Year : 2020 | Volume
: 7 | Issue : 1 | Page : 4--10
Coronavirus disease 2019 and the elderly: Focus on psychosocial well-being, agism, and abuse prevention – An advocacy review
Debanjan Banerjee1, Migita Michael D’Cruz1, TS Sathyanarayana Rao2,
1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, JSS Medical College and Hospital and JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
Dr. Debanjan Banerjee
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru
Age and agism are significant vulnerabilities for the coronavirus disease 2019 (COVID-19). While the number of cases and fatalities rises throughout the globe, the elderly are prone both to the physiological and psychosocial aftermaths of the infection. As the focus on management is predominantly directed toward precautionary measures and searching for a biological cure, the mental well-being of this vulnerable population is unfortunately neglected. Besides being prone to isolation, loneliness, stress, grief, depression, and anxiety during the lockdown, the seniors are also victims of stigma, prejudice, and abuse, stemming from agism. Substance abuse-related complications and cognitive disorders are added concerns. Elder abuse in every form has particularly been concerning during the present pandemic. Especially those staying alone, those with sensory or cognitive impairment, and those institutionalized are at a greater risk. Considering the increasing number of aging population, such biological disasters can have notable acute and long-term consequences on overall health and well-being of the seniors, if not adequately cared for. A holistic care based on biopsychosocial model needs to be in force for elderly mental health care during the pandemics, supplemented by research to shape policies. Keeping this in background, the advocacy review glances at the unique challenges that the older adults face during COVID-19 with special focus on psychosocial well-being, agism, and abuse. It also highlights the important facets for elderly care and abuse prevention during such crises.
|How to cite this article:|
Banerjee D, D’Cruz MM, Sathyanarayana Rao T S. Coronavirus disease 2019 and the elderly: Focus on psychosocial well-being, agism, and abuse prevention – An advocacy review.J Geriatr Ment Health 2020;7:4-10
|How to cite this URL:|
Banerjee D, D’Cruz MM, Sathyanarayana Rao T S. Coronavirus disease 2019 and the elderly: Focus on psychosocial well-being, agism, and abuse prevention – An advocacy review. J Geriatr Ment Health [serial online] 2020 [cited 2020 Nov 28 ];7:4-10
Available from: https://www.jgmh.org/text.asp?2020/7/1/4/288235
Coronavirus Disease 2019: the Problem Statement
The world is facing a new global health threat. The coronavirus disease 2019 (COVID-19) has emerged as a “life-changer” for human civilization. Various nations have closed down their borders, global economies have been slashed and travel has been restricted worldwide. Billions are quarantined at their own residences in an attempt to control the outbreak. These unprecedented times have struck heavily on daily lives of millions, especially the vulnerable sections. One such population are the elderly, who ironically are susceptible to both the infection and the lockdown imposed to control it. Already predisposed to the severity and fatality of COVID-19 due to age, the psychosocial implications also tend to be more significant for them. Isolation, neglect, lack of autonomy, and risks of abuse are the few commonly observed offshoots of this pandemic. Social distancing can impact their mental well-being, increasing the risk of psychiatric disorders. With a rapidly aging world, when the number of people above 60 years is greater than that of under-five children, ensuring the holistic safety of seniors is of utmost importance during such biological disasters. Lessons from past pandemics show that the elderly are at the highest risk for both acute and long-term consequences. Data from the classical “pestilences” of the bubonic plague in the 13th century, the Spanish flu of 1918, the Asiatic cholera, and the severe acute respiratory syndrome (SARS) show the increased vulnerabilities of the elderly besides increased case fatality rates., As the world is still in the early clutches of the COVID-19 pandemic, it might be worthwhile to take prompt steps to decrease the morbidity and protect the quality of life of the older population. Keeping this in background, this commentary glances at the unique challenges faced by the aged, the social implications, and attempts to highlight the ways forward.
