Handbook on COVID-19 Pandemic and Older Persons: Narratives and Issues from India and Beyond 9819914663, 9789819914661

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Mala Kapur Shankardass   Editor

Handbook on COVID-19 Pandemic and Older Persons Narratives and Issues from India and Beyond

Handbook on COVID-19 Pandemic and Older Persons

Mala Kapur Shankardass Editor

Handbook on COVID-19 Pandemic and Older Persons Narratives and Issues from India and Beyond

Editor Mala Kapur Shankardass Tutor and Visiting Faculty Freelance International Consultant Gurugram, Haryana, India

ISBN 978-981-99-1466-1 ISBN 978-981-99-1467-8 (eBook) https://doi.org/10.1007/978-981-99-1467-8 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023, corrected publication 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

This volume represents a major achievement. Its 40 chapters bring together a great diversity of issues and national experiences from across the world, but they all share the same focus of concern: how the pandemic has disproportionately harmed people at older ages. The specific vulnerability of older people has been most obvious with reference to the numbers who have succumbed to the pandemic (Cuevas Barron et al. 2022). By the close of 2022, it was possible to take stock of the past three catastrophic years. As the final Lancet COVID-19 Commission report notes, there have been about 17.7 million excess deaths since the start of the pandemic; of these, 83% have been people aged 60 or more (Sachs et al. 2022). This equates to nearly 15 million deaths of older people that would not have occurred without the pandemic: family members, friends, and colleagues, many of whom were not even permitted to see their loved ones in their final hours. The same Lancet report estimated that about half of all COVID-19 deaths during the pandemic occurred in 2022 and the second half of 2021. This was a period when relatively effective vaccinations were already available in large numbers and were being rolled out in all but the poorest countries. Why were these vaccination programmes unable to do more to prevent these deaths? The answers are, of course, highly complex. Nevertheless, one key issue stands out: many countries did not prioritise older people over other ages (Lloyd-Sherlock et al. 2022). For example, by the start of 2022, the proportion of older people in India who had been vaccinated against COVID-19 was no higher than it was for people at younger ages, for whom the risks of death and serious illness were relatively minimal. At this time, 62 million older people in India had received either just one dose or none at all. Yet rather than prioritise this at-risk age group, the focus of the national government had shifted to vaccinating children.

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The case of India is far from exceptional. Many other countries in Asia, Latin America, Europe, and Africa have applied similar prioritisation policies, whereby the main criterion for inclusion has been socio-economic status rather than age (Lloyd-Sherlock et al., 2021). By 2022, all such countries held enough stock of vaccines to fully protect all older people as well as front-line health workers. The failure to protect older people was not primarily due to vaccine nationalism (albeit not denying that such nationalism occurred); it was a matter of political choices. This global gerontocide went largely unremarked by the media or international organisations; this reflects a clear demonstration of the low priority that older people receive. As we all know from personal experience, the effects of COVID-19 extended far beyond mortality. The chapters in this excellent volume provide valuable insights about these manifold effects, including the wider health impacts of the pandemic, disrupted access to health services for unrelated conditions, and the toll on mental health caused by fear and isolation. Individuals of all ages have suffered greatly and in different ways, but the specific vulnerabilities of older people have received scant attention. Paradoxically, the COVID-19 pandemic offered an opportunity for all of us— academics, policymakers, and experts—to re-evaluate our attitudes towards older people and later life. Instead, ageism has become ever more evident in responses, discourses, and social attitudes. During the pandemic, there has been a powerful discourse that younger people were paying the price for older adults, through physical distancing, reduced income, and other sacrifices. This built on a broader discourse of intergenerational injustice that had been fermenting before the pandemic. An analysis of 82 629 tweets relating to older people and the pandemic identified over 1,300 “death jokes” that made light of the pandemic since it mainly affected older adults (Xiang et al. 2021). By 2023, the pandemic appears to have become a more manageable and less existential global threat. However, COVID-19 is still with us and still poses a disproportionate risk to the health and survival of the most vulnerable older people. The focus of the pandemic has flitted from country to country and variant to new variant. Currently, it is China’s “turn”. Despite mass vaccination, large number of older people, especially in poor countries, are yet to receive their first dose, let alone a booster. And, of course, the threat of virulent and deadly new variants remains. It is to be hoped that at least some lessons have been learned over the past 3 years. The number of older people who died during the pandemic have varied enormously between countries. In Poland, for example, age-standardised excess mortality during 2020 was nearly ten times the rate in neighbouring Germany (Islam et al. 2021). One wonders what lessons, positive and negative, could be extracted from these divergent experiences. The lack of a major global report (either published or, to my knowledge, in the pipeline) that takes comprehensive stock of how the pandemic affected older

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people is deeply disappointing. In the face of this global policy failure, I applaud the success of Prof. Mala Kapur Shankardass and her collaborators in creating what is destined to become a reference text on these issues. January 2023

Peter Lloyd-Sherlock Senior Researcher Brazilian Care Association Professor of Social Policy and International Development University of East Anglia Norwich, UK [email protected]

References Cuevas Barron, G. et al. (2021). Safeguarding people living in vulnerable conditions in the COVID19 era through universal health coverage and social protection. Lancet Public Health. https:// doi.org/10.1016/S2468-2667(21)00235-8. Islam, N., Shkolnikov, V.M., Acosta, R.J., Klimkin, I., Kawachi, I., Irizarry, R.A. et al. (2021). Excess deaths associated with covid-19 pandemic in 2020: age and sex disaggregated time series analysis in 29 high income countries. BMJ, 373, 1137. Lloyd-Sherlock, P. et al. (2021). Does vaccine ageism amount to gerontocide? Lancet, S398(10304), 952–953. https://doi.org/10.1016/S0140-6736(21)01689-5. Lloyd-Sherlock, P., Guntupalli, A., & Sempé, L. (2022). Age discrimination, the right to life, and COVID-19 vaccination in countries with limited resources. Journal of Social Issues. 30. https:// doi.org/10.1111/josi.12561. https://doi.org/10.1111/josi.12561. Sachs, J., et al. (2022). The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 400(10359), 1224–1280. Xiang, X., Lu, X., Halavanau, A., Xue, J., Sun, Y., Lai, PHL, & Wu, Z. (2021). Modern senicide in the face of a pandemic: An examination of public discourse and sentiment about older adults and COVID-19 using machine learning. Journal of Gerontology, Series B: Psychological Sciences and Social Sciences 14, 76(4), e190–e200.

Acknowledgements

The making of this book begins with experiencing the impact of the COVID-19 pandemic on older people through the appearance of academic articles, media reports, government concerns, NGO activities, and older persons’ voices reflecting multiple concerns. Dialogue with many national and international experts working on ageing issues, some established and few budding scholars, led to capturing through their contributing chapters narrations from various countries about the impacts of the pandemic. I am grateful to all the authors for resonating with my vision and desire to share with a wider audience thoughts, research, and valuable work on this important topic. I thank each one of them for presenting in diverse ways and from different perspectives many insights which provide a deep understanding of the global and the respective national situations and make this publication a meaningful collection. In order to bring to the reader the various problems related to the COVID-19 pandemic and solutions emerging in different contexts, all the contributors to this book worked hard in providing updated data specific to their topic and showed quite a lot of patience when because of covering many aspects the work got a bit delayed for publication. Every author brought together ongoing discussions and commentaries representing many viewpoints, and I really appreciate their dedication to doing so. For publishing this significant book, support and cooperation are provided by one and all whose names appear in the title of the contents. They have all made this volume rich in substance and content, and I am extremely appreciative of each one of them for making this possible. My heartfelt gratitude to Prof. Peter Lloyd-Sherlock, UK, for providing a lucid Foreword to my book, to Dr. Giovanni Lamura, Italy, to Prof. Marvin Formosa, Malta, and to Margaret Gills, Canada, for eloquently writing Blurbs for this Handbook. I really appreciate the encouragement of all these professionals well known for their work on ageing issues. I would also like to thank two young intern researchers Aryaman Chand and Khushi Chandani who helped with the bibliography search on the topic. The compilation of literature submitted by them was useful in identifying focus on specific countries, emergent topics, and authors. Their enthusiasm to do the needful provided impetus to me for taking this project forward by reaching out to professional ix

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colleagues in placing this work for a wider readership. These combined initiatives make me happy that focus on older people will get the necessary attention for taking forward their interests from a right-based approach especially in dealing with the present pandemic and such crisis if it happens in the future. This section would not be complete without my acknowledging the support extended by Satvinder Kaur, Senior Editor, Humanities and Social Sciences, Rini Christy, Project Coordinator, Books Production, and the publishing team of Springer Nature to fruitfully take forward the delivery of this academic project which will interest a broad cross section of the population wanting to give visibility to issues related to older persons. Finally, I also want to thank my family members, my husband, my son, daughterin-law, my grandson, toddler granddaughter, and my extended clan of siblings for their support, and necessary distractions to improve my concentration, focus on this worthy project, and get over depressing feelings on thinking about vulnerabilities of older people across the world. It was stimulating working on this topic as I am hopeful and happy that it will lead to raising awareness and much needed action for the betterment of ageing populations. Gurugram, India

Mala Kapur Shankardass, Ph.D. Academician, Author, Activist, Consultant, Researcher and Tutor

Appreciation for the Book

“This volume provides a multifaceted overview of relevant dimensions of older people’s lives affected by the recent pandemic. The topics addressed by this wellstructured and comprehensive volume range from the dramatic impact on residential care facilities to changes that occurred in clinical settings, up to trends concerning community-dwelling older persons. Cross-national analyses and country case studies make this book a must for any scholar interested in achieving a comprehensive view of the key lessons that the recent pandemic has taught us for the future of our ageing world.” —Dr. Giovanni Lamura, INRCA IRCCS—National Institute of Health and Science on Ageing, Ancona, Italy “This timely handbook provides an understanding of COVID-19 that moves beyond Anglo-phone and Western understandings of the pandemic by focusing upon Southern Asian and international experiences that include, amongst others, the United States, Liberia, Iran, Turkey, and Australia. This is a fascinating and much-needed analysis of the impact of COVID-19 on realities that have flown under the radar such as dementia care, family relations, and neglect and abuse to demonstrate sensitivity to inequalities over the life course and later life especially. Mala Kapur Shankardass’ work makes a robust case for a reorientation of contemporary public policy and ageing services to mitigate the challenges being faced by present and incoming older persons in a post-pandemic social fabric.” —Prof. Marvin Formosa, Department of Gerontology and Dementia Studies, Faculty for Social Wellbeing, University of Malta

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Appreciation for the Book

“Handbook on COVID-19 Pandemic and Older Persons: Narratives and Issues from India and Beyond edited by Dr. Mala Kapur Shankardass provides a comprehensive examination of the devastating impact of the pandemic on older persons. Compiling writings by experts on ageing in India and around the globe, The Handbook explores the real experiences of older persons affected by COVID-19 including the physical and psychological impact, clinical management, healthy ageing in adverse times, and the extraordinary resilience of older persons. This book is an excellent exploration of the unprecedented pandemic and its impact on older persons.” —Margaret Gillis, President International Longevity Centre Canada, Co-President International Longevity Centre Global Alliance

Contents

Part I

Introductory Section—Critical Global Concerns and Responses

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Older Persons and Covid-19 Pandemic: An Exposition . . . . . . . . . . . . Mala Kapur Shankardass

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Impact of Covid-19 on Older Population: Review of the Initial Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ritu Rana

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COVID-19: A Worldwide Hecatomb in Long-Term Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dominique Predali

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Trends in the Management of Aged Population During the COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sushil Kumar Maheshwari

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Clinical Management of Severe Acute Respiratory Infection (SARI) in Elderly Patients Infected with Covid-19 . . . . . . . . . . . . . . . . Avinash Chakrawarty and Kamal Bandhu Klanidhi

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Loneliness, Isolation, Neglect, and Abuse in Elderly Population Due to COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . Anweshak Das

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Bereavement and COVID: Dual Trouble in the Elderly . . . . . . . . . . . Surbhi C. Trivedi, Mansi P. Somaiya, and Alka A. Subramanyam

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Active Ageing in COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Sumity Arora

Part II Specific Issues and Different Country Narratives 9

Effects of the COVID-19 Pandemic on Elderly People in Italy . . . . . 131 Alessia Bertolazzi and Albertina Pretto

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10 Psychosocial Condition of Older Poles in the COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Zofia Szarota and Artur Fabi´s 11 Intergenerational Family Relations in Old Age During Regular Times and in Covid-19 Period . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Sigal Naim, Ariela Lowenstein, and Ruth Katz 12 The COVID-19 Routine: Towards Integrated Interventions in Detecting, Identifying, and Treating Elder Abuse and Neglect in Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Tova Band-Winterstein and Sara Alon 13 From Vulnerability to Resilience: How do Elderly Holocaust Survivors Living in a Nursing Home in Israel, Cope with the Threat of COVID-19? A Group Therapy Case Study . . . . . 189 Erga Drori 14 The Effect of the Covid-19 Pandemic on Older Persons: The Reality of Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 I¸sıl Kalaycı and Metin Özkul 15 Mental and Physical Health of Iranian Older Adults With Positive Covid-19 Status During the Fifth Wave of Pandemic . . . . . . 221 Shahram Moradi, Tahereh Sokout, Abedin Bakht Abnoos, Nobaya Ahmad, and Abdolrahim Asadollahi 16 Mental Health and Psychological Well-Being of the Elderly During the COVID-19 Pandemic in Russia . . . . . . . . . . . . . . . . . . . . . . 241 Anna Vasileva, Timur Syunyakov, Mikhail Sorokin, Maya Kulygina, Tatyana Karavaeva, Olga Karpenko, Alexander Yakovlev, Elena Zubova, Daria Smirnova, and Alisa Andrushchenko 17 Older Australians During the COVID-19 Pandemic: Experiences and Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Eileen O’Brien Webb 18 Governing Risk and Older Age During COVID-19: Contextualizing Ageism and COVID-19 Outbreaks in Australian Aged Care Facilities During 2020 . . . . . . . . . . . . . . . . . . 277 Peta S. Cook, Barbara Barbosa Neves, Cassie Curryer, Susan Banks, Annetta H. Mallon, Jack Lam, and Maho Omori 19 United States Treatment of Older Adults During the COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Pamela B. Teaster and Manasi Shankar

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20 Daily Life Among Adults in a Maryland Condominium During the Early Stages of the COVID Pandemic . . . . . . . . . . . . . . . . 329 Cynthia Thomas 21 Challenges Faced by Institutionalized Elderly in COVID Era—Insights of a USA Doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Ruchika Kuba and Chandini Sharma 22 Global and U.S. Policy Perspectives on COVID-19 and Impacts on Older Adult Care and Older People of Color: Syndemic Theory and Public Health Strategies for Palliative Care . . . . . . . . . . . 361 Mary Beth Quaranta Morrissey and Patricia Brownell 23 In Praise of Older Canadian Indigenous Peoples . . . . . . . . . . . . . . . . . 373 Elizabeth Podnieks 24 “Initial Responses to the Impact of Covid-19 on Older Persons in Argentina” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Lia Susana Daichman and Rosa Ana Silberman 25 Encounter of Older People in Sub-Saharan Africa with COVID19: A Review of Literature . . . . . . . . . . . . . . . . . . . . . . . . . 415 Dolline Busolo 26 COVID-19 Impact on Older People in Liberia: Analysis . . . . . . . . . . 433 Samuel Togba Slewion 27 The Impact of COVID-19 Pandemic on Older Persons in Nigeria: A Double Jeopardy of Vulnerability . . . . . . . . . . . . . . . . . . 453 Eniola O. Cadmus and Lawrence A. Adebusoye 28 The Seven Dimensions of Active Ageing in Response to Covid-19 in Indonesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465 Dinni Agustin, Lili Indrawati, Tri Suratmi, and Tri Budi W. Rahardjo 29 Older Persons in Nepal and the effect of COVID-19 . . . . . . . . . . . . . . 489 Smriti Pant and Saugat Koirala 30 Challenges and Lessons Learnt Among Older People During the COVID 19 Pandemic in Sri Lanka . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 Shiromi Maduwage, Nadeeshani Buwanika Walpita, and Bhumini Janani Karunarathne 31 COVID-19 Trends and Experiences in Pakistani Population . . . . . . . 507 Muhammad Sajjad Sarwar and Ehtesham Khalid 32 Impact of COVID-19 on Elderly: A Perspective from Pakistan . . . . 521 Sarosh Saleem, Maria Javaid, and Nashmia Mahmood

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33 Older Adults’ Mobility Amid COVID-19 Pandemic in Bangladesh: Safety and Perceived Risks of Using Public Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 Selim Jahangir, Ajay Bailey, Seama Mowri, Md. Musleh Uddin Hasan, and Shanawez Hossain 34 COVID-19 and Elder Abuse: Critical Issues for India . . . . . . . . . . . . . 555 Khushboo Khatri, Pooja Vora, and Avinash De Sousa 35 Exploring the Abuse Intervention Model to Understand the Effects of COVID-19 on Elderly in India . . . . . . . . . . . . . . . . . . . . . 565 Anupriyo Mallick 36 Psychosocial Aspects of Geriatric Mental Health During COVID-19: The Issues for India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 Riddhi Laijawala, Karishma Rupani, and Avinash De Sousa 37 Mental Well-Being of Older Adults and Access to Healthcare During the COVID-19 Pandemic in Karnataka, India . . . . . . . . . . . . . 587 Divya Sussana Patil, Ajay Bailey, and Sobin George 38 COVID-19 and Dementia Care: Critical Issues for India . . . . . . . . . . 607 Bhumika Shah and Avinash De Sousa 39 Seeing the Rainbow Through the Prism of COVID-19: An Indian Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619 Vidya Shenoy 40 Second Wave of Corona and Elderly Mental Health in India: Challenges and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633 Chandrakala Diyali Correction to: Mental and Physical Health of Iranian Older Adults With Positive Covid-19 Status During the Fifth Wave of Pandemic . . . . . Shahram Moradi, Tahereh Sokout, Abedin Bakht Abnoos, Nobaya Ahmad, and Abdolrahim Asadollahi

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About the Editor

Mala Kapur Shankardass is nationally and internationally known sociologist, gerontologist, and health social scientist based in India. She retired end of March 2021 as Senior Faculty Member from Delhi University after 38 years of academic career but continues to deliver lectures across countries and states in India. She is a researcher, writer and an activist. She has published many books on ageing issues and related fields with well established international publishers and over 100 articles in reputed journals, books, magazines and newspapers. She Consults with international and national organizations, including United Nations agencies, is part of advisory board of certain journals, reviewer with well-known publishing houses, member of different government committees and associated with few NGOs as Executive and Governing Body Member. She runs her own Voluntary organization as well and works on improving quality of life concerns as people age.

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Part I

Introductory Section—Critical Global Concerns and Responses

Chapter 1

Older Persons and Covid-19 Pandemic: An Exposition Mala Kapur Shankardass

Abstract Almost all countries affected by the COVID-19 indicate the severity of the impact of the pandemic on older people. Not only was the threat of death looming large, more than for other age groups on older people affected by the COVID virus but their psychological health was also greatly impacted. The rights of older people were compromised in many countries, especially of the disadvantaged and the vulnerable among them. They experienced elder abuse, isolation, and various kinds of deprivations, and in many places they could not access health care due to different concerns some related to policies unfavourable towards them, at times due to indifferent attitudes and behaviour of family and community members and also because of their own shortcomings in certain ways. Often, their needs were ignored or overlooked, while at the same time by certain governments and in many countries prompted by WHO and UN agenda specific attempts were also made to address their general and special needs. Awareness campaigns were also started to improve services and facilities for those ageing in societies and have inclusive policies for all age groups. However, despite such measures, older people did face many difficulties, some generic and some man-made in all aspects of their life be it economic, social, and psychological, or health. This introductory chapter expands on many aspects of the impact of the pandemic on older people and also connects the various chapters of the volume from different countries and on multiple themes in a web of providing a comprehensive understanding of the effect which the pandemic had on older people. While the chapter and the book make an attempt to provide a deep understanding of the concerns and responses, it however does not claim to be exhaustive in the light of limited data available as yet on many crucial and pertinent issues. Nonetheless, the book and this chapter do attempt to cover many important relevant concerns and responses to the pandemic for older people on various fronts which will enrich the readers as academicians, researchers, policymakers, or civil society members. M. K. Shankardass (B) Tutor, International Institute on Ageing - United Nations, Malta, Valletta, Malta e-mail: [email protected] Founder Member & Managing Trustee, Development, Welfare and Research Foundation, New Delhi, India Asia Representative, International Network for Prevention of Elder Abuse, New Delhi, India © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_1

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Keywords Vulnerability · Mortality burden · Socioeconomic crisis · Right right-based approach · Responses

The COVID-19 pandemic made the world grapple with unparalleled social, economic, and health crises affecting persons of all ages in all conditions and geographical areas. However, older persons have become one of the more visible vulnerable segments of the population. Research reports, studies conducted by different agencies, media coverage, and various narrations from around the world indicate a high mortality burden upon older persons due to the COVID-19 pandemic and various other challenges arising out of the socioeconomic crisis faced by them right from the start of the COVID-19 virus in Asia from December 2019 and in Europe from January 2020. The lives of older people have been disrupted proportionally higher than other segments of the population. Governments, civil society organizations, families, and older people themselves have been looking at multiple ways to deal with the onset of the spread of the coronavirus, and there have emerged many good practices, success stories as well as failed attempts to come to terms with the on-going problem of the pandemic. Varied perspectives, some referred to in this book too, related to fields of economics, environment, gender, geriatrics, gerontology, psychology, and sociology, have provided an understanding along with guidance to handle the issues impacting older people due to the prevailing COVID-19 pandemic from a humanistic and right-based approach. The impact of the COVID-19 pandemic on older people has been diverse notwithstanding the geographical and regional disparities, educational levels, and socioeconomic and health status. Accordingly, responses to deal with and manage the coronavirus whether coming from global, regional, national, or local sources have in the last couple of years brought a new “normalcy” and in many ways diverted the situation of complete societal breakdown to finding workable solutions for governments at the central/federal, state/county, and grass roots levels. Significantly, much of the emerging issues due to the COVID-19 pandemic and responses as well as suggestions to address them have been put in the public domain mainly through journal articles, and reports of national and international agencies including UN organizations. Books focusing on the topic of older persons and the COVID-19 pandemic are limited and deal with specific aspects or few nations, mainly European or American, and more particularly focus on care aspects including long-term social care and take into account a public health approach (Chatterjee & Chatterjee, 2022; Łuszczy´nska & Formosa, 2021; Miller, 2021, 2022). The present book as is further delineated below and reflected through diverse chapters provides wider coverage than done so far in publications by including within one volume African, Asia Pacific, European, and American countries. The present collection provides global as well as national perspectives on dealing with the pandemic by covering multiple issues which impacted diverse dimensions of the lives of older people at the family, community, and societal levels. By discussing policies, practices, concerns, responses, and gaps and taking forward the agenda to reduce various vulnerabilities of older persons, the

1 Older Persons and Covid-19 Pandemic: An Exposition

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present volume makes a valuable contribution and provides a significant narration to the emerging literature on the topic. As the title of the book suggests with a focus on India and countries beyond, this meaningful publication covers discourses that provide an understanding of the COVID-19 pandemic impacts on older people from a cultural, social, and globalized perspective taking into consideration viewpoints without being limited by hegemonic thinking and imperialistic thoughts. Thus in the midst of the few available books on the topic, the present collection goes further in scholastic understanding by providing a wider scope to comprehend the COVID-19 pandemic impacts on older persons from both Western and non-Western world views, taking in Europocentric as well as Afrocentric, Americentric, Asia–Pacific centric, and Latinocentric thoughts on older persons’ lives, policy responses, development of services, and programmes during the COVID-19 pandemic. Availability of critical analysis of the situation, even though scarce in some ways as much of published material highlights more the ground reality of the needs and circumstances of older people, has been helpful in planning for services, programmes, and facilities and bettering the lives of older people along with their carers. Many governments and other stakeholders working with and for older people with guidance from UN organizations have put in practice frameworks to respond to the impacts of the COVID-19 pandemic more from a recovery mode which is to meet the needs of the different segments of the population. The suggestion is for urgent action with shared responsibility and within the parameter of the Sustainable Development Goals (SDGs) which is the current agenda of all nations with special emphasis on at-risk groups among whom older people get priority (United Nations, 2020). Recommendations are also to mobilize resources under the respective national government initiatives related to Universal Health Coverage (UHC) and Primary Health Care provisions and use guidelines presented for achieving the UN Decade for Healthy Ageing (WHO, 2020). Globally, countries as a response to deal with and manage the COVID-19 pandemic situations outline health, and socioeconomic and humanitarian measures which help populations to cope with the situation. In terms of addressing concerns which impacted older people universally, attempts have been made to save, protect, and rebuild their lives. But how successful these attempts have been is still being assessed, though certain studies capture good practices as well as critique what is in place and make grounds for taking forward urgently action plans that can make a concrete difference to older people in the present and the future. Nonetheless, what seems encouraging is that experts involved with ageing issues are viewing this current pandemic not only as a crisis but also as a challenge to bring greater emphasis on recognizing the needs of older people, and developing services, programmes, and policies that prioritize ageing populations. In addition, experts involved with ageing issues indicate the adoption of an integrated holistic approach bringing in connections between socioeconomic and health factors which improve the status and images of older people in society, help in developing enabling environments that minimize their marginalization, and reduce discriminatory practices against them including ageism, violence, abuse, and deprivations in terms of social and health security measures (Gietel-Basten, 2021; Shankardass, 2020 [b]). It calls for rethinking, rebuilding, and

