What Are the Health Priorities of Older Adults During a Pandemic?

This is the nineteenth document in a series of discussion notes addressing fundamental questions about the COVID-19 crisis and response strategies. These documents are based on the best scientific information available and may be updated as new information comes to light

Written by Laura Delgado-Ortiz, Gabriela Cárdenas-Fuentes, Ximena Goldberg and Judith Garcia-Aymerich (ISGlobal’s Non-communicable Diseases and Environment Programme), this document explores three areas in which the pandemic could be having a greater impact on older people (on chronic diseases, on physical mobility and on mental health) and proposes a series of mitigation measures.

Throughout the COVID-19 pandemic, older people have been viewed as the most vulnerable group. Since the start of this health emergency, studies have indicated that being over 65 years of age and having chronic illnesses—two factors that often go hand in hand—increases a person’s risk of developing more severe versions of the disease. In Spain, official reports have shown that this population group has the highest rates of hospitalisation for COVID-19, admissions to intensive care units and deaths.

Consequently, some countries have adopted differentiated policies for preventing COVID-19 in older adults. In Colombia, for example, older people have been strictly barred from using public spaces. Other countries, including Spain, have placed stringent restrictions on older people’s movements outside of their homes and assigned time slots for them to go outdoors, thereby reducing their risk of contracting COVID-19 but also hampering their mobility and limiting their social interactions.

The pandemic has therefore placed a double burden on older people: higher risk of becoming infected and developing more severe versions of the disease, plus increased vulnerability to the effects of confinement.

Impact on Chronic Diseases in Older Adults 

During the pandemic, health services have been forced to reorganise their operations, prioritising the care of patients with severe COVID-19 and leaving patients with other diseases on the back burner. This reorganisation has resulted in delayed diagnosis of diseases, as well as delays, modifications and interruptions in pharmacological, surgical and other treatments. These irregularities can be traced back to multiple factors, including the following:

• Lack of medical staff, materials and/or space
• Difficulty transporting patients to health care facilities (car/ambulance/taxi)
• Self-selection by people who fear becoming infected during medical appointments or who choose not to see a doctor so as not to “be a nuisance”
• Modification of usual treatments that could have immunosuppressive effect
• Reduced availability of donor organs

Some researchers and media outlets have started to quantify and report the pandemic’s effects on chronic disease management. In the Netherlands, for example, the national cancer registry has seen a drop in the number of new cases since the start of the pandemic; this decrease has been associated with the suspension of national screening programmes, among other factors. In the United Kingdom, the pandemic is expected to cause a delay of three to six months in the diagnosis and surgical treatment of cancer patients, which could lead to as many as 4,700 deaths. In the field of cardiovascular disease, a survey by the Spanish Society of Cardiology found that 40% of heart attacks in Spain went untreated during the first week of lockdown and 48% fewer therapeutic coronary interventions were administered. In Italy, all-cause mortality during the pandemic has been estimated to be 126% higher in men and 85% higher in women than during the previous five years—percentages far exceeding the number of deaths attributed to COVID-19.

To counteract this situation, many health care centres have encouraged self-monitoring (e.g. in diabetic patients) and introduced or expanded access to remote medical care via telephone or online consultations. Although these remote forms of care reduce the risk of infection and encourage the use of new health technologies, they are not always effective for older people with limited technological abilities, or for those who require in-person attention (e.g., a physical or neurological examination). Therefore, it is critical to reinstate continuity of care according to the principles of equity and universal access by developing technological resources that are respectful of people with limited digital literacy.

Impact on Physical Mobility

The pandemic and related confinement measures have led to a reduction in mobility. In the 30 days following the declaration of the global pandemic, daily step counts decreased, on average, by more than 27% across the globe. For older adults, the decrease in physical mobility during lockdown is likely to have been greater than average due to a number of factors, including a lack of daily work commitments, difficulty accessing community spaces (due to the absence or unsuitability of lifts and stairs), dependence on others for mobility and fear of infection, even in post-lockdown stages. Fear of infection, in particular, may continue to drive a reduction in mobility that could have long-term effects.

Using the conceptual framework developed by the World Health Organisation (WHO) to describe functioning, disability and health, the effects of lockdown-related mobility limitations on older people during the pandemic can be grouped in three categories:

1. Deficits in body functions and structures
2. Limitations on activity levels
3. Limitations on participation

As a result, older people may experience a reduction in activity both inside and outside of their homes, thereby increasing the likelihood that social isolation will persist even after the pandemic subsides.

Impact on Mental Health

the COVID-19 pandemic can be expected to generate a significant increase in mental health problems in the form of symptoms of anxiety and depression, alcohol and other drug abuse, self-harm and suicide. The impact could be even greater in older people, who already pose a global challenge in the field of mental health. According to the WHO, about 20% of people over 60 years of age have some form of mental or neurological disorder due to risk factors that can appear at any point in life, other risk factors specifically associated with ageing and the natural loss of capacities, and the presence of disease.

Some of the mental health consequences for older adults are directly associated with the characteristics of COVID-19. The serious risks associated with coronavirus infection in older people have prompted media outlets to emphasise the importance of self-care and personal hygiene in this population. However, such awareness-raising actions repeatedly expose people to alarming information that can lead to pathological fear of infection and chronic worrying about the disease, which in turn increase levels of stress and anxiety.

Moreover, the effects of preventive isolation have not been the same across the entire population. Confinement measures have limited older people’s daily activities, such as meeting up with friends, caring for grandchildren, taking walks and shopping. Lockdown orders also entailed the closure of common spaces—including civic, cultural and community centres—which provide important venues for interaction in this age group. Whereas younger people have been able to use technology and digital platforms to stay in touch with friends and family, some older people have not made use of these tools. According to INE data from 2019, just 24.8% of people over 75 years of age have ever used the Internet. During the pandemic, this digital divide leads to even greater disconnectedness in older people, deepening their feelings of isolation and loneliness , which were already a serious public health problem even before the pandemic and are associated with more severe symptoms of depression and anxiety.

Older people are also susceptible to the impact of other changes related to the pandemic and confinement, including an increase in caregiving activities for dependent family members and financial uncertainty affecting their own stability or that of their household. In light of school closures, many families have had to rely on the help of older people for caregiving tasks, sometimes in contravention of health recommendations. In addition, older people have been particularly affected by mourning processes and the loss of loved ones, especially among the population living in long-term care facilities.

Finally, it is worth remembering that dependent older people are particularly vulnerable to various forms of abuse, including physical and psychological abuse. Worldwide, it is estimated that elder abuse affects one in six older adults. 

Conclusions and Recommendations to Keep Older People From Being Left Behind

It is crucial to increase the visibility of older people as a population that is especially vulnerable to the social, economic and health-related effects of confinement. The following recommendations describe best practices for the development of future initiatives:

1. Guarantee continuity of access to health care for older people. Given the threat of new waves of infection (or new viruses), it is essential to plan for the reorganisation of the health system to ensure that the system will be capable of handling emergencies without neglecting the care of older people with pre-existing conditions.
2. Encourage physical mobility in older adults. It is essential to continue promoting physical activity and mobility exercises both at home and outdoors, taking into account the special needs of older adults and people with chronic diseases.
3. Minimise the effects of confinement on the mental health of older adults . The COVID-19 pandemic and resulting lockdown will leave psychological scars on all of us. We need to be prepared to prevent mental health problems in older people by promoting the early detection of symptoms related to anxiety and depression, as well as alcohol and other drug abuse.
4. Listen to older people. It is essential to involve older adults in the development of action protocols and initiatives that concern them.