”Age and Agism”: the Two Common Vulnerabilities
Nearly four million have been affected globally with COVID-19 and almost three lakhs succumbed to it, the numbers rising as we speak. The World Health Organization (WHO) has rightly declared it as a “Public Health Emergency of International Concern” within a month of its origin, as an outbreak of such a large scale affecting every aspect of life has not been seen in modern times. The causative agent of COVID-19, novel coronavirus SARS-CoV-2, is definitely less fatal than its earlier congeners (SARS and Middle East respiratory syndrome) but much more contagious with increased human–human transmission risk. One of the reasons being that the viability of the virus in aerosol and various surfaces is up to 2 weeks, though the exact scientific consensus on that is yet to be established. Majority of infections are mild, but few have pneumonia and acute respiratory distress syndrome, which can eventually lead to mortality. Furthermore, the severity and fatality of the infection is higher in the elderly, immunosuppressed patients, and people with preexisting respiratory illnesses, chronic medical problems as well as under-detection of symptoms. The elderly are at an unique risk of all these vulnerabilities together. During the first wave of infection in China, 20% of deaths were aged above 60 years. Chinese Centre for Disease Control and Prevention has reported a fatality rate of 3.6% in 60–69 years' age group which can rise up to 20% above 80 years. Similar findings have been resonated in countries with high COVID-19 deaths such as Italy, Spain, South Korea, Iran, and the United States. It has also been seen that in old age, there can be mortalities even without lung involvement. It is related to nonspecific multi-organ failure and septicemia. An age-wise comparative study done by Liu et al. among hospitalized cases of COVID-19 showed that the elderly group (above 55 years) had increased duration of hospital stay, delayed clinical recovery, increased lung involvement, faster progression of the illness, and eventually increased fatalities. The need for mechanical ventilation and oxygen therapy was doubled in the elderly age group, and their blood also showed decreased lymphocytes and C-reactive protein, both of which are markers of adequate immune response to the virus.
Issues with mobility, chronic uncontrolled illnesses (such as diabetes, hypertension, pneumonitis, osteoarthritis, and cognitive decline), multiple medications, and increased need for hospitalizations due to various other factors further increase the susceptibility of the elderly. Connective tissue disorders, endocrinopathies, cerebrovascular accidents, osteoarthritis, and other inflammatory conditions have been shown to alter immune response and complicate the course of COVID-19 infection. The prevalence of these disorders increases with age, thus adding to the risk. Studies have also shown the psychosocial burden of the elderly due to the pandemic. Prolonged social isolation has been mentioned as a “serious public health concern” for the elderly as it increases the risks of cardiovascular, autoimmune, neurocognitive, and mental health-related disorders. A longitudinal mediation analysis had shown that social disconnectedness increases the prevalence of depression, anxiety, stress, and insomnia in older adults. While isolating them is essential for their own physical safety, enforcing it without supervision will increase loneliness, worsen mood state, compromise their autonomy, and affect their overall well-being.
The unique vulnerabilities of the elderly predisposing them to the pandemic threat are:
Frailty (the age-related sum-total biological and psychosocial vulnerability of the individual) that is related to movement restriction, malnutrition, and poor immunity Loneliness, neglect, isolation, and poor nutrition (more so in old care homes and institutionalized setups)Sensory problems (difficulties in vision and hearing) that can prevent them from taking adequate precautionsChronic illness, polypharmacy, increased health-care need, and physical supportImpaired cognitive abilities (memory, processing speed, thinking, and language) that worsen with age can prevent them from comprehending and adhering to the precautionary instructions. People affected with dementia might have behavioral problems and wandering tendencies that can add to challenges of keeping them isolated at times of such outbreakSocial distancing might not always be possible (multiple people in various roles are involved in their care, including domestic help for those who stay alone). Older adults often live by habits developed over years that form an important part of their day. Sudden disruption of this schedule can be traumatizing. Daily walks in the park or to meet peer group and need to obtain daily essentials can