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bringing paradigm changes in institutions, in relationships in the family and community, and in social systems. It seeks a revised national and global agenda where older people are brought into the development process at micro- and macro levels. Pivotal to all these new discourses is harnessing opportunities that demographic transition is bringing in societies and changing the age-old narrative of overlooking older people in terms of their needs as identified by them. Bringing older people to the centre stage of policies and programmes related to the health, and social sector including financial security, social protection, literacy, and digital inclusion as well as in developing enabling and supportive environments is a strong sentiment being expressed by all involved with ageing issues. Voices to spearhead this movement became more powerful during COVID time when older people were seen to be severely hit by the pandemic (Shankardass, 2021). Not only was the threat of death looming large for those affected by the coronavirus but their psychological health was also greatly impacted as gloomy situations surrounded them along with intergenerational relations getting stressed and ageism was being experienced on a new high in various societal responses. The rights of older people were compromised in many countries, especially of the disadvantaged and the vulnerable among them. They experienced elder abuse, isolation, and various kinds of deprivations and in many places could not access health care due to multiple concerns, some related to policies unfavourable towards them, at times due to indifferent attitudes and behaviour of family and community members and also because of their own shortcomings in certain ways such as the habitual practice of neglecting health. Besides, the digital illiteracy of older people created many barriers to accessing health care and information in almost all countries when lockdowns happened due to coronavirus (Seifert, 2020). As much research around the world indicates older person’s intersectional position but nonetheless the assessment of their situation made governments and other stakeholders ealizes the urgent key need for digital literacy for accessing information, communicating with various intimate and wider societal connections and procuring all kinds of products and requirements for their daily life (Martins & Jaarsveld, 2020). Certain governments and other organizations by assessing the critical situation of older people during the pandemic and also prompted by WHO and UN agenda prioritized their responses to safeguard and protect the interest of ageing populations. Thus, specific attempts were made to address their general and special needs pertinently in the context of those seen as unmet. For instance, many experts effectively argued for not misrepresenting and undervaluing older persons in the discourses revolving around the pandemic since its onset (Fraser et al., 2020). Rightfully, the discourses called for strengthening intergenerational solidarity and supporting older people by connecting and integrating them into society and not isolating them. Universally through various voices, there emerged an attempt to reduce ageism seen at its peak during the COVID pandemic which though generally associated more with Western societies (Levy & Macdonald, 2016) is seen to be prevailing in non-Western contexts too. Disturbingly for gerontologists and many others too, the COVID-19 pandemic accentuated the devaluing of older persons’ lives. Reports from various quarters as shared by certain chapters in this book too indicated from the time the coronavirus

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surfaced and spread the infection, older people were seen to be the most at-risk segment of the population. While this in some ways was seen as a justifiable protective shield influencing many isolating and social distancing guidelines for older persons, as seen by certain critics of prevailing policies, this patronizing attitude towards ageing populations gave greater attention to mortality concerns rather than noticing and emphasizing their various health and social needs. Numerous studies of different creditability and using varied methodologies discuss older people being vulnerable to loneliness, social exclusion, and experiencing psychosocial burdens during pandemic times (Shankardass, 2021). These factors because of underlying ageist thoughts due to both cultural and globalizing factors enunciated during the pandemic besides other contributing issues were identified during the 2020s as significant risk factors undermining the position of older people in society and require to be addressed for reducing the burden. D’cruz and Banerjee (2020) advocate for nations to take concrete steps in mitigating the suffering of older people by having programmes and policies which take care of their loneliness, isolation, dependency, and stigma, remove abusive environments, marginalization, and restrictions in accessing health care, and overcome ageism, and lack of security besides providing services for curing them from different kinds of morbidities, looking after their frailty, sensory and cognitive impairments and bringing down fatality rates. Many experts working on ageing issues call for measures which put in place taking care of physical, physiological, and psychosocial needs of older persons (Shankardass & Mallick, 2020a). Quite rightly as pointed out in a few analyses of the COVID-19 pandemic situations in Asia Pacific, often the mental health wellbeing of older persons is overlooked (Hwang et al., 2020). Wu (2020) in a study demonstrated how loneliness, depression, and social isolation were the outcome of the deleterious impact of COVID-19. Many chapters in this volume touch on these aspects by describing the ground reality and suggesting solutions to handle the crisis due to the COVID-19 pandemic. The harmful impact of certain government policies on the lives of older persons started to surface after a few months of the “isolating models” employed in the socalled care concerns for ageing groups of people in societies (Armitage & Nellums, 2020). For many Western nations, this had a detrimental impact on long-term care provisions in the American and European regions. In addition, experts point out that looking solely at older people as high-risk populations for the coronavirus did not help in stopping the spread of the infection as younger populations in many instances and countries overlooked taking necessary precautions and preventive measures. Media reports over the last few months highlight irresponsible behaviour by citizens, more so among young adults than older in wearing face masks, following social distancing norms, and hygienic practices. Yet, there were in all countries greater emphases on making older generations adhere to rules for pandemic prevention and taking precautions in a more stringent manner than for younger people. On the other hand, very pertinently in relation to debates about older vis-a-vis younger generations were concerns pertaining to adequate care provisions available for saving lives. There are anecdotal accounts from many countries in all continents of older people being deprived of bed allocation in hospitals and emergency treatment priority with

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reasoning for them being nearer to end of life phase than those who had the possibility of living for many more years after being cured from COVID-19. Significantly, at times such choices were also on the instance of older persons who gave greater value to a younger life than to their later years. Ironically, there are no simple clearcut right and ethical decisions regarding whose life matters more and from whose perspective, which sacrifice has meaning for familial relationships, and for society as a whole. This dilemma is profoundly a serious matter in COVID-19 pandemic times. The present volume points towards covering such dimensions quite like a few earlier available books but goes into more topics, country-specific and extended time periods than what previous publications refer to. While this book, in no way, attempts to be exhaustive as not possible with the ever-evolving dynamic situation of the pandemic, it nevertheless tries to cover different dimensions and various perspectives, and elaborates on experiences, commentaries with meaningful dialogue in throwing analytical and descriptive light on circumstances, consequences, and outcomes of the impact of the pandemic on older persons globally as well as in the respective nations as representation. In continuation with varied narrations about COVID and its impact on older persons going beyond ethical, political, economic, and health considerations are instances of humanistic and social tales of cooperation and support provided by families and civil society members to enhance coping mechanisms of ageing populations, be it in terms of meeting care needs, procuring daily provisions for carrying on with routine activities and requirements, and identifying emerging needs for digital literacy and help in learning about new information and communications systems. The adoption of multiple practices to improve relationships, being mutually beneficiary partners, and being a strong asset for each other in times of pandemic crisis are stories which carry weight in gerontological, psychological, and sociological discourses as much as tales of things going wrong in communications between younger and older generations because of wider social, economic, health, and political environment which are being manifested in all negative ways too in the respective societies. Clearly, given the broad outline of the anticipated and the actual situation of older persons during the COVID-19 pandemic times, advocating for placing them in right-based framework and focusing on their quality of life issues are of paramount importance, and the present publication through several chapters brings attention to these domains. The last 2 years from the end of 2019 till the present have many awareness campaigns in place globally to improve services and facilities for those ageing in societies and have inclusive policies for all age groups. However, despite such measures, older people continue to face many difficulties, some generic and some man-made, in all aspects of their life be it economic, social, and psychological, or health. Information on these aspects is forthcoming in many forms, and this publication too collates it by bringing narrations from India and beyond from both global and national perspectives. But as this book also shares through various chapters and it is also seen in some of the other articles published in different mediums, scientific journals, books, newspaper reports, and other sources of media coverage since last few months commentary on the impact of the COVID-19 pandemic for older persons

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increases public, research, and academic discourses on placing older people in the development framework so that such health and social crisis can be avoided in the future. I recognize the urgent need for socioeconomic responses to the impact of the COVID-19 pandemic, but while the contributions from different scholars could provide narrations on the social and health dimensions in this volume, those on economic aspects could not be included in detail due to unavoidable and compulsive reasons. However, it is not to undermine the importance of streamlining social security and protection measures including looking at employability aspects, supporting economic activities, jobs, especially in the informal sector, and helping older people ride over the adversity period brought in by the pandemic. Li and Mutchler (2020) in their analysis of the economic impact because of COVID-19 point out experiences of older people related to insecurities in health having a co-relation to insecurities in income and it intersects with poverty situation among them. Many studies since the last few years indicate the dependence of older people on their petty incomes and that of their families to manage later years, but this changed during the pandemic with many from younger and older generations losing their jobs, small businesses closing down, and with low social security provisions in many countries particularly in the Asia Pacific region the economic vulnerabilities really increased. Many governments had problems in rolling out social security benefits and universalizing it was a big issue and concern. Nonetheless, attempts were made in different countries to subsidize workers and older citizens going through financial difficulties with various kinds of benefits such as free food rations and free medicines and provide other social security measures. Various targeted interventions helped ageing populations as part of the strategy to “normalize” lives and build up their resilience (UNDESA, 2020). Gietel-Basten (2021) narrates examples of income and social protection programmes rolled out in different countries during COVID-19 to help older people in particular who were experiencing poverty. What has also been observed by experts researching ageing issues during the COVID-19 pandemic is an increase in dependence on older people for caregiving in families and in many instances being abusive for them (Shankardass, 2021). A study conducted by Lee (2020) for Asian Development Bank captures the increased reliance on older people as unpaid family carers, a practice in existence in many Asian countries for long but which exacerbated since December 2019 when coronavirus started to hit countries. The need for nations to strengthen robust macro-economic policies along with taking into consideration micro-level community processes also becomes pivotal in the context of recovery from the financial crisis brought in by the pandemic. International Labour Organization right from the first phase of the coronavirus started to emphasize the strengthening of social protection in countries (ILO, 2020). As United Nations stresses quite in the early phase of the crisis faced by the spread of the coronavirus, older people with due consideration to gender equality must be facilitated to live cohesive life with intergenerational understanding at the family, community, and societal levels (UN, 2020). It is noteworthy that UN agencies within the broader context of enabling countries to achieve SDGs agenda by 2030 supported initiatives from a development, rights, humanitarian, and emergency response perspective for

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surpassing difficulties faced due to the pandemic and, in particular, paid attention to overcoming inequalities, especially gender-related and by exposing vulnerabilities in social, political, economic, and biodiversity systems (ibid.). It is absolutely relevant in the present-day context to take lessons from the failures of societal systems which almost collapsed during the last 2 years of the pandemic effect and adopt futuristic directions from age and gender-sensitive approaches by incorporating the reality of ageing societies. Urgency in accelerating responses is the crux of the matter to wade over COVID-19 pandemic impacts for all age groups and more so for older populations as their vulnerability and for specific disadvantaged groups within this segment is at stake in almost all societies as some of the chapters in this book highlight in the context of specific areas of concern be it with regard to elder abuse, health and social care systems, digital inclusion, community responses, intergenerational issues, etc. While few chapters discuss concerns from a global perspective, there are many chapters providing country-specific information taking into account existing socio-economic realities, particular institutional arrangements, and forms of responses. Finally, while countries continue to assess the impacts of COVID-19 on older people and experts present their recurring critiques of prevailing policies, programmes, and initiatives taken to deal with the crisis along with an analysis of the resilience, courage, and coping mechanisms used by older people, the dialogue which must carry on with the participation of all stakeholders is how to avoid such crisis which had major health, social, economic, administrative, and political ramifications. What should be futuristic directions for emergency preparedness? Universally, it is pertinent and relevant for all nations as a strategy for disaster management and for making better provisions for the lives of people as they age to remove various obstacles and shortcomings which come with accessing health and social care including long-term care, mental health care, social security and protection mechanisms, and financial resources necessary for maintaining certain living standards. The crux of the matter is to understand through narrations, through documented sources, and through evidence what failed with the onset of the coronavirus, what could be managed and worked in dealing with the pandemic, what changes are needed to better and secure the future of older persons, in other words, what needs to be put in place as a way forward so that vulnerabilities of older people are minimized when any crisis occurs. Hopefully, the collection of chapters in this book with the intention of providing a meaningful discourse on understanding the impacts of the COVID-19 pandemic makes a positive contribution towards understanding this topic which has been part of the discussion of many. It is an opportunity to reflect on what can move forward.

References Armitage, R., & Nellums, L. B. (2020). Covid-19 and the consequences of isolating the elderly. Lancet Public Health. Chatterjee, S. C., & Chatterjee, D. (2022). Covid-19, older adults and the ageing society. Routledge

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D’cruz, M., & Banerjee, D. (2020). An invisible human rights crisis’: The marginalization of older adults during the COVID-19 pandemic-an advocacy review. Psychiatry Research 292,113369. https://doi.org/10.1016/j.psychres.2020.113369. Epub 2020 Aug 3. Fraser, S., Lagacé, M., Bongué, B., Ndeye, N., Guyot, J., Bechard, L., Garcia, L., Taler, V., CCNA Social Inclusion and Stigma Working Group, Adam, S., Beaulieu, M., Bergeron, C. D., Boudjemadi, V., Desmette, D., Donizzetti, A. R., Éthier, S., Garon, S., Gillis, M., Levasseur, M., Lortie-Lussier, M., Marier, P., Robitaille, A., Sawchuk, K., Lafontaine, C., & Tougas, F. (2020). Ageism and COVID-19: What does our society’s response say about us? Age & Ageing, 49(5), 692–695. https://doi.org/10.1093/ageing/afaa097. PMID: 32377666; PMCID: PMC7239227. Gietel-Basten, S. (2021). Building back better’ for older persons after covid-19. HelpAge International. Hwang, T. J., Rabheru, K., Peisah, C., Reicham, W., & Ikeda, M. (2020). Loneliness and social isolation during the covid 19 pandemic. International Psychogeriatrics, 32, 1217–1220. ILO. (2020). Social protection is pathway to pandemic recovery. International Labour Organization. Lee, S. H. (2020). Impact of covid 19 on welfare of older persons, Asian Development Bank. https:// www.adb.org/site/default/files/event/659586/impact-covid-19-welfare-older-persons.pdf Levy, S. R., & Macdonald, J. L. (2016). Progress on understanding ageism. Journal of Social Issues 72, 5–25. Li, Y., & Mutchler, J. E. (2020). Older adults and economic impact of covid 19 pandemic. Journal of Ageing Social Policy, 32, 477–487. Łuszczy´nska, M. & Formosa, M. (2021). Ageing and covid-19: Making sense of a disruptive world. Routledge. Martins Van Jaarsveld, G. V. (2020). The Effects of Covid 19 among the elderly population: A case for closing the Digital Divide. Frontiers in Psychiatry, 11, 577427. Miller, E. A. (2021). Older adults and covid-19: Implications for aging policy and practice. Routledge. Miller, E. A. (2022). The covid-19 pandemic and older adults: Experiences. Routledge. Shankardass, M. K. (2021). Home, the vulnerable and the pandemic. In G. D. Tripathy, A. Jalan, & M. K. Shankardass (Eds.), Sociological reflections on the covid-19 pandemic in India: Redefining the normal (pp. 35–50). Springer Nature. Shankardass, M. K., & Mallick, A. (2020a). Mental and physical wellbeing of elderly requires special focus during pandemic. Indian Express. Shankardass, M. K. (2020b). Safe guarding older people in the times of the pandemic. Blog, Springer Nature. Seifert, A. (2020). The digital exclusion of older adults during covid 19 pandemic. Journal of Gerontological Social Work, 63, 674–676. UNDESA. (2020). Covid 19 and older persons: A defining moment for an informed, inclusive and targeted response, UN/DESA Policy Brief 68. United Nations. (2020). A UN framework for the immediate socio-economic response to COVID-19 APRIL. UN-framework-for-the-immediate-socio-economic-response-to-COVID-19.pdf WHO. (2020). The UN Decade of Healthy Ageing -2021–2030, World Health Organization, Geneva. https://www.who.int/initiatives/decade-of-healthy-ageing Wu, B. (2020). Social isolation and loneliness among older adults in the context of covid 19: A global challenge. Global Health Research and Policy, 5, 27.

Chapter 2

Impact of Covid-19 on Older Population: Review of the Initial Phase Ritu Rana

Abstract The pandemic COVID-19 has affected the whole of the world. Starting with a few cases in the confined parts in January 2020, as of 28 December 2020, there have been 79,673,754 confirmed cases of COVID-19, including 1,761,381 deaths.1 In India, from 3 January to 28 December 2020, there have been 10,207,871 confirmed cases of COVID-19 with 147,901 deaths.Older people are disproportionately hit by COVID. The risk for severe illness from COVID-19 increases with age, with older adults at the highest risk.2 They are at higher risk due to decreased immunity, body reserves, and multiple associated co-morbidities like diabetes, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease.3 The COVID case fatality rate in a population of age 60 and older ranges from 2 to 20% across the countries.4 COVID-19 has changed older people’s routine, care, and support. The virus has caused inexpressible fear and distress. It has confronted the elderly badly physically, economically, and psychologically. The World Health Organization has published a policy brief analysing the impact of the COVID-19 pandemic on senior populations, highlighting vulnerability, abuse, neglect, and the impact on health, rights, and longterm care services. The chapter is an attempt to provide an overview of the impact COVID-19 has impressed upon the older population and is based on the reports and studies available in the public domain. Keywords The concern · Impact · Vulnerability · Provisions

Covid-19 COVID-19 is the disease caused by a new coronavirus called SARS-CoV-2. COVID is the short form of Corona Virus Disease and 19 refers to 2019, when the disease outbreak occurred. Formerly, this disease was referred to as “2019 novel coronavirus” or “2019-nCoV”. The disease has spread rapidly throughout the world and in March 2020, World Health Organization declared it a pandemic. R. Rana (B) HelpAge India, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_2

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The most common symptoms of infection with COVID-19 are fever, dry cough, and fatigue. Other less common symptoms reported are loss of taste or smell, nasal congestion, conjunctivitis (also known as red eyes), sore throat, headache, muscle or joint pain, different types of skin rash, nausea or vomiting, diarrohea, chills, and dizziness.5

Global Impact of Covid-19 The COVID-19 pandemic has led to a dramatic loss of human life worldwide and presented an unprecedented challenge to world not only for public health but also to basic essentials, livelihoods, and social connect. Countries dealing with existing humanitarian crises or emergencies are particularly exposed to the effects of COVID-19.6 According to the WHO, the economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty, while the number of undernourished people, currently estimated at nearly 690 million, could increase by up to 132 million by the end of the year. Although no age is spared by the deadly virus, older people and persons having co-morbidities are affected most. The public health crisis affected them physically, socially, psychologically, and economically.

Effect on Health and Care of Elderly Older People are at Higher Risk of Contracting Coronavirus and Severe Illness About 80% of people who have died from the virus in China were over 60 years of age, as reported by China’s National Health Commission7 in February 2020. Chinese citizens who developed Pneumonia due to Corona were of an average age of 55 years, according to a Lancet study. On 3 April 2020, WHO stated that “in many countries, older people are facing the most threats and challenges at this time. Although all age groups are at risk of contracting COVID-19, older people face significant risk of developing severe illness if they contract the disease due to physiological changes that come with ageing and potential underlying health conditions.” Centre for Disease Control and Prevention (CDC) reported that 8 out of 10 deaths in the United States were in adults 65 years old and above.8 More than 50% of all fatalities involved people aged 80 years or older. Reports show that 8 out of 10 deaths are occurring in individuals not only with at least one comorbidity, in particular those with cardiovascular disease, hypertension, and diabetes but also with a range of other chronic underlying conditions.

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Report from Italy9 stated that the Mean age of patients dying from COVID-2019 infection was 78 years. In India with an estimated population of 106 million, people 60 years and above experienced the harsh effect of COVID-19 on the segment. Majority of people affected by coronavirus in India were between the age 45 and 74 years as per a report of July 2020,10 and the highest share of deaths was in the age group 60–74 years.

Healthcare Delivery During Covid Restrictive public health measures including lockdowns and health resources grappling with COVID response created a barrier for senior people to access health services. As people age, they are more likely to experience multi-morbidity and conditions like diabetes, hypertension, cardiovascular diseases, chronic obstructive pulmonary disease, and chronic kidney disease. These conditions require continued long-term treatment, failure to which may lead to complications. A crucial lesson learned from the Pandemic is that once the hospitals are occupied with COVID cases, non-COVID cases urgently needing inpatient care could not be hospitalized. Many cases have been reported who suffered the disruptive healthcare service and changes in protocols owing to COVID. An article by a Physician from New York which was published on 17 April 2020, at NEJM.org.11 featured some such cases. A woman in her 70s developed chest pressure and shortness of breath. She was reluctant to go to the hospital, and when she presented (at a highly regarded institution), she needed urgent intubation. When chest radiography revealed bilateral interstitial oedema, she became a “COVID rule-out” and was transferred to the ICU. By the time her COVID test result was awaited, her troponin level climbed, causing increasing concern about an acute coronary syndrome. She underwent the urgent surgery only after her COVID test result turned out negative. By then, she had developed progressive cardiogenic shock, and ultimately died. Cancer care often requires frequent visits to the hospital for chemotherapy/radiotherapy/immunosuppressive therapy which was disproportionately affected by COVID-19. It was not recommended to visit hospitals as the visit may worsen immunosuppression and may affect survival. Elective surgeries were cancelled, and the protocol has made patients wait for months who were planned for resection of tumours and were offered systemic therapy. In India “A 50-year-old’s leg had to be amputated because the patient, from a district near Chennai, held back by lockdown and the subsequent fears around COVID-19, could not make it in time to the hospital and his foot infection had turned severe with cellulitis, a serious bacterial infection leading to gangrene, death of tissues.”12

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Long-Term Care and Old Age Homes Country reports by International Long-Term Care Policy Network13 COVID-19 infections in long-term care facilities varied widely; in Sweden, by the end of April, 25% of long-term care facilities in the whole country had COVID-19 outbreaks, with 67% of long-term care facilities in Stockholm affected. In Italy,14 in the province of Bergamo, more than 600 nursing home residents died between 7 and 27 March 2020. In Australia, 2,050 nursing home residents were diagnosed with COVID-19 till 12 October 2020. Long-term care residents’ deaths represented 85% of all deaths due to COVID-19 in Canada. Conditions like insufficient Personal Protective Kits at the facilities initially, limited training for staff and caregiver staff, asymptomatic cases, and multiple entries of staff and other essential workers (who worked at multiple facilities) were some of the causal actors of outbreaks of COVID-19 in Long-Term Care Facilities.15 Later with restrictions imposed and continued to date, seniors residing in old age homes and long-term care facilities are not allowed to meet their fellow mates and are living secluded lives. Another challenge that emerged is to get caregivers and other help like cooking food, sanitation, etc.

Mental Health of Older Adults and Pandemic Covid-19 Repeated caution to stay at home, restricting visitors, keeping social distance even with family members, high vulnerability of elders to contract the virus, and media and news channels flooded with COVID-related news have created anxiety and fear in the elderly. Wide-ranging mental health status of the older population is reported during the pandemic ranging from lower as compared to other age groups.16 A survey published by Centre for Disease Control and Prevention (CDC) among 933 participants aged 65 years and older reported anxiety disorder (6.2%), depressive disorder (5.8%), or trauma- or stress-related disorder (TSRD) (9.2%). As per the survey, these rates were lower in older adults as compared to other age groups. These findings are similar to other reports from high-income countries. A cross-sectional study involving 3840 community-dwelling older adults aged 18 through 80 years from Spain noted that older age (60–80 years) compared with younger age (40–59 years) was associated with lower rates of anxiety, depression, and posttraumatic stress disorder (PTSD). A longitudinal study involving 1679 community-dwelling older adults (65–102 years) in the Netherlands found that although loneliness increased after the pandemic, mental health levels remained unchanged before and after the start of the pandemic. Mental Health issues like anxiety (ranging from mild to severe), non-specific psychological distress, depression, stress symptoms (including PTSD), insomnia, hallucinations, paranoid and suicidal ideations, etc. have been reported during the pandemic.17

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Online studies in India reported fear, anxiety, and feeling of confinement among the older population during the pandemic.18, 19

Economic Impact on Older Population During Covid-19 The pandemic has had its ramifications on every segment of the population. It has affected the daily living of the older population specifically. Due to higher risk of getting affected with the virus and serious complications owing to co-morbidity, elders were hit hard financially especially economically marginalized elderly with low or no income. The cost of hospitalization has escalated and the reserves, if any, succumbed to it for many. Guidelines for elders to stay at home during the pandemic have led to the unemployment of many who otherwise could have worked being physically fit. In the past three decades, the share of the older population in the labour force has shown nearly 10 percentage points.20 The income and employment impacts are thus large. According to a working paper, unemployment rates in the United States in April 2020 increased to 15.43% for those aged 65 and older, compared to 12.99% for those aged 25–44.21 Early evidence from the UK suggested greater effects on the pay of older compared with those of prime age: 30% of employees aged 60–64 stated that they were receiving less pay following the COVID-19 outbreak, compared with 23% of those aged 35– 49 years (Gustaffson, 2020).22 Claims for unemployment benefit nearly doubled among those aged 50 and over between February and June 2020 (Centre for Ageing Better and Learning and Work Institute, 2020). HelpAge India did a telephonic survey in June 2020 with 5099 elders 60 years and above the age (Urban: 2639, Rural: 2460) highlighted that 65% of respondents had experienced an impact on their livelihood during COVID-19. They had no work or faced a drastic loss in their wages. Of these, 60% were from rural areas, while 40% were from urban areas. 71% of respondents reported an impact on the breadwinner of their family (loss of work/wages) by the lockdown. Of these, 61% were from rural areas, while 39% were from urban areas. According to the International Labour Office (ILO),23 there are over 67 million domestic workers worldwide, 75 per cent of whom are working informally, 80 per cent are migrants, and the vast majority are women.24 Many of them are above the age of 50 years and continue to work as domestic help. Domestic workers support the households in keeping their homes clean, caring for, and cooking and in many other ways like driving, gardening, etc. The pandemic has restricted their work as domestic help initially due to lockdown and later the fear of households acquiring infection from them eventually jeopardizing their source of income. There is a positive story as well showing older adults engaging themselves in various self-regulation strategies helping them to age successfully at work (e.g. Kooij et al., 2020; Taneva and Arnold, 2018; Zacher et al., 2018a).

