The Main Issues and Challenges Older Adults Face in the SARS-CoV-2 Pandemic: A Scoping Review of Literature

Introduction

On Mar 11, 2020, the World Health Organization (WHO) declared the Coronavirus Disease 2019 (SARS-CoV-2) a pandemic, based on more than 118000 cases in over 110 countries and territories with sustained risk of further global spread (1). The Center for Disease Control (CDC) estimates that eight out of ten reported deaths in the United States have been in older adults. Case-fatality risk estimation indicates the mortality rate to be as low as 0.6%; however, older persons are at a much higher risk of mortality (about 15%) than younger persons (2). At the time of writing this article (until 6 Sep, 2020) there have been 27,217,064 global COVID-19 cases, with 800,906 deaths. Older adults accounted for approximately 80% of these deaths.

Older adults with underlying co-morbidities and chronic conditions suffer the adverse COVID-19 outcomes (3). Although public health approaches, including wearing face masks, massive screening, physical distancing, and quarantine, were the critical control measures, these actions might negatively affect older adults in wellness dimensions (4). Despite the former SARS outbreak in 2003, there are many gaps in services and support for older adults in a pandemic. They confront multiple barriers in accessing health care services and other supplies such as food and medications (5). Additionally, residents of nursing homes are generally older people with several underlying diseases and cannot care for themselves. The WHO estimates that half of all COVID-19 deaths in Europe happened in older adults living facilities (6).

Due to the current spread of the virus and emergency need for their isolation, the older adults living in these facilities experience loneliness and reduced access to health services due to fear of getting infected (7). Virtual contact with their families and telehealth can be used to reduce social isolation address their ongoing healthcare needs (8). Some countries’ effective measures in protecting this age group can help other countries prevent adverse outcomes and reduce the burden of care and costs imposed on families and governments. This paper has reviewed the available evidence on older adults’ issues in the COVID-19 pandemic, actions taken by different countries, and solutions offered in the literature.

Materials and Methods

This scoping review study was conducted according to the framework proposed by Arkesy and O’Malley developed in 2005 including six steps (9).

Results

Out of the 3,292 retrieved documents, 195 were identified as duplications. By screening the titles and abstracts, 2,877 were excluded from the study due to their irrelevancy. An additional ten documents were excluded after further review. Thus, 210 documents were reviewed for this study (Fig. 1). Table 2 illustrates the characteristics of the included documents. After content analysis, six themes were extracted from the results (Fig. 2, Table 2).

• Support and information sources

During the pandemic, supporting older adults can be done in several fields. One of the actions is the Coronavirus Aid, Relief, and Economic Security (CARES) Act (2020), which included USD 955 million allocated to support older adults with disabilities, by providing meal services, cost coverage for tests and treatment, telehealth services, and home health services through reauthorizing Title VIII Nursing Education Programs (11). In the US, significant federal government measures included The Families First Coronavirus Response Act on March 18, 2020, which included USD 250 million for nutrition services, providing paid sick leave to patients with COVID-19, and telehealth services (12). At the public level, a massive screening policy, contact tracing, and physical distancing in the majority of countries (4); financial domain insurance coverage in France and China (13); and coverage of total hospitalization costs by Medicare and private insurance in the US have been implemented (14).

In Uruguay, giving older workers subsidies to ensure no urgency to leave home for work and providing food for those in need are among the key financial support efforts (15). Argentina’s Ministry of Health has established a self-assessment application for primary screening for the virus (16). In Singapore, the Agency of Integrated Care, in collaboration with many charities, supports older adults at risk of social isolation and creates educational television programs targeting older adults (17). Another program is the publication of guidelines. The International Association for Gerontology and Geriatrics, Asia/Oceania (IAGG-AO) has published COVID-IAGG-AO guidance to prevent COVID-19 in older adults (18). The UK government published guidance known as ‘shielding’, advised older adults to stay at home, and introduced a registration website for offering services such as the delivery of boxes with essential supplies (19).

• E-Health services

In a pandemic, face-to-face contact between patients and clinics decreases. Here, telemedicine efficiently provides interaction among them (20). Also, social contact via telephone or video-calls may increase the feeling of wellbeing (21). In this case, the Digital Healthcare Act – DVG in Germany enables people to use healthcare apps for online video consulting and access to a secure healthcare data network (22). In the U.S more than USD 500 million in medicare assigned for tele-consulting by health systems such as Jefferson Health, Cleveland Clinic, Kaiser Permanente, and Providence (23). The US Department of Health and Human Services has made it easier to use these services by suspending some of the Health Insurance Portability and Accountability Act (HIPAA) and expanding the use of telehealth (24). Coronavirus Preparedness and Response Supplemental Appropriations Act provides funding for research and public health activities on COVID-19 and allows for the use of Medicare services without restrictions (25). However, many older adults cannot use technology and do not have access to smartphones and internet connection (21). In the UK, less than 50% of adults aged ≥75 yr have access to the internet (26). The role of volunteer groups in helping older adults to use technology is essential (27).