lead to increased exposure to the infection and hence increased fear. Many older adults find it quite challenging to psychologically accept the “restrictive” regulations of mobility issued by the government for containing the outbreak, even if they understand the needThe elderly might not be aware and updated about the authentic information related to infection, amid the plethora of “information pollution” that is already prevalent. Confusion and misconceptions might result in noncompliance to precautionary measures, faulty treatments, and overmedicationInadequate COVID-19 testing and consequently less detection can risk them to be asymptomatic carriers of this highly contagious infectionExistential issues of “what after me” and “what about my family” due to the fear of death are common in older adults. Self-neglect can result from a willful surrender to pandemic situations, misconstruing the risk of infection and overestimating the threat. The other concern in older adults is that of a dignified death, which is threatened during the ongoing lockdown, travel restrictions, and social distancing. A pertinent fear arises of a sudden and lonely death in solidarity and loneliness, away from the family, devoid of the last wishes that one had. Essentially, the context of the apprehended “death” becomes a greater worry than death itself, which can affect the emotional well-being. Spirituality is an important coping factor for the elderly, and the interruption of religious rituals as a part of last rites for the demised can prevent healthy grievingPsychosocial vulnerability, especially at times of lockdown and quarantine: loneliness, anxiety, and uncertainty can give rise to depressive disorders, insomnia, and chronic stress. Grief and bereavement due to loss or distancing from their loved ones can be significant and chronic. They are also at increased risk for posttraumatic stress syndrome, if the stress is prolonged. Alarmingly, suicide risk is also two to three times more in the elderly population and is often underreported. A nationwide mental health survey in China during the present pandemic showed that one-third of those above 60 years suffered from grief, depression, anxiety, and insomnia  (mentioned further in a later section)COVID-19 has brought about a distinct change in the epidemiology and treatment gap of addiction disorders. Alcohol abuse, alcoholism, and stress-related drinking have increased globally secondary to the pandemic crisis. It has been hypothesized that ethanol reduces adaptive immunity and upregulates the angiotensin-converting enzyme-2 receptors, which are the targets of SARS-CoV-2 infection. The sudden lockdown in India has led to increase in complicated withdrawals, which can be fatal if untreated, especially for the elderly. Consumption of adulterated alcohol and methanol are other life-threatening risks. Opioid substitution treatment can get hampered, and excessive smoking can further worsen the preexisting pulmonary conditions of the older adults predisposing them to the infective effects of COVID-19. Importantly, self-care and precautionary measures get impaired with poor treatment seeking adding to the vicious cycle of substance abuse, which has much more detrimental health effects in the seniorsLack of domestic help and basic living amenities in those living alone due to the lockdown can make survival a greater problem than the threat of infection. Considering that the domestic helpers cater to multiple houses with unknown standards of hygiene and safety, they run the risk of being asymptomatic carriers of the infection. This often adds to the uncertainty and fear experienced by the elderly whom they serve. This is a “dual-edged sword” as the seniors residing alone are often dependent on their daily help, but at the same time apprehensive and fearful about contracting infection. This serves an important source of vulnerability, both physical and emotionalDifficulty in digital connectivity: Due to various reasons such as lack of familiarity, cognitive or sensory deficits, and difficulties in adapting to a new practice, many senior citizens might not be proficient enough to stay in touch with their loved ones through social networking (WhatsApp, Facebook, etc.) and video-conferencing methods, which are recommended worldwide during the COVID-19 crisis for social connectedness. Especially the older adults residing alone might not have the required assistance when they want to connect virtually with their families. This can add to the frustration and helplessness. Even though digital connection appears to be a rational substitute, it has been shown in earlier studies that the elderly prefer personal communication and care, rather than virtual interactions. During the current pandemic situation, staying physically “segregated” adds to their loneliness and social isolation.