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Social Impact Elder Abuse and Ageism As defined by World Health Organization “Ageism is the stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs. During the course of the pandemic, a lot of media coverage was observed about the higher risk to the older population. The discourse has negatively exaggerated ageism against older people. Elder abuse is significantly underreported. Only 1 in 24 cases may be reported. Social isolation which has increased during the pandemic has posed a significant risk for elder abuse, specifically in older adults with cognitive impairment, physical frailty, and dependence on others for care. All of these risk factors have been compounded by COVID-19. Psychiatric Times published an article in September 202025 mentioning a trend of Twitter and Facebook posts during COVID reflecting ageism against the elderly. Aged people were largely portrayed as helpless and frail. There were discussions about rationing of care for older during the pandemic and that the death of the elderly is not as important as the younger generation. A story by an Indian journalist on World Elder Abuse Awareness Day (15 June) mentioned a survey in which 71% elderly responded to experiencing increased abuse during the lockdown and after. The abuse was of nature ranging from disrespect, verbal abuse, not talking to them, and denial of their needs including health care to proper food.26

Bringing Back the Normalcy While strong measures to contain the spread of COVID-19 and bring back life to normal are being taken by countries including vaccination, continued effort will be required to improve the status of the elderly. It is essential to make health and care services accessible for older people in all situations be it an emergency, epidemic, or pandemic. The digital literacy of older people needs to be enhanced so that they can use mobile apps for receiving information and for communicating with family members and be able to connect to tele health service providers. Tailored and accurate information needs to be provided to them on staying healthy and on getting help when required. The pandemic has taught the world many new things. Our seniors have also gained new skills. They are now better technology savvy as compared to earlier times. Many have adopted self-care and learned the importance of being healthy. Time has shown the importance of family, and the connect between generations has increased as most of the young population worked from home and the students had online classes. This

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has made them spend some time together. An insight arose on saving resources for health and wellbeing and on advanced legal work.27 The coordinated and continued effort of the individual, family, society, public, and private and non-government organizations can reshape life after COVID-19.

Notes 1. 2. 3. 4. 5. 6.

7. 8. 9. 10.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

https://covid19.who.int/ https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html Health Advisory for Elders during covid -19 https://www.mohfw.gov.in/pdf/AdvisoryforElde rlyPopulation.pdf https://ourworldindata.org/mortality-risk-covid#case-fatality-rate-of-covid-19-by-age https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answershub/q-a-detail/coronavirus-disease-covid-19 https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people’s-livelihoodstheir-health-and-our-foodsystems#:~:text=The%20economic%20and%20social%20disrupt ion,the%20end%20of%20the%20year https://www.medicinenet.com/script/main/art.asp?articlekey=228505 https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html https://www.epicentro.iss.it/en/coronavirus/bollettino/Report-COVID-2019_9_april_2020. pdf Number of COVID-19 cases India 2020 by age group, Published by Sandhya Keelery, Sep 1, 2020 https://www.statista.com/statistics/1110522/india-number-of-coronavirus-cases-byage-group/ https://www.nejm.org/doi/full/10.1056/NEJMms2009984 https://thewire.in/health/national-health-mission-covid-19-medicine-vaccine https://ltccovid.org/country-reports-on-covid-19-and-long-term-care/ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30149-8/fulltext https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336111/ https://jamanetwork.com/journals/jama/fullarticle/2773479 Li et al., 2020; Tan et al., 2020; Gao et al., 2020; Qiu et al., 2020; Roy et al., 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139237/ The Elder Story: Ground Reality during Covid 19 Impact & Challenges A HelpAge India report (June 2020). Policy Brief: The World of Work and COVID-19 June 2020. https://www.ilo.org/wcmsp5/gro ups/public/@dgreports/@dcomm/documents/genericdocument/wcms_748428.pdf. Early Evidence on the Impact of COVID-19 and the Recession on Older Workers; Truc Thi Mai Bui, Patrick Button & Elyce G. Picciotti. https://www.economicsobservatory.com/how-might-coronavirus-affect-older-workers www.ilo.org/wcmsp5/groups/public/---ed_protect/protrav/travail/documents/publication/ wcms_155951.pdf. . https://www.psychiatrictimes.com/view/elder-abuse-and-ageism-during-covid-19 https://timesofindia.indiatimes.com/india/abuse-has-increased-during-lockdown-say-71-ofelderly/articleshow/76377324.cms https://www.tandfonline.com/doi/full/10.1080/08959420.2020.1759758

Chapter 3

COVID-19: A Worldwide Hecatomb in Long-Term Care Facilities Dominique Predali

Abstract The death rate in LTCFs was described as an unimaginable tragedy by Hans Kluge, Europe WHO regional director. Across the world, during the first wave of COVID-19, between 30 and 80% of total fatalities occurred in nursing homes. The figures are staggering because nursing home residents only account for 1 to 6% of the total population. These deaths were not all due to the virus. Various studies show that lack of means and personnel, abandon, poor quality of care, neglect, abuse, violation of human rights, confinement, loneliness, and psychological problems are killers too. The pandemic shone a light on these facilities and their long-standing issues resulting from drastic cost-cutting, chronic understaffing, dire working conditions, high staff turnover, low wages, untrained staff, and profit over care. It also exposed governments’ ageism and statutory neglect such as policy decisions to issue triage guidelines regarding old people hospital admissions, to discharge symptomatic patients from hospitals to LTCFs, to prioritize hospital workers for PPE and PCRs, to disregard the potential impact of COVID-19 on LTCFs, and to allow violation of residents’ Human rights. The failed to enforce regulations, to prioritize care home residents and staff in response measures, to report mortality figures in LTCFs. Keywords Ageism · Excess deaths · Neglect · Abuse · Understaffing · Cost-cutting · Profit over care · Statutory neglect · Triage · Human rights violations · Confinement

“Covid-19 Stalked Nursing Homes Around the World” (Mathews, 2020); “Across the world, figures reveal horrific toll of care home deaths” (Observer Reporters, 2020); “Covid-19 Global Roundup: The Grim Crisis in Care Homes” (CGTN, 2020); “The Whole Corridor Is Dead: Europe’s Coronavirus Care Home Disaster” (O’Leary, 2020). A Canadian study stated that people living in long-term care facilities had had more chances of dying of COVID-19 than the rest of the population (Liu, 2020). It D. Predali (B) 46 Place Carmes, 76000 Rouen, France e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_3

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was true for most countries. With bodies and body bags piling up in nursing homes, coffins piling up at cemeteries, morgues, mortuaries, churches, crematoriums, ice rinks, refrigerated trailers, refrigerated warehouses, stadiums, and streets, the horrific toll of LTCF deaths around the world could not be hidden. Data, collected by the London School of Economics at the end of June 2020, show that, from the onset, COVID-19 spread more quickly in LTCFs around the world, and was responsible for 30 to 81% of total deaths (LTCFs—for convenience’s sake, these will include nursing homes, care homes, residential care facilities, resting-homes, and retirement homes) (Comas-Herrera, 2021). Even in countries with a generally low COVID death rate, these institutions were hard-hit. In Slovenia and Canada, 81% of all COVID casualties occurred in LTCFs. These figures are shocking because LTCFs house less than 2% of the total population. The mass fatality of the institutionalized elderly, due not only to COVID-19 but also to neglect, further highlighted a dysfunctional long-term care system and the debacle of healthcare systems globally (Giri, 2021; Hu, 2020; Orecchio-Egresitz, 2020). As usual, officials were saddened, disturbed, troubled, disappointed, and deeply surprised at what happened, wondering how it could happen. For decades, long before COVID-19 was on the radar, healthcare professionals, advocacy groups, and families had tried to alert governments and the media about unacceptable conditions in LTCFs. COVID-19 just exacerbated an already existing crisis in the sector and shone a spotlight on it. For the first time, the media reported what was happening in these institutions worldwide and presented the situation as a global issue, a planetary humanitarian crisis.

COVID-19 or Neglect? Dying of neglect: the other COVID care home scandal (Heneghan & Jefferson, 2020); Not just COVID: Nursing home neglect deaths surge in shadows (Sedensky & Condon, 2020), COVID-19 or neglect? Canada reflects on the heavy death toll in nursing homes (FRANCE24, 2021); COVID ravaged N.J. nursing homes. Did neglect from caretakers make things far more deadly? (Livio, 2021). During the first wave, some LTCFs in Canada were among the worst impacted in the world. Dramatic understaffing required the deployment of the Canadian Armed Forces (CAF) in 47 LTCFs in Quebec and seven in Ontario (Badone, 2021). After their action in Ontario, the CAF published a “deeply disturbing report” (Brewster, 2020). This “extremely troubling” document revealed “the deplorable conditions”, in these facilities (Mialkowski, 2020). It showed that COVID-19 was not the sole killer. Neglect, due to understaffing, lack of means, equipment, and training, was as lethal as the virus. In one facility, 26 residents died of dehydration because of a severe staff shortage. In others, dehydration and malnutrition, not COVID, were the cause of death. Most of the healthcare professionals (60%) were either down with COVID or didn’t turn up because they were terrified. The remaining staff, overworked, mainly untrained, proved inefficient. It meant that old people were not

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fed or given inappropriate meals or rotten food. They were being force-fed, choking, and staffers were unable to help. Residents were unkempt, unwashed for weeks, and left in soiled diapers and dirty bed linen. Infection control was almost inexistent. The CAF team reported “a near 100% contamination rate for equipment, patients and overall facility.” Staff didn’t change their Personal Protection Equipment (PPE) or used inappropriate PPE. They failed to disinfect equipment, including thermometers, between residents. There were no civilian registered nurses or 1 for 200 patients and no in-house MD. Before the CAF teams’ intervention, medical monitoring was non-existent. Wound care, and catheter care, was left to be desired. Patients were heavily sedated, given the wrong medication, brutally handled, and left bedbound and unturned in their beds, causing bedsores. Poor patient documentation was also a problem, and so was a lack of communication between shifts. Psychosocial support was absent. Supplies, including wound care supplies, were low or not accessible. Empty liquid oxygen generators were out of use, and oxygen concentrators were difficult to access. The premises had not been disinfected and were filthy. Faeces and vomit stuck to floors and the walls. Cockroaches, ants, and insects unknown crawled around the place (Mialkowski, 2020). This report was only made public a year later. The CFA also released a similar report on Quebec’s dysfunctional LTCFs. The shocking death rate was declared a “Canadian tragedy that must not be allowed to happen again” (Holroyd-Leduc & Laupacis, 2020). Yet during the second wave, the same horror scenario repeated itself. In some facilities, residents were abandoned in their waste, naked or scantily clad, crying, vomiting, dying of dehydration, and left choking. Again, dangerous understaffing, lack of sanitation, including PPE shortage, and terrible neglect resulted in dozens of preventable deaths (Iqbal, 2021). In Spain, too, the army deployed to disinfect critical infrastructures, including LTCFs, found old people, in absolute squalor, abandoned by staff, and some of them dead in their beds (cbc.ca, 2020a, b). Médecins sans Frontières (MSF) also sent medical and logistics teams to facilities. Their report confirmed the same systemic issues (MSF, 2020a), and a drastic deterioration of residents’ health (IO-MSF, 2020). MSF found similarly alarming living conditions in care homes in Belgium. The staff did not know basic hygiene rules and safety and treatment protocols (MSF, 2020b). A local MSF project coordinator explained that LTCFs were requested to function like hospitals but lacked the protective means and necessary personnel to do so. They were confronted with a “true humanitarian crisis” (IO-MSF, 2020). MSF also intervened in facilities in France, Portugal, Switzerland, the Czech Republic, and Michigan. In France, paramedics found decomposing bodies in the bedrooms of a facility run by the Paris City Hall (Libert, 2020). In some LTCFs, COVID patients’ mortality was 30%, a rate higher than during Ebola pandemics in Africa, said epidemiologist Sylvain Diamantis. To find out why he took his team to a facility near Paris (Diamantis & Noel, 2020). The place lacked everything from PPE to staff—half the care auxiliaries and nursing aides were absent on sick leave, there was no registered nurse on the premises, the in-house doctor had vanished, and GPs stopped visiting their patients. The residents were confined to their rooms, and, with only one care assistant for 200 highly dependent residents, most of them didn’t get any help to drink, eat, wash, or change. Severe dehydration, malnutrition, lack of medical care,

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infection control, and basic hygiene caused more deaths than the virus, explained Sylvain Diamantis (Personnal communication, 2021). With care, water, and sometimes oxygen, all these deaths, linked to confinement and not to COVID, could have been prevented. The team set up a task force to deal with the crisis. After a few days, the fatality rate dropped to 5%. Other task forces were sent to LTCFs, with hospital nurses. Many patients had COVID, but most of them just needed water and food. Some required oxygen but without intubation. None of them died. Diamantis and his team carried out two more studies: one study in 3 LTCFs with 2 of them attached to a hospital. More patients died in the third facility, not affiliated to a hospital. The infection rate was higher and medical care lower (Tarteret et al., 2021). The other one, conducted in 8 LTCFs, confirmed the previous results. A task force with nurses and specialists succeeded in diminishing fatalities (Dolveck & Strazzulla, 2021). A similar successful hospital–nursing home partnership was implemented as an emergency response in Toronto (Stall et al., 2020). Other hospitals set up “COVID-19 SWAT teams” sent as reinforcement in Ontario nursing homes (News.ontario.ca, 2020). Data in England and Wales, between late December 2019 and early July 2020, further confirm that 345 non-COVID hospital and LTCF patients died of dehydration (ONS, 2020). This 48% increase was due to inadequate medical monitoring, understaffing. and a ban on family visits. According to a charity, the staff was “at breaking point”. A facility in the North of England operated on 25% of its staff during an outbreak (Booth, 2020). A national survey in Italian nursing homes from early February to early May showed that the same devastating lack of care contributed to the same adverse events, hospitalizations, and deaths as in other countries. Among the common causes of preventable deaths, they listed dehydration, falls, urinary tract infections, bowel obstruction, delayed or inappropriate interventions, and no care or poor care. Researchers also reported increased use of psychoactive drugs and physical restraints, inappropriate prescriptions of drugs, and mistakes in medications. Understaffing and inexperienced staff, unable to work as a team and adequately document and communicate daily care, were deemed responsible for the situation (Lombardo et al., 2020). In the US, “Reports of neglect and abuse of nursing home residents seemingly unrelated to Covid-19” were received by the New York Attorney General’s Office (OAG Letitia James, 2021). An investigation in Connecticut LTCFs found a decline in residents’ well-being with increased depression, unplanned weight loss, and bedsores. It also showed that facilities with a high number of recent bedsores also had higher COVID infection rates and deaths per licensed bed (Rowan, 2020). HRW reports weight loss, dehydration, bedsores, lack of hygiene, depression, anxiety, and a worrying increase in psychotropics prescriptions, all of which may contribute to premature deaths (HRW, 2021). At the University of California, Prof. Steve Kaye is conducting a study on non-COVID deaths due to abuse and neglect. Data analysis from 15 000 nursing homes shows that, between March and November 2020, these deaths could amount to 40 000 (+15%). It also indicates that the higher the number of COVID deaths in a home, the higher the number of non-COVID deaths. Causes of

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death, all preventable too, include dehydration, malnutrition, poor hygiene, medical care and supervision, overmedication, errors in medication distribution, and lack of psychosocial support (Sedensky & Condon, 2020). Canada saw a disproportionate increase in psychotropic drug prescriptions from the beginning of the pandemic until the end of September. It includes an extra 1000 residents who had not been prescribed this medicine before lockdown (Stall et al., 2021). Italian nursing homes showed a 5.7% increase. Antipsychotics were up 20% in Argentina, and benzodiazepines, 15.1% (Jan et al., 2021). During COVID-19 Wave I, a higher number of UK nursing home residents was prescribed antipsychotics. The patients receiving most of these drugs suffered from dementia (Howard et al., 2020). The Office of National Statistics reported 17 316 death certificates in England and Wales in April 2020, stating dementia and Alzheimer’s disease as the cause of death. The number of these deaths was 3 times higher than the previous 5-year average for April (GOV.UK, 2020a, b). High mortality, linked to inappropriate prescriptions of antipsychotics in UK nursing homes, was established in a 2009 report. It indicated an 85% increased risk of adverse events and death (Banerjee, 2009). Harvard scientists confirmed that among elderly nursing home residents with dementia, specific antipsychotics increased mortality risks (Park et al., 2015). In Finland, a 60% increased risk of death in people with Alzheimer’s disease was reported (Koponen et al., 2017). A meta-analysis confirms increased risks for all patients when prescribed antipsychotics (Ralph & Espinet, 2018). Data examination from a New York City psychiatric geriatric clinic shows that COVID-19 dementia outer patients prescribed antipsychotics have higher mortality risks (Austria et al., 2021). These findings confirm a previous study at Yale New Haven hospital, suggesting that patients on antipsychotics, hospitalized for COVID, had a mortality rate double of patients who were not taking them (Li et al., 2020a, b). One of the reasons might be that these drugs induce an immune dysfunction in COVID-19 vulnerable elderly psychotic patients (May et al., 2020). Patients without dementia are at risk too (Kheirbek et al., 2019). Psychotropic drugs (antipsychotics, antidepressants, and benzodiazepines) are extensively prescribed off-label to non-psychotic patients of all ages, including LTCF residents (May et al., 2020). A year before the pandemic, HRW USA revealed that they were given to residents without informed consent, without benefits to them—they have undesirable side-effects such as the risk of pneumonia (Taipale et al., 2017), stroke, falls (Sterke & van Beech, 2012), and mortality (Maust et al., 2015), and had been proven ineffective in treating dementia—but for staff convenience (Stall et al., 2021) (HRW, 2018). The overuse of chemical restraints, such as antipsychotics, benzodiazepines, and sleeping medication potentially harmful to the residents, is closely linked to understaffing (Du & Wolf, 2019; Gurwitz et al., 2017). There is a paucity of studies on excess non-COVID deaths due to neglect, but there is enough pre-COVID research to show that the virus made matters exponentially worse.

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Systemic Neglect “Outbreaks of Covid-19 are not the result of inattentiveness or shortcomings in long-term care facilities,” said Stephen Hanse, New York nursing home lobbyist. Everything points to the contrary.

Inadequate Staffing Robert Brent explains that people move to LTCFs because they need skilled nursing. Yet this results in shorter life expectancy. These facilities are ineffective in preserving the lives of the frail elderly. Even patients with dementia live longer outside LTCFs. One of the reasons for a decrease in life expectancy correlates to a shortage in skilled staffing levels (Brent, 2021). Another of his studies shows that these institutions increase dementia symptoms, and it is best to avoid them (Brent, 2022). Over 100 studies in the past 25 years document the importance of optimal staffto-patient ratio for a higher quality of care, i.e. less dehydration and malnutrition, lower pain and infection rates (fewer bedsores, infections including urinary tract infections, and fewer antibiotics), and fewer patients sent to hospitals. Fewer antipsychotics resulted in fewer falls, lower hospitalization rates, and lower mortality rates (Harrington et al., 2020a, b). After examining data from 15 035 LTCFs in the USA, Prof. Grabowski confirms that adequate staffing correlates with limiting mortality and the magnitude of COVID in the facilities (McGarry et al., 2020). Research using CMS data from the same number of LTCFs confirms that facilities with lower staffing ratios (1 to 3 stars regarding nurse staffing) had higher COVID-19 incidence (18–22% more weeks) than facilities with 5-star staffing ratios (Williams, 2021). Increased nursing aids time to feed, wash, and change is also associated with a lower risk of an outbreak (Gorges & Konetzka, 2020). Professor Li discovered that in LTCFs with at least one COVID case, every 20 min of extra registered nurse staffing-time resulted in a 22% decrease in COVID cases (Li et al., 2020a, b). Studies in California established similar outcomes (Harrington et al., 2020a, b; He, 2020). Kingsley and Harrington’s case study of US for-profit LTCFs chain, The Ensign Group Inc., showed that the COVID-19 number of infections were higher in their understaffed facilities (Kingsley & Harrington, 2022).

Poor Infection Control Practices At the beginning of the pandemic, the UK government declared it very unlikely that nursing home residents would become infected (GOV.UK, 2020a, b). Yet these facilities are known to be highly susceptible to infections, the perfect places for the proliferation of viruses. In the US, their residents suffer from 1.6 million to 3.8

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million serious infections, causing 380 000 deaths (Reid et al., 2020). Before COVID, outbreaks of annual influenza were the first infectious mortality cause (Lansbury et al., 2017; Utsumi et al., 2010). Every winter, transfers of residents to hospitals created a shortage of beds in the UK (Matias et al., 2016). In France, influenza kills around 10 000 LTCF residents a year. During 2015–2016, flu victims were twice as many. In Paris, mostly in winters, infected elderly patients on stretchers are crammed into hospital corridors. A systematic review of infectious disease outbreaks in LTCFs before COVID shows that influenza, other respiratory tract infections, gastroenteritis, and GAS (group A streptococcus) infections were the most common there. It also found that failure to follow basic infection control practices facilitated contamination. Half the studies identifying the cause pointed to person-to-person transmission. Inadequate decontamination and poor hand hygiene were high on the list of infection facilitators (Lee et al., 2020). Dr. Charlene Harrington explains that only registered nurses are infection control trained. And that shortage of staff was a contributing factor to California facilities’ vulnerability to the pandemic (Harrington et al., 2020a, b), so was working restriction for ill staff, which was not well implemented during the outbreaks in the LTCFs (Lee et al., 2020). Viruses are mainly transmitted from staff to residents (Lansbury et al., 2017). A 2000 study in Sweden showed LTCF aides to be high transmitters because they are more likely to continue working even if sick. Their economic situation prevents them from taking unpaid sick leave (Aronsson et al., 2000). A recent study showed high mortality rates in people born in Somalia, Lebanon, Syria, and Turkey, employed in low-paid sectors, such as health care, who live in crowded households in high-density areas, and who have to commute (Rostila et al., 2021). In the USA, most healthcare workers who died of COVID were people of colour. More than a third were born outside the United States. The highest death rate was among those born in the Philippines. Most of these deaths happened in LTCFs, many of them due to inadequate PPE (The Guardian, 2021). In a survey by The Standing Committee of European Doctors (CPME), one of the questions was about COVID-19 prevalence amongst ethnic minority healthcare staff. In most countries, surveys based on ethnicity are illegal. Only the UK answered that Black, Asian, and Minority Ethnic (BAME) minorities are disproportionally represented amongst the COVID-19 deaths of healthcare workers in the UK, with most of them born outside the UK (Philippines, Asia, Africa, and Eastern Europe) (HSJ, 2020). In the CPME survey, France did not answer the question about deceased healthcare workers’ ethnic origin. Yet, according to a 2020 study, foreign-born essential workers in low-paid jobs were worst hit by the virus (INSEE, 2021). In Paris and most of the large towns, half the sick nursing aides and care auxiliaries were born in Sub-Saharan Africa. They lived in overcrowded hostels or flats situated in densely populated poor suburbs and used crowded public transport to commute to work. Because of their precarious employment status, they cannot afford to take unpaid sick leave. Some were asked to carry on working, even when they were COVID positive (Diamantis S—Personnal communication, 2021). Health authorities agreed that hospitals, and LTCFs experiencing dire shortages, could allow asymptomatic healthcare personnel to continue working (INFIRMIERS, 2020), so did Belgium authorities (RTBF, 2020), and American states such as Oklahoma, North Dakota

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(NBC NEWS, 2020), and Iowa (IOWA REPUBLIC RADIO, 2020). In Quebec, with absenteeism well over 50% during the first wave, COVID-positive staff were ordered to work. The health minister explained that this exceptional measure followed the Quebec Public Health institute’s scientific advice (Stevenson & Shingler, 2020).

Insufficient Safety Supplies Measures adopted during the 2003 SARS epidemic allowed Hong Kong to react immediately to COVID. All LTCFs knew and applied social distancing, rigorous hygiene, and wearing masks. It was not the case in the West, with its poorly equipped facilities and staff untrained in infection control (Szczerbi´nska, 2020). On 28 February 2020, Danielle McCann, Quebec’s health minister, claimed that if COVID hit the province, the necessary measures to protect healthcare workers and patients were there. On 30 March, the minister for seniors promised to hire more staff and buy more PPE. By the end of April, many facilities were still facing a dire shortage of PPE (Stevenson & Shingler, 2020). In the CPEM survey, only Hungary, Latvia, Montenegro, and Serbia declared no shortages of PPE (CPEM, 2020). In the USA, in July 2020, 25% of nursing homes still suffered a lack of PPE and staff (McGarry et al., 2020). By December 2020, these shortages were still on the agenda (Jacobs, 2020). According to the CPEM survey, PCRs were scarce almost everywhere. Most medical professionals were tested only when symptomatic, except in Austria, Serbia, Croatia, the Czech Republic (only LTC staff), Slovakia, Georgia, Latvia, and Cyprus. No specific testing protocol was given in Bulgaria, Poland, Slovenia, or Spain (CPEM, 2020). The unavailability of PPE and PCRs at the beginning of the first wave in almost every country was an essential factor in the high level of contamination, so were the WHO’s highly confusing guidelines recommending wearing a mask only when sick or caring for a sick person and emphasizing that wearing a mask alone was not enough (Lai-yam Chan et al., 2020). Most countries followed them. The British Government advised staff should not wear masks as they do not protect against respiratory infections (GOV.UK, 2020a, b). In some facilities, in Italy, Spain, France, Sweden, the US, and Canada, following the WHO recommendations, managers told health workers not to wear masks because they would frighten residents (Tavernini & Di Rienzo, 2020; Winfield, 2020; Legorano, 2020; Girard, 2020; Stern & Klein, 2020; Reilly, 2020; Russell, 2020; Tu Than Ha, 2021). “Based on new research findings”, the WHO changed its guidelines on wearing face masks on 5 June 2010, advising governments to encourage people to wear them (Kelland, 2020). Using PPE is now accepted as an essential strategy for reducing transmission in LTCFs. Gloves, masks, gowns, eye protection, and sanitizer were all tested. A UK study demonstrated an increase in the spread of COVID-19 in residents when eye protection and face masks became less available to staff in facilities in Norfolk, England (Brainard et al., 2020a, b).

