|Year : 2020 | Volume
| Issue : 2 | Page : 78-81
Caregivers' concerns for older persons during COVID-19 pandemic
Kuljeet Singh Anand1, Himank Goyal1, Abhishek Juneja1, Rakesh Kumar Mahajan2, Mina Chandra3
1 Department of Neurology, Dr RML Hospital, New Delhi, India
2 Department of Microbiology, Dr RML Hospital, New Delhi, India
3 Department of Psychiatry, Dr RML Hospital, New Delhi, India
|Date of Submission||17-Jun-2020|
|Date of Decision||21-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||21-Jan-2021|
Dr. Kuljeet Singh Anand
Department of Neurology, Dr RML Hospital, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
The newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been isolated and identified from patients with unexplained pneumonia in Wuhan, China, in December 2019. SARS-CoV-2 mainly causes mild-to-severe respiratory tract symptoms. Elderly people, particularly those with underlying comorbidities, are likely to develop a more severe COVID-19 disease as compared to young people. Therefore, the Centers for Disease Control and Prevention has recommended that older people, living in community settings, should stay at home as much as possible. While all of this is challenging for older people living in the community and long-term facilities, it can also create enormous stress and challenges for their caregivers. It is challenging for caregivers to provide appropriate care while taking care of their own health and maintaining social distancing norms. This calls for the use of different types of caregiving support for elders living in community as well as long-term care centers including the use of novel approaches and technology. A formal approach needs to be framed, taking help from the social workers to attend to the concerns of caregiving during the crisis of COVID-19.
Keywords: Caregiver concern, COVID-19, older person
|How to cite this article:|
Anand KS, Goyal H, Juneja A, Mahajan RK, Chandra M. Caregivers' concerns for older persons during COVID-19 pandemic. J Geriatr Ment Health 2020;7:78-81
|How to cite this URL:|
Anand KS, Goyal H, Juneja A, Mahajan RK, Chandra M. Caregivers' concerns for older persons during COVID-19 pandemic. J Geriatr Ment Health [serial online] 2020 [cited 2021 Mar 3];7:78-81. Available from: https://www.jgmh.org/text.asp?2020/7/2/78/307585
| Introduction|| |
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a newly discovered coronavirus, isolated and identified from patients with unexplained pneumonia in Wuhan, China, in December 2019. SARS-CoV-2 mainly causes respiratory tract symptoms ranging from mild self-limiting disease to severe pneumonia, acute respiratory distress syndrome, septic shock, and systemic multi-organ failure syndrome. As we know at present, there are no specific drugs for this disease. The world is currently facing the largest pandemic since the influenza pandemic of 1918, and the elderly population is the most vulnerable globally.
| Etiopathological Mechanisms of More Severe COVID-19 Infection in the Elderly|| |
The presence of chronic comorbidities, including diabetes mellitus and hypertension, along with a compromised immune defense system makes older people more susceptible to infection. Suboptimal innate and adaptive arms of their immune system allow the virus to replicate aggressively and to spread to lower parts of the respiratory system causing pneumonia.
Further, elderly patients have other medical comorbidities such as diabetes and hypertension which are associated with a more severe disease as compared to young people resulting in prolonged hospitalization, higher intensive care admissions, and greater mortality rates. Early studies put the mortality rate of COVID-19 for people between ages 70 and 79 years at 8' and for those over age 80 at 14.8'. Elderly people are also predisposed to other nonrespiratory complications of COVID-19 such as myocarditis and stroke which contribute to enhanced mortality in this population.,
The Centers for Disease Control and Prevention has recommended that older people, living in community settings, should stay at home as much as possible in view of the higher chances of complications from COVID-19 in this subpopulation. When long-term care facilities have COVID-19-positive elderly patients within their facility, they are advised to separate those with and without COVID-19 through quarantine and cohorting, which often result in residents being mostly confined to their rooms.
| Biopsychosocial Challenges for the Caregivers|| |
Caregiving for the elderly, both familial and professional, is challenging at all times and has become even more so in the COVID-19 pandemic scenario. The care provided by the informal caregivers including family members can take various forms, such as providing assistance with activities of daily living or offering social and emotional support.