Mental Health and Coronavirus Disease 2019: Relevance for the Elderly
The COVID-19 crisis is an unprecedented one globally. All the abovementioned risk factors add to the mental health burden of the elderly and can have detrimental effects on the quality of life. Unfortunately, research related to this field is still scarce. Few commentaries have glanced at the need of special advocacy for the elderly mental health, mentioning digitalization of connections as a priority and warning about loneliness and social disintegration as the major offshoots of the pandemic and resultant lockdown., Besides the fear, risk of abuse, and discrimination during COVID-19, many seniors reside miles away from their children. Western countries such as the United States (U. S.) and United Kingdom (U. K.) have been disproportionately affected by the pandemic with increased mortality rates. The elderly whose children reside in these countries stay in a constant state of worry, apprehension, and helplessness. On the other side, the inability to receive their physical presence and care if ill or hospitalized during this global lockdown can add to the emotional frailty. As mentioned earlier, virtual association, though an option, cannot be a substitute for a “loving touch” from family. Furthermore, demise or loss of their spouse or children due to the infection, with lockdown hindering adequate last rites, can further compound the grief. All of these can be independent risk factors for late-life depression, which can be clinically polymorphic, underdetected during other priorities during pandemics also increasing the risk for suicides. An online survey conducted in 1074 people from Hubei, China, showed decreased mental well-being, increased depression, and poorer quality of sleep in the elderly (age >55 years), compared to substance use and anxiety which were more in the younger population. Another prospective longitudinal study conducted on 1738 participants from 190 Chinese cities reported a higher rate of physical (somatic) symptoms associated with anxiety, increased trauma scores, and decreased sleep, which increased with age and were related to isolation, perceived stress, and dissemination of health information by media. On the contrary, a study by Huang and Zhao mentioned younger people having more depressive and anxiety symptoms than their elder counterparts. A study from Northern Italy stated individual factors (sensory and cognitive deficits, comorbidities, and polypharmacy), infective factors (neurotrophic effects of the virus, immunocompromised state, and frailty), and environmental factors (social isolation, institutionalization, and intensive care admissions) as the important risks for psychosocial condition of the elderly and reported 30%–50% neuropsychiatric associates of COVID-19 to be delirium, agitation, and depression, though the exact prevalence of each was not reported. A multinational (Brazil, Portugal, and Norway) report on the mental health of the elderly during COVID-19 cautioned against increased hospitalization, fear of death, stigma, age-related prejudice, and distancing from family as the factors for increasing psychiatric comorbidity in this age group. Risk minimization, physical safety, and social integrity were the suggested steps by these authors based on the case vignettes that they have discussed. Special at-risk sections within the elderly are those with poor social support, residing alone, with preexisting mental disorders and homeless. Substance abuse-related complications as mentioned earlier can increase both morbidity and mortality. A position paper on “COVID-19 and substance use disorders” by the International Society of Addiction Medicine raises the concern of addictive behaviors adding to the public health burden and identifies adults >60 years old at significantly higher risk. Baker and Clark recently recommended a biopsychosocial approach to deal with their social isolation during the pandemic by reducing the infective risk, supportive counseling sessions, psychoeducation of the families, and their continued involvement in care.
Stigma of “agism:” the Precursor to Abuse
There is another aspect to it, the stigma of agism. Often, the elderly are marginalized population. Even though traditionally humans are taught to respect and take care of the older generation, the innate fear of “aging,” “losing vitality,” and death have made “agism” a prevalent “social evil.” The WHO defines agism as “the stereotyping, prejudice, discrimination against people based on their age.” Society equates aging with loss of “charm and beauty” of the youth and hence has given the risk to various forms of old-age abuse. Such stigma and abuse can flare up at times of an outbreak which has an age-specific vulnerability. A recent systematic review by Chang et al. has linked agism with multiple negative physiological and psychosocial consequences. Common conversational content during this pandemic, like ”Oh, you are mostly a target, you need to be safe,” “It is the old who are dying, so you better stay separate lest you get infected” or “you need to take more care, or else you might infect others” seem apparently benign but laden with reproach and stigma. The elderly are prone to have chronic bronchitis, obstructive lung disease, common cold leading to chronic cough, sore throat and flu-like symptoms which are easily mistaken for those of COVID-19. This can lead to social segregation, stigma and impaired mental well-being. Overcrowding, neglect, and poor self-care in old-age homes are other contributing factors. Stress has an independent impact on immunity and hence can increase the proneness to any infection. Autonomy and self-dignity can be hampered during the worldwide lockdown that they are experiencing, which might further impair their mood, appetite, and sleep. Many of them live alone and are struggling with basic amenities such as food, domestic utilities, and hygiene along with the lingering fear of the pandemic. The latent agism and preexisting stigma can manifest as violence and abuse against the elderly, especially during entrapment and lockdown situations when many families are spending significant unbuffered time, like never before. Aggression, substance abuse, irrational reasoning, and familial power hierarchy can get amplified during pandemics. This can potentiate elder abuse, a serious concern of the COVID-19 crisis.