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Statutory Neglect “We saw it coming in Spain, let alone what was happening in Asia. And we knew that people in long-term facilities would be left without the care they need,” says Laura Tamblyn Watts, the CEO of CanAge, a national seniors’ advocacy organization. She deplored a failure of leadership at every level of government (Gatehouse, 2020).

Governments Chose to Protect Hospitals “You lock old people in a nursing home and keep them away from their families, and then you put Covid patients in there?” (Ferré-Sadurnì, 2020). The WHO declared COVID-19 a global pandemic on 11 March 2020. Ten days later, they recommended that LTCFs should be prepared to accept hospitalized COVID-19 residents medically stable and if they can care for the patients in isolated rooms (WHO Interim Guidance, 2020). To protect the NHS, Boris Johnson’s government advised hospitals to send their untested patients to LTCFs. Between 17 March and 30 April, 47 600 patients were discharged and sent to LTCFs (Hodgson et al., 2020). According to The Telegraph, the facilities were paid to take them (Knapton et al., 2020). Later on, in August, COVID-free care homes were offered £1 500 weekly fees by local authorities to take in COVID-19 hospital patients, an offer hard to refuse as local authorities are the main providers and funders of the LTCFs clients (Peart, 2020). A member of the All-Party Parliamentary Group (APPG) regretted that the NHS treated LTC residents as second-class patients by discharging them without ensuring that the facilities would provide the care they required and without testing them to make sure they would not contaminate other residents, personnel, and partners (APPG Coronavirus, 2020). On 2 April, the WHO confirmed that asymptomatic carriers could transmit the virus. The Department for Health and Social Care (DHSC) acknowledged its previous hospital discharge policy of not requiring negative tests before transfers/admissions into care homes (Amnesty International, 2020a, b, c). The DHSC also told nursing homes that staff who had contact with a COVID-19 patient while not wearing PPE could remain at work (Learner, 2021). As of 15 April, patients had to secure a negative test before being transferred to a LTCF (NAO, 2020). Visits by family and friends were banned the same day (Comas-Herrera et al., 2020). But PPE and PCRs were still in short supply. Regular testing for care homes did not happen before 7 September—221 days after COVID was declared a level 4 national incident by the NHS (Amnesty International, 2020a, b, c). Under Irish Health Service Executive (HSE), between the beginning of March and the end of May 2020, 4460 untested acute hospital patients were sent to LTCFs. It was declared a necessary risk. By June, 1 000 had died. After implementing negative test results before patient transfers, an HSE report did not acknowledge the transmission

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by untested patients (Extra.ie, 2020). Family visits were banned on 6 March and PPE was available by 4 April (Comas-Herrera et al., 2020). On 8 March 2020, Attilio Fontana, president of Lombardy, signed an official resolution—DELIBERAZIONE N° XI/2906—authorizing overwhelmed hospitals in the North of Italy to discharge virus patients to LTCFs (Regione Lombardia, 2020). This led to the silent massacre of the residents and carers (Tavernini & Di Rienzo, 2020). According to a health worker, the facilities were paid e150 to take these patients voluntarily (IPS, 2020; Politico, 2020). Staff started buying their masks and PCRs on 30 April. Visits were no longer allowed on 4 May. In the US, they ended on 13 March. Yet on 25 March, NY Gov. Andrew Como signed an order allowing the discharge of COVID-19 positive hospital patients to nursing homes (Governor Andrew M Cuomo, 2020). Twelve other states, including California, Pennsylvania, and New Jersey, ordered hospitals to send stable COVID patients to nursing homes even though PPE and PCRs were not available before 27 April and, in some cases, still lacking by the end of December 2020 (Jacobs, 2020). According to a Health Department’s report, over 9 056 COVID positive patients were sent to some 310 nursing homes in NY State. Most of which already had a least one infected staff member or resident. Outbreaks followed these transfers, but, according to the same report, contaminated staff members caused them. Yet, the first version of the Health Department’s report indicated that 58 nursing homes had been COVID free before taking in hospital patients. An updated version of the same document brought the number of virus-free facilities down to six (Propublica, 2020). Governor Cuomo had to revoke the order on 15 May. Hospitals could no longer send patients to nursing homes unless the facilities could provide adequate care for them and unless the patients had been tested negative (Governor Andrew M Cuomo, 2020). LTCF owners made a substantial profit. Before the pandemic, in October 2019, Medicare and Medicaid changed their reimbursement system. Medicare increased its financial incentive for LTCFs accepting Medicare patients from hospitals. During April 2020, facilities were paid 9% more for Medicare (short stay) COVID patients than for non-COVID Medicaid (long-stay) patients: $699 per patient per day. They evicted less profitable residents, without informing their families, to replace them with more lucrative contaminated ones. Many old and disabled patients were forced to leave and dumped in homeless shelters or rundown motels. These involuntary discharges are legal, but they must be planned. Residents must be given a 30-day written notice and must be safely relocated. During Wave I, 26 ombudsmen reported 6 400 such evictions in 18 states, but they estimate the figures are a definite undercount. In New Mexico, one LTCF evicted all the residents to make room for more lucrative COVID patients (Silver-Greenberg, 2020). Quebec, Alberta, and Ontario regional governments, shaken by what was happening in Italy, discharged hospital patients en masse to LTCFs. In Ontario, between 2 March and 3 May, 2 200 hospital patients were transferred to LTCFs. Not only COVID patients but also most of them elderly, generally considered to be “bed blockers”, were actively discharged from public hospitals to public and private LCTFs, hotels, and even homes without adequate care. This was done without considering their right to consent and their care needs (Hurley et al., 2021; Herhalt, 2021). In

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Montreal, Health authorities paid $133 800 to 3 private homes to take three patients (Grant & Ha, 2020). Visits to all LTCFs and hospitals ended on 13 March 2020 in Ontario and 15 March in Quebec. Two weeks after the ban, Quebec health authorities reported 3 430 cases (Stevenson & Shingler, 2020). Ontario, Quebec, and B.C. LTCF workers still faced a critical shortage of PPE at the end of April 2020 (Drinkwater, 2020). Alberta Premier Jason Kenney ordered the transfer of hospital COVID positive patients to LTCFs (Alberta-Health-services, 2020; Dickinson, 2021).

Triage Protocol for the Elderly On 31 January 2020, before COVID-19 was declared a pandemic, French Health Minister Agnès Buzyn declared that France was extremely well prepared to face the epidemic (Le Quotidien Du Medecin, 2020), hospitals were ready to face it (Parisien, 2020a, b), and had the means to get a very fast diagnostic (BFM TV, 2020a, b). Her successor, Olivier Véran, proudly confirmed that the country was ready because of its rock-solid healthcare system. “You’d be surprised at how fast it can adapt.” (INTER, 2020). A month later, triage was implemented. Regional authorities sent a ministerial circular to LTCFs instructing them not to send their residents to overwhelmed hospitals, except for the most severe cases (Ministère des solidarités et de la santé, 2020). Age was a criterion for care, but no specific age cutoffs were given (Miralles et al., 2021). Within a few days of the circular release, IC patients over 75 dropped from 19 to 7%, and those over 80 from 9 to 2%. Most of the triage was done at the emergency call level (Service d’Aide Médicale d’Urgence or SAMU). In the worst-hit regions, they refused to transfer COVID residents to an ICU or a hospital (Orfali, 2021). LTCFs lacked the logistics, resources, and skills to look after the sicks who, in some facilities, were left to die, said Dr. Bradol (Bradol, 2020). He explained that to ease patients’ end of life, nursing assistants were injecting them Diazepam—a psychotropic drug. They should not have done it. Even doctors are not supposed to do this alone (Izambert, 2021). The media did not discuss the issue too difficult to expose publicly, claimed a journalist (Le Monde, 2020). One weekly paper leaked the guidelines, asking if old people were being denied IC (Le Canard Enchainé, 2020). The French Academy of Medicine and the French Society of Geriatrics and Gerontology strongly reacted against it. This directive was relinquished on 23 April (Miralles et al., 2021). In the East of France, one of the worst-hit regions, the regional care agency (ARS) director declared that there was no valid reason to stop hospital bed closures and workforce reductions at Nancy hospital (Le Parisien, 2020a, b). On 18 August 2021, at the height of Wave 4, Guadeloupe (French West Indies) overwhelmed hospital ICUs only accepted patients under sixty and without a medical history (Lecot, 2021). Italy, boasting the oldest population in Europe, published triage guidelines on 16 March (SIAARTI, 2020). At the height of the first wave, the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care set an age limit for ICU admissions (Vergano et al., 2020). It varied in different hospitals, going from 80 to

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75 or less. Transfers of LTCF patients to hospitals were blocked in some regions or very limited. According to the National Institute of Health report (Istituto Superiore di Sanità, ISS), even the most serious cases were treated in LTFCs (Berloto et al., 2020). Two geriatricians warned that a “dramatic, unwanted, silent […] most subtle viral ‘gerocide’ was taking place in Italy.” Gerocide is the intentional mass killing of people deemed old (Cohen, 2020). In this case, it was due to clinical failure, unpreparedness for such a crisis and inability to dissociate elderly patients with acute geriatric care needs from the frail elderly. A policy of funding cuts, over decades, seriously affected elder care (Servello, & Ettorre, 2020). Hospitals sued physicians who dared openly discuss the choices they’d had to make (Orfali 2020a, b, c). In Ontario, during March and April 2020, only 15.5% of LTCF COVID residents died in hospital. LTCFs used blanket no-hospitalization policies or attempted to discourage families from sending their loved ones to the hospital, leaving the contaminated residents with minimal care in horrendous situations in their last days. LTCF operators testified before the Ontario LTC COVID-19 Commission that they were not to hospitalize residents as hospitals refused transfers of infected patients or sent them back to the facility only a few hours after being admitted (Hurley et al., 2021). Those hospitalized in Quebec and Ontario were discharged to LTCFs to stop blocking beds and respirators and leave them for the “appropriately sick”, thus spreading the virus into nursing homes not equipped to look after them (Cohen, 2020). Although all official guidelines underline that age should not be the sole criterion, Switzerland set a clear age limit above 85 years, or 75 years in case of specific health conditions, for ICU admissions in case of bed shortages (Jöbges et al., 2020). In case of absolute ICU bed shortage, age was also a factor in guidelines from South Africa, where younger patients should be a priority. Australia, New Zealand, and Canada gave the same recommendations (Jöbges et al., 2020). Some hospitals did refuse LTCF COVID patients in Canada (RSC-SRC, 2020). In Ontario, at the height of Wave I, the hospitalization rate for COVID residents was only 15.5% against 81.4% for people living in the community (Wallace, 2020a, b). Although the British Medical Association guidelines emphasized the fact that triage based on age would be illegal and discriminatory (Jöbges et al., 2020), a COVID-19 Decision Support Tool, drafted by clinicians, gave doctors a scoring system based on age, frailty, and underlying conditions. According to this system, patients over 70 would be borderline candidates for IC admissions (Times, 2020; Experts, 2020). The NHS never officially endorsed the COVID-19 Decision Support Tool (Martin, 2020), yet NHS hospitals denied access to COVID-stricken LTCF residents: DNH orders were given (Bush, 2020). Hospital admissions for nursing homes decreased by 11 800 (minus 79%) during March and April. Only the sickest were accepted (Hodgson et al., 2020). At the same time, elderly patients were also massively discharged to LTCFs (West, 2020). NHS hospitals gave transfer and DNR (do not resuscitate) orders. They also imposed DNAR (do not attempt resuscitation) or DNACPR (do not attempt cardiopulmonary resuscitation; Open Access Government, 2020; Bush, 2020). These codes legally request a healthcare team to let people die (Open Access Government, 2020). According to a report by the Queen’s Nursing

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Institute, these were “blanket” DNRs applied by GPs to nursing homes all around the country, without previous discussion with residents, families, or healthcare staff (Bush, 2020). Some practices and hospitals also contacted elderly patients asking them to sign DNRs to protect the NHS (Knightly, 2021). Except that hospital beds were emptier than usual: 40.9% of acute beds (37,500) were unoccupied, four times below habitual occupancy (West, 2020). The QNI report says that a decision, made at a high level, requested UK care homes to label all their residents as DNRs. Peter Kyle, MP for Hove in Sussex, said it looked like LTCFs in his constituency were organizing for all COVID contaminated residents over 75 to stay in their facilities, rather than sending them to hospital. They issued DNRs en masse because they were all unequipped to intervene or ventilate (Booth, 2020). LTCF managers contacted Amnesty International to report that some GP surgeries, and Clinical Commissioning Groups (CCGs), requested them to put DNAR forms into their residents’ files. On 23 March 2020, CCGs in Sussex issued guidelines for General Practices (GP) to assist care homes, requesting them to check if all their residents had a DNAR order. If this was not the case, they were asked to add one to their files. The guidelines also told GPs to look for patients without a DNH order and ensure they had one in place (Amnesty International, 2020a, b, c). Hospitals in Madrid had instructions to refuse LTCF patients. Guidelines from the department of health to these facilities, on 16 March, stated that their residents should not be hospitalized (DNH) due to the current lack of IC beds and ventilators (Rada, 2020). The Belgium Society of Intensive Care Medicine guidelines were explicit: age alone could not be a criterion to discriminate against older people (Jöbges et al., 2020). But Amnesty International found that, at the beginning of the pandemic, LTCF residents were not sent to hospital, not until a circular explicitly stated that a transfer should always be possible if in the patient’s best interest and by his wish, whatever his age. Most COVID residents died in these facilities, whereas other COVID deaths happened in hospitals (Amnesty International, 2020a, b, c). In Sweden, where LTCF residents’ deaths made up for half the casualties, care workers were discouraged from sending sick patients to hospital (Social Europe, 2020). DNH applied, even for 65-year-olds, explained RN nurse Latifa Löfvenberg, fired for whistleblowing (News, 2020). The Wall Street Journal reviewed an email by the manager of one of the facilities telling nurses not to transfer virus residents to hospitals (Pancevski, 2020). According to a study, infected elderly residents were more likely to die than to be admitted to ICU. Only 13% patients over 70 who died of COVID at the beginning of the pandemic were in hospitals (Kamerlin, 2020). Yet many hospital beds were empty. A large field hospital, specially erected in Stockholm in April 2020 to prevent hospitals from being overburdened, was pulled down in June 2020 without ever taking in any patients. Regular hospitals had been able to cope (Ringstrom, 2020). Latifa Löfvenberg told the media that residents were denied oxygen, given morphine instead, and left to die suffocating. Professor Yngve Gustafson, a geriatric-medicine specialist confirmed that, after the decision was made not to send the patients to hospital, they were denied simple care, “such as nutrient instillation, antibiotics for respiratory infections, and supplemental oxygen administration”. Unfortunately, most facilities cannot deliver such treatments at night.

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Instead, COVID patients are given palliative drugs including morphine and midazolam, “both causing them to suffocate rapidly” (RT, 2020). Professor of geriatrics Dagens Nyheter reported that these “active death aids” had been given extensively to COVID patients in hospitals and LTCFs (Tellerreport, 2020). After studying over 200 cases of care denial, Prof. Yngve Gustafson concluded that with basic vital care, many of these patients would have survived. Dr. Jon Tallinger also blew the whistle when doctors were told not to bother with effective treatment, including oxygen (without intubation). They were warned against a possible oxygen shortage, which, according to him, is nonsense as Sweden, unlike other countries, still manufactures it (Business Insider, 2020). Sweden’s Health Care Inspectorate’s (IVO) report confirms that LTCFs patients were denied oxygen treatment (The Local, 2020). In the CPEM study, only the Netherlands admitted to triage, but other countries implemented it. Ageism in healthcare is not new. The term bed-blocker was coined in the late 1950s. COVID just exacerbated it (Rueda, 2021). Age discrimination causes health problems: higher mortality risks, and social and psychological impacts (Silva et al., 2021). Worldwide measures to “protect the institutionalized elderly”, including some recommended by the WHO (such as banning visits and COVID-patients’ transfers to LTCFs), violated old people’s fundamental right to “the highest attainable standard of health”, defined on an international level by the WHO “as a fundamental right of every human being” (WHO, 1946), UN Human Rights Council, European Convention on Human Rights, the Oviedo Convention, as well as nationally. The problem of these violations had been on most of the organizations’ agendas long before the pandemic (Baer et al., 2016).

Visitor Bans in Nursing Homes You lock old people in a nursing home and keep them away from their families, and then you put covid patients in there? (Ferré-Sadurnì, 2020). The March 2020, WHO guidelines for LTCFs recommended limiting or avoiding visitors as much as possible while emphasizing that the use of PPE and limiting visits and group activities may affect the well-being of residents and staff (WHO, 2020). One of the first measures most countries adopted was to restrict visits, except in endof-life situations. A report in Ireland stated that this policy was insufficient to stop the spread. Most outbreaks happened after 23 March 2020, 11 days after implementing visiting restrictions (12 March), and into the first week of April (Report to the Minister for Health, 2020). Other key factors included untested staff working without PPE and PCRs and untested patients discharged from hospitals to LTCFs. In the US, on 20 March 2020, the Centers for Medicare & Medicaid Services (CMS), the federal regulator for nursing homes, banned visits, except in end-of-life situations. A year later, their chief medical officer and director told HRW that limiting visits and inspections resulted in more neglect or decline amongst LTCF residents (HRW, 2021).

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Banning or limiting visitors in severely understaffed facilities proved disastrous. Family members usually act as unpaid caregivers, helping extensively with daily care. It goes from grooming or nail cutting to tasks usually performed by the staff, such as bathing, showering, toileting, helping their loved ones to bed, to eat and drink, bringing them food and doing their laundry. They also ensure their relative is well cared for and provide vital support. They are the link between the old person and the outside world (Puurveen et al., 2018). And yet, few assessed the risks before cutting off this lifeline, proving the essential role relatives play in the care team was not understood (APPG Coronavirus, 2020). A Michigan ombudsperson told HRW that residents were neglected because relatives could not visit and provide support (HRW, 2021). When the CMS barred visits in US LTCFs on 20 March 2020, they also stopped state survey agencies and ombudsmen from entering the facilities (HRW, 2021). It meant that abuse and neglect went mainly unreported during the lockdown. Most residents cannot report abuse without help from their relatives, and those who can will not for fear of retaliation or because they know the staff will not believe them. In her 2021 report “The Fundamental Rights of the Elderly in EHPADs”, France’s Defender of Rights1 (ombudsperson) stated that the number of complaints plummeted during the first lockdown but rose drastically afterwards (Hédon, 2021). Extended periods of isolation, over a year in some places, accelerated physical and mental health deterioration. Studies by Diamantis et al. and the CMA reports showed an increase in dehydration, malnutrition, lack of hygiene, and deaths. Research in Connecticut LTCFs between March and July 2020 showed the same physical deterioration, with up to a 150% increase in weight loss compared to the average during 2017–2019, more incontinence incidents, depressive symptoms (+15%), and significant cognitive decline (Seegert, 2020; Zamora & Romero, 2022). The absence of physical contact also increased anxiety, failure to thrive, frailty, sarcopenia, and disabilities (Avidor & Ayalon, 2022; Shrader, 2021; Pitkälä, 2020; Boucaud-Maitre, 2020). Residents lost speech, memory, will to live, and no longer recognized their family (APPG Coronavirus, 2020). More anxiety and depression resulted in more overprescribed psychotropics, and this despite a limited efficacity and high risks. Loneliness is considered a risk factor for moving to a LTCF (Hanratty et al., 2018). Research shows that it is a health risk that can lead to premature death, like obesity, smoking, and lack of exercise. It can increase the risk of dementia by 50%, heart disease by 29%, and stroke by 32%. During the lockdown, socially isolated patients suffering from heart failure were four times more likely to die, 68% more likely to be hospitalized, and 57% more likely to end up in IC. Further research confirms that loneliness and isolation were responsible for increased anxiety, depression, suicides, vascular and neurological pathologies, accelerated Alzheimer’s progression, and an increased risk of mortality. Yet little is done in LTCFs to prevent or reduce loneliness. Studies on loneliness in LTCFs before COVID-19 are rare. Most tend to concentrate on the loneliness of community-dwelling elderly people. A meta-analysis of 1

The Defender of Rights is a single autonomous institution in charge of defending Human Rights and liberties in keeping with the constitution.

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13 studies on the prevalence of loneliness in LTCFs concludes it is high enough to call for worry (Gardiner & Laud, 2020). Pre-COVID-19 studies suggested that 55% LTCFs residents in northern Sweden and 56% residents in Norway suffered from loneliness (Naik Mhs, 2020). The percentage was higher in Spain with almost 71% of the residents (Molas-Tuneu et al., 2022). The COVID-19 lockdown made matters worse. In higher-quality nursing homes that followed the Centers for Disease Control and Prevention (CDC) recommendations and, with lower COVID deaths, isolated residents subjected to severe isolation died of loneliness (Cronin & Evans, 2020). If the virus doesn’t kill me the loneliness will, said a resident (National Academies of Sciences, 2020; Montgomerry et al., 2020). When visitors were allowed again in mid-May, depression rates declined, and cognitive functions increased (National Academies of Sciences, 2020). Claire Hédon, currently serving as Defender of Rights, alerts to an increase of human rights violations in LTCFs. Among these, she points to a series of arbitrary rules such as protocols and guidelines denying residents the freedom to come and go (article 13 UDHR, article 15 European Social Charter, article 12 ICCPR) (Hédon, 2021). This violation is a long-standing one, stopping residents from circulating inside the facility, imposing a curfew, restricting visiting hours, and limiting outings even in the absence of medical reasons (Lafi, 2019). During the first lockdown, on 31 March 2020, the government published on its COVID-19 website guidelines for LTCFs. Among them was a recommendation to stop all individual and collective residents’ outings. It was confirmed in another publication on 20 April, indicating that permission might exceptionally be granted to the residents to leave the premises by the management. But none of these guidelines was backed by law, explains Claire Hédon in her report. So, despite their mandatory terms, the ministry’s guidelines defer decision-making to facilities managers. Measures to temporarily suspend residents’ outings are as restrictive as house arrest or detention and should only be taken within the appropriate legal framework. During the first lockdown, restrictive measures were implemented outside the right legal frameworks and did not offer procedural safeguards intended by law. She also denounces the prevalence of physical and chemical restraint use in the whole country, mainly to compensate for the lack of personnel. These measures are decided by the staff, without a doctor’s prescription, with no time limit, no traceability, and in violation of the law (Hédon, 2021). These restrictions went beyond official guidelines, even after residents were fully vaccinated. LTCFs did what they wanted, “they protected them [residents] to death”. A Pennsylvania’s LTC data specialist in the Ombudsperson’s office revealed that some facilities’ restrictions were stricter than state and federal guidelines’ demand. These were to ensure residents were safe (Rubinkam, 2022). Australian Government public health guidance allowed a maximum of only two people per visit. Facilities were also permitted to implement their own restrictions. And so, they did well beyond the government’s guidelines (HRW, 2020). The UK official recommendation, stated by Boris Johnson, was that healthy relatives could visit elderly care home residents, but at least 100 facilities barred visits. Bupa, a private operator running 125 homes, said visits would not be allowed “except in exceptional circumstances” (Newman, 2020). In Canada, said Dr. Samir Sinha, director of geriatrics at Toronto’s Sinai Health System, most

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LTCFs found an excuse to extend the lockdown. Some even use it as a sales argument: “We’re going above and beyond to keep you safe.” In other words, you will have to stay locked in your rooms (Porter, 2021). The media revealed that in a LTCF, door handles on rooms of positive COVID-19 residents had been removed by management to stop them from spreading the virus (Espinosa & Talbot, 2021). UK’s MPs were told that LTCFs have become like prisons, since the lockdown (Parliament, 2021). In France, albeit fully vaccinated and with a negative PCR result, most residents were not allowed out (France Info, 2021). In the USA, on 21 March, The New York Times titled “Elderly, Vaccinated and Still Lonely and Locked Inside”. Germany and Holland implemented the same restrictions in LTCFs. However, when the ban was relaxed in one facility in Frankfurt am Main and in 26 in Holland, no resident tested positive (Heudorf et al., 2020). An article in The Conversation describes these facilities as “prisons by a different name”. Like carceral institutions, they use chemical and physical restraints. They lock residents up in their rooms to optimize surveillance and control with minimal staffing costs (Fritsch, 2022). This was common practice long before the pandemic, caused mainly by austerity policies.

Dying Alone “Many of them died alone … following the heart-breaking impossibility of being taken care of in the ways and times necessary for a geriatric subject.” (Servello, & Ettorre, 2020). In many cases, essential visits, including compassionate care and end-of-life visits, were overlooked. Families were not allowed to see their loved ones before they died. They were denied the right to give them a proper burial.

LTCF Residents’ Forgotten Deaths COVID-19 exposed a flagrant lack of data on older persons, observed Claudia Mahler (OHCHR, 2020). This includes nursing home deaths. At the beginning of the outbreak, several European countries and the USA withheld them. In Europe, except for Belgium, only in-hospital deaths were taken into account. France waited till 2 April before changing to a reporting process including all deaths. Figures that day went from 509 to 1355 (Discombe, 2020). However, this new process was still based on incomplete figures as some private groups, including Korian, the largest private for-profit group in France, failed to report their cases and deaths. The Regional Health Agency head for the Paris region explained that this specific difficulty seemed to be a strategy. Korian denied the fact (Braun, 2020a, b). COVID fatalities also surged in the UK as official figures included LTCF deaths (counted as deaths in the community) on 30 March 2020 (UKBBCNews, 2020). In Spain, local authorities were asked, on 23 March, to submit data twice a week, but they didn’t or missed deadlines, or they transmitted erroneous figures (Carreño, 2020). The government was still unable to report

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the exact COVID death toll in LTCFs and included only hospital LTCF resident deaths in their official figures till 24 July 2020 (Sepulveda et al., 2020). LTCF deaths were still uncounted in Italy by mid-March. Only hospital patients with severe symptoms were COVID tested (Parodi, 2020). By the end of April 2020, the US government made it compulsory for LTCFs to report the number of suspected and confirmed COVID cases and COVID fatalities. But some states, including New York State, refused to include residents who died after being transferred to hospital (Redmond, 2020). LTCF resident deaths inclusion does not give an accurate picture. After an underestimation, the WHO guidelines led to an overestimation worldwide. If people had previously tested positive, their deaths are recorded as caused by COVID-19, ditto for people who died assumed to be infected (Frei, 2022a, b).

