Afflicted Living

The Pandemic's Deep Impact on the Elderly

The Chinese novelist Fang Fang, who has lived most of her life in Wuhan, documented her days during Wuhan's dramatic Covid-19 lockdown from January 25 through March 24, 2020, in Wuhan Diary: Dispatches from a Quarantined City. She is in her sixties and writes with the perspective of one who has seen the burdens placed on both the elderly and the young during the early days of the coronavirus pandemic. As the epidemic in Wuhan wore on, Fang Fang predicted that there would be lasting consequences from the social isolation and massive number of deaths. On February 12 she wrote,

Here in Wuhan it is hard to find anyone who isn't experiencing some form of psychological trauma from all this. This is something that I'm afraid none of us can avoid. . . . And there are so many more traumatic stories that will continue to be a psychological burden on people for a very long time to come. Once this plague has passed, I'm afraid that Wuhan will need an army of counselors and psychologists to help the people get through the aftermath."¹

For most people, Covid-19, the disease caused by the SARS-CoV-2 virus, is not deadly. It may have lingering, sometimes debilitating effects, but deaths have largely occurred among the elderly and those with co-morbidities. According to the CDC, eight out of ten Covid-19 deaths in the U.S. occurred among people over 65. Those between 75 and 84 years old are 220 times more likely to die from Covid-19 than are 18-to-29-year-olds.

Additionally, many older people live in assisted-living or long-term care facilities, which have had a difficult time controlling outbreaks. According to the Long-Term Care Covid tracker, even though less than 1 percent of the U.S. population lives in long-term care facilities, this group accounts for 38 percent of Covid-19 deaths (about 116,000 as of December 17).²

Moreover, research over the past several years has shown that loneliness and isolation cause some diseases to worsen. Elderly persons who are isolated and lonely have a 50-percent increased risk of developing dementia and a 32-percent increased risk of having a stroke. They are also four times more likely to die of heart failure. Evidence points to lockdowns as causing increases in depression, anxiety, and suicidal thoughts among people with dementia.³

This situation poses a difficult conundrum: we must decide between the possibility of the vulnerable dying sooner via a painful, suffocating death from Covid, or dying more slowly via the mental torture and cognitive decline brought on by prolonged isolation. To believe that the physical affliction is worse than the mental one is not to understand mental distress very well. It ignores the fact that people over 75 have the highest incidence of suicide in the United States.⁴

A Personal Taste of the Dilemma

I am not in the over-65 demographic, but I had a small taste of this dilemma. I was diagnosed with cancer early during the pandemic. On the day of my multi-hour surgery, which would hopefully put everything in remission, Texas was having a surge of Covid cases. My husband and I found out in the pre-op room that the hospital's rules had been changed. I would not be allowed any visitors while I recovered in the hospital. My husband could stay for about an hour after the surgery, but then would have to leave.

In my anger, I said to my nurse, "So they're sacrificing mental health for physical health, then?" She looked at me sympathetically and said, "I'm sorry." My surgeon said with less sympathy, "Look, it's a pandemic. We're having to do tough conversations over Zoom." Obviously they weren't happy about this, either.

Like many of the isolated elderly, I struggled using technology to connect with people. In my case, the effects of the chemo made my hands too numb and sensitive to use my phone. After two days, when I could manage a video call, it was too exhausting to stay connected for very long. Also, the nursing staff was overtaxed, having to help me with tasks that visiting family members often do, like refilling my water or handing me a book. In long-term care facilities, there were more reports of patients falling during the pandemic, largely because the facilities were short-staffed and lacked the help that residents' family members had previously provided.⁵

I ended up staying less than a week in the hospital, thanks to my tireless nurses. But the answer to my question in the pre-op room was "yes"; they were sacrificing mental health for physical health. The tradeoff was appropriate in my case, given the risks, but it is not so clear that such a tradeoff is appropriate for the elderly.

When All Options Cause Harm

While it will take time to see the full effects of the pandemic on the elderly, some things are already evident. In September, Politico reported that deaths attributed to Alzheimer's and dementia were 20 percent greater than usual during the summer of 2020.⁶ Kevin Jameson, president of the Dementia Society of America, told Politico that the protective equipment that staff must wear, even just masks, can disturb people with dementia: "People are so masked up and covered up in the care of these individuals that it becomes really isolating for people with dementia," he said. "Their way of understanding their world requires them to see and hear multiple cues to understand what's going on."⁷

A spokesman for the National Consumer Voice for Quality Long-Term Care said his organization received numerous calls from family members saying their loved ones were losing the will to live. Many were dying from social isolation or "failure to thrive" during the pandemic. Several residents have said they feel like they are in prison because they cannot see family members or go outside. The daughter of an 82-year-old resident at a nursing home where a Covid outbreak occurred told of having to deal with her father's suffering from both worsening dementia and Covid-19. She was unsure which was worse for her father, the virus or the lockdown.⁸

For an elderly person to live at home with family isn't necessarily a better situation, either. I know of a case where a 90-year-old man's dementia worsened at home, where his normal routines were disrupted. He improved once he was able to move to an assisted-living facility where he was able to interact with more people than in his immediate household, keep to a regular schedule with specific activities, and receive immediate nursing care when needed.