• Access to essential supplies in the self-isolation

Older adults who do not have access to essential supplies such as food and medication are provided support to address these challenges in different countries. For example, Korea has provided emergency care services for older peoples who have experienced interruptions in care services (28). Online food ordering and food delivery services have been provided in China, the UK, and Uruguay (29). Delivering frozen meals for low-income older adults is a proposed intervention by the National Council on Aging in the US (30).

A measure taken by all Whole Foods Market stores in the U.S, Germany, the UK, and Canada is allocating private hours for the older adults before opening to others and limiting the amount of each product that an individual can buy (27). Some of the Government of Canada COVID-19 Fiscal Response includes an elderly support plan (of which, USD 9 million in 2019–20), and supporting food banks (of which, USD 25 million in 2019–20) (31). US programs are allocating USD 250 million for the Senior Nutrition Program which provides meals on weels to older peoples who are cregivers, low-income, or frail (32). Another key measure that is prominent in many countries such as Italy, South Korea, Argentina, and the US is the formation of volunteer groups for helping with out-of-home work for older adults, such as grocery shopping (27).

• Long term care facilities (LTCFs)

About 60% of the world population would become infected (33), with one of the main factors being the increasing population of older adults living in LTCFs. Many of the facilities face many challenges, including insufficient equipment and staff, absence of standards for infection diagnosis, complex needs of residents (34), staff members who work at more than one facility, untrained workers, and enforcement of quarantine (35). Several professional institutions including the WHO (36) and CDC (37) have drafted guidelines for the provision of infection in these facilities. The Ministry of Health, Labour, and Welfare of Japan recommended suspension or restriction on use of daycares, restriction of visits to LTCFs, and other related guidelines (38). Some efforts of the Centers for Medicare & Medicaid Services (CMS) in American LTCFs include funding teams of infection control experts during the first outbreak, direct reporting of new cases and deaths to the CDC, supplying Personal Protective Equipment (PPE), restricting visits, eliminating all group activities, implementing a new detection tool, recommending to state and local officials to collaborate with facilities to allocate certain sites for positive cases, and advocating hospitals on mass testing for all older people (14).

Other measures discussed in Macron’s statement in France were putting restrictions on nursing home visitations and prioritizing the care of older adults (39). The use of technologies such as Beam Robot 9 to minimize human-to-human contact in Singapore effectively prevented the spread of the virus in LTCFs (40). Weekly telephone calls with residents by volunteer students in the Telephone Outreach in the COVID-19 Outbreak (TOCO) program have brought social contact to older adults and students (41). Some additional offered solutions are frailty assessment using Clinical Frailty Scale (CFS), accurate morbidity and mortality reports, coordinated surveillance, and research around LTCFs and frail residents (42).

• Physical and mental consequences of self-isolation

The adverse effects of isolation may be felt by older people, especially those who already had a mental illness (43). Social isolation increases the prevalence of loneliness, dementia, delirium (44), and suicide (21), along with the changes in physical activity, drinking, and sleeping patterns (43).

Fear of death is related to a weakened immune system defensive response and increased susceptibility to disease (45). Some reports indicate that at first, COVID-19 may present atypical symptoms such as altered mental health in the absence of typical symptoms; thus, mental health findings related to COVID-19 should be considered (46). Models such as SAVE (socialization, adequate nutrition and protein supplementation, vitamin D, and exercise) have been shown to prevent frailty progression (47), as have recommendations of professional organizations such as the Chinese Society of Geriatric Psychiatry and Alzheimer’s Disease(48), Australian Psychological Society (49), and Alzheimer’s Disease International (50). Some of the potential consequences of isolation for older adults are lack of access to regular medication, elder abuse, and the likelihood of increased hospitalization (51). Maintaining mental health to cope with stress is an important aspect in preventing suicide. The National Health Commission of China (NHC) and the American Association of Retired Persons (AARP) have designed steps to prevent suicide (52, 53). The UK and US governments have published guidelines to detect domestic abuse, track how and where it was reported, and provide a list of all available services (54,55).