Elder Abuse and Coronavirus Disease 2019: the Dual Vulnerability
The WHO defines elder abuse as a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, that causes harm or distress to an older person. This includes both acts of omission and commission. It can range from physical, psychological to financial abuse and even frank neglect. Since the time COVID-19 started, incidents of family violence and abuse have been increasing against the elderly, and public warnings have been issued related to the same by the American Bar Association. In the guidelines for care in the elderly during COVID-19, the WHO and Centers for Disease Control and Prevention (CDC) have both mentioned the risks of abuse and the urgent necessity to prevent and mitigate it., At certain times, restriction of autonomy and noninvolvement in decision-making done in good faith can also impair the rights of the elderly and lead to marginalization. Abandonment, neglect, and denying access to information can be the other offshoots, more so for the institutionalized seniors. To explain the abuse risk during the COVID-19 pandemic, Mosqueda et al. have proposed a theoretical model called the Abuse Intervention/Prevention Model. The model focuses on a triad of intersecting factors, namely the vulnerabilities of the elderly during the pandemic, the “trusted other,” and the context of abuse. The unique vulnerabilities of “age and agism” have already been discussed above, the trusted person might be a family member, a paid caregiver, a domestic help, or the old-age institutional management. The contexts are mostly situational and sometimes individualistic during pandemic situations.
Elder abuse tends to more common in communities where both the victims and perpetrators lack mental health treatment or social care support in community. Lockdown has increased demands for all essential services, and the elderly have difficulty in accessing many of them as most have moved online. Barriers to access of care lead to underreporting, self-stigma, and normalization of abuse. The helplines at our tertiary care have received frequent calls for help regarding restriction of mobility, neglect, inability to connect to loved ones, and overcrowding without face masks and adequate sanitary facilities in care homes and hospitals. People with dementia, especially those away from family, are at an increased risk. In the COVID-19 situation, with increased digital exchange, financial scams and exploitation of the elderly are common by opportunistic strangers. Even research in the elderly population during the time of pandemics, without appropriate informed consent, can be considered to be violation of their rights and dignity. The coronavirus has instigated agism in thoughts and remarks right from its initiation in China. With time, as the case fatality rate has increased in the aged, unfortunate and utilitarian comments have been passed regarding “needs of the many versus needs of the few.” In a similar context, it is ironic that the elderly population is rapidly growing and emotional well-being is a prime requirement for their healthy longevity.
Caring for the Elderly during Coronavirus Disease 2019: the Way Forward
Awareness about the special needs of the elderly during such crises and sensitivity to their vulnerabilities are the premise on which help can be provided. Caring for them needs to be a collective responsibility at all levels. Few important facets are highlighted below:
”Physical distancing” needs to be implemented rather than social distancing. Regular telephonic/digital contact needs to be maintained with them to ensure they have adequate emotional support. Every individual has their “special” loved ones which can be grandchildren, children, spouse, or even pets. Meeting them frequently over video-conferencing helps foster hope and happinessConsidering their vulnerability, it is better for them to avoid going out or meeting too many people. Additional effort is necessary to supervise whether their hand and respiratory hygiene are ensured. Simple directions (written or recorded) in their language are appropriate for those for stay away from the familiesHospital visits are best avoided during the pandemic. Tele-consultations have been started by most institutes. Technology access might be a challenge in some, and adequate guidance is necessary. Emergency medical or psychiatric consultations can always be availed, should need arise. The availability of common psychotropics needs to be ensured at the district levelsAll elective surgeries such as cataract, hernia, or knee replacements (unless complicated) are better postponedBulk of statistics does not mean much to them, however, the elderly have all the rights to be updated for their own safety. The status of the pandemic and necessary precautions needs to be explained in simple terms, especially for those with sensory or cognitive difficulties. “Digital screen time” needs to reduce to avoid panic and confusionThe older adults in isolation or quarantine need special care: ensuring support through telephonic counselling, virtual contact with their loved ones and maintaining adequate nutritional needs are vitalFamily members need to be sensitive to the early symptoms of COVID-19 and testing if needed should be promptly done. This, however, should not give rise to panic, self-isolation, and stigma. Medical advice is the best choice for any clarificationIt is for the best interest not to medicate the elderly with any drug (antivirals, hydroxychloroquine, any herbal supplement, or advertised quick remedy) as a preventive or curative strategy for COVID-19. They can be life-threatening. It is always better to seek professional help