A Multibillion-Dollar Business On 22 May 2020, Korian had lost 707 residents to COVID, but by the end of June 2020, its revenue was up by 6.2% and totalled e1,877 million (Business Wire, 2020). The same year, the group planned to distribute a dividend of e54 million to their shareholders but changed their minds under public pressure (Pozzi, 2020). Orpea announced revenue growth of nearly 5% to e3,922 million for 2020 (Orpea, 2021). In the USA, the Ensign Group Inc. showed impressive growth and profitability during the pandemic, with revenues of $2.5 billion, $4.5 billion market capitalization, and strong profits for 2020 (Kingsley & Harrington, 2022). Genesis HealthCare announced 3 billion in revenues in the first three 2020 terms. Executives were paid bonuses, yet The New York Times reported that the company received over $300 million in COVID government grants and loans (Goldstein, 2020). LTCFs are receiving billions of bailout dollars for COVID, but many experts and watchdogs are asking where is the money going? (Edelman, 2021). In 2020, in Ontario, the three largest for-profit LTCF companies listed paid out $171 million to their shareholders while, at the same time, receiving $138.5 million through provincial pandemic pay for their front-line workers (). The value of the global long-term care market, which is highly privatized and financialized, was $1.04 trillion in 2021 (GVR, 2021). An ageing population and guaranteed government subsidies make for an excellent investment for shareholders but not for residents.

De-hospitalizing Healthcare Systems In the last decades, governments from the US, Canada, and Europe have been massively reducing hospital bed capacity, resulting in “hallway medicine”, with patients waiting on stretchers in corridors for days. This downsizing is part of a long-established policy of de-hospitalizing healthcare systems. LTC hospital beds,

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considered too expensive, are usually transferred or sold, mainly to private forprofit groups. These non-medicalized facilities have lower staff–resident ratio than hospitals (already short staffed) and less qualified staff. Hospital restructuring was implemented to curb public health expenditures, as the number of dependent old people is rising dramatically, and experts are forecasting an Alzheimer’s tsunami. A UNDP study on the privatization of health care shows that a 10% increase in private health expenditure relates to a greater spread of COVID cases (+4.3%) and more COVID-related deaths (+4.9%). It also shows that hospital capacity does affect COVID mortality. On average, a 10% increase in hospital beds per 1 000 people results in a 1.67% decrease in COVID deaths. It confirms what happened in Italy (Assa & Calderon, 2020). In France, between 2003 and 2018, 73 000 hospital beds were closed and 49 000 LTC geriatrics beds went to LTCFs (Dress, 2020), 40% less expensive. Access to hospital beds was not accounted for by the study. Sweden and the UK had empty hospital beds but still denied them to LTCF residents. After the USA, Canada, and Australia, multi-billion listed companies and private equity have been taking over LTCFs in Europe and are starting to do so in China, Japan, and Korea. Private for-profit facilities, as well private not-for-profit and public ones, were all hit by COVID but, as before the pandemic, private for-profit suffered most cases and most casualties. There are no studies in Europe, but American and Canadian studies show the adverse effects of private ownership on residents’ health: more COVID outbreaks and deaths, lower level of staffing and worse COVID outcomes (Akhtar-Danesh et al., 2022; Papke, 2021; McGregor & Harrington, 2020). Gupta and Howell demonstrate how private equity ownership affects residents’ welfare and spending at LTCFs (Gupta et al., 2020). According to researchers’ estimates, private equity ownership increases short-term mortality by 10% and spending by 19%, mainly paid by taxpayers. Declines in patient-level health measures, worsening mobility, elevated use of anti-psychotics, less nurse time per patient, and less compliance with federal and state standards of care, all explain increased mortality. Statisticians from the Direction for Research, Studies, Evaluations and Statistics (DREES), a subordinate to the Ministry of Health, reveal that for-profit facilities were significantly hardest hit than other facilities, possibly because of lack of staff and subcontracting. They also explain that their understaffing policy might have had consequences, notably during the second wave, resulting in twice as many residents’ contaminations (DREES, 2021). “Covid-19 has exposed the catastrophic impact of privatizing vital services”, testified 6 UN special rapporteurs. They also observed that outsourcing vital goods and services to the private sector did not relieve governments of Human Rights obligations. But by contracting out public goods and services, right holders are transformed into clients of private companies solely dedicated to profit maximation, no longer accountable to the public but shareholders.” (Farha & Bohoslavsky, 2020).

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Governments and Nursing Homes Governments and corporate for-profit LTCFs have long-standing relationships. In Ontario, on leaving office, Premier Harris joined the board of directors of Chartwell, the largest LTCF corporation. For this, he receives CA$229,500 per year, and his estimated holdings in the company are CA$7 million (Malek, 2020). He is also one of Premier Ford’s advisors. Like Ford’s government, Harris’ drastically cut public spending on health care and encouraged privatization of these facilities by channelling provincial public funding to privately owned for-profit companies. His successor, former premier Davies, was also on a facility corporation board and went on the board of the second largest LTCF corporation, Revera Inc. (Badone, 2021). Paris Public Hospitals (AP-HP) chief executive from 2002 to 2006, Rose-Marie Van Lerberghe, sold LTC beds to Korian, before joining them in 2006, as chairman of the executive board. The same year, she led the company’s initial public offering (Korian, 2006). Sophie Boissard, the present CEO, held various positions in the public sector. Amongst others, she was a member of the State Council, ex-advisor to François Fillon, and deputy manager of the cabinet of the Minister of Economic Affairs and Finance, Christine Lagarde. More recently, Grégory Emery, a physician, and a Public Health & Social Medicine specialist with a master’s degree in ethics, health security advisor to the Minister of Health during the first 15 months of the pandemic, was going to join Korian as director of public affairs. But the High Authority for transparency in public life stopped him. That is a first in France. Private equity Waterland bought up 120 rehabilitation clinics in Germany. Managing directors come from McKinsey, a firm known for increasing and speeding up the privatization of the UK NHS. The same firm contacted EU Health commissioner Stella Kyriakides at the beginning of March 2020, offering advice on shaping the EU’s response to COVID. They argued they had previously helped governments shape their response to several global crises, including SARS, MERS, and Ebola, and that they were actively helping governments organize effectively in the face of COVID. They have also helped WHO rethink approaches to emergencies (Corporate Europe, 2021). When writing this chapter, most governments have not taken drastic measures to reform LTCFs. Only Norway is re-municipalizing previous privately owned facilities. Multinationals consider Norway to be politically difficult, a “no-go zone”. In July 2021, there were only five private for-profit facilities in the country (Lexander et al., 2021a, b). Although working conditions are better, municipal homes remain understaffed, and a 2020 report shows that violence, abuse, and neglect are common in private and public facilities (Botngård & Malmedal, 2020). What some governments have done is amend their laws to protect LTCFs. In the USA, in July 2020 (Brooks & Beiko, 2020), 26 states shielded the industry from civil liability2 and 3 states, from criminal and civil liability.3 In Canada, 2

AK, AL, AR, AZ, CT, GA, HI, IL, KS, KY, MA, MD, MI, MS, MT, NC, NJ, NV, NY, OK, PA, RI, UT, VA, VT, and WI. 3 NC, NJ, and NY.

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Ontario (Novakovic, 2021), New Brunswick and British Columbia (Young, 2020), and Alberta (2021) passed COVID-19 liability protection bills, except for acts or omissions caused by gross negligence. According to Amnesty International, Spanish nursing home deaths won’t be investigated (Amentsìa Internacional, 2022).

Conclusion America now knows that nursing homes are broken. Does anyone care enough to fix them? (Khimm, 2021); Nursing Homes Were Broken Long Before COVID (Miller, 2021); Nursing homes must be made a thing of the past (Guinn, 2020); Just Abolish Rest Homes (Janssen, 2020). The COVID-19 devastating mass tragedy in privately and publicly financed LTCFs exposed the long-standing failures of these institutions around the world. Regardless of ownership, long-term care is “an illusion of care” (Till, 2021). The whole system is broken and has been for a long time. The shocking living conditions and absence of care are fifty years old (Braithwaite et al., 2007; Estabrooks, 2020). Over 150 reports in Canada alone pointed to the dire situation, but nothing changed (Estabrooks, 2020). Parliamentary reports, recommendations, investigations, books, and documentaries, all regularly tell the same stories worldwide, to no avail. Yet, people generally accept that ending one’s life in a LTCF is, to quote Angela Davies, “an inevitable and permanent feature of our social lives”. Will the pandemic help raise awareness of the urgency of putting an end to warehousing the elderly? Will it raise awareness of the importance of human rights protection at any age during health crises and indeed, at all times? It remains to be seen.

References Akhtar-Danesh, N., Baumann, A., Crea-Arsenio, M., & Antonipillai, V. (2022). COVID-19 excess mortality among long-term care residents in Ontario, Canada. PLoS ONE, 17(1), e0262807. Alberta, G. O. (2021). COVID-19 civil liability protection Bill 70 extends COVID-19 civil liability protection to the health sector, including continuing care. Retrieved from Alberta.Ca https:// www.alberta.ca/covid-19-civil-liability-protection.aspx Alberta-Health-Services. (2020). Medical Officer of Health Guidelines for Transfers, Discharges and Admissions During COVID-19 Pandemic. Retrieved from Alberta Health Services: https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-guidelines-tra nsfers-discharges-admissions.pdf Amentsìa Internacional. (2022). Residencias: la deficiente investigación sobre lo sucedido extiende la impunidad y obstaculiza el acceso a la verdad a las familias. Retrieved from Amenstìa Internacional https://www.es.amnesty.org/en-que-estamos/noticias/noticia/articulo/residencias-ladeficiente-investigacion-sobre-lo-sucedido-extiende-la-impunidad-y-obstaculiza-el-acceso-ala-verdad-a-las-familias/

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WHO. (2020). Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19. Retrieved from WHO,: https://apps.who.int/iris/bitstream/handle/10665/ 331508/WHO-2019-nCoV-IPC_long_term_care-2020.1-eng.pdf Williams, C. Z. (2021). The association of nursing home quality ratings and spread of COVID-19. Journal of the American Geriatrics Society, 69 (8), 2070–2078. Winfield, N. (2020). Click to copy RELATED TOPICS Italy Understanding the Outbreak Europe General News Milan Virus Outbreak Europe Dimension of virus ‘massacre’ in Italy nursing homes grows. Retrieved from AP News: https://apnews.com/article/1287853b082ae91663c0d bc894078428 Young, H. (2020). Governments shouldn’t shield essential workers from COVID-19. Retrieved from Canadian Underwriter: https://www.canadianunderwriter.ca/insurance/governments-shouldntshield-essential-workers-from-covid-19-1004198034/ Zamora, E. B. C., & Romero, M. M. (2022). Psychological and functional impact of COVID-19 in long-term care facilities: The COVID-a study. American Journal of Geriatric Psychiatry, 30, S1064–7481(22), 00011–2.

Chapter 4

Trends in the Management of Aged Population During the COVID-19 Pandemic Sushil Kumar Maheshwari

Abstract The world is struggling with the COVID-19 pandemic: the most crucial global health calamity of the century, by closing international and national borders, quarantining suspected persons, testing and treating patients, and by complete or partial lockdown, etc. This pandemic and measures taken to fight it have struck heavily on millions, especially the vulnerable older adults who are staying alone, struggling for basic needs, managing without household help, and worrying about handling any medical emergencies. Keeping the lessons from past pandemics in the background about the highest risk of the elderly for both acute and long-term consequences including isolation, neglect, lack of autonomy, and risks of abuse and psychiatric disorders, etc., ensuring the holistic safety of seniors is of utmost importance. Senior care services in India are still at the beginning stage but it is urgent and imperative that we address the growing needs of elderly management during the pandemic time and post-pandemic times. To manage the elderly during COVID-19, we need to learn more about the problem and how it is affecting our seniors. Along with this, learnings from past pandemics may be very useful in planning the core strategies at all levels to mitigate the sufferings of the elderly due to this pandemic. New technologies and advances in the health care system are also emerging as an opportunity and strengthening the care services in times of pandemic as never before. Keywords Vulnerable older adults · Lockdown · Pandemic · Isolation · Senior care services · COVID-19 pandemic

Introduction The world is facing a global threat since December 2019 from the Coronavirus disease (COVID-19). The disease emerged in the Wuhan region of China caused by the SARS-CoV-2, and within a month, the World Health Organization (WHO) declared it a pandemic (WHO Director-General’s Opening Remarks at the Media S. Kumar Maheshwari (B) Baba Farid University of Health Sciences, Faridkot, Punjab, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_4

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Briefing on COVID-19—11 March 2020, n.d.). A pandemic is defined as “a disease occurring over a wide geographic area and affecting an exceptionally high proportion of the population” (Merriam Webster Dictionary. Pandemic. Available from: https:// www.Merriamwebster.Com/Dictionary/Pandemic, n.d.). The last pandemic was the H1N1 flu that affected the world in the year 2009 (Influenza (Seasonal), n.d.). As of 24 September 2020, over 32 million cases have been identified globally in 213 countries and territories around the world. Out of which, over half (over 17 Million) of the cases are identified in three countries including the Unites States of America (7 Million), India (5.73 Million), and Brazil (4.66 Million). Among these cases, though around 24 Million have been recovered, around 75 lakh cases are still active with over 63,000 people in critical condition. The pandemic has already taken a toll of over 9.8 million fatalities around the world (Coronavirus Cases (Live), n.d.).

Elderly and COVID-19 Though the SARS-CoV-2 causing COVID-19 affects people of all ages, however, some groups of people are found to be at an increased risk for severe COVID-19 disease such as older people (people over 70 years of age), people with co-morbid illnesses such as diabetes, hypertension, cardiac and respiratory disease, cancer, and chronic liver disease, etc. (Coronavirus Disease 2019 (COVID-19) Situation Report-51, n.d.). The world’s population is ageing and every country in the world is experiencing fast-growing numbers of older persons in their population. Ageing is the universal biological process of growing older that is absolutely natural and applies to all living creatures. The elderly person is defined as a person who has completed 60 years or more. Another system commonly used in developed countries classifies the elderly into three groups: the young-old aged (60–74 years), the middle-old aged (75–84 years), and the old-old aged (85 years and over) (Alterovitz & Mendelsohn, 2013). According to data from World Population Prospects: the 2019 Revision, by 2050, one in six people (16%) in the world will be over the age of 65, up from one in 11 (9%) in 2019 (United Nations, 2019). In 2018, it made history as persons aged 65 or above outnumbered children under five years of age globally. The number of people aged 80 years or over is 143 million in 2019 and is projected to triple in 2050 (United Nations, 2019). Like other countries, a major demographic issue for India in the twenty-first century is also population ageing. The aged population has increased from 7.5% (77 million) of the total population in 2001 to 8.6% (104 million) by 2011 and is predicted to be around 19% (approx 300 million) by 2050. 15.92% of the total population belonged to the age group of 50 years and greater according to the Indian census 2011 (Share of Population over Age of 60 in India Projected to Increase to 20% in 2050: UN—The Economic Times, n.d.). Today, most of these older people in the world are going through a very tough phase in their life in view of the coronavirus threat, which has affected the elderly massively, and they find it very difficult to adjust themselves in fast-changing world in COVID era. As per CDC, 8 out of 10 COVID-19-related deaths reported in the

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Fig. 4.1 Mortality rates related to COVID-19 by age group (Bonanad et al., 2020)

United States have been among adults aged 65 years and older (Coronavirus Disease 2019 (COVID-19), 2020; Freed, 2020). In India, more than 90% of the people who died, both men and women, were above 40 years of age and people above 50 years of age constituted 76.7% of COVID-19-related deaths (90% of Those Killed by Covid in India Are Older than 40, 69% Are Men, 2020). A recent meta-analysis with a total of 611,1583 subjects (141,745 or 23.2% including aged ≥80 years) of COVID-19 patients from different countries highlights age as the determinant factor for mortality with mortality rates observed lowest (aging.covid19 World Health Organization. (2020). COVID-19 Strategy Up Date. World Heal Organ. https://www. who.int/publications-detail/covid-19-strategy-update-14-april-2020. www.who.int. Yip, P. S. F., Cheung, Y. T., Chau, P. H., & Law, Y. W. (2010). The impact of epidemic outbreak: The case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong. Crisis, 31(2), 86–92. https://doi.org/10.1027/0227-5910/a000015. Yoon, M. K., Kim, S. Y., Ko, H. S., Lee, M. S. (2016). System effectiveness of detection, brief intervention and refer to treatment for the people with post-traumatic emotional distress by MERS: A case report of community-based proactive intervention in South Korea. International Journal of Mental Health Systems,10(1). https://doi.org/10.1186/s13033-016-0083-5.

Chapter 7

Bereavement and COVID: Dual Trouble in the Elderly Surbhi C. Trivedi, Mansi P. Somaiya, and Alka A. Subramanyam

Abstract The COVID pandemic has wreaked havoc in the lives of many due to the loss of family and close relatives. Elder individuals have borne the brunt of this impact, possibly more. Challenges with the normal collective and social grieving process, due to the restrictions that are posed by the pandemic, may lead to more prolonged and complex reactions in the elderly, putting them at a higher risk for various mental health problems such as a longer grief reaction, anxiety, and depression. This impact brought by bereavement is superimposed on an already possibly existing underlying emotional impact due to loneliness and lack of social interaction brought about by the pandemic. In addition to bereavement due to the loss of the life of a loved one, elder individuals are also coping with various other losses, the loss of—participation in social activities and social interactions, independence, safety, financial security, and sense of control over life. Additionally, some of the elders have also started experiencing anticipatory grief, where they fear the loss of life—either of their own or of their loved ones, and this thought is emotionally overwhelming for them. It is important for mental health professionals to realize that this has multiple layers, and hence the approach to management becomes all the more complex and challenging, which will be discussed here. Keywords Elder individuals · Bereavement · Grief · Mental health

Bereavement and Grief Bereavement is the experience of losing a loved one and grief is the natural response that one has to this loss. A bereaved person passes through various stages as they S. C. Trivedi (B) Department of Psychiatry, Dr. L. H. Hiranandani Hospital, Mumbai, Maharashtra, India e-mail: [email protected] Department of Psychiatry, Nanavati Max Super Speciality Hospital, Mumbai, Maharashtra, India M. P. Somaiya · A. A. Subramanyam Department of Psychiatry, T.N.M.C. and B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_7

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adapt to the loss and the changes that the loss has brought about in their lives. Denial, anger, bargaining, depression, and acceptance are the 5 stages of grief as given by Elizabeth Kubler-Ross (Kübler-Ross, 1969). Acute grief is painful and is associated with a lot of mixed feelings and confusing thoughts. Gradually, a bereaved person manages to accept the grief and they find their own ways of keeping the memories of the lost loved one and honouring those memories. They reconnect and restore their sense of purpose and meaning. The bereaved person strengthens the other ongoing relationships and restores the sense of belonging to a world in which the lost loved one is not present. Eventually, a bereaved person adjusts, adapts, and heals. Grief quietens in the process but never in the true sense of the word does it end—it moves on to occupy a place in the bereaved person’s life, a place that is significant but not dominating, nor incapacitating. Studies using fMRI have shown the involvement of anterior cingulated cortex (ACC), posterior cingulated cortex (PCC), prefrontal cortex (PFC), insula, and amygdala in the brains of grieving people, suggesting that these are the areas of the brain which result in the symptomatology of grief (O’Connor, 2019). These are the areas of the brain that are also involved in the experience of pain, emotional processing, and emotional memories. As we talk about the neurobiology of grief, let us understand how Covid-19 is impacting the brain of elders before we discuss the impact of Covid-19 on bereavement in the elders.

Covid-19 and the Ageing Brain Just as visible changes in physical health happen with age, over a period of time brain also slowly loses some of the neurons and this change is inevitable. This loss is very slow before age of 60 years but increases after the age of 60 years. Loss of neurons is not uniform with the cerebral cortex having the greatest loss compared to other parts of the brain though they also have noticeable changes. This can cause a decline in the cognitive functions, skills, and abilities of the elders. Stroke, fatigue, depression, confusion, concentration problems, and forgetfulness are the various neurological complications observed due to Covid-19. Research (Boldrini et al., 2021) has found that the SARS-CoV-2 causing Covid-19 can damage the brain in the following ways: . Damaging brain cells directly . Impacting the blood flow to the brain . Triggering off immune mechanisms that produce immune molecules that could damage the brain cells. Those who have had more severe Covid-19 infections have higher chances of neurological complications and long-lasting effects of the complications. The elderly are a vulnerable group for developing more severe Covid-19 infections and hence

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stand a higher chance of the virus impacting the brain and the consequent longterm complications. The resultant changes in the brain can further impact the griefprocessing mechanisms of the brain in these elders.

How Covid-19 Pandemic is Affecting Grief Sudden and/or unexpected deaths have happened due to Covid-19 infection. The nature of coronavirus and Covid-19 infection is such that hospitalizations due to Covid-19 have necessitated quite a few restrictions when compared to most other hospitalizations due to other illnesses. Unlike other illnesses, when a person gets admitted due to Covid-19 infection, family members, relatives or friends are unable to stay with the admitted person and are not even able to meet them in person. This inability of being able to be with and inability of being able to tend to them the lost loved one when they were hospitalized, increases the burden on the bereaved family members who are already grieving a Covid-19 related death (Carr et al., 2020). In funerals due to Covid-19 deaths, limited family members are allowed. Viewing the body of the deceased may not be allowed. Many a times, the close family members may themselves be hospitalized, may be under isolation or unwell, and may not be able to attend the funeral of their loved one. Some may be unable to attend due to travel restrictions. Usual faith and culture-based practices and rituals are not allowed in deaths due to Covid-19. The in-person social support that one would get following the death of a loved one is restricted due to the various travel restrictions and social distancing norms due to Covid-19. All of these impact the way in which individual processes and resolves grief (Stroebe & Schut, 2021; Petry et al., 2021). The elders are a vulnerable group, at high risk of getting coronavirus infection and developing a more severe form of illness. Also, mortality rates have been found to be more among this group. Along with being a vulnerable group as regards morbidity and mortality due to Covid-19, the elders also are a group who might suffer more and multiple losses due to Covid-19—loss of spouse, loss of sibling, loss of friends—all being more or less in the same age group. This fact along with the challenges in the normal grieving process posed by the pandemic as mentioned above, may lead to more prolonged and complex grief reactions in the elderly and puts them at a higher risk for developing various mental health problems. Along with the loss of loved ones, elders are also coping with certain other losses due to the pandemic.

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Other Losses Leading to Grief in Elders During the Covid-19 Pandemic Along with the death of a loved one, almost all the elders are also experiencing multiple other losses due to the changes brought about by the Covid-19 pandemic. The various other losses that pose a challenge for the elder are: . Loss of routine as the pandemic made it essential for the elders being a vulnerable group, to stay indoors . Loss of financial security due to the multiple changes in the economic setup of the society that the pandemic has brought, at times also due to the need for finances for treatment of Covid-19 illness or loss of the main financially supporting member . Loss of social connections due to the need for social distancing and restrictions on travel . Loss of community leisure and religious activities due to the multiple restrictions on public places necessitated due to the pandemic . Loss of safety as even simple activities such as going out of the house or having visitors at home also carry a risk of contracting the coronavirus infection, and we still don’t have a way by which one can protect oneself 100% from the coronavirus infection . Loss of freedom to choose their way of living and making decisions and a sense of loss of control over their own lives . Loss of meaning and purpose looking at the huge morbidity and mortality due to coronavirus . Loss of identity . Loss of certainty about the future due to the uncertain nature of the virus. These losses were very suddenly and unexpectedly brought about by the Covid-19 pandemic. As they are losses of significant aspects of life, these losses also lead the elders towards grief.

Complicated Grief and Elders Adapting to a loss is not easy but most people manage to do so eventually. Sometimes, however, the grieving process gets derailed. When a person is not able to resolve something about the experience of the loss is when complicated grief arises (Mortazavi et al., 2020). It could be certain traits of the bereaved person or it could be about the relationship shared with the loved one who has died that makes a bereaved individual unable to resolve the grief. There could also be factors related to the circumstances in which the death happened or the context of death. All of these risk factors may impact the bereaved elder during the current pandemic, putting the elders at high risk for complicated grief. The elders already trying to adjust to the changes brought about by the pandemic, the death of a spouse who might be at times

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the only and main support system during the Covid-19 pandemic introduced restrictions, death of younger members of the family, sudden deaths of family members or due to more severe Covid-19 illness or late detection, inability to be around the loved one who has died when they were hospitalized or isolated—all of these could derail the grief process and lead to complicated grief in the elders. Complicated grief is a grief reaction differing from normal in duration or intensity. There is difficulty in accepting death, persistent preoccupation with the deceased, intense sadness, anger, denial, and blame. The response exceeds the expected social, cultural, or religious norms for the individual’s culture and context, and results in significant impairment in functioning of an individual. There is a persistent and painful yearning for the lost loved one. It can be debilitating and may interfere with the normal functioning and quality of life of an individual. Recognizing complicated grief in elders is important because it can lead to impairment in physical health, mental illness, cognitive impairments and increase in suicidal risk in them. It can also lead to increased and early mortality in them.

