#CoronavirusSA: Pathogen vs person
With the elderly population disproportionately affected by complications from Covid-19, the novel coronavirus has highlighted the physical well-being of older persons. According to the World Health Organisation (WHO), older people are particularly at risk of developing fatal complications from the virus. Mental health experts, however, have warned that focusing purely on the physical health of the elderly while ignoring the psychological impact of the pandemic could prove to be as deadly, if not more so, than the virus itself, writes Jamaine Krige
“Hi mom!” A chorus of voices chime in greeting and the faces of a middle-aged couple and two children fill the small screen. Seventy-eight year old Elna Ferreira’s* eyes brighten. “We miss you,” her daughter says, as the rest of the family nods in unison. The old lady smiles. “My family,” she says to the care worker holding the phone. “My daughter.” She points at the screen.
In the video they tell her they’re still stuck at home but that the children may return to school soon. “We’ll visit as soon as we can. We love you and we wish we could be there with you right now.” The short video ends and she keeps looking at the phone, but when no new media appears her eyes dull again. With bony fingers, she tugs at the blanket covering her. “Where are my family?” She asks, pleadingly. “Where are my family? I want to see my mother.”
The facility she stays at makes provision for their elderly residents to stay in contact with family through technology, but not everyone has this luxury.
Reinette Greyling* has moments of lucidity, but they are becoming fewer and farther between. Lying in the frail care wing of a facility for the elderly, she has not seen her family for two months. No visitors have been allowed since the pandemic started. Many of the residents have underlying health conditions. At 84–years–old, Greyling has cardiac problems and advanced Alzheimer’s disease. Her condition has deteriorated during lockdown, she is more confused and her memory has worsened. She cries often, waking at night to call for her husband, her children, and her long-deceased mother. Her blood pressure has started to spike and she now needs medicine for her blood sugar levels. Her lucid moments have become the exception rather than the norm.
As life expectancy increases, so does the number of people over the age of 60 living with multiple chronic conditions like hypertension, diabetes, and cardiac conditions. The current Covid-19 pandemic raises acute challenges in the management of physical, social and mental health of the elderly. Statistics South Africa’s 2018 mid-year population report records around 8.5% of South Africa’s 57.7 million residents as over the age of 60.
Dr Sebastiana Kalula is an associate professor and senior specialist of geriatric medicine at the University of Cape Town and director of the Institute of Aging in Africa. She says the elderly are made vulnerable by the accumulative changes that occur in the body throughout their lives, which express themselves more acutely as people reach an advanced age, as well as weakened immune responses.
But, she adds, they are not only physically vulnerable. “Many factors also increase the social and psychosocial vulnerability of older people.”
At risk of more than COVID-19
The WHO warns that older adults, especially those with cognitive decline or dementia, may become more anxious, angry, stressed, agitated, and withdrawn during the outbreak.
Retha Hamman*** is almost ninety years old and suffers from Alzheimer’s disease. Two weeks into the lockdown, she asked for her Bible to be opened to the book of Revelations. Despite having poor situational awareness and advanced memory loss, she wanted to know what the book said about the coming plague. She’s been having nightmares ever since.
Dr Kim Laxton is a practicing psychiatrist with a special interest in geriatric psychiatry and the mental health of the elderly. “I’m concerned because there are two aspects to this situation – the pathogen and the person.” She says government has engaged virologists and epidemiologists when making decisions about lockdown, but not with behavioural psychologists and geriatric psychiatrists. “The decisions are made on a scientific and pathological basis, but I’m not sure they’re made on a person-basis. We talk about groups and statistics, not about people.”
Kalula agrees. “We age differently, depending on exposure. We must realise that people of the same age can be totally different.” She says it’s time for a different approach. “Things should be individualised because there is more heterogeneity in the older persons than any other age group.”
Laxton says psychological wellbeing cannot be overlooked when safeguarding the physical health of the elderly. “People don’t understand the physical impact that stress has on a person,” she explains. “It’s not just about being overwhelmed, stress is a disease that causes inflammatory processes in the body. Mental stress equals inflammation.”
Stress as an inflammatory process
Studies link systemic inflammation to delayed immune responses and increased risks of pneumonia, high blood pressure, diabetes, atherosclerosis, cardiac disease, cancer, high cholesterol and obesity – all conditions that increase the risk for complications from Covid-19.
“If we’re only protecting them against pathogens, we get full marks,” says Laxton. “But we’re creating a whole pandemic on the side and a new subset of patients in the process.”
Stress and its symptoms, like insomnia, weaken the immune system and can lead to drug or alcohol misuse, while negatively impacting neurodegenerative diseases like Parkinson’s, Alzheimer‘s and dementia. According to Laxton: “Stress is a disease too, and needs to be treated as such.”
Medical professionals advise stress-reducing activities to maintain physical health in all age groups – regular exercise, good nutrition, social contact and hobbies. Many of these, however, have been limited or absent in recent weeks. “We’ve basically said forget about the human – about exercise, hobbies and social contact; you must isolate. But the human condition calls for society to come together when times are tough,” says Laxton.