Authentic guidance sources by public health agencies (WHO, CDC, and Ministry of Health and Family Welfare, Government of India) have clear guidelines for elderly care during the pandemic. They can be advocated and adhered toEssential service-delivery helplines (food, water, medications, and other necessary amenities) are helpful for those stranded alonePsychosocial issues are vital, and families need to be sensitive to them. It is natural to be stressed, but signs of excessive panic, depression, sleep problems, or suicidality need urgent attention from a qualified mental health professional. Suicidality is already an added risk in the elderly, and more attempts tend to be successful. Late-life depression can be polymorphic and hard to detect, which further increases the risk of self-neglect and self-harm. Substance abuse and associated comorbidities need prompt detection and treatment. Harm reduction approaches might be helpfulThe elderly are best involved in decision-making even at times of crisis. They need to have their rights, self-respect, and dignity preserved and protected. Their will to quarantine, intimacy, and sexual autonomy are to be respectedDigital literacy for older adults: Digitization of existing services means little unless there is provision for penetrance into older populations, where only 18%–25% of respondents in surveys have access to smart devices and the wherewithal to operate them meaningfully. This can also be achieved for those with mild cognitive deficits. Recently, a novel study looked into the effects of a television-based assistive integrated technology TV-AssistDem (TeleVision-based ASSistive Integrated Service to support European adults living with mild dementia or mild cognitive impairment) and found it to be comparable to the control groups on reducing sleeping problems, improving psychological well-being, greater social involvement, and better activity structuring Targeted welfare interventions for minorities and vulnerable subgroups among the elderly, namely the gender and sexual minorities, refugees, migrants, the internally and externally displaced, racial, ethnic, religious and caste minorities, the disabled, persons with dementia, persons living in long-term care facilities, and socioeconomically underprivilegedPrevention of abuse needs special priority and considerations [Box 1].[INLINE:1]
Coronavirus Disease 2019, the Elderly, and Mental Health: Special Implications for India
India reported its first COVID-19 bcase on January 30, 2020. After a slow initial phase, as of today, it has the largest number of confirmed cases in Asia, with more than 2.7 lakhs infected and 7745 succumbing to the infection. India's case fatality rate, however, is 2.8%, which is much lower against the global 6.13%. Decreased testing rate compared to the population and selective testing of the symptomatic individuals have been proposed as a reason by some researchers for this figure. Overall, the mortality rate appears to be lower and age being a significant risk factor for the same like the rest of the world, though the majority of the affected Indians are in the younger population. These statistics, however, hint little at the public health burden of a country that is predicted to reach 1.7 billion population by 2050, with the elderly likely to form 20% of them. Besides, the lack of adequate mental health services and service utilization, prevalent stigma, and knowledge-attitude-practice gap toward mental health compound the challenges related to the psychosocial comorbidities during the COVID-19 pandemic. The sudden lockdown has also increased substance abuse-related complications, which act as a “double blow” to both their mental health and physiological risk to the virus. The fear and vulnerabilities of the elderly exist, along with the challenges of digitalization and accessing telemedicine services unlike the other developed countries. Even simple telephonic access for consultations and online prescriptions are difficult in a country where majority are not adequately equipped for technology use. Furthermore, physicians face challenges in evaluating the elder adult through the online media. An age-structured impact of social distancing during the four-phased lockdown in India shows increased psychosocial burden above the age of 50 years, with increased loneliness and decreased social interaction. Taking care of their needs in a sociocultural context will be important, tailored to their requirements. Personal “touch,” empathy, and validation of their distress have been shown to improve their psychological resilience. In the varied sociocultural contexts of India, helping their personal social connections, improving their company, doorstep delivery of essentials, respecting their dignity and autonomy as well as scheduling their day with preserved mobility, will help in their psychosocial care. Their physical safety needs supervision, and spirituality can be a vital source of coping during such times of distress. Agism and stigma have been prevalent in India during the pandemic, added by the effect of social media. Fighting misinformation, involving the seniors in decision-making, and keeping them adequately informed can enhance their perceived sense of safety. The Indian Pandemic Act, 1897 is already set for an overhaul in the face of COVID-19, and incorporating the mental health needs of the elderly will be vital. As the caseload peaks in the next few months in the subcontinent, systematic research on the elderly and their mental health will help us understand population-based risk, their lived experiences and unmet needs, that can shape policies and improve the preparedness for such futuristic crises.