Survivor’s Guilt Survivor’s guilt—a person usually experiences survivor’s guilt when a person goes through a traumatic event or experience and concludes that they were probably less deserving or unworthy of survival through the event or experience or that someone else deserved to survive more than they deserved to. The Covid-19 pandemic has led to an increase in the number of individuals, especially an increase in the elderly facing survivor’s guilt. Elders, as mentioned earlier, are one of the vulnerable groups in the Covid-19 pandemic. This age group has been found to have higher morbidity and mortality rates due to coronavirus infection. Survivor’s guilt can arise in the elderly when they survive the coronavirus infection and hear about someone else who succumbs to the same infection—someone else could be a family member or a friend and at times it could even be the news of the death of a stranger due to Covid-19. The guilt is of survival through an illness despite being in a more vulnerable group, while many others around them, whom they feel deserved to survive more than they do, could not survive. In an elder who has not had Covid-19 or has had a milder course of Covid-19 illness, survivor’s guilt can also be triggered by the elder getting news of someone having a more severe or prolonged Covid-19 or suffering from long-term consequences of the illness. Considering the fact that the elders have a higher chance of getting infected with the coronavirus, the feeling that one could probably have been a potential carrier for another person to get the infection and that other person had to suffer its consequences can also lead to survivor’s guilt in elders. Those elders who have experienced relatively better outcomes during the pandemic, such as those who have had better access to medical services and medical help, better access to vaccines, less losses due to the pandemic, and better economic stability, might also

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feel that they were less deserving of these more ideal outcomes and as a consequence suffer from survivor’s guilt. Survivor’s guilt can lead to symptoms of repetitive and ruminating thoughts about illness or death or the person who died, sadness of mood, difficulty in sleep, lack of motivation, anger, irritability, increased anxiety, feelings of helplessness and worthlessness, isolating oneself socially, self-neglect, and at times suicidal ideas. An elder might also, in an effort to prove oneself worthy of survival, try to overcompensate with activities that make them feel deserving of survival.

Bereavement Guilt Another type of guilt—bereavement guilt—could be triggered when an elder feels that they have not been able to live up to their own expectations in the relationship with the loved one who could not survive.

Gratitude Guilt Once one survives a traumatic event, one would ideally expect oneself to be grateful for it. However, due to the losses that the elder might face due to the Covid-19 pandemic, it might be difficult for an elder at times to be able to address his or her survival as a blessing and have gratitude for being able to survive. This can lead to gratitude guilt in the elders—feeling guilt for not being able to take survival as a blessing.

Survivors Pressure Elders could also experience survivors pressure. When there is the loss of a family member, the elder might experience the pressure of taking control of the situation at home and of the family. This pressure in an elder would be more internally generated. Survivors guilt, bereavement guilt, gratitude guilt, and survivors pressure—all become a challenge to the normal grieving process and complicate the grief process.

Anticipatory Grief Anticipatory grief is the grief one experiences in advance of an anticipated impending loss. During the coronavirus pandemic, a lot of elders have started experiencing anticipatory grief where they fear the loss of life—either of their own or of their loved

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ones. The uncertainty of the nature of the coronavirus infection and the course of the illness leads to this thought of loss, a thought which is emotionally overwhelming for them. They start grieving before a loss has happened. Elders might be having a continuous feeling that something bad is going to happen in the future, even though they might not be able to define what exactly might happen. As a result of this feeling, they might try to prepare themselves for whatever they feel might be the worst-case scenario with the thought that when the event happens in actual life. it will not have a big and devastating impact. However, they might have continuous, repetitive, and ruminating thoughts about the anticipated loss in the process of doing so to prepare themselves. The body generates a stress response to these thoughts—continuous thoughts lead to continuous stress response and the elder may feel exhausted, hyper-vigilant, and anxious continuously as a result. Trying to be prepared in a balanced way might be helpful, but this extreme way could be disastrous for an elder.

Grief and Pre-existing Illness in Elders A bereaved elder might be suffering from a pre-existing mental or physical illness. Bereavement can worsen the underlying mental illness in an elder. In those elders already suffering from a mental illness, bereavement and grief can increase the symptoms or cause worsening of the illness—in those elders who are well maintained on treatment, it can cause recurrence of symptoms, and in those who are symptomatic, it can worsen the symptoms. This is because dealing with a loss adds on to demand on the mental resources of the elder who are already coping with two things—one is handling of the existing mental illness and the other adjusting to the multiple changes brought about by the Covid-19 pandemic. As a result, the mental health resources of the elder might get overwhelmed when faced with the additional task of handling a loss. If the loss is of a family member or friend who has been the primary caretaker for the elder with mental illness—physically, emotionally or financially—then it will further impact the treatment and recovery process of mental illness in the elder. In elders with neurocognitive impairment, losses experienced during the pandemic further worsen their cognitive abilities. Bereavement in elders with cognitive impairment overburdens the cognitive abilities that are already compromised and tend to push them towards the more severe end of the spectrum of cognitive impairment. Elders with cognitive impairment also find it more difficult to process the loss and adjust to the many changes that the loss brings along with it. Those with more severe cognitive impairment may be unaware of the loss and maybe unable to experience it or they may confuse the present loss with some other or previous loss. Hence, they maybe unable to express their grief, however they might be able to experience that something is not right which could cause them distress and manifest in behaviour problems in such elders with severe neurocognitive impairment.

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In the group of elderly individuals, those elders who have chronic physical illnesses are at a higher risk for developing Covid-19. This fear of contracting the illness can increase stress levels among many such elders. Bereavement further adds to these stress levels and can lead to mental health problems in them as well as the increased stress levels tend to worsen chronic physical illness also. In those elders who have not had an earlier mental illness, bereavement and grief put them at a higher risk of developing a mental illness. They are at a higher risk of developing anxiety disorder, depression, acute stress disorder, post-traumatic stress disorder, obsessive–compulsive disorder and cognitive impairment.

How to Help the Elders Deal with Bereavement and Grief During the Covid-19 Pandemic It will be helpful to educate the elders about bereavement and grief, the ways in which the Covid-19 pandemic can affect these two, and how to deal with bereavement and grief during the pandemic era. The bereaved elders can be helped to deal with the grief by making them aware of the following ways to cope with it: 1.

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Pay attention to your feelings and validate them— A bereaved elder needs to understand that grief is a natural response to loss and is very important not to avoid or suppress the feelings that one experiences as a result of a loss. There is no right or wrong way of experiencing grief and there is no time frame for experiencing it. At the same time, there are no age restrictions to the feelings that one might experience due to a loss. Even though there are certain stages of grief, it is not essential that one will follow all the stages sequentially during the grief process. An elder might go to and fro, between the various stages during the grief process before it resolves. Also, the grief response to every loss might be different. One might experience different feelings—there might be numbness, pain, sadness, anger, and regret—one should acknowledge and validate the feelings even if one doesn’t like them. Avoid comparing— It is important for an elder to avoid comparing their feelings with others who have had the same or a similar loss. Comparing their feelings or way of coping with others may make an elder self-criticize their feelings or themselves. Everyone will have their own different way of dealing with a loss and have their own time they will take to resolve their grief. Find your own way to say goodbye and treasure the good memories that you have— Things like writing down a message for the lost loved one, going through the old photos and reviving the good memories, and talking to family and friends about the lost loved one can help. Stay connected to family and friends—

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A bereaved elder shouldn’t let social distancing and travel restrictions come in the way of connecting with family and friends. They can connect to family and friends through telephone calls, video calls, and social media. Due to the grief, there might also be feelings of wanting to stay alone—this needs to be identified and one shouldn’t let this feeling disconnect them from family and friends. It is essential for them to stay in touch, discuss their feelings, and reach out in case they don’t feel well. 5. Limit news and social media information overload— Continuous news of morbidity and mortality due to the ongoing pandemic may further impact the grieving process. However, at the same time, an elder would prefer to stay in touch with the happenings around which makes an elder feel connected and aware of society in a time when travel and meeting people are restricted. Not looking at the news in the morning hours, watching/reading the news a little later in the day in the afternoon or evening, and limiting news time in the day are the various ways in which this can be addressed. 6. Practice self-care— It is important to give attention to one’s health and nurture oneself. The elder should take care of their sleep and nutrition and should take enough rest, even if they don’t feel like doing so. Activities such as yoga, physical exercise, and meditative practices will help. Also, the elder needs to be patient with themselves. If they are taking time to get back to their baseline productive self, then they give themselves that time. They shouldn’t rush themselves into healing feeling that they belong to an age group where they are expected to be more mature in handling their emotions and feelings. 7. Create a routine— Giving a structure to the day helps in the healing process 8. Finding meaning— Having faith in a higher being, in our resilience, and in our connection to society as a whole can help one understand the loss and deal with it better. It helps one to find meaning and purpose after the loss. 9. Address the guilt— If there is guilt, it should be recognized and addressed or else it can complicate the grief. One way of addressing the grief is by trying to restructure guilt into gratitude and pursuing activities that help express gratitude. 10. Ask for help— In case the elder experiences pervasive feelings of sadness, excess irritability, continuous feelings of anxiety, or suicidal ideas they should contact a mental health professional immediately for help. The family members and primary care physicians also need to be educated regarding bereavement and the normal grieving process in elders and what challenges the bereaved elders could face with both during the pandemic. Both family members and primary care physicians can encourage the bereaved elders to vent their feelings and help the elders to understand and accept their grief through conversations that are open-ended and empathic. There are times when an elder may be

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preoccupied with concerns about the illness details or treatment details of the lost loved one, they can be encouraged to talk about the same with the primary care physicians who can address their questions and help them understand the facts so as to prevent those queries from predominating in their minds. This will also help the bereaved elder identify the fact that help is available for them and that are not alone. The family members and primary care physicians can also help the elders to identify who could be there in their support structure and help them to connect with those people. There are also support groups for grieving individuals. Joining a support group and expressing and sharing one’s feelings can also help a bereaved elder through the grief process. It is also important to make the family members and primary care physicians aware of what all factors could derange the grieving process. Awareness of these and early identification of the risk can help prevent the development of complicated grief and other mental health problems in the bereaved elder by providing interventions in time. Family members and primary care physicians should also be psycho-educated to look out for any signs and symptoms of complicated grief and mental illness in the bereaved elder and to help them get help from a mental health professional if they notice any such signs or symptoms. Assessment by a mental health professional will help identify the correct problem and start timely treatment. Even though mobility or travel might be an issue for the bereaved elder considering the travel restrictions due to the Covid-19 pandemic, they can easily access mental healthcare through telemedicine services (Vahia et al., 2020). For complicated grief, psychotherapy is the main line of treatment. The beststudied ones are Complicated Grief Psychotherapy (CGT) and certain cognitive behavioural-based therapies. These therapies are more grief specific and have been found to be more effective than depression-specific treatments in case of complicated grief. Hence, it is essential to be able to identify and differentiate complicated grief from depression. CGT and other Cognitive behavioural-based therapies work on identifying the factors that lead to the grief process getting derailed in an individual and help them process the grief and heal (Wetherell, 2012; Goveas & Shear, 2020). As is important to identify complicated grief and differentiate it from depression in the bereaved elder, so is important to identify the mental health disorders such as anxiety, depression, etc., which the bereaved elders have a high risk of developing. These mental illnesses could arise as a result of bereavement and will further complicate the grief resolution. Hence, it is important to recognize them, differentiate them from the normal grieving process and complicated grief and provide timely treatment. Elders who show signs and symptoms suggestive of anxiety disorder, depression, acute or post-traumatic stress disorder, obsessive–compulsive disorder, cognitive impairment, and other mental illnesses should be referred to psychiatric services so that they can be assessed and started on appropriate treatment. This is the group that will need initiation of pharmacotherapy. In case of elders, it is also very important to watch out for suicidal thoughts because bereavement and grief do act as risk factors that can lead to suicidal thoughts in the elders and they may not voice those thoughts but may try to act on them. Elderly who have suicidal thoughts usually require hospitalization and inpatient treatment.

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Hospitalization helps ensure safety as the elder will be in a supervised environment and under 24 hours observation. Care should be taken to keep all the sharp objects, medicines, which can be used by the elder to self-harm, away and out of their reach. Hospitalization also helps in pharmacological management of the suicidal elder as in case of elders the initiation of pharmacotherapy is usually started at a low dose and slowly adjusted so that the likely side effects can be monitored and dose increased after making sure the elder is able to tolerate the medication, but in case of an elder who is suicidal more aggressive pharmacological management might be needed and hospitalization allows the elder to be under constant monitoring. Once the immediate suicidal risk has settled, it is important to help the elderly to identify and work on ways to cope with the triggers for suicidal thoughts, to help them develop coping strategies to deal with suicidal thoughts if they come again, and develop their safety network of people whom they can contact immediately in case the suicidal thoughts come up again. A separate mention is needed of helping an elder with neurocognitive impairment deal with bereavement and grief. An elder with neurocognitive impairment might have partially or completely lost the cognitive skills required to process and resolve grief due to the loss of a loved one. At times, caregivers may avoid telling an elder with neurocognitive impairment about the loss, however, this should be usually done only in case of severe neurocognitive impairment and when the elder is not significantly connected with the person who has passed away. When breaking the news to them, it is better to do so when the elder is calm, and should be done in simple and short sentences with clear words. Consistency in the approach of everyone taking care of or around the elder such as family, friends, and the healthcare professional is important so that the way they pass on the information to the elder and communicate with them is the same so as to avoid confusing the elder. If there is no reaction or distress expressed at the news, that is okay—one shouldn’t try to force them to understand and respond to the loss. They might also forget about the loss and may keep asking for the person who has passed away, in such cases, they might need to be reminded repeatedly, but the reminders need to be in simple words for the first time. They might get as upset as they did when they heard the news the first them. Putting up a photograph of the person who has passed away in a way that is visible to the elder, and talking about them in the past tense may be of help in such situations. Elders with neurocognitive impairment may need help to be able to express and cope with their feelings about the loss. Reminiscing using photos, videos, stories, and incidents about the person who has passed away might help the elder to express themselves and may aid the grieving process.

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Bibliography Boldrini, M., Canoll, P. D., & Klein, R. S. (2021). How COVID-19 affects the brain. JAMA Psychiatry, 78(6), 682–683. Carr, D., Boerner, K., & Moorman, S. (2020). Bereavement in the time of coronavirus: Unprecedented challenges demand novel interventions. Journal of Aging & Social Policy, 32(4–5), 425–431. Goveas, J. S., & Shear, M. K. (2020). Grief and the COVID-19 pandemic in older adults. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 28(10), 1119–1125. Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan. Mortazavi, S. S., Assari, S., Alimohamadi, A., Rafiee, M., & Shati, M. (2020). Fear, loss, social isolation, and incomplete grief due to COVID-19: A recipe for a psychiatric pandemic. Basic and Clinical Neuroscience, 11(2), 225–232. O’Connor, M. F. (2019). Grief: A brief history of research on how body, mind, and brain adapt. Psychosomatic Medicine, 81(8), 731–738. Petry, S. E., Hughes, D., & Galanos, A. (2021). Grief: The epidemic within an epidemic. The American Journal of Hospice & Palliative Care, 38(4), 419–422. Stroebe, M., & Schut, H. (2021). Bereavement in times of COVID-19: A review and theoretical framework. Omega (westport), 82(3), 500–522. Vahia, I. V., Jeste, D. V., & Reynolds, C. F. (2020). Older adults and the mental health effects of COVID-19. JAMA, 324(22), 2253–2254. Wetherell, J. L. (2012). Complicated grief therapy as a new treatment approach. Dialogues in Clinical Neuroscience, 14(2), 159–166.

Chapter 8

Active Ageing in COVID-19 Sumity Arora

Abstract The COVID-19 also known as Coronavirus disease erupted in 2019. It was caused by the SARS-CoV-2 virus. The disease had halted the daily life and the world economy and also affected community health. It was declared as pandemic and caused lockdowns in many areas. It caused a sudden change in the lives of the public that led to mass hysteria, anxiety, ambiguity, and panic. Amid the crisis situation caused by COVID-19, the elderly population was more prone to the effect of the virus. In addition, it made the elderly more vulnerable to psychological issues caused by the pandemic situation. It is well known that the elderly have more physical predisposition towards coronavirus but it is high time to pay attention to the mental health of the elderly population as the number of cases of Coronavirus kept on increasing. Further support, care, and attention would be required to protect the overall wellbeing of the elderly. The knowledge and awareness of the effect of COVID-19 effect on the elderly have increased the fear and uncertainty in the minds of the elderly. Researches have shown that Fear in the elderly including death fear, fear of losing loved ones, and fear/guilt of being the carrier of COVID-19 have increased the probability of mental illness like depression, adjustment disorder, post-traumatic stress, etc. Further stress increases the risk of suicidal ideations and attempts, which is an added concern. Stress in any form is associated with a decrease in immunity that affects physiological defense systems in the older adults. This article would summarize the active ageing during the COVID-19. Active/healthy ageing strategies in old age would promote the mental health of the elderly. The strategies include environmental manipulation, specific mental health promotional activities along with comfort and hygienic living surroundings, and healthy lifestyle. The promotion of mental health is largely dependent on these strategies and also on the resources to meet their basic needs and social support for older populations and their caregivers. Keywords Active ageing · Health promotion · COVID–19 · Mental health

S. Arora (B) Faculty of Mental Health Nursing, Panna Dai College of Nursing, Deen Dayal Upadhya hospital, New Delhi, India e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_8

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Introduction to Healthy/ActiveAgeing As per WHO,1 Every individual should have the opportunity to live a long and healthy life. Health risks (violence, pollution, etc.), behaviour, quality health, social care, and opportunities during ageing are all highly influenced by the environment. Healthy Ageing enables individuals to live and perform the activities which they value in their life by creating the opportunities and environments.1 Healthy Ageing can be experienced by everyone. Healthy ageing doesn’t mean being disease-free or illness-free because the majority of elderly are suffering from one or more ailments or disorders, it means that wellbeing will be little affected when conditions are under control.

Definition of Active/Healthy Ageing Active/Healthy Ageing is the process of developing and maintaining the functional ability that enables wellbeing in older age. Functional ability is defined as the ability of individual to live and perform the activities which they value in their life. This includes the following capabilities: . . . . .

To meet basic needs; To take decisions; To be able to move; To establish and maintain relationships; and To be a contribution to society.

Functional abilities include not only individual’s intrinsic/internal capacity, but also include the environment and how they interact with each other. Intrinsic/internal capacity of the individual includes physical and mental abilities. Physical abilities like ability to hear walk, see, and run and mental abilities like ability to think, remember, etc. Factors like changes in old age, injuries, and diseases in old age affect the intrinsic capacity of the individual thus affecting the functional abilities. Society, home, and community comprise the environment of the individual. It also includes various other factors like values, belief, attitude, relationship among people, social policies, health policies, etc. Thus, a key to healthy ageing is good interaction between the environment and internal capacity. It means a healthy environment maintains and sustains the internal capacity and thus supports functional abilities.

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Key Consideration 1. Diversity—Diversity means diverseness or variabilities. Diversity in old age refers to variability in levels of functional ability, i.e. mental and physical abilities. Few elderly aged 80 years or more have the better functional ability in comparison with 30-year-old. Other elderly may need extensive assistance and support even to meet basic needs like bathing, brushing, eating, dressing, etc. Thus, diversity should be taken care while framing policies to improve the intrinsic abilities or functional abilities. 2. Inequity—Inequity in terms of place of birth, gender, educational status, and financial status plays as an important factor in individual life and thus affects functional ability and healthy ageing.

Active/Healthy Ageing Between 2015–2030, the focus of WHO was Healthy Ageing. In 2002, a policy framework changed active ageing with healthy ageing. Healthy ageing encourages the need to perform action in various aspects of old age and enable the elderly to be active and serve as an asset for the communities, family, etc.

COVID-19 and Active/Healthy Ageing (OssenbruggenErik et al. 2020)2 Coronavirus (COVID-19) endangers the activities for healthy/active ageing around the world during 2020–2030, decade considered as the decade of Healthy Ageing. During COVID-19, there is a challenge to daily life because of the lockdowns and physical distancing practices. Due to this situation, our older citizens are most affected. Today, there is a need for a long-term strategy on active and healthy ageing.

COVID-19 and Old Age It is evident from the research studies that the elderly are more vulnerable to COVID– 19 infections. For instance, the majority (nearly 90%) of elderly more than 65 years old in Spain were victims of Coronavirus. The same statistics were observed in other countries like 94% elderly in the Netherlands, 96% in Norway, 95% in Sweden, 87% in the United Kingdom, 91% in France, etc. The highest COVID-related death count was observed in the areas of Strasbourg, Paris, Lille, and Lyon. Worldwide, evidence have shown that the urban elderly population has the highest death rates,

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e.g. in the UK, Norway, Sweden, etc. Among 346 areas of the UK, Salford which is a metropolitan region ranked 7th in the Death due to COVID-19 (Nordregio, 2020).3

The Important Role of Digitalization in Healthy/Active Ageing Digitalization like the use of the Internet and mass media played a wise role during COVID-19, when physical distancing was of paramount importance. In areas where many elderlies stay together become the vector to spread the virus. Here digitalization played an important role in the protection of the elderly. Physical distancing is a major factor for increasing loneliness in the elderly. So, the sole solution to the problem is Digital communication. To handle loneliness, this innovation of digitalization becomes the facilitator of social interaction.

Efforts to Maintain Healthy Ageing in COVID-19 Following actions in various aspects are required to counter the effect of COVID-19 on elderly 1. 2.

3.

Improving knowledge of digitalization—As discussed above, digital literacy is a necessity to prevent loneliness. Spread of information through Traditional media—In elderly, many at times it becomes impractical to learn digitalization, here the role of traditional media plays a part. For, e.g. television. For instance, “Social Distance Bus” experiment was done in Amsterdam. It drives and made announcement throughout the multicultural neighbourhood of the city. Medical messages, warnings, and advice were broadcasted in 7 languages during the COVID-19 times. During the pandemic lockdown period in India, the media comprises of Newspapers, Radio, Television, Magazines, social media as well as other modern media platforms played a significant role in providing accurate and reliable content and updates about the reality of coronavirus in India; providing accurate health communication messages across India about the COVID-19 by sharing knowledge about the precautionary measures, dangers, and symptoms of the COVID19; providing new perspectives about the situation in India and other countries (Usman, 2020).4 Need for a long-term plan—Effects of COVID–19 require a long-term plan as these effects are not for short term. They have a long-lasting impact on our lives. Improvement in the situation of the basic health of the elderly, removing the socioeconomic inequalities, and making cities/states more comprehensive for the elderly are some of the long-term strategies for our older age.

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Need for special treatment for long-term illnesses other than COVID-19— Elderly people have co-occurring long-term disorders for which they need access to health facilities. There should be special clinics at special timing to remove age-based/gender-based discrimination. This should be available for all diseases and disorders other than those caused by COVID-19 (like mental illness, heart problems and diseases, oncological issues, neurological disorders, etc.) (Donatella & Roberto, 2020).5 Psychological support—During COVID-19, home quarantine, Isolation, and confinement were the major factors to increase mental illnesses in older adult6 (Armitage & Nellums, 2020). And had affected negatively on the psychological status of older adult. Psychological support is most important in this situation for better and effective coping. Psychological support can be given through telephone consultations and regular phone calls from near and dear ones like friends, relatives, social workers, volunteers, clinicians, etc. Provision of Basic necessity—During the time of home isolation or quarantine, sometimes it is difficult for elderly who stay alone in having food, medicines, and general household supplies. Municipal corporations/social worker has an important role to play in small and big cities to help the elderly during quarantine as their social, informal, and formal network. Special attention to people with disability—Special consideration should be given to the elderly with disabilities during quarantine. Measures of maintaining social/physical distance, wearing/use of protective layers like masks, gloves, etc. could be disabling as it interferes with their power to communicate (mainly people suffering from sensorial deficits). For instance, wearing gloves may be a restriction for elderly with visual impairment as it may interfere with their tactile abilities which was necessary for reading, communication, and knowing the environment. The confinement at home could also reduce home visits by own family, fast friends, doctors, social workers, and professionals that supported the elderly during their daily life. Thus, special attention to people with a disability need to be given in all the phases of the pandemic, with a major focus on the availability and accessibility of important information, messages, and communication. Diet—Diet, health, and physical activity are all directly linked with each other. Healthy and balanced nutrition is important to maintain good physical health and mental health. It is also important for the prevention of disease. Older people need to be fed healthy especially during the pandemic where they are the most at-risk group, and their capacity to fight disease, prevent illness, and recover from infections greatly depend on their eating and drinking habit. Remember the following tips for Healthy food . A diversity in food items together with fruits and vegetables. . Consume foods including wheat rice, corn, whole grains, legumes like lentils and beans and including fish, meat, milk, or egg. . Fresh fruits and raw vegetables like cabbage, lettuce, carrot, and radish without salt for snacks.

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. . . .

9.

Salt intake should be limited to 5 g which is equivalent to one teaspoon/day. Fats and oils should be consumed in moderate and restricted amounts. Trans-fats produced by industry like fried food should be avoided. Intake of sugar like sweets, soft drinks, carbonated drinks, flavoured water, juices, and fruit drinks in powder form should be in limited and in reduced amounts, etc.

Physical activity at home—Physical illness and reduced immunity are the result of inactive lifestyle. Due to these reasons, during a COVID-19 pandemic, physical activity is especially important. Physical activity needs to be adjusted in the home conditions when outdoor activities are restricted especially during the pandemic time. The following points can be remembered: a. Minimum 150 min of moderate physically active for all over the week/or minimum 75 min of intense physical activity all over the week, or both. b. 300 min moderate intensity physical activity per week for additional benefits in health. c. People with low mobility should do exercises for three or more days a week to improve balance and prevent injuries. d. WHO recommends exercise for Muscle and bone strengthening activities at least 2 days a week including larger muscle groups.

10. Respect recommendations of WHO—World Health Organization and the Ministry of Health have given certain recommendations for the situation of the COVID-19 pandemic as it affected all people worldwide. Globally in order to reduce the number of patients and fatalities. The elderly need to adhere to the recommendations of the WHO for active and healthy ageing. If they have a problem with loneliness, the elderly should look for their loved ones over the phone or social networks, they should not lose touch with family and friends, they should not forget about physical activity, and most important healthy diet as well as to be regularly informed about the recommendations given by WHO for protection against COVID-19. 11. Postpone unnecessary doctor visits—Postpone elective procedures, other non-essential doctor visits, and annual checkups, if the elderly at home is feeling well. For chronic illnesses, help them to stay in touch with doctors and ask if they offer telemedicine. Rather than face to face, telemedicine enables therapists and patients to discuss and communicate at online platforms over video, email, or other means. 12. Avoid travel—During the pandemic situation, non-essential travel should be avoided particularly cruises or itinerary trips that may expose them to hordes.