Another tragic example occurred in Toronto in October. Nancy Russell, a sociable, 90-year-old retirement-home resident, had endured one two-week lockdown early in the pandemic and was so afraid of the isolation and loneliness she would face when a second lockdown was announced that she requested euthanasia, which is legal in Canada, where it is euphemistically called "medical aid in dying." According to her daughter, Russell had declined severely during the previous lockdown, when residents were confined to their rooms. Even though Russell understood why her retirement home had such strict rules, she could not stand the thought of another two weeks of isolation and so asked for death. Her first request was denied, but her health continued to deteriorate, and eventually she was euthanized in the presence of family and friends—who, ironically, would not have been allowed to visit her had she decided to live.⁹

Suicide among the elderly is often prompted by incurable health conditions, such as cancer, chronic pain, and dementia. During the pandemic, long-term care facilities have been short-handed, resulting in patients with these conditions receiving less care than they normally would. This, plus the social isolation and anxieties over family members possibly becoming ill has led to fears that more elderly persons will become suicidal.¹⁰

A Different Kind of Grief

The pandemic situation among the elderly is having a ripple effect in society. Many people ache to be at the bedside of their dying loved ones, but have to settle for saying their last goodbyes over Zoom or FaceTime. Although several states and hospitals have loosened their restrictions since last summer, and now allow one or two family members at a patient's bedside, this still leaves many family members unable to see their loved ones.

Additionally, some people may be burdened with guilt from accidentally spreading Covid to an elderly loved one. Tech entrepreneur Red Smith experienced such trauma after his 83-year-old father contracted and eventually died from Covid-19 following a small Father's Day get-together. Smith was especially upset that he could not be with his father while he was in the hospital. The closest he could come was on a single occasion when he could join other family members outside the hospital while the nurses disconnected his father's oxygen long enough to allow him to be moved to the window, where he could look out and see his family holding signs reading "We Love You" and "Fight as Hard as You Can." Two days later, his father died.11

People like Red Smith have had to forego the normal rituals surrounding grief and death. Instead of the customary large gatherings of family and friends, funerals have become small or virtual, or have been postponed. This leaves many with lingering grief without closure. Studies have shown that this "prolonged grief disorder" can cause physical, mental, and spiritual distress, which isolation only worsens.

Undoubtedly, in hindsight, it will become clear that better choices could have been made to mitigate the harms done to the elderly by pandemic-related policies, but I am not sure that many of the consequences could have been avoided. This is the tragedy of disaster situations: we begin by stabilizing the immediate crisis, but there is always an aftermath that may take much longer to process and to mend.

Notes
1. Fang Fang, Wuhan Diary: Dispatches from a Quarantined City, translated by Michael Berry (HarperVia, 2020), 81, 82.
2. "The Long-Term Care COVID Tracker," The COVID Tracking Project, The Atlantic: https://covidtracking.com/data/long-term-care.
3. Emily Paulin, "Is Extended Isolation Killing Older Adults in Long-Term Care?" AARP (Sept. 3, 2020): aarp.org/caregiving/health/info-2020/covid-isolation-killing-nursing-home-residents.html.
4. National Institute of Mental Health: nimh.nih.gov/health/statistics/suicide.shtml.
5. Tucker Doherty, "Summer wave of dementia deaths adds thousands to pandemic's deadly toll," Politico (Sept. 16, 2020): politico.com/news/2020/09/16/dementia-deaths-coronavirus-nursing-homes-416530.
6. Ibid.
7. Ibid.
8. Ibid., note 3.
9. "Facing another retirement home lockdown, 90-year-old chooses medically assisted death," CTV News (Nov. 19, 2020): ctvnews.ca/health/facing-another-retirement-home-lockdown-90-year-old-chooses-medically-assisted-death-1.5197140.
10. Ibid., note 3; Mark A. Reger et al., "Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?" JAMA Psychiatry (Apr. 10, 2020): https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2764584.
11. Todd S. Purdum, "Drive-by burials and FaceTime farewells," STAT (Dec. 9, 2020): statnews.com/2020/12/09/drive-by-burials-and-facetime-farewells-grief-in-the-covid-era-will-weigh-on-the-american-psyche-for-years-to-come.