• Neglect of Older adults, ageism and age discrimination

In the COVID-19 crisis, there are a number of ways older adults who would like to assist the humanitarian efforts to fight the pandemic can participate in doing so. These include participating in voluntary back-to-work programs for retired medical staff and in programs that assist in preparing PPE (56). Normally, older adults also take care of their grandchildren and support their employed children economically; however, older adults have been unable to partake in these responsibilities due to the pandemic (57). It appears that the negative assumptions and age-related stigma about older people (such as being vulnerable and frail against COVID-19) have resulted in the collapse of their prominent roles in a pandemic (58). Evidence of openly ageist discourses, the abandonment of older adults in LTCFs (59), media coverage about expensive care for older adults that portrays their mortality as less important than the mortality of other age groups, and age discrimination in providing health services in hospitals will very likely contribute to feelings of worthless and anxiety symptoms in older adults (60, 61). Undocumented mortality of older adults in France and ventilator allocation to younger adults according to US guidelines also indicates the perception of the deaths of older adults to be insignificant (62, 63). On March 29, Public Health England published guidelines to maintain a sense of belonging and good mental health in light of the ageist discourses around COVID-19 (64). Nevertheless, there is an urgent need to fight age discrimination in delivering health services in every country (65). Following ethical guidelines such as the American Geriatrics Society recommendations could support older adults’ rights (66).

Discussion

In our scoping review to identify the available evidence on challenges faced by older adults amidst the COVID-19 pandemic, 210 documents were included for analysis. The highest percentage of the articles were published in the Journal of the American Geriatrics Society (12.38%), were letters (20.95%), were from the US (38.09%), and were published in June 2020 (29.52%). The six themes presented above were extracted from the results of the documents. Despite efficient measures on supporting older adults, the increase in infection rates and mortality is undeniable.

In the absence of exclusive treatment or vaccine, each country should follow the available guidelines and monitor the adequate distribution of kits, medications, and ventilators. It is essential to include all age groups in care programs, respect the older adults and fight stigmatization and abuse, allocate equipment to LTCFs, screen all caregivers and visitors, cancel all in-person group activities, and monitor vital signs (14). Decision making on resource prioritization should be taken based on frailty stratification (66). Policy changes in the US including acts and guidelines focuses on supporting older adults and caregivers (67). Mass media’s role is essential in public education and reinforcing collective intergenerational solidarity to avoid age discrimination (60).

Multidisciplinary teams should start free services for older adults living alone and who have chronic conditions (68). While telemedicine can be utilized to avoid human-to-human contact, older adults cannot use it, and many doctors are not accustomed to its application (8). Hence, there is a need for guidance, along with encouragement from government and rapid mobilization of tele-consultation platforms, in providing instructions on the use of telehealth, e-health, and other virtual applications (69).

In pandemics, the shortage of resources and risk of infection among the workforce in LTCFs needs further policymaking. Fair salaries can encourage experts and staff to work in LTCFs and hospices (70). Compensational strategies to address PPE shortages, such as importing, reclaiming, reusing, and extending supply, should be considered to make effective use of PPE resources (71).

Visit restrictions are a more significant challenge for LTCFs residents. In this regard, a video call can be a suitable measure to maintain wellbeing by minimizing unnecessary exposure to the virus (72). Specific protocols and training can protect residents and staff in each country (73). Religious beliefs and practices are helpful in coping with stressful conditions and, in many studies, are associated with less anxiety (74).

Younger people can support older adults during isolation by delivering groceries, helping in daily activities, and working to keep them socially connected with educational technology (75). Online social and entertainment services can keep them physically and mentally active (65). Because the number of articles on COVID-19 has constantly been increasing, many studies conducted after June 2020 may be missed in our study. Other articles or guidelines may have been published in other languages or by different organizations and are not included in this article.

Conclusion

The studies discussed in this article highlighted the importance of older adults’ issues and challenges during the COVID-19 pandemic and have suggested solutions for supporting them. Despite the adverse outcomes among older adults, very few interventional studies have been done in terms of extracted themes such as training older adults to work with smartphones and investigating the effects of video calls on mental health. Therefore, future research should also focus on implementing and evaluating interventions to improve older adults’ physical and mental health amidst the COVID-19 pandemic.

Further studies should also focus on the rights of older adults in issues related to COVID-19 to support decisions in allocating resources to different age groups. Implementing standard and evidence-based practice guidelines in nursing homes to protect residents and staff is crucial. Due to the increasing number of articles published on COVID-19, further reviews are needed to extend the knowledge on older adults’ issues during the crisis.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.