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Healthy Ageing Checklist

Box 1: The Checklist for Healthy Ageing • Encourage good brain health and emotional wellbeing • Promote good physical health • Deal and address common chronic health issues (e.g. pain, falls, decreased memory, depression and suicide, isolation, incontinence, and polypharmacy) • It is helpful to learn to adjust the management of chronic conditions • Believe in preventive health services for older adults • Plan care in advance including medical, legal, and financial

Ways to Promote Good Physical Health Physical health can be improved in the following ways: 1. Regular Exercise—It will help older adults to increase their strength, muscle power, and mobility, and also care should be taken to not overexert or get injured. During COVID-19, Minimum exercise at Home is necessary to maintain health. 2. Avoid smoking—It is well known that smoking is injurious to every aspect of physical health. Active smoking not only damages the lungs, but also it increases the risk of heart attacks, neurological problems like strokes, and other forms of cancer. It causes COPD (chronic obstructive pulmonary disease) which can cause problematic symptoms for years. Researches have established the fact that even after smoking-related health problems have been developed, quitting smoking will decrease symptoms and the elderly’s chance of premature death. Since nicotine is physically and psychologically addictive, which makes quitting smoking hard. Only 3–6% of people succeed in self-management of quitting attempt. Self-management should be combined with medications and counselling to help quit smoking. All this together usually increases the chance of successfully quitting to 30%. 3. Proper sleep—Studies have concluded that poor physical health like cardiovascular disease, increased levels of inflammatory blood markers, and decreased immune function is linked to chronic sleep deprivation. It also causes fatigue, which can make it hard to be physically active (and is bad for mood, too). 4. Avoid chronic stress—Stress exacerbates the physical health problems and predisposes to cardiovascular disease, insulin resistance, and decreased immunity. As per research findings, stress may accelerate “cellular ageing,” and it also increases inflammatory markers in the blood. Common causes of stress in the elderly may include financial stress, work-related stress, relationship stress, and caregiving stress. Strategies like proper sleep, regular physical exercise, meditation, and techniques of relaxation can reduce chronic stress and help to cope with specific sources of stress.

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5. Sustain a healthy weight—Obesity is a major risk factor for debility in the elderly. Obesity in the elderly makes them prone to develop insulin resistance, atherosclerosis, or gastrointestinal problems or sometimes uncomfortable symptoms in the belly or bowels7 (Kernisan, 2020). 6. Complementary and Alternative Medicine—Yoga and meditation are techniques used as complementary and alternative Medicine. It can be used as an alternative to address the needs of those with limited mobility and those who have challenging physical activity and it is tailored to the ability levels of the elderly.

Staying Healthy at Home To stay healthy at home, one should maintain good physical health (Table 8.1), maintain Good mental health (Table 8.2), quit tobacco (Table 8.3), and eat healthy (Table 8.4) Maintaining good mental health (Table 8.2)

Quit Tobacco to Stay Healthy Active Smokers have a greater chance of infections with coronavirus as they are frequently putting their hands to their lips. When infected with coronavirus, they have higher chances of becoming severe because their lung function is already weakened. Quitting is necessary to reduce the above risks and to lead a healthy living. (Table 8.3) Table 8.1 Staying physically active and Healthy at Home 1 Staying physically active • Doing 3–4 min of light physical movement like walking, standing, or stretching the body and taking a short nap from sitting will relax the muscles, increase muscle activity, and improve blood circulation • Regular physical activity/short/light weight exercise will be beneficial for both the body and mind. High blood pressure, the risk of heart disease or stroke, type II diabetes, cancers, or other conditions that may increase susceptibility to COVID • Activities that improve balance will help the elderly in the prevention of falls and injuries. It also improves bone and muscle strength and increases balance and keeps the body flexible and fit • Small Regular physical activity at home can help to set a routine. It is even important to promote good mental health, thereby reducing depression, the risk of cognitive decline, and even delaying the onset of dementia

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Table 8.2 Looking after mental health 1.

Be informed

Actively listen to guidelines, recommendations, and advice from international, national, and local authorities. Try to follow trusted media news and channels, like local and national TV and radio. Be in touch with the latest news from WHO on the online platform

2.

Set a routine

• Start from Early morning waking up • Maintain good personal hygiene • Try to avoid junk and eat regular healthy meals • Regular Exercise • Assign adequate time for work and rest • Assign some time for things you enjoy • Go to bed at similar times every day

3.

Minimize exposure to too much newsfeeds Reduce the time for too much news or information because it may increase the feeling of anxiety/distressed. Try to find the latest news/information at some specific times of the day or if required once or twice a day

4.

Maintain Social contact

During the pandemic when movements are restricted, telephone and online channels and other online platforms can be used to keep in regular contact with people and maintain social contact

5.

Limit the Alcohol, tobacco, and drug use

Minimize the quantity of alcohol or try to abstain from alcohol. Do not initiate drinking alcohol to reduce stress or as a way of dealing with fear, anxiety, boredom, and social isolation Researches have not demonstrated that alcohol is protective against viral or other infections. But harmful use of alcohol may be associated with an increased risk of infections and severe treatment outcomes Alcohol also decreases the capacity of a person to take appropriate precautions to protect self from infection, such as compliance with hand hygiene

6.

Screen-time

Limit the time elderly spend in front of a screen every day. Regular breaks from screen activities should be ensured

7.

Limit playing Video games

When at home, sometimes video games can be a mode to relax, it may become tempting to spend much more time on them than usual for long periods but make sure to maintain the right balance with offline activities in daily routine (continued)

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Table 8.2 (continued) 1.

Be informed

Actively listen to guidelines, recommendations, and advice from international, national, and local authorities. Try to follow trusted media news and channels, like local and national TV and radio. Be in touch with the latest news from WHO on the online platform

8.

Healthy use of Social media

Social media accounts should be used to promote healthy, positive, and optimistic stories. Wherever you see misinformation, try to make a habit of correcting it

9.

Help-others

If possible, support may be offered to people in need in the community like helping them with food and shopping

10. “Support health workers”

Find opportunities either online or through other communities to offer thanks to health-care workers in the country and other people who worked during COVID-19

11. Avoid discrimination

In situations of uncertainty, fear is a normal reaction. But sometimes fear is expressed in ways that are hurtful to other people Note: Be kind. Avoid discrimination against people because of fears of the spread of disease, i.e. COVID-19 Avoid discriminating against health workers. They deserve our motivation, respect, and gratitude COVID-19 has affected people all over the globe. Do not attribute it to any specific group in the community

12. Remember

Regular contact with loved ones by telephone, email, social media, or video conference can be maintained Regular routines and schedules for eating, sleeping, and activities you enjoy must be followed Daily physical exercises at home when in quarantine to maintain mobility One month supply or longer of regular medicines must be kept Find out how to use social help in the form of calling a taxi, food delivery, or asking for medical care If needed, ask for support from family members, friends, or neighbours

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Table 8.3 Quit tobacco to Staying healthy Postponement

Postpone smoking as long as possible before giving in to your urge

Take deep breathing

10 deep breaths for relaxation until the urge passes

Drinking water

Drinking water can be used as a healthy alternative to a cigarette in the mouth

Use Distraction

Indulge in activities like showering, reading, walking or listening to music, etc

Table 8.4 Eat healthy 1. Include a variety of food, including fruits and Eating healthy means a mix of wholegrain vegetables in the diet including rice, wheat, legumes, maize, lentils, and beans Eat plenty of fresh fruit and raw vegetables, and also include some animal sources of foods, e.g. meat, fish, eggs, and milk Unprocessed wholegrain like maize, millet, oats, wheat, and brown rice can help to maintain fullness and act as a rich source of valuable fibre For snacks, choose raw vegetables, fresh fruit, and unsalted nuts 2. Cut back on salt

Salt intake should be limited to 5 g which is equivalent to one teaspoon/day Always use salt in a sparingly and reduced amount in sauces and other condiments (like soy sauce, stock, or fish sauce) Avoid the use of canned or dried food Choose varieties of vegetables, nuts, and fruit, without added salt and sugars Avoid keeping the salt on the dining table, try keeping fresh or dried herbs or other spices like pepper for added flavour instead Check the labels on food Choose products with a lower level of sodium content

3. Fats and oils to be eaten in moderate amounts • When cooking, olive, soy, sunflower, or corn oil can be used in replacement of butter, ghee, and lard • White meats like poultry, fish, etc. can be selected for food because they have lower fats than red meat; cut down on eating the meat with visible fat and minimize the consumption of processed meats • Use toned or full-toned versions of milk and dairy products • Limit industrially produced trans-fat like processed, baked, and fried foods. Use steaming or boiling instead of frying food when cooking (continued)

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Table 8.4 (continued) 4. Decrease sugar intake

Minimize the use of sweets and sugary drinks like carbonated, fizzy drinks, juices, and fruit juice drinks Avoid flavoured water, energy drinks, sports drinks, ready-made versions of tea and coffee, and flavoured milk Fresh fruits contain less sweet content. Snacks such as cookies, cakes, and chocolate contain more sugar. Dessert should be opted wisely • Avoid giving sugary foods to even children. Avoid adding salt and extra sugars to complementary foods given to children less than 2 years of age, and even should be limited beyond that age

5. Maintain hydration

Good hydration is vital for ideal health. Avoid flavoured drinking water to limit intake of sugar and extra calories

6. Follow WHO’s Five keys to safer food

Maintain food hygiene Separate raw and cooked food Cook meticulously Keep food at appropriate and safe temperatures Using safe water and safe raw materials

There are many resources within the community to support, e.g. Quit line Counsellors, m Cessation programmes to support in the journey to quit.

Eat Healthy Eating healthy food is very important during the pandemic. It affects the ability of the body to prevent, fight, and recover from infections. Healthy food is important for increasing immunity when foods or dietary supplements are ineffective in the prevention or cure of COVID-19 infection. Healthy food can also reduce the occurrence of health problems like obesity, heart disease, diabetes, and cancer (Table 8.4).

Healthy Communication in the Promotion of Healthy Ageing During COVID-19 Pandemic Geriatric medicine requires even more effective and specific communication skills. It is essential to improve communication to promote healthy ageing at all levels from local to global level.8 (Marijana et al., 2020).

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Policy Making on Active and Healthy Urban Ageing Planning for age-friendly environment which can foster active and healthy ageing becomes even more important in the advent of the COVID-19 crisis. Hence, policy action in this direction should be taken at all levels of decision-making and planning, ranging from the global level to cities and local communities to ensure good health for the elderly and to promote healthy and active ageing throughout their lives.

The Decade of Healthy Ageing The 2020 observance of the International Day of Older Persons also promotes the Decade of Healthy Ageing (2020–2030). The Decade of Healthy Ageing is especially important in the light of COVID-19, since there is a need for a long-term vision and systematic approach to ageing societies. The focus of the Decade of Healthy Ageing (2020 to 2030) is to improve the living condition of the elderly, their families, and the communities in which they live. It would be done by ten years of concerted, catalytic, and collaborative efforts of governments, civil society, national or international agencies, health professionals, the media, and the private sector. Rigorous global action on Healthy Ageing is urgently needed in this decade. Researches have shown that the prevalence of elderly (people aged 60 years or older) is more than one billion with most living in low- and middle-income countries. Many of the elderly require even the basic resources necessary to give meaning and dignity to life. Many other elderly face multiple barriers that prevent their full participation in society. 3 August 2020: The Decade of Healthy Ageing has been endorsed by the 73rd World Health Assembly There are ten priorities in this decade. These ten priorities provide the way forward. The following concrete actions and priorities are required to attain the objectives of the WHO Global strategy and action plan on ageing and health. 1.

2.

3.

Connecting people—The first priority is to build a platform for the elderly for innovation and change. Change for Healthy Ageing could be done by connecting people and ideas from all around the world. Support countries in planning and action—the next priority is to support countries to get the skills and tools. countries need to create policies that enable people to live long and healthy lives. Data collection—The collection of better global data on Healthy Ageing is the need of the hour. It is well proved that “What gets measured gets done”. Thus, it is important to collect accurate, updated, and meaningful data together on Healthy Ageing.

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4.

Research activities—The focus is to promote need-based research with the objectives on the needs of older people. 5. Alignation of health system—Align health systems to the needs of older people so that the elderly can get whatever they need at any time. 6. A long-term care system—The focus of Healthy Ageing is to lay the foundations for a long-term care facility in all countries. It will enable the elderly and their family to get the care and support they need to live with dignity and enjoy their basic rights. 7. Availability of human resources—Ensure the human resources necessary for integrated care. For this, it is important to have trained and skilled People to deliver quality health and long-term care services for older people. 8. Global campaign—Under this Decade of Healthy Ageing, it is important to undertake a global campaign to combat ageism. It means changing the way we think, feel, and act towards age and ageing. 9. Investment in Healthy Ageing—The starting point for sustainable, equitable, and effective responses is a better understanding of the costs and opportunities of Healthy Ageing. 10. Global Network Development—To build age-friendly Cities and Communities, it is important to develop a global network. These age-friendly cities and communities all around the world will enable the elderly to do the things they value.

National Program of Health-Care for the Elderly in India: A Hope for Healthy Ageing9 (Verma & Khanna, 2013) The National Program For The Health-Care For The Elderly (NPHCE) Vision And Objectives The NPHCE is an effort of the International and national commitments of the Government. It is envisaged under the UN Convention on the Rights of Persons with Disabilities. This programme is under the National Policy on Older Persons adopted by the Government of India in 1999 and Section 20 of “The Maintenance and Welfare of Parents and Senior Citizens Act, 2007” which aims to provide medical care to Senior Citizens. Vision of the Programme (1) Provision of accessible, affordable, high-quality, comprehensive, and dedicated long-term care services to the elderly. (2) Building a new “architecture” for Ageing. (3) Creation of a framework to enable age-friendly environment. (4) Promotion of the concept of Active and Healthy Ageing. Specific Objectives Of NPHCE

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1. “To provide an easy access to promotional, preventive, curative, and rehabilitative services through community-based primary health-care (PHC) approach”. 2. “To identify health problems in the elderly and provide appropriate health interventions in the community with a strong referral backup support”. 3. “To build the capacity of the medical and paramedical professionals as well as the care-takers within the family for providing health-care to the senior citizen”. 3. “To provide referral services to the elderly patients through district hospital regional medical institutions”. 4. “Convergence with National Rural Health Mission (NRHM), Ayush, and other line departments like the Ministry of Social Justice and Empowerment”. Strategies for Achievement of the Objectives of the programme 1. PHC approach—Community-based domiciliary visits by trained health-care workers is included as PHC approach. 2. Dedicated services—Better provision of facilities and services are provided at PHC/CHC (Community Health Centre) level like facilities of equipment, machinery, trained and skilled Health-care workers, additional Manpower, and provision of Information, Education, and Communication (IEC). 3. Maintenance of district hospital—Dedicated facilities and services at the district level hospital with a minimum10 bedded wards capacity, additional manpower, machinery and equipment, provision of consumables materials and drugs, and focus on training and IEC. 4. Tertiary level medical facilities—Under this, the focus is on Strengthening of eight Regional Medical Institutes to provide advanced tertiary level medical facilities for the elderly. Strategies include the introduction of PG courses in geriatric medicine. In-service training of health personnel at all levels in elderly care and elderly abuse. 5. Information, Education, and Communication (IEC)—Use of mass media, folk media, and other communication channels to reach out to the target community of elderly. 6. Continuous monitoring and evaluation—Continuous monitoring and evaluation of the NPHCE Programme and more researches are encouraged in geriatrics and implementation of NPHCE. 7. Public–private partnerships—Promotion of public–private partnerships in geriatric health-care. 8. Mainstreaming AyushUnder the Ministry of Social Justice and Empowerment in the field of geriatrics, Ayush is focused on revitalizing local health traditions. 9. Reorientation of medical and Nursing education to support geriatric issues. The Expected Outcomes Of NPHCE 1. A dedicated geriatric OPD and 30-bedded geriatric ward in regional geriatric centres (RGC) in eight Regional Medical Institutions for the management of specific diseases of the elderly. 2. Training of health personnel in geriatric health-care in regional geriatric centres (RGC).

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3. Research Activities in Regional geriatric centres (RGC). 4. Post-graduation in geriatric medicine (16) from the eight regional medical institutions. 5. Video Conferencing Units for capacity building and mentoring in geriatric care in regional geriatric centres (RGC). 6. At District level geriatric units along with geriatric OPD and 10-bedded geriatric wards in 80–100 District Hospitals. In the selected districts, setting up of Geriatric clinics or rehabilitation units for domiciliary visits. 7. Provision of equipment at Sub-centres for community outreach services. 8. Training and manpower development in geriatric care. Package of Services under NPHCE 1. Provision of promotional, preventive, curative, and rehabilitative services in an integrated manner for the Elderly in various Government health facilities. 2. The package of services would depend on the level of health facility and may vary from facility to facility. 3. The range of services will include activities for prevention, health promotion, and diagnostic facilities and also facilities for the management of geriatric medical problems. 4. Outpatient department, in-patient ward facilities, day care services, rehabilitative services, and home-based care as needed. 5. Districts will be linked to RGCs for providing tertiary level care. 6. Integrated services under the programme at district and above as more specialized health-care are needed for the elderly. Institutional framework for the implementation of NPHCE At the state and district level, Financial Management Groups (FMG) of Programme Management support units, which are established under NRHM, will be responsible for maintenance of accounts, the release of funds, expenditure reports, utilization certificates, and audit arrangements. The activities at different levels would be carried out by the funds released to States/UTs by the State Health Society (SHS). The Government of India releases the funds for the programme. State Health Society will retain funds for the activities at the state level activity and would release aids to the DHSs. NPHCE would maintain separate bank accounts at each level through NCD cells Table 8.5.

Role of Nurse in Healthy Ageing Nurses play a crucial role in the promotion of health and in supporting healthy ageing for the elderly. Nurses are trained and expert in critical thinking, health assessment, clinical examination, problem-solving/decision-making skills, coordination, and leadership which is essential to support healthy ageing. Nurses have an

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Table 8.5 Health facility work at centre related to healthy ageing At Sub-centre Level

Health Education Home Visits for care and attention to housebound or bedridden elderly Training to the family members Arrange for ambulatory devices

Primary Health Centre

Weekly geriatric clinic (by Medical Officer) Maintenance of record Conduction of a routine health assessment Routine Clinical examination of eye, Blood Pressure, and Blood sugar Public awareness on Promotional, preventive, and rehabilitative aspects

CHC

First referral unit Set up of a rehabilitation unit

District hospital

Geriatric clinic/regular OPD with10-bedded geriatric facility

Regional geriatrics Centres

Geriatric clinic/specialized OPD 30-bedded geriatric clinics

advantage that they are trained to work in all settings like community, clinic, general ward, long-term care facility, acute and chronic ward, correctional care, and support elderly in all. They work as leader, supervisor, and mentor for staff. The focus of health-care is curative rather than preventative. Since the role of caregiver and family is very important, nurses work with family members too to make them understand their role. Skills of the nurse are as follows: 1. 2.

To identify opportunities to support healthy ageing. Being competent in recognizing and responding to all conditions of the elderly like deterioration in health, cognitive and functional decline, and be trained and skilled and well informed in the latest technology to provide appropriate care. 3. To update the Nursing curriculums to include age-specific care and support to the elderly and placement in elderly clinic care settings. 4. To develop, implement, and evaluate the Nurse-led care models to support healthy ageing. 5. To participate in policy formation for the elderly. 6. To develop Career development pathways to support nurses to specialize in healthy ageing. 7. To be skilled, trained, and educated for providing quality care, palliative care, and end of life care for older age people. 8. To work towards promoting functional, physical, social engagement, and mental wellness. 9. To provide high-quality safe care to elderly. 10. To gain knowledge and understanding for the identification of problem and challenge the stereotypes that promote ageist attitudes. 11. To understand the identification and mandatory reporting of elder abuse.

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Conclusion The COVID-19 pandemic has impacted the population globally in drastic ways. Healthy and active ageing is the need of the hour. In this chapter, various strategies and dietary management for healthy ageing are discussed. Elderly in many countries are facing the serious threats and challenges due to their physiological conditions and existing underlying health problems. It is important to give them easy access to health-care services during the pandemic for both emergency and primary health-care even at home, online, or in any way affordable to them. Resources should be provided to health-care workers, social care providers, family members, and community members to support the elderly. These resources should include innovative approaches to reach older people through telemedicine and technology. During the pandemic, Digital literacy came up. Its knowledge needs to be enhanced in the elderly so they can use mobile apps for getting information and even used for communication with family members and health-care providers, and community service providers even when physically separated. Along with the elderly, their families and caregivers have to be supported as a priority for healthy ageing during the pandemic. Programmes and services need to be prioritized that help to meet older people’s needs, promote their health, and keep them out of the hospital. Ensure adequate facilities of home care, nutritious healthy food, toiletries, medicine, and social support and information for mental and emotional wellbeing. Older people also need accurate information on ways to stay healthy during the pandemic and strategies to deal with it. The most important way to promote active ageing in this situation is a checklist including a focus on diet, exercise, etc. WHO has developed various guidelines and advisory for policy-makers, health-care professionals, and long-term care facilities for older people in the context of the COVID-19 outbreak. Lastly, Nurses have important and diverse roles in our society. The nurse role encompasses autonomous and collaborative care of the elderly. They have a role in health promotion, prevention of illness, health-care delivering, promotion of safe environments, acting as advocate, participating in research activities and health policy-making, and patient and health systems management and education. The Healthy ageing commences from childhood, and focus on health promotion strategies could delay, minimize the onset and protect from the severity of diseases and age-related decline. Healthy ageing focuses to save health costs and also reduce the long-term support needs of the elderly. Nurses should be educated, trained, and supported for the delivery of activities related to health promotion and prevention programmes in order to support healthy ageing in all settings. Old age programmes must ensure equitable access and embrace the diverse characteristics, life experiences, and accumulated wisdom of elderly. Government must take care that these programmes of elderly must include care of nutrition, active living, tobacco cessation, preventing falls and abuse in elderly, integrated chronic disease management with comprehensive care, and participation in proactive palliative care in elderly and end of life (EOL) care planning. In order to achieve these goals, nurses must undergo

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training and get education to develop and maintain knowledge and competence to support healthy ageing.

Notes 1. World Health Organisation. https://www.who.int/ageing/healthy-ageing/en/. 2. OssenbruggenErik, F., & Stjernberg, M. (2020). Healthy and active ageing is more important than ever. https://nordregio.org/healthy-and-active-ageing-is-more-important-than-ever/. 3. Nordregio. (2020). Healthy and active ageing is more important than ever. News report. 3rd June 2020. 4. Usman, B. B. (2020). Impact of COVID-19 and Pandemic Lockdown in India: Role of Media during Lockdown (pdf). Available from: https://www.researchgate.net/publication/342787 067_Impact_of_COVID-19_and_Pandemic_Lockdown_in_India_Role_of_Media_during_ Lockdown [accessed Oct 30 2020]. In book: “Impact of COVID-19 & Pandemic Lockdown in India: Ramification in Environment and Human Life” Publisher: Eureka Publications. 5. Donatella R. P., & Roberto P. (2020). Ageing and COVID-19: What Is the role for elderly people? Geriatrics, 5(2), 25. https://doi.org/10.3390/geriatrics5020025. 6. Armitage, R., & Nellums, L. B. (2020). COVID-19 and the consequences of isolating the elderly. Lancet. 7. Kernisan, L. (2020). How to Promote Physical Health While Aging: The Healthy Aging Checklist. https://betterhealthwhileaging.net/how-to-promote-physical-health-for-healthy-aging/. 8. Marijana, B., Veljko, D., Neda, P., & Ivana, D. (2020). Healthy communication in the promotion of healthy aging during COVID-19 pandemic. Croat Medical Journal, 61(2): 177–179. https:// doi.org/10.3325/cmj.2020.61.177. 9. Verma, R., & Khanna, P. (2013). National program of health-care for the elderly in India: A hope for healthy ageing. International Journal of Preventive Medicine, 4(10), 1103–1107.

Part II

Specific Issues and Different Country Narratives

Chapter 9

Effects of the COVID-19 Pandemic on Elderly People in Italy Alessia Bertolazzi and Albertina Pretto

Abstract This chapter presents an analysis of the effects of the pandemic on the elderly population in Italy by examining the government’s responses and prospects for assistance to the elderly, which are currently linked to the National Recovery and Resilience Plan (PNRR). We look over the paradigm of long-term care, encouraged by the European Union and adopted through the reforms that took place in France, Germany, Spain, and Austria. It contrasts with the existing elderly care services in Italy. The European Union has criticized the latter to such an extent that it refuses to include such services in the category of policies dedicated to non-self-sufficient people. Given that the PNRR’s first investments are being defined, it is crucial to move in the right direction, especially to prepare the ground for the overall reform of this sector, which has been expected for three decades and has now been promised by the Italian government in 2023.