In the COVID-19 era, family members mostly provide basic care to the elderly at home while struggling to adhere to social distancing norms as well as ensuring that the elderly themselves do not get exposed to COVID-19 through the elderly not observing due precautions either due to impaired cognition or carelessness.
In addition, many households are mutigenerational with the elderly living with their adult children and grandchildren. Many caregivers are experiencing caregiver burden while providing care to the elderly with their comorbid illnesses along with managing household chores, children staying at home with schools closed down, and their own professional commitments. There are increased financial stress, time demand, and worry about the health of the elderly and possibility of getting COVID-19 infection and likely death which can contribute to the large increase in caregiver anxiety as per a recent study. This can result in familial caregivers experiencing helplessness about not being able to completely protect the elderly against COVID-19 infection or provide the type or amount of care required.
Caregivers also worry about becoming infected with COVID-19 themselves or about other family members and friends and passing on the infection to the elderly inadvertently.
In addition to competing demands on caregivers' time, many may simply be afraid to spend time in physical contact with an older adult due to concern for spread of infection. This can inadvertently lead to neglect of older adults.
Family members often also provide periodic care to older relatives who are living in long-term care settings, including nursing homes and assisted living facilities. As there is a significant staff shortage in long-term care settings, which has been exacerbated by COVID-19 pandemic, family members may experience extreme stress while providing care in these formal settings.
To lessen the chance of infection among older people in nursing homes, more local authorities are banning visitors to nursing homes and long-term care facilities. As a consequence, the residents of nursing homes become more socially isolated though caregivers try to ensure regular telephonic communication to help reduce social isolation.
On the other hand, it has been observed that under the dual stress of fear of infection and worries about the residents' condition, the level of anxiety among staff in nursing homes increases and they develop signs of exhaustion and burnout.
In view of the combination of social distancing and higher complication rate in older persons, their caregivers in community and long-term care settings need different types of formal caregiving supports.
Caregivers of older adults have always had to coordinate and negotiate caregiving responsibilities with other family members and friends. During COVID-19 pandemic, the focus of this coordination and support has changed.
With more limited ability to have in-person contact, many caregivers are trying to use virtual technologies to stay connected with their care recipient. While some older adults may be comfortable with these technologies, most are not, and those with limited financial means may not have the necessary smartphone, computer, or high-speed Internet to use them. While certain care tasks can be replaced by virtual assistance (e.g., medication reminders), many others require in-person contact and may not be carried out during this time, leading to neglect of care that can have significant personal and health consequences. Digital technologies and remote visits also present challenges. For older adults without the financial means or tech-savvy, video televisits may not be feasible. Proactive assessment of patients' access to the necessary devices and Internet or data services can identify those with limitations and allow for alternative strategies for these patients, such as simple telephone visits.
All of these factors make caregiving for older family members during this global pandemic difficult.
| The Indian Scenario|| |
About 9' of the India's population is above 60 years, and about half of these individuals (i.e., 52 million) are part of the lowest income group, making them the most vulnerable. Many older individuals are battling with loneliness, limited mobility, restricted access to medical facilities, and the lack of financial security.
A survey by HelpAge India (2018) estimated that about 6' of older adults in India live alone, which is likely to increase by the current curbs on movement and contact due to the pandemic. The restricted movement of public transport and road travel during lockdown and subsequently made it difficult for caregivers, children, or other family members to reach their older relatives staying alone in different parts of the country. This has also made it difficult for older adults with chronic conditions requiring timely follow-up consultations with their doctors, which may adversely affect the mental and physical health of these individuals. As a result, many elderly people are dependent on the community initiatives. The Indian government is trying hard to contain the outbreak by appealing the citizens to keep watch over the health of older adults in their families, by limiting their contact with others and maintaining social distancing.