The older adults might have a range of challenges during the pandemics, but most are preventable. COVID-19 is still in its early times. Much more psychosocial morbidity is expected in the months to follow, and the health services need to be prepared for the same. The Indian Pandemic Act, 1897 needs an update in the true sense. This might be a good opportunity to include the protection and well-being of the older adults during the pandemics. The vulnerabilities of the elderly and their dependencies need to be collectively addressed with organized and systematic efforts at all levels. Cross-sectional and longitudinal research into their psychosocial issues and lived experiences during the pandemic will help estimate population-based risk and shape policies. The seniors might be vulnerable and frail due to age, but they are not weak. To quote Albert Camus “The old can go through every plague” from his classical La Peste (The Plague), the resilience of the elderly can be amazing, if adequately cared for and the young can borrow from their strengths. How one treats their seniors during a disaster, shapes what treatment they receive in futuristic crises. COVID-19 delivers yet another opportunity for the same.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||Singhal T. A review of coronavirus disease-2019 (COVID-19). Indian J Pediatrics 2020;87:281-6.|
|2||Banerjee D. Age and ageism in COVID-19': Elderly mental health-care vulnerabilities and needs. Asian J Psychiatry 2020;51:102154.|
|3||World Health Organization. Ageing and Life Course. Available from: https://www.who.int/ageing/en/. [Last accessed on 2020 Jun 10].|
|4||Cohn SK, Cohn SK. The Black Death Transformed: Disease and Culture in Early Renaissance Europe. London: Arnold; 2003.|
|5||Cunha BA. Influenza: Historical aspects of epidemics and pandemics. Infect Dis Clin North Am 2004;18:141-55.|
|6||World Health Organization. Coronavirus Disease 2019 (COVID-19): Situation Report; 2020;118:92.|
|7||Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents 2020;55:105924.|
|8||Feng Z, Li Q, Zhang Y. Novel coronavirus pneumonia emergency response epidemiology, The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41:145-51.|
|9||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.|
|10||Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.|
|11||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:e14-e18.|
|12||Yang J, Zheng Y, Gou X, Pu K, Chen Z, Guo Q, et al. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: A systematic review and meta-analysis. Int J Infect Dis 2020;94:91-5.|
|13||Gerst-Emerson K, Jayawardhana J. Loneliness as a public health issue: The impact of loneliness on health care utilization among older adults. Am J Public Health 2015;105:1013-9.|
|14||Santini ZI, Jose PE, York Cornwell E, Koyanagi A, Nielsen L, Hinrichsen C, et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. Lancet Public Health 2020;5:e62-e70.|
|15||Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-56.|
|16||Lebret S, Perret-Vaille E, Mulliez A, Gerbaud L, Jalenques I. Elderly suicide attempters: Characteristics and outcome. Int J Geriatr Psychiatry 2006;21:1052-9.|
|17||Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatr 2020;33:e100213.|
|18||Marsden J, Darke S, Hall W, Hickman M, Holmes J, Humphreys K, et al. Mitigating and learning from the impact of COVID-19 infection on addictive disorders. Addiction 2020.|
|19||da Silva J, Testino G. Risks of Alcohol Abuse, Alcoholism and Stress-Related Drinking During the COVID-19 Pandemic. Alcoholism Drug Addict Alkoholizm I Narkomania; 2020. p. 32.|
|20||Arya S, Gupta R. COVID-19 outbreak: Challenges for Addiction services in India. Asian J Psychiatr 2020;51:102086.|
|21||Bharati N, Giri A. National Herald; 28 March, 2020. Available from: https://www.nationalheraldindia.com/opinion/domestic-workers-in-the-times-of-covid-19-lockdown. [Last accessed on 2020 Jun 10].|
|22||Kovaleno OH, Spivak LM. Psychological well-being of elderly people: The social factors. Soc Welfare 2018;8:163-76.|
|23||Jawaid A. Protecting older adults during social distancing. Science 2020;368:145.|
|24||Ahmed MZ, Ahmed O, Aibao Z, Hanbin S, Siyu L, Ahmad A. Epidemic of COVID-19 in China and associated psychological problems. Asian J Psychiatr 2020;51:102092.|
