.¹

Although all age groups are at risk of contracting COVID-19, the elderly are at a higher risk of mortality and severe disease, with those over 80 years old dying at 5 times the average rate.⁵ Elderly are more vulnerable to infections due to senility, and various pre-existing comorbidities such as diabetes, hypertension, cardiovascular disease, and chronic kidney disease. Increased age is a major risk factor for COVID-19 due to various factors including weakened immune system, physical inactivity, and stress.⁶ Elderly people who belong to middle and higher-income groups are prone to develop obesity and its related complications due to a sedentary lifestyle and decreased physical activity.⁷ Elderly staying with multi-generational households increase their susceptibility to COVID-19 infection as younger members’ more exposure to COVID due to their outdoor activities such as job and shopping. Elderly with cognitive impairments, disabilities, and visual disabilities have difficulty following COVID-19 appropriate behavior or coping with self-isolation.

Indian elderly have to face lots of social pathology such as elder abuse, neglect, lack of income, loneliness, and poor access to health care facilities.⁸ The strict and prolonged lockdown initiated in many parts of the country to prevent the spread of severe acute respiratory syndrome coronavirus 2, restricted physical activity, and produced social isolation-associated stress. These factors may further deteriorate the health of older people, contributing to adverse health outcomes in this population.⁹ Social distancing and disconnection can predispose depression and anxiety in the elderly which may further increase the risk of adverse outcomes of COVID-19.⁶ Other risk factors include poor nutrition, dementia, dehydration, and various clinical complications, especially in frail and bedridden patients.¹⁰ A lack of a timely diagnosis and therapeutic and preventive measures increases the risk of a severe infection.¹¹

More than 533 million confirmed cases and over 6.3 million deaths have been reported globally as of June 12, 2022.¹² India’s official cumulative COVID death count was more than 5.2 lakh as of June 22^nd, 2022.¹³ People aged 60 years or above accounted for 53% of COVID-19 deaths in the country and around 24.6% of them had prior comorbidities.¹⁴ Case-fatality rate of COVID-19 among more than 75 years was 7.45% and 3.41% for 60–75 years in West Bengal, whereas Kerala had 54% of all COVID deaths in the geriatric population.¹⁵

CHALLENGES IN ELDERLY HEALTHCARE

The elderly encountered serious challenges in accessing routine health care due to the sudden lockdown following COVID-19 havoc. In developing countries like India, vulnerable health systems or healthcare requiring out of pocket expenditure leave millions of destitute without access to routine health care. Sudden lockdowns and attention to health resources on COVID-19 caused a setback for older persons. Access to healthcare was jeopardized due to the closing down of public hospitals during the lockdown for the isolation of COVID-19 patients. It created barriers between healthcare institutions and the elderly to obtain routine health services for their existing comorbid conditions. Diversion of the workforce to COVID duty also disrupts the provision of basic health care to the elderly, causing further solitude and discomfort. Older persons with disabilities and chronic conditions such as diabetes, hypertension, and cardiovascular diseases experienced challenges in accessing routine medical care and became more depreciated.⁵

Elderly patients have numerous diseases including psychological problems such as depression and dementia. Female sex, widowed status, nuclear families, and stressful life events are some contributing factors to the development of depression in the elderly. Besides this, a negative caregiver approach toward dementia patients is also responsible for development of mental problems in the elderly such as agitation, restlessness, irritability, emotional distress, and sleep disturbance.¹ Rampant use of hydroxychloroquine during the first wave of the pandemic created a scarcity of medicine for elderly patients of rheumatoid arthritis. The paucity of an adequate number of skilled geriatricians in India is a big problem in dealing with geriatric diseases such as dementia, depression, falls, frailty, and urinary incontinence.¹

Geriatric populations have many socioeconomic issues such as economic insecurity, not getting a timely pension, loss of a spouse, social isolation, elder abuse, and neglect.¹ There was poor treatment adherence to non-communicable diseases such as diabetes, hypertension, and cardiovascular diseases due to less income during lockdown. At the inception of the lockdown, widespread panic among migrants across India’s major cities and states caused repeated attempts of migrant laborers to return to rural hometowns.¹⁶ Young migrant laborers returning to their villages due to loss of work also increased the economic burden on the families of lower socioeconomic class. The bulk of these migrant workers were daily wage laborers, who were grounded after the lockdown and started moving from cities to their native places slowly. Eminent challenges faced by these itinerant workers were due to loss of wages, food, shelter, anxiety, and fear of getting infected. Many migrants succumb to death either due to hunger, accidents, or comorbidities and some even commit suicide due to hardship.¹⁷

The elderly still depend substantially on their wages to hold themselves and their family. Half of the elderly have some source of personal income, that is, social security measures such as provident funds, fixed deposits, savings bank interests, life insurance policies, pension schemes, post office deposits, and non-service people get some amount of incentives as part of different national health programs, schemes for the elderly population in rural as well as urban areas. These earnings by the elderly are not enough to meet their requirements and medical costs for non-communicable diseases. COVID-19 also increased out of pocket expenditure due to frequent COVID testing and treatment. Recently, people of lower socioeconomic status have been facing a great hurdle to meeting expenses of the elderly due to attrition of income following the unforeseen COVID-19 pandemic and consecutive nationwide lock-down.^1,3