In India, caregiving is largely by the family members as there are extremely limited alternative institutional facilities and welfare support for those with long-standing illnesses. In addition, most families prefer to care for the ill person at all stages of illness. However, urbanization and advent of nuclear families place an important concern for care of older adults who have limited access to technology and health care.
| Special Issues|| |
People with neurocognitive disorders have limited access to information about the COVID-19 pandemic. They might find it difficult remembering and understanding safety instructions, such as wearing mask. The lack of understanding causes them to ignore these instructions leading to higher chance of infection. The cost of medical care and the need for dementia support have an additional adverse impact.
As recommended by Alzheimer's Disease International organization, mental health and psychosocial support should be delivered to these people.
Frailty has been defined as a “syndrome in which there is an increase in individual's vulnerability for developing an increased dependency and/or mortality when exposed to a stressor.” According to a recent study, frailty was associated with an increased risk of readmission or death within 30 days after discharge and increased use of health-care services. The presence of moderate-to-severe frailty was identified as a poor prognostic marker for COVID-19, thus requiring the implementation of more strict preventive measures and comprehensive caregiving measures to prevent mortality in this group from the present pandemic.
| People Living with Disability|| |
People living with disability (PLwD) gain less access to health-care services and experience worse outcomes in any epidemic. COVID-19 threatens to exacerbate these disparities, particularly in low-income and middle-income countries, where 80' of PLwD reside, and capacity to respond to COVID-19 is limited. Disability-friendly health programs must be designed to educate these people regarding the disease and its prevention.,
| Elder Abuse|| |
Elder abuse is a hidden epidemic ranging from physical, psychological to financial abuse, as it is rarely reported due to cultural factors. An increase in domestic violence with lockdowns in COVID-19 pandemic has been called a “Double Pandemic.” The lockdown and home quarantine measures resulted in the elderly having to spend more time with abusive family members resulting in a spike in domestic violence including financial abuse as the families faced increasing financial constraint due to the accompanying recession. For instance, in Nepal, police complaints against elderly abuse doubled between March and May 2020 as compared to the previous quarter.
Elder abuse has been accompanied by lack of availability of social work and legal service providers who are either closed or diverted for COVID-19 duties, and many shelters and dharamshalas have been repurposed for COVID-19 quarantine leaving most elderly care settings (which continue to function) as overwhelmed and understaffed.
| Discrimination in Access to Health Care|| |
Globally, several elderly COVID-19 patients have faced issues of refusals for hospitalization, intensive care unit admissions, and ventilator access as many health-care facilities have chosen to focus on the young. This diminished access to health care for the elderly has been reported from places such as Bangladesh, Cameroon, and Congo. For example, in Cox's Bazar refugee camps in Bangladesh, health workers were reported to be afraid to treat older people even with seasonal flu in case they had COVID-19.
| Possible Solutions|| |
There is much we do not know about the course of this pandemic, and the long-term impacts on our communities and on caregiving are just emerging. We know that COVID-19 will continue to transform the delivery of long-term services and caregiver support. At home, a safe distance should be maintained while providing the care with the use of protective aids as advised by the community guidelines. The elderly should be educated about personal protective equipment usage and indications as well as technologies which can keep them virtually connected with their family members. At long-term care centers and hospitals, an attempt should be made for virtual visits by caregivers. Social work professionals must be sensitized to the needs of family caregivers who may be experiencing added burden, stress, and depression and the differences in needs based on a variety of family circumstances.
