An expert explains: how to help older people through the COVID-19 pandemic
March. 12, 2020
The fatality rate for people over 80 from COVID-19 is almost 15% according to data from China. Dr. Kate Tulenko explains why older people are so much more vulnerable, as well as the impact coronavirus is having on health systems across the globe and health workers.
As cases of coronavirus continue to rise around the world, the weeks and months ahead will stretch healthcare systems to the extreme.
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Data from China, where the outbreak began in Wuhan in December, shows older and elderly people (aged 60 plus) are the most vulnerable to COVID-19 .
Dr. Kate Tulenko is a physician and CEO of Corvus Health, a global health workforce services firm. Here she explains why the elderly are more at risk and how to help older family members during the outbreak.
Why are the elderly more vulnerable to coronavirus?
There are both physical and social reasons. Older people don't have as strong an immune system so they are more vulnerable to infectious disease. They’re also more likely to have conditions such as heart disease, lung disease, diabetes or kidney disease, which weaken their body’s ability to fight infectious disease.
In many countries, they are more likely to be in institutionalized settings like a nursing or retirement home, or living with family in a more crowded situation where there's a greater risk of infection.
The elderly might also have isolation or mobility challenges. So because they're isolated, they can't get information about what to do, or they're not able to get food they need if stores are out of stock and things become more difficult. In many societies, seniors are more likely to live in poverty, which makes it more difficult for them to get the things they need and to take care of themselves. Poverty presents a whole range of challenges pertaining to health.
Why is the mortality rate higher for older people?
There's a direct correlation between mortality and age. So if you're 60 to 69, the mortality rate is at 3.6%. At 70 to 79, it’s 8%. And if you're 80 or above, it’s 15%. In some of the data I’ve seen, it’s even higher, at 18%. The elderly are more likely to get acute respiratory distress syndrome, the acute lung injury that is causing many of the deaths. But it seems the virus is also more likely to affect the heart than any similar viruses, so they're actually seeing people dying from heart attacks who have COVID-19. A dialysis centre in Wuhan had a number of patients die from coronavirus without any pneumonia, so it just stresses the body in general. It doesn’t have to be the pneumonia that kills them.
A side-effect of the impact of coronavirus on the health system is we'll see the elderly will be more likely to die of other causes. If you're in Milan right now, you're 70, and you have a heart attack, you're going to get substandard care because the system is overwhelmed. The elderly are hospitalized on a daily basis at much higher rates than younger people and they are not going to get the quality care they deserve during the outbreak.
If you were an elderly person who has a three-month check-up with the doctor today, should you go? You have to weigh the risk of getting coronavirus with the benefit of seeing the physician. And for most people, it is probably best to skip that visit. But what if it’s something like diarrhoea? Normally, they would be seen, but now they may consider just staying home and treating it there, which is a risk as well. So it's a real dilemma. Luckily, in some countries, physicians’ offices are starting to do telemedicine visits, but these may be difficult for seniors to access.
If you're aged 60 and above, what can you do to protect yourself?
The main message is that people really just need to change their behaviour for two to three months. They’re not being asked to socially isolate themselves forever. When you look at the curve of the outbreak in Wuhan and Hubei, it's really only been two months, so stay safe for two months, and you’ll most likely be alright.
A lot of the advice is the same for everyone, but with a vulnerable group, it’s that much more important because they’re at risk. The main points include:
Practise social distancing, so don’t receive any visitors unless absolutely necessary. If you have to see others, make sure it’s only healthy people and preferably no children, because they can be asymptomatic carriers.
Don’t leave home unless absolutely necessary, have neighbours shop for your groceries and refill any medications.
If you have to go out, avoid large groups, don't shake hands or hug, keep a distance of at least three feet from people and avoid touching your face. Wash hands when you return home.
Read the US Centers for Disease Control and Prevention’s recommendations for at-risk groups here.
How can relatives help senior members of their family?
The key is communication – many seniors don't have smartphones and they might not speak the main language of the media. Families need to make sure they call on a regular basis to help combat social isolation. And families are going to need to have extremely uncomfortable conversations around end-of-life decisions, such as whether they want to be resuscitated or have chest compressions in the event of a heart attack. It gives families a greater sense of peace once they have had the conversation.
What about elderly people in care homes?
Lots of people ask me, “Should I pull my loved one out of the nursing home?” It really depends on their situation and your situation. You might have children and you might have a crowded environment as well. Also there might be a fall risk. Nursing homes are set up to prevent people from falling, there are handrails everywhere and no trip hazards. If you take that person and put them in a strange environment, they're more likely to break a hip and there are risks associated with moving them.
Health workers in nursing homes will need to have refresher training in infection control and the proper equipment to protect them and the residents. For two or three months they will need to suspend any social activities, such as art class, and allow residents to eat in their rooms, so they don't congregate.
What impact is COVID-19 having on health systems worldwide?
In many countries, the health system will be overwhelmed, like we saw in Wuhan and we’re seeing now in Italy. The World Economic Forum just published a piece that was written by an Italian physician about how they don't have enough ventilators for people , and they have to prioritize people. It's well-established in the medical community that when you have limited resources, you use those resources for the person most likely to survive. Older people cannot be prioritized for ventilators or for the antiviral that helps against the virus. That's going to be a huge challenge.
I just read a report from Seattle where many of the elderly are only receiving compassionate care, which doesn't mean they'll die, but they're not getting the scarce resources of the antivirals and the ventilators. I think unfortunately, in some communities, older people will be asked to stay at home because they won't be able to be cared for in a hospital. That's an extreme case and I don't think we've seen that yet.
A lot of it will depend not only on the robustness of the health system, but also the average age of the country. The average age in China is 37; in Japan it’s 47 – and in Sub-Saharan Africa, it’s 20. So Africa has fewer older people, but more untreated infectious diseases, so it’s hard to say what the impacts on the elderly in low-income countries would be.
What about the impacts on health workers?
Health workers are going to need a lot of mental health support. It can be extremely traumatic to have to turn someone away from care or have to ration care, especially for someone who reminds you of your grandmother.
There are huge debates going on around what to do when health workers are exposed. In California, a single sick person was exposed to 200 health workers, so they had to self-isolate. But most hospitals during flu season are already at capacity and COVID-19 will push them over capacity, so they can’t afford to lose a single health worker.
The most important thing is the need to practise universal precautions and treat every patient the same. Most people got familiar with universal precautions during the HIV epidemic. There was so much stigma, they eventually ended up handling every patient as though they had HIV and that was an effective measure.
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