key: cord-0929563-njn7yxwb authors: Banerjee, Debanjan title: ‘Age and Ageism in COVID-19’: Elderly Mental Health-care Vulnerabilities and Needs date: 2020-05-05 journal: Asian J Psychiatr DOI: 10.1016/j.ajp.2020.102154 sha: e3f33ebea017e0976b647b8edd495cc6268219d0 doc_id: 929563 cord_uid: njn7yxwb nan COVID-19 has been postulated to be less fatal than its earlier congeners like Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), caused by the same family of viruses. However, the SARS-CoV-2 is much more contagious with an increased human-human transmission . Though majority of the cases are mild, few can progress to pneumonia and consequently Acute Respiratory Distress Syndrome (ARDS), which can eventually lead to mortality. This severity and fatality have been found to be higher in the elderly, immunosuppressed, socially impoverished, people with pre-existing respiratory conditions and chronic medical comorbidities: all of which can be predisposing risk factors at an increased age (Novel, 2020). The geriatric age-group already has unique physical, psycho-social and environmental vulnerabilities, owing to the frailty. During the first wave of the outbreak in China, 20 percent of deaths were above 60 years of age (Wu and McGoogan, 2020) . Based on The Chinese Centre for Disease Control and Prevention data, the fatality rate among 60-69 years old is around 3.6 percent, which increases to 18 percent above 80 years . This is also correlated with the viral load and virulence, and similar data has been reported from the worst affected countries like South Korea, Iran, Spain, Italy and the United States (Rothan and Byareddy, 2020). Also, age is an independent mediating factor between mortality due to COVID-19 and non-pulmonary involvement, as non-specific multiorgan dysfunction syndrome (MODS) and septicemia are common in the geriatric population. An age-wise comparative study by Liu and colleagues (2020) showed that patients of COVID-19 above 55 years had three times increased mortality. They also had increased hospitalization, delayed clinical recovery, increased pulmonary involvement, faster disease progression, and comorbidities of diabetes, hypertension, history of cerebro-vascular accident (CVA) and chronic obstructive pulmonary disease (COPD). The need for mechanical ventilation and oxygen therapy were double in them and their blood showed decreased lymphocytes, Creactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR): all of which are markers of inflammatory response to the virus. Further issues in elderly are the sensory problems, polypharmacy, impaired cognitive abilities and increased visit to health-care facilities, which can serve as additional burden in case of any infectious disease. Neglect, loneliness, isolation, depression, anxiety and abuse are the associated evils especially at times of social distancing practiced during present times. This can be more problematic in the institutionalized elderly (example: those in old-age care homes). The distancing and hygiene measures might not be adequate in all of these places. The uncertainty and fear of the pandemic can have increased effect on the minds of the aged, as they are aware of their vulnerability. The fear of death stays lost in the existential fear of losing their loved ones and guilt of possibly being the carriers of the infection. Due to generation limitations and sensory and cognitive deficits, they may be unaware of the updates related to the COVID-19 situation making them easy targets of misinformation and inadequate precautionary measures are followed. The effects of the quarantine can be paramount leading to loneliness, physical distancing from their loved ones, grief, anxiety and chronic stress that can have long-standing psychological effects. Preliminary research so far has shown increased incidence of depressive disorders, complex post-traumatic stress (PTSD) and adjustment reactions in the elderly (Banerjee, 2020) . Furthermore, increased suicidal ideations and attempts consequent to stress, on the background of the already existing suicidality risk in the elderly, is an added concern. Any form of stress is associated with decrease in immunity. Also, under-reporting of the psychiatric symptoms has also been observed during the COVID-19 pandemic in a recent study done in elderly (Armitage and Nellums, 2020) . Many of the seniors are living alone, where basic living amenities are a regular problem due to lack of travel options and scarce domestic help during the lockdown. Loneliness is a potent risk factor for depression, especially when chronic and associated with lack of physical activity (Aylaz et al., 2012) . Many elderlies might not be well-versed with technology leading to increased emotional distancing in absence of even digital contact with the families. Added to that, is the social stigma of ageism magnified by this outbreak that can lead to marginalization, segregation, abuse and increased institutionalization. This can hamper the autonomy and self-dignity that are important in resilience for any age group. Families and care givers need to be holistically involved in the care of the elderly, with increased sensitivity to their mental health. Few measures that can be undertaken to ensure their psychological well-being are: 1. Ensuring the adequate three-pronged precautionary measures as suggested by WHO (social distancing, hand and respiratory hygiene). They need to be explained about the needful in simple and relevant terms. J o u r n a l P r e -p r o o f 2. Social connectedness with their loved ones is essential together with social integration. They need to be involved in decision-making at familial levels, during times of such crisis. 3. Providing adequate emotional support is vital to those living alone. Ensuring their basic needs, safety and dignity will help them to stay free from stress and fight loneliness, more so in lockdown situations. Their doubts need to be addressed periodically to allay the pandemic-related anxiety. 4. Tele-facilities for health care consultations are better rather than physical access. That decreases the physical health risks and reduces fear. 5. 'Digital screen time' is better reduced, more so for the elderly to prevent misinformation and panic. They need to be updated about the COVID-19 situation and the necessary measures in a relevant manner. Vivid data and unnecessary statistics are better avoided. 6. Those in day-care or old-age homes might need special care. Preventing overcrowding, encouraging physical activity, enhancing family support and ensuring nutrition are vital for their overall well-being. Abuse can be increased in such situations and need to be prevented and identified at the earliest. 7. Self-medication can be fatal (especially with drugs like hydroxychloroquine) and needs to be avoided at all costs. 8. Various elder-friendly helplines exist specific to various countries both for telephonic counselling as well as food or essential deliveries at home. They need to be made aware of the same and seeking mental health care, if in need, should be actively encouraged. 9. The families and caregivers need to be sensitive to the increased needs of those with pre-existing disorders like dementia, depression and other neurological disorders. COVID-19 and the consequences of isolating the elderly Relationship between depression and loneliness in elderly and examination of influential factors How COVID-19 is overwhelming our mental health Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): the epidemic and the challenges Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): the epidemic and the challenges Clinical features of COVID-19 in elderly patients