At the same time, there is a need to sensitize health-care providers to provide nondiscriminant equitable health care to the elderly, police, and social work professionals for addressing elder abuse as well. The entire community needs to step forward to help the elderly cope with the ramifications of COVID-19 pandemic. Systemic changes with refined policies and frameworks spreading awareness, increased use of technology, and better health infrastructure are necessary. Frameworks, increased awareness, use of technology, and better access to health are necessary.
| Conclusion|| |
COVID-19 has presented unique biopsychosocial challenges for the elderly as well as caregivers of the elderly. Provision of health care both at home and at care facilities in COVID-19 pandemic scenario has resulted in additional caregiver stress and burden. Attempts to help the elderly and mitigate caregiver burden can help build new support resources for the elderly at community level which can be sustained after COVID-19 pandemic too. Awareness drives can help society at large, and health-care professionals identify the incremental caregiver burden in COVID-19 scenario and its determinants and address them effectively. At the same time, the community awareness of unique biopsychosocial issues of the elderly will be enhanced. The COVID-19 hygiene precautions and restriction advisories may get inculcated in the caregivers resulting in better long-term care. Similarly, technological support developed to alleviate caregiver burden can also be sustained as an adjunct component of elderly care in India. COVID-19 pandemic should be viewed as an opportunity to bring about paradigm shift in multidisciplinary elderly care in India and other low- and middle-income countries.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al
. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-33.
Liu K, Chen Y, Lin R, Han K. Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. J Infect 2020;80:14-8.
Abdulamir AS, Hafidh RR. The possible immunological pathways for the variable immunopathogenesis of COVID19 infections among healthy adults, elderly and children. Electron J Gen Med 2020;17:202.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al
. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.
Basu-Ray I, Almaddah NK, Adeboye A, Soos MP. Cardiac manifestations of coronavirus (COVID-19). In: StatPearls. TreasureIsland (FL): StatPearls Publishing; 2020. Available from: Available from: http://www.ncbi.nlm.nih.gov/books/NBK556152/
. [Last accessed on 2020 Jun 22].
Avula A, Nalleballe K, Narula N, Sapozhnikov S, Dandu V, Toom S, et al
. COVID-19 presenting as stroke. Brain Behav Immun 2020;87:115-9.
Elizabeth L, Rajean PM. Caregiving in times of uncertainty: Helping adult children of aging parents find support during the COVID-19 outbreak. J Gerontol Soc Work 2020:1-11.
Makaroun LK, Bachrach RL, Rosland AM. Elder abuse in the time of COVID-19-increased risks for older adults and their caregivers. Am J Geriatr Psychiatry 2020;28:876-80.
Geng F, Stevenson DG, Grabowski DC. Daily nursing home staffing levels highly variable, often below CMS expectations. Health Aff (Millwood) 2019;38:1095-100.
Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo JL, et al
. Dementia care during COVID-19. Lancet 2020;395:1190-1.
Nagarkar A. Challenges and concerns for older adults in India regarding the COVID-19 pandemic. J Gerontol Soc Work 2020;63:259-61.
Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al
. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392-7.
Kahlon S, Pederson J, Majumdar SR, Belga S, Lau D, Fradette M, et al
. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ 2015;187:799-804.
Armitage R, Nellums LB. The COVID-19 response must be disability inclusive. Lancet Public Health 2020;5:e257.
Boyle CA, Fox MH, Havercamp SM, Zubler J. The public health response to the COVID-19 pandemic for people with disabilities. Disabil Health J 2020;13:100943.
Banerjee D, D'Cruz MM, Rao T. Coronavirus disease 2019 and the elderly: Focus on psychological well-being, agism, and abuse prevention - An advocacy review. J Geriatr Ment Health 2020;7:4-10. [Full text]
Bodrud-Doza M, Shammi M, Bahlman L, Islam AR, Rahman MM. Psychosocial and socio-economic crisis in bangladesh due to COVID-19 pandemic: A perception-based assessment. Front Public Health 2020;8:341.
Duong MT, Karlawish J. Caregiving at a Physical Distance: Initial Thoughts for COVID-19 and Beyond. J Am Geriatr Soc 2020;68(6):1170-1172.
Vaitheswaran S, Lakshminarayanan M, Ramanujam V, Sargunan S, Venkatesan S. Experiences and needs of caregivers of persons with dementia in India during the COVID-19 pandemic-A qualitative study. Am J Geriatr Psychiatry 2020;28: 1185–94.