The elderly not only feared for their lives but also the stigma associated with COVID infection. The lockdown expanded their apprehension further, as they dealt with severe income loss, isolation, and uncertainty. The biggest hurdle for the elders has been accessing healthcare, buying medicines, groceries, and banking during the pandemic.¹⁵ Elderly were more prone to develop severe coronavirus infection due to their pre-existing comorbid conditions and senility.⁸ Prolonged periods of isolation had a deleterious effect on the mental health of the elderly, as they were more digitally engaged compared to the younger generation.⁴ They have to visit hospitals and rehabilitation centers for routine checkups, treatment of non-communicable diseases, and other geriatric problems such as arthritis, urinary incontinence, dementia, depression, and frequent fall which also increases the chance of exposure to COVID-19. COVID-infected elderly were also afflicted by systemic factors related to the health system as many of the quarantine centers did not have suitable infrastructure such as lifts or differently abled-friendly toilets for the elderly.¹⁸ There are also instances of healthcare professionals discriminating against elderly COVID-19 patients and declining admission to them during the first phase of the pandemic.¹⁹ Some private hospitals took advantage of this situation and were advocating for COVID-19 testing for all non-COVID-19 patients and their family members coming to the hospital each time. They made COVID-19 tests mandatory for elderly patients requiring dialysis inflated the overall expenditure of treatment for these patients and enhanced their mental agony.²⁰ Loss of socialization, decreased exercise, and increased mental strain and mental health problems have significant deleterious effects on the elderly, and lockdown repercussions are likely to be permanent and could create substantial risks to the quality of life of the elderly in coming days.²¹ It is prudent that concerned authority and policymakers realize the needs of elderly during the formulation of guidelines regarding social distancing measures.²² The COVID pandemic has seen increased use of telemedicine for reaching the unreached population due to lockdown and containment strategies to prevent the spread of COVID infection. The elderly encountered a great challenge to access and use technology compared to other younger generations.²¹ A recent study indicated that about 40% of elderly people were incompetent to use telehealth resources, mainly due to a lack of skills in dealing with technology.²³

The impact of the pandemic on caregivers of the elderly is deleterious and they have to deal with their anxiety, fear, and needs in life.^24,25 It is therefore prudent to focus on the needs of the caregivers and in the implementation of isolation and protective measures in future policies.²²

OPPORTUNITIES IN GERIATRIC HEALTHCARE

National health programs focusing on the elderly existed for quite a long time but still, we are deprived of an adequate number of geriatricians, carers, and geriatric health clinics to look after geriatric people. It is now time to look positively rather than focusing our attention on the dilemma of paucity during this difficult period of the COVID-19 pandemic.¹

Early identification of high-risk elderly is the first step in protecting the vulnerable populations. Medical decisions should depend on individualized clinical assessments, the medical needs of vulnerable elderly, and the best scientific evidence. Mental health services and palliative and geriatric care services should be continued during this challenging time. Urgent action should be taken to prioritize testing of vulnerable populations living in nursing homes and assisted living (long-term care facilities) for early detection and treatment of COVID infection in areas of high community transmission. COVID-19 cases or mortality happening in care facilities are reported and augmentation in monitoring and supervision activities in residential care facilities is required. Community-based services and support to the elderly, including social and legal services, should be continued. Visitor policies in residential care facilities, hospitals, and hospices should stabilize the protection of elders with their need for family and connection. Contingency plans and strategies to deal with the challenges encountered by migrants, older refugees, and displaced persons should be ready.^5,26

A few initiatives which can be helpful for the geriatric population during the pandemic are given below-

1. Training of Accredited Social Health Activist (ASHA) in basic knowledge of elderly care and engaging them in elderly care

2. Training of primary care physicians in geriatric care

3. Building mobile clinics and teams for regular evaluation and treatment of elderly COVID patients

4. Domiciliary visits by health care workers and medical officers for bedridden elderly in difficult-to-reach areas

5. Starting weekly geriatric clinic at the primary health center, the bi-weekly geriatric clinic at the community health center

6. Provision of geriatric wards for in-patient care of the elderly at District hospitals

7. Special queue for elderly patients in outpatient department ticket counter

8. Provision of home collection of samples for laboratory investigations for frail elderly

9. Periodic health camps in remote rural areas for the geriatric population

10. Assess the needs of the elderly: more isolated or those with limited mobility and cognitive decline or dementia need targeted support, including mental health and psychosocial support

11. Reinforce services to prevent and protect the elderly, particularly elderly women, from any form of violence and abuse, such as domestic violence and neglect

12. Support older persons and their carers to use digital communication or different channels of communication to be connected with their families and social networks

13. Build well-equipped community digital centers with support for the elderly for teleconsultation

14. COVID-19 preventive measures and accessibility to services should be percolated to the elderly

15. Increase mobile services to provide access to more isolated or disabled elderly

16. Use of teleconsultation for elderly residing in backward areas

17. Easy referral services for elderly patients requiring specialist care

18. Tie with communities and use different channels of mass communication such as radio broadcasts, print notifications, and text messages to reach the elderly

19. Reverse quarantine of the elderly due to the alarming rise of mental health issues and sustained isolation of the elderly during the unlock phases

20. Strengthen care facilities for the elderly considering their rights, and autonomy, and avoid labeling the elderly as uniformly frail or vulnerable.

CONCLUSION

The geriatric population is vulnerable to COVID infection and more prone to developing severe COVID infection. Access to healthcare has been jeopardized due to the sudden closure of government, and private hospitals, and the acute crisis of workforce trained in geriatric care during the lockdown. The paucity of an adequate number of skilled geriatricians in India is a big issue in dealing with geriatric problems. Prolonged isolation, increased mental stress, and loss of socialization have negative effects on the minds of the elderly population. Prioritizing COVID testing for early detection and treatment is of utmost importance to reduce COVID deaths in the elderly population. Training of healthcare professionals on geriatric care and the use of teleconsultation can be a way forward in geriatric health care.