|25||Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun 2020;87:40-8.|
|26||Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res 2020;288:112954.|
|27||Serafini G, Bondi E, Locatelli C, Amore M. Aged patients with mental disorders in the COVID-19 Era: The experience of Northern Italy. Am J Geriatr Psychiatry 2020. [In Press].|
|28||Monteiro-Junior RS, Carneiro LSF, Barca ML, Kristiansen KM, Sampaio CA, Haikal DS, et al. COVID-19 pandemic: A multinational report providing professional experiences in the management of mental health of elderly. Int Psychogeriatr 2020; p.1-2.|
|29||Farhoudian A, Baldacchino A, Clark N, Gerra G, Ekhtiari H, Dom G, et al. COVID-19 and substance use disorders: recommendations to a comprehensive healthcare response. An international society of addiction medicine (ISAM) practice and policy interest group position paper. Auton Neurosci 2020;11:129-46.|
|30||Baker E, Clark LL. Biopsychopharmacosocial approach to assess impact of social distancing and isolation on mental health in older adults. Br J Community Nurs 2020;25:231-8.|
|31||Officer A, de la Fuente-Núñez V. A global campaign to combat ageism. Bull World Health Organ 2018;96:295-6.|
|32||Nelson TD, editor. Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, MA: MIT press; 2004.|
|33||Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons' health: A systematic review. PLoS One 2020;15:e0220857.|
|34||Armitage R, Nellums LB. COVID-19 and the consequences of isolating the elderly. Lancet Public Health 2020;5:e256.|
|35||World Health Organization. Missing Voices: Views of Older Persons on Elder Abuse. World Health Organization; 2002.|
|36||Coronavirus Update for the Elder Law Community. Available from: https://www.americanbar.org/groups/law_aging/resources/coronavirus-update-and-the-elder-law-community/. [Last accessed on 2020 Jun 10].|
|37||Supporting Older People During the COVID-19 Pandemic is Everyone's Business. Available from: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/4/supporting-older-people-during-the-covid-19-pandemic-is-everyones-business. [Last accessed on 2020 Jun 10].|
|38||Centers for Disease Control and Prevention. COVID-19 Guidance for Older Adults. Available from: https://www.cdc.gov/aging/covid19-guidance.html. [Last accessed on 2020 Jun 10].|
|39||Mosqueda L, Burnight K, Gironda MW, Moore AA, Robinson J, Olsen B. The abuse intervention model: A pragmatic approach to intervention for elder mistreatment. J Am Geriatr Soc 2016;64:1879-83.|
|40||The Conversation. Available from: https://theconversation.com/coronavirus-lockdown-measures-may-be-putting-older-adults-at-greater-risk-of-abuse-137430. [Last accessed on 2020 Jun 10].|
|41||Brooke J, Jackson D. Older people and COVID-19: Isolation, risk and ageism. J Clin Nurs 2020;29:2044-46.|
|42||Ferner RE, Aronson JK. Chloroquine and hydroxychloroquine in covid-19. BMJ 2020;369:m1432.|
|43||Conger K, Griffith E. As Life Moves Online, an Older Generation Faces a Digital Divide. The New York Times. Available from: https://www.nytimes.com/2020/03/27/technology/virus-older-generation-digital-divide.html. [Last accessed on 2020 Jun 10].|
|44||Goodman-Casanova JM, Durá-Pérez E, Guzmán-Parra J, Cuesta-Vargas A, Mayoral-Cleries F. Telehealth home support during COVID-19 confinement: Survey study among community-dwelling older adults with mild cognitive impairment or mild dementia. J Med Int Res 2020;22:e19434.|
|45||Ministry of Health and Family Welfare. Government of India. COVID-19 INDIA. https://www.mohfw.gov.in. [Last accessed on 2020 Jun 10].|
|46||Agarwal A, Lubet A, Mitgang E, Mohanty S, Bloom DE. Population aging in India: Facts, issues, and options. In: Population Change and Impacts in Asia and the Pacific. Singapore: Springer; 2020. p. 289-311.|
|47||Kar SK, Arafat SY, Kabir R, Sharma P, Saxena SK. Coping with mental health challenges during COVID-19. In Coronavirus Disease 2019 (COVID-19). Singapore: Springer; 2020. p. 199-213.|
|48||Singh R, Adhikari R. Age-structured impact of social distancing on the COVID-19 epidemic in India. arXiv preprint arXiv 2020;2003:12055.|
|49||Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.|
|50||Camus A. La Peste (The Plague). New York: Vintage; 1947. p. 46.|