The human behind the pathology
Depression can present differently in the elderly, making it more difficult to diagnose. “We often don’t see low moods,” Laxton explains. “We see irritability, insomnia, generalised body aches and abdominal pain, and when we give an antidepressant they improve.” Depression in the elderly can also present with neuro-cognitive deterioration – worsening memory, processing speed, attention and concentration. “If we isolate these people, we’re not going to see these symptoms and people are just going to fade.”
She says suicide rates among the elderly are the highest of any age group. “Are we going to lose more people from unnatural causes as a direct result of Covid-19, simply because we didn’t think of the human behind the pathology.”
Anxiety and depression may, however, not be the appropriate diagnosis for what many older people are experiencing. “I think we’re seeing a lot of grief, not necessarily in the sense of a recent loss of a person, but the loss of the status quo, the loss of a routine, the loss of family…” When isolated, painful memories surface more readily. “When you are alone in your thoughts, you remember past losses and you relive them,” she explains.
Isolation from family and friends has a bigger impact on the elderly than on their younger counterparts. “Losses are more common as people age,” Kalula agrees. “For someone lucky enough to have a job that they got up for every day, that is taken away too. These changes occur as we get older but are exacerbated by the pandemic.”
Laxton says the elderly are in a different phase of life – one where purely protecting them from a pathogen may end up doing more harm in the long run. The fears younger people have differ from those of the elderly. “A lot of people of 80 or 90 don’t fear death, they fear a loss of dignity, fear for the health of their loved ones, or fear that they may never see friends and family again.”
Another fear is the loss of purpose. “Under lockdown, in their own minds they become more useless, more dysfunctional and more disabled. We’re sticking them in a vacuum for their own protection and taking away the bit of purpose they have,” Laxton explains.
Kalula says the contribution of older people, especially in an African context, goes largely unrecognised. “Within our African context we rely on informal care more than formal care. Older people are caregivers, to their own children, grandchildren and among themselves.” With older people fulfilling this role, the younger generations are free to work and contribute to the economy. “We need to recognise their historic contribution and continuing contribution to society and give them voices, involving them in policy decisions. The elderly have suffered more from the effects of social distancing and the lockdown because it impacted their purpose.”
One way to safeguard the health and dignity of the elderly while still ensuring a sense of purpose would be to encourage residents of old age homes or retirement villages to start projects, such as knitting campaigns to provide blankets to protect those less fortunate against the coming cold. “Give them the tools and let them engage with the world by helping to alleviate some suffering,” says Laxton. Those who possess sewing skills can be given materials to make cloth face masks, which are currently in high demand. “There are ways to foster social cohesion and connection without putting them at risk,” she explains.
Technology to connect
Technology can help bridge social distance, as with Ferreira and her family, but Laxton says caution must be exercised. Tech-facilitated interactions may be confusing, and video calls may be upsetting if the elderly cannot see loved ones in person. Kulula says that technology connects younger people, but “in Africa we have left the older person behind”. They lack the skills to use it, and due to economic circumstances many also lack the resources.
Those who have access to technology risk exposure to fake news, Laxton warns. “It’s important to talk to your older folks and give truthful information, but it must be correct information,” Laxton explains, adding that withholding the truth is not advised. “They can work out that there is something else going on; that the world is in crisis.”
Fostering daily hope
Laxton says even younger, healthy individuals are struggling to stay hopeful and optimistic. “I tell my patients of all ages – stop thinking beyond a few days. Monday is going to happen, but we don’t know much more than that.” Many older people are dealing with sickness, disability, neuro-cognitive decline and other end-of-life experiences, and some are under palliative care. “For them, hope isn’t the same as for you or for me, where we talk about vaccines and a post-Covid future. For them, we need to focus on daily hope.”
For someone who knits, that might mean knowing that the blanket they are making will keep someone warm this winter. For someone nearing the end of their life, it may mean revelling in the moment and enjoying the sunshine in the garden. “For them we need a more immediate hope, an instant hope, that there is a point to what they are doing. There should be a sense of gratification, of joy in this moment right now. They should be looking forward to that daily hope.”
The risk of health problems and diseases is a natural part of aging. “Why is Covid-19 different?” Laxton asks. “Why is this coronavirus so much of a risk that we are prepared to increase other risks – of depression, hypertension or substance abuse in the older population? There’s no right or wrong answer – but I think it is time we start asking the question. And maybe the right people to ask are those most affected.” She agrees with Kulula, saying that the elderly need to be consulted before decisions are made for them. Afterall, she adds, they’re not dead yet. – Health-e News
*Not their real names.
For more information on Covid-19 in South Africa, you can call the toll-free line on 0800 029 999, or you can send a message that says “Hi” on WhatsApp to the number 060 012 3456. You can also visit the SA Coronavirus website.