Introduction: Facing the COVID-19 Pandemic in Italy1 The case of the pandemic in Italy is noteworthy for several reasons. First, we were among the foremost countries to face the COVID-19 pandemic. On December 31, 2019, the Wuhan Municipal Health Commission (China) reported to the WHO a cluster of pneumonia cases of unknown etiology. While the world looked at what was happening in China, on January 30, 2020, the Italian government confirmed that the virus was detected in two Chinese tourists visiting Italy. The first case of secondary virus transmission occurred in the municipality of Lombardy in mid-February. The number of cases increased in the same month when 16 people in Lombardy and Veneto were confirmed to be infected. The number of infected and dead people

1

The chapter is the product of the collaboration of the two authors. However, Albertina Pretto has written paragraphs 1 and 4, and Alessia Bertolazzi has written paragraphs 2 and 3. A. Bertolazzi (B) · A. Pretto Sociologist, University of Macerata, Macerata, Italy e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_9

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started to increase so rapidly that after a few weeks of partial restrictions, on March 9, the Italian government imposed a national lockdown. Neither the government nor the Italian citizens were prepared to deal with a national lockdown. Shops, schools, offices, and restaurants were closed. Three or four times a day, institutional cars with loudspeakers passed through the streets repeating the same message: “Stay at home”. Only one person from each family could go to the supermarket to buy food. Almost all aspects of Italian society came to a halt. We had neither masks nor disinfectants. Hospitals were filled with sick people whom doctors were unable to cure, so a growing number of people began to die. At the end of March 2020, with about 90,000 people infected and 9,000 deaths, Italy was the European country hit hardest by what, in the meantime, had been declared a pandemic by the World Health Organization (Pretto, 2021). In the Summer of 2020, the situation improved and certain restrictions were lifted. However, after the Summer holidays and the reopening of schools, a rapid increase in infections was recorded yet again. Italy faced new severe six-month restrictions, including a national curfew and, sometimes, total lockdowns at the local level. Thanks to the vaccination campaign, which started in Italy on December 27, 2020, the situation seemed to be gradually improving; however, the emergence of the Omicron variant and its high transmissibility gave rise to a high number of infections, deaths, and subsequent restrictions, particularly during Autumn 2021 and Winter 2022. Although the pandemic is a terrifying event that has shocked people worldwide, we illustrate how older people probably comprised the population that suffered the most.

Overview of the Italian Elderly Care Model Between the end of the Second World War and the 1970s, the welfare system was set up in Italy without providing for a sector dedicated to the care of the elderly (since it did not represent a political issue) unlike what happened to institutionalized welfare policy areas such as the pension system, which was subject to progressive reforms (Ferrera, 2012). Policies aimed at the care of the elderly began to be outlined in the 1980s through a sequence of new interventions that were introduced into the existing institutional networks. Particularly at the beginning of the 1990s, the Italian model of care could be classified as a residual model (Pavolini & Ranci, 2008; Ranci & Pavolini, 2015). The coverage for the population aged 65+ that received benefits was lower than 10% (in contrast to countries adopting a universalistic approach, with coverage above 20%), and a large part of the benefits was provided not through services but in cash allowances. During the following decade, a political orientation towards the defamiliarization of care within European welfare systems produced an extension of long-term care policies and in-kind services for the elderly (Ranci & Pavolini, 2015). However, in Italy, no radical long-term care policy took place, leading to the failure of implementing a comprehensive reform for the elderly, partly for the rationalization of

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public social spending (Costa, 2013). Consequently, the expectations of families have been unmet and tensions have emerged between the formal care system and a semi-informal or informal system that has developed to overcome the lack of public services (Pfau-Effinger et al., 2009; Pfau-Effinger & Rostgaard, 2011). In particular, the shifting of women’s role within the labour market, with their increasing participation in the labour force and a reduction of their availability to provide care for elderly family members, contributed to the creation of a social need that has been increasingly satisfied through paid services. This process of commercialization of elderly care implied that eldercare was increasingly based on fee-for-service and that the relationship between the caregiver and care-recipient became contractual (Pfau-Effinger & Rostgaard, 2011). In the absence of national reform, innovations and new services for elderly care have been locally driven even though this has exacerbated the lack of an organic and integrated organization of national policies. Ferrera et al. (2012) reconstructed the social–historical framework in which the fragmentation of policies for the elderly originated. In this context, local authorities and public health agencies have had to overcome this lack of unitary organization, generating a high degree of horizontal fragmentation among welfare sectors or areas over the years. A dual system has progressively been established in the country where some northern and central regions have implemented long-term care services similar to the Central European models. However, other regions, especially in the south, have stuck to rates of service coverage for the elderly much lower than the European standard (Pavolini, 2004). Moreover, the failure of social policy reforms for the elderly is aligned with the main process of change that concerns the Italian national healthcare system and two aspects: decentralization and managerialism. Formalized by the 2001 constitutional reform, the decentralization process of healthcare systems has been framed by the market-oriented reforms of the 1990s. It created multi-level governance, in which the state establishes essential healthcare provisions (“Livelli essenziali di assistenza”) and allocates a national fund to provide the resources to regions; meanwhile, the regions are responsible for the organization and provision of health services (France & Taroni, 2005). Instead, following the new public management paradigm, the managerialism reforms of Italian healthcare that started in the 1990s have had a complex objective of introducing new organizational models to guarantee the maintenance of the quality of care while rationalizing the resources to be invested. The adoption of private-sector management techniques, the introduction of a quasi-market logic between public and private providers, and the implementation of instruments of performance-based payment for health providers were the main measures taken (Anessi-Pessina & Cantù, 2006). However, in a context where there are historical differences in institutional efficiency between Italian regions (Putnam et al., 1990), the effect of decentralization has been an increase in health inequalities and territorial divide in access to healthcare services (Pavolini & Vicarelli, 2012). Several studies have demonstrated that regional differences can explain inequalities in the use of medical care (van Doorslaer & Masseria, 2004) and the heterogeneous outcomes of the Italian regions in terms of

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the effectiveness of healthcare (with Centre-Nord regions showing a better performance vs. South regions) (Cavalieri & Ferrante, 2016; Ferrè et al., 2012; Marinacci et al., 2010). An example of these regional differences is the indicator of satisfaction with the medical care received in the hospital (ISTAT [National Institute of Statistics], 2022). While 47.7% of Italians in the northern regions and 47.2% in the central regions were highly satisfied, the data drops to 27.2% in the southern regions, including 23.5% in the islands (Sicily and Sardinia). Therefore, the pandemic hit a system characterized by a fragmentation of the policies for the elderly, decentralization of health policies to the regions, and a growing territorial gap in the performance of regional health systems and its impact on the health of the population.

The Impact of the COVID-19 Pandemic on the Italian Elderly Population In Europe, the COVID-19 pandemic crisis management lacked Europe-based coordinated actions, and it has been driven largely by country-specific responses. According to Bouckaert et al. (2020), crisis management in Italy has mainly been centralized based on a top-down logic between the national government, which played a key role, and regions. While responses in the early stages of the pandemic were regionally based, structures and procedures were soon organized to ensure national policy coordination. The establishment of the Scientific Technical Committee was the most significant action taken by the government. The emergency decrees progressively assumed by the government left the regions with a residual role, allowing them to intervene in a few expressly foreseen circumstances. The changed relationship of power between the state and the regions during the health emergency gave rise to some institutional conflicts on matters of the jurisdiction (Bosa et al., 2021). Some regional presidents publicly criticized the decisions adopted by the government. In a few cases, some regional laws or measures that were in contrast with decrees adopted at the national level were challenged by the state before the administrative judge and the Constitutional Court (Longo, 2020; Marchetti, 2021). In an attempt to draw a picture of the government and regional response to the pandemic, one can consider data on the impact of the pandemic on total population mortality. According to ISTAT and the National Institute of Health (ISS) reports on the impact of the epidemic on total mortality, from the beginning of the pandemic to February 2, 2022, nearly eleven million cases of COVID-19 have been confirmed in Italy (out of a population of approximately 60 million). Over the same period, 145,334 people died due to SARS-CoV-2 infection; 53% of deaths occurred in 2020, 41% in 2021, and 5.8% in January 2022 (ISTAT-ISS, 2022). It should be highlighted that in Italy, 22% of the population is currently over 65, and 6.8% is over 80. Consistent with previous studies demonstrating that the

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consequences of COVID-19 infection are dependent on age (Davies et al., 2020), the average age of Italian patients who died and were SARS-CoV-2 positive was 80 years. Considering the age groups, the most significant contribution to excess mortality, compared to the average of the years 2015–2019, was due to the increase in deaths of the population over 80, which explains 72% of the overall excess mortality. The increase in mortality in the 65–79 age group explained a further 21% of excess deaths. Moreover, the analysis of the medical records of 8,436 decedents revealed that the majority (67.8%) had three or more diseases (ISTAT-ISS, 2022). By measuring changes in standardized mortality rates obtained by relating deaths to the population at the same age structure, mortality increased by 9% at the national level in 2020 compared with the average for the five-year period from 2015 to 2019 (ISTAT, 2021). Regions reporting increases significantly higher than the national average were the northern regions (Piedmont, Valle D’Aosta, Lombardy, and the Autonomous Province of Trento). The regions of Central (Lazio, Marche, Tuscany, and Umbria) and Southern Italy (Abruzzo, Basilicata, Calabria, Campania, Molise, Puglia, Sardinia, and Sicily) did not show any significant changes (Fig. 9.1). Although the northern regions were the most affected by the virus, the southern regions with the greatest structural weaknesses in terms of health service provision achieved positive mortality control. The structural weaknesses of some regional health systems have likely been mitigated by a highly centralized management of the health crisis. This centralization has allowed the same measures to be applied throughout the national territory, both in terms of monitoring cases and treating the disease.

Fig. 9.1 Correlation between standardized COVID-19 incidence rate and standardized COVID-19 death rate in Italian regions. Source Reprocessing of data by ISTAT (2021)

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However, a strong criticality emerged in the management of the elderly population within nursing homes. According to Cinelli and Longo (2021, p. 158), “the inadequacy of the current (dis)organization of the social-health sector emerged in a disruptive way during the COVID-19 pandemic, in which the absence of clear governance led to a delayed management of the health emergency in residential facilities, even though they represented the services in which there was the highest concentration of frail individuals at lethal risk of the virus”. Amore et al. (2021) observed a correlation between mortality in ageing people and the number of people in nursing homes, demonstrating that the Italian elderly in long-term care facilities have been dramatically struck by the infection (Amore et al., 2021). To address this critical situation, the National Institute of Health in collaboration with the Ministry of Health developed a specific surveillance system to monitor the frequency and impact of SARS-CoV-2 infections in long-term care facilities. Moreover, through the government’s Relaunch Decree, the strengthening and reorganization of the community care system for the elderly have been planned. Moreover, the National Strategic Plan for SARS-CoV-2/COVID-19 vaccination identified as priority categories for the first phase of the vaccination campaign health and social care workers, staff, and residents of residential care facilities for the elderly, those over 80 years of age, persons 60–79 years of age, and the population with at least one chronic co-morbidity. However, despite the measures taken, according to the report of Amnesty International Italy, “the response of the Italian government to the COVID-19 pandemic has not been adequate to protect and guarantee the human rights of the guests of the residential social and welfare facilities for the elderly” (Amnesty International Italy, 2020, p. 11).

Conclusion: Perspectives on PNRR and Mistakes to Avoid As noted in the previous sections, the Italian system of care for the elderly presents several critical points that have been known for decades. The crisis triggered by the pandemic has offered Italian politics the possibility of a reform of policies addressed to the elderly population. Almost 25 years after the proposal of the Onofri Commission (1997), which has never been realized, Italy has not implemented structural reforms in this field, while all other European countries have reformed their long-term care system since the 1990s (Da Roit & Ranci, 2021). Recently, the European Centre for Social Welfare Policy and Research has highlighted Italian criticalities in this area, publishing the first European study aimed at assessing government policies for supporting the rights of older people concerning their long-term care and assistance needs (Birtha et al., 2019). Analysing the results obtained from the various areas identified in this study, it can be said that Italy shows an average score of 1.8 and ranks 11th out of 12 countries

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investigated. The country’s weaknesses emerge above all in the areas connected with the right to assistance of non-self-sufficient elderly persons. More specifically, Italy shows the worst performance in interventions regarding the choice of care managers, advanced treatment dispositions, and the maintenance of family ties. The protection from abuse and maltreatment, freedom of thought and expression, and level of health guaranteed (with specific reference to long-term care policies and the guarantee of an adequate standard of living) appear to be weak areas for Italy. Sufficiently guaranteed but to be observed and monitored are the areas of participation and social inclusion as well as the area related to equal access to care services, whether home-based, semi-residential, or residential (Birtha et al., 2019; Menghini, 2020). Additionally, critical issues emerged due to the pandemic in all areas of healthcare systems for the elderly. Nursing homes were subjected to high levels of risk: the lack of a sufficient number of personal protective equipment and the shortage of personnel were indicated, respectively, as the first and second main causes of difficulty (Gori & Trabucchi, 2021). Semi-residential facilities remained closed for many months, and considerable difficulties emerged in relation to home-based services, leaving the elderly who used them alone or under the care of their families. The social distancing imposed by the pandemic and the consequent isolation has highlighted the need for socialization and the needs related to independent mobility. As Monteduro and Nanetti stated, “a condition of fragility has become evident that characterizes the elderly and lies somewhere between full self-sufficiency and non-self-sufficiency. This is a condition that cannot be predetermined a priori or through a medical analysis and whose characteristics differ significantly from subject to subject” (Monteduro & Nanetti, 2021, p. 5). Nowadays, the PNRR2 could become the stimulus for improving or solving the pre-existing Italian criticalities resulting from the pandemic. The Italian PNRR is the investment programme for accessing Next Generation EU resources, which in turn stems from the European Commission’s decision to make available to the member states a powerful economic tool for coping with the effects of the pandemic (Gori et al., 2021). The PNRR, which will allocate over seven billion euros in favour of the elderly for the period 2022–2026, “is aimed at the formal identification of essential levels of services for the older people who are dependent” (President of the Council of Ministers, 2021). Interventions in favour of the elderly appear in three of the six missions of the PNRR: in Mission 1 “Digitization and Innovation”, the plan calls for investment in fast Internet connections (broadband and 5G) for many public facilities, including all healthcare facilities (telemedicine and remote assistance, electronic medical records, etc.). Mission 5 “Inclusion and Social Cohesion” plans to process legislation regarding the system of interventions in favour of the elderly, which is to be adopted by Spring 2023 and is aimed at identifying essential levels of services, the allocation of a part of the funds for the prevention of the institutionalization of 2

Piano Nazionale di Ripresa e Resilienza. #Next Generation Italia, available at: https://www.gov erno.it/sites/governo.it/files/PNRR.pdf.

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the elderly dependents, and the reconversion of residential facilities into groups of autonomous apartments. Finally, as a part of Mission 6 “Health”, a substantial investment will be made for the creation of community homes (dedicated to the chronically ill, mostly the elderly), the increase of home care services to accommodate 10% of the elderly population (65+) by 2026, and the development of intermediate care through the creation of community hospitals (Pavolini, 2021). Since the first investments of the PNRR are currently being defined, it is essential to plan each choice and ensure that it is possible to avoid errors that could compromise the effectiveness of the plan itself.

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Chapter 10

Psychosocial Condition of Older Poles in the COVID-19 Pandemic Zofia Szarota

and Artur Fabi´s

Abstract The chapter presents selected activities of entities specializing in the creation of Polish—national and regional—social policy, as well as local institutions of social assistance and health care in the perspective of the COVID-19 pandemic. The analysis of the situation of the older people was based on a search for external reports and on the results of research using non-directive problem interviews. A survey with twelve individuals aged 60–79 years was conducted in June and July 2020. Another study was conducted in April 2021 to diagnose the resilience strategies of the same study participants. The psychological effects of older adults’ (self-) isolation and their adaptive strategies were identified. The COVID-19 pandemic contributed to the deprivation of the needs of the older generation, including the need for safety, the need for connection and belonging, to the strengthening of their sense of loneliness and information disorientation. Stages of response to pandemic stress and physical isolation (shock, familiarization, rebirth, relaxation, normalization) and stages of their adaptation to the crisis situation (anxiety, separation, rationalization, adaptation, distance, hygiene, task action, activity) were recognized in study participants. Keywords Old age · COVID-19 pandemic · Crisis · Resilience · Public policy

Polish Policy Towards Older Adults and Old Age Poland is a Central and Eastern European country, a member of the European Union, with a relatively short history of public policy towards old people and old age. Issues of social policy and social protection in Poland are regulated, among others, by the Act on Social Welfare (Ustawa o pomocy społecznej, 2004). It provides for the Z. Szarota · A. Fabi´s (B) WSB University, D˛abrowa Górnicza, Poland e-mail: [email protected] Z. Szarota e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_10

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division of assistance tasks between three sectors—government administration, local governments, and NGOs. The elderly are not separate subjects of this Act, which is well perceived and interpreted in the country. To indicate in the Act the age of an old person or a phase of life such as old age as a reason for applying for benefits would be considered stigmatizing. The Social Welfare Act provides for all persons remaining in life crisis—poor, chronically ill, etc.—their due care and social benefits, which include cash benefits (e.g. benefits) and non-cash benefits (e.g. social work, counselling and crisis intervention, care services in the place of residence, in support centres and in family welfare homes, residence, and services in a social welfare home) (ibidem). Social support issues are managed by the Ministry of Family and Social Policy, which manages the activities of other entities, including the Social Insurance Institution (pensions) and the State Fund for Rehabilitation of the Disabled (important from the perspective of older people). Constitutional issues of accessibility to medical services and treatment are regulated by separate legislation (Ustawa o s´wiadczeniach opieki zdrowotnej…, 2004). Services are supervised by the Ministry of Health and the National Health Fund. In addition to hospitalization and outpatient, spa treatment, services are provided in treatment and care institutions and nursing and care institutions, where the majority of patients are elderly and advanced age persons. The so-called senior policy is defined as “a set of activities of public administration bodies and other organiations and institutions that implement tasks and initiatives shaping the conditions for dignified and healthy ageing” (Ustawa o osobach starszych, 2015). Since 2013, the Council for Senior Citizenship Policy has been operating at the Polish government, which provides a forum for open dialogue on the concept and shaping of Polish social policy towards old age and ageing society (Zarz˛adzenie nr 2…, 2013). The long-term Government Programme for Social Activity of Older Persons and its continuation, i.e. the Aktywni + programme, are implemented, with funds earmarked for the creation of conditions for a dignified and active old age, expressed in outcomes including lifelong education, increased participation of older persons in all areas of social life and high quality social services (Uchwała nr 167 Rady Ministrów…, 2020). In Poland, there are various expert groups acting in the interests of older people, such as the Expert Commission on Older Persons at the Ombudsman’s Office, whose tasks since 2011 have included the issues of access of older people to medical services and long-term care facilities, as well as quality of care, activation of older people, access of older people to consumer and financial services, the situation of older people in the labour market, care and social security, intergenerational relations and perception of older people in society, the media and public administration (Komisja Ekspertów ds. Osób Starszych, 2020). Non-governmental organizations which bring together older people and work for their benefit supporting them in healthy and active ageing are thriving and effective. Among them, it is worth mentioning the Polish Association of Retired Persons, Pensioners, and Wheelchair Beneficiaries (Polski Zwi˛azek Emerytów, Rencistów

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i Inwalidów), which has existed since 1975. In 2007, the National Federation of Universities of the Third Age was established, and in 2012 the National Foundation Alliance of Universities of the Third Age was set up. The diversity and effectiveness of their activities are impressive. It is worth mentioning that the number of Polish U3As is huge, the second in Europe, after Italy. The first U3A was established in 1975 in Warsaw, and in 2018 there were more than 640 institutions in the country, bringing together around 120,000 listeners (GUS, 2019).

Socio-demographic Situation of Older People in Poland—An Outline of the Problem In a country of more than 38 million citizens, there are 7.1 million people over 65, of which about 1.7 million are over 80 (Cierniak-Piotrowska et al., 2021). This means that the share of old people (aged over 65) in Poland’s general population is over 18%. The trend of ageing of the Polish population, which has been growing for several decades, is a result of increasing life expectancy, a demographic trend of double ageing, and a low birth rate. Socio-economic development, medical progress, and professionalization of treatment and care services have significantly prolonged the lives of Poles. The average life expectancy of women in Poland in 2020 was 81.7 years, and men 74.1 years. Healthy Life Years (HLY) increased slowly in the decade 2009–2019, but was around 60 years in 2019, as the general population experienced a decline in the number of life years without more severe diseases and disability (GUS, 2020). Healthy life expectancy, compared to European countries characterized by particularly long life expectancy without severe diseases, performs badly. Data characterizing the health status of Polish older people indicate that it is below the average European level (Eurostat, 2021). For Poles, health is the most important value in life—nine out of ten place it among the three most important life values (GUS, 2015). However, data characterizing the health status of Polish older people shows that it is below the average European level (Eurostat, 2021). The percentage of people rating their health very well or well in Poland, depending on the age group, is nearly two or three times lower than the averaged corresponding data from European countries (Komisja Ekspertów ds. Osób Starszych, 2020, s. 57). Health services are not appreciated by the general public in Poland, and two-thirds of Poles have a negative opinion of the department’s services (CBOS, 2018). Challenges for health care include the lack of comprehensive health care for older people and unequal (and difficult especially in rural areas) access to health care and care support. A systemic neglect is the lack of access to geriatric care—in 2018, 73,700 geriatric consultations were provided out of 116.3 million specialist consultations, accounting for only 0.06% of total outpatient consultations (Komisja Ekspertów ds. Osób Starszych, 2020, p. 20). The health care and social assistance systems are disconnected and do not take into account the specific medical and care needs of

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the elderly, and are severely underfunded. They do not guarantee the required availability of services, their continuity and comprehensiveness, effective coordination of health and social services, i.e. coordination of specialist care by a family doctor and supervision of medication, nursing care of chronically ill patients at home, taking laboratory tests at home, access to rehabilitation services, care services, support of a senior citizen’s assistant, and provision of transport. As a result of this neglect, older people in Poland declare poor health much more often than in other European Union countries. This is determined by non-health factors, e.g. living alone, material situation, availability of nurse visits at home, and availability of transport (to clinics, laboratories). Low salaries and staffing deficits in health and social welfare departments are a significant challenge, as was particularly evident at the height of the pandemic (Komisja Ekspertów ds. Osób Starszych, 2020, p. 18–32). In one aspect, the material situation of Polish seniors is exceptionally positive— the vast majority of them feel financially secure and have their own flats or houses, equipped with the necessary appliances and devices. A study of household budgets shows that the average income per person in the households of pensioners is among the highest in Poland, and for 22% of men and 15.5% of women, it is sufficient to meet all needs without special saving. If one lives frugally, more than half of older people have enough money for everything. Almost every fourth woman and every sixth man lives very frugally, saving for major purchases. The remaining approx. 6% live at the minimum subsistence figure and 0.6–0.7% below the subsistence level. There are more women than men in the most economically deprived groups (Bł˛edowski, 2020). According to the general assessment of the quality of life, six in ten older Poles described it as good, and one in four had no opinion. A feeling of a very good quality of life was declared by almost 14%, bad was indicated by 2.4%, and extremely bad by one in a hundred. The greatest dissatisfaction stemmed from self-assessment of health and functioning of the senses, while the greatest joy was generated by personal relationships (Tobiasz-Adamczyk, 2020). One in five people over 60 lived alone; however, only 4.4% of men and 6.7% of women felt always or often lonely. Two-thirds never or almost never felt lonely (Szatur-Jaworska, 2020), which indirectly may indicate a large resource of social support for older people.

The Situation of Older People in the COVID-19 Pandemic The year 2020 was the most dramatic in terms of deaths since World War II. In Poland, 477,355 people died (Eurostat, 2021), including more than 28,500 due to or with COVID-19. The number of deaths increased primarily in people over 60 years of age—they accounted for as much as 94% of the excess number of deaths compared to 2019 (Ministerstwo Zdrowia, 2021). Female newborn life expectancy decreased from 81.8 years in 2019 to 72.9 years in 2020; for males the decrease was not as drastic, dropping from 74.1 years to 72.6 years (GUS, 2021). The citizens,

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including the older persons, had limited access to doctors, as health clinics were closed, some hospitals and hospital wards were turned into infectious disease institutions, and many medics had to abandon their specialization and deal with infectious diseases. Medical teleconsultations were functioning, but outpatient health rehabilitation and physiotherapy departments, sanatoriums, spas, and nurses’ offices were closed. There was a higher epidemiological risk among patients in care institutions, and the phenomenon of over-mortality increased among residents of social welfare homes (Komisja Ekspertów ds. Osób Starszych, 2020). Signature information from a public statistician reports that one in four nursing home residents became ill due to the Sars-CoV2 virus, and 40% of their residents were over 80 years old. The COVID-19 pandemic has had a huge impact on the lives of all people. Older people, however, face particular challenges and as a group may be at risk of significant mental deterioration. Risk factors include their age generating mental and physical health problems, and their tendency to limit extensive social contact and surround themselves with family and close friends (Philip & Cherian, 2020). The pandemic crisis has contributed to a reduction in the frequency of visits to doctors, thus generating a higher risk of illness and complications of already existing diseases. Almost 60% of surveyed people aged 60 and over in Poland declared that their mental health was worse than before the pandemic (SeniorHub, 2021). Already in the initial phase of the pandemic, the Polish government announced the protection of its citizens through mass vaccination, starting with groups at higher risk of Sars-CoV2 infection and more difficult course of the disease, which primarily included medical services and the elderly. A report (Zrałek, 2021) on the implementation of the right to health protection for the elderly in Poland in the COVID-19 pandemic shows that there were many difficulties during the vaccination process. Every third person over the age of 70 turned to various institutions for help in arranging vaccination. Patients mainly reported a problem in getting through to the clinic or vaccination centre by telephone. They pointed to receiving unreliable information and an “unfriendly” course of conversation. In practice, there was a loss of time spent on an unanswered or delayed call to the health centre, misinformation in terms of knowledge about the further procedure, or referring those interested in vaccination to other registration points. For the frail and sick, standing in queues to register for vaccination was burdensome. In outpatient clinics, the elderly were mainly refused vaccination due to the lack of available vaccination times. The institutions supporting the elderly mainly reported problems with transporting the person to the vaccination centre, and the second problem was the unstable vaccination schedule, which often changed (Zrałek, 2021). A third, irrational inconvenience, was the sometimes long distance between the vaccination centre and the place of residence, even several hundred kilometres. Other studies point to the problems of carers of the elderly in a pandemic (Bakalarczyk & Kocejko, 2021). Eight out of ten interviewees admitted that they did not receive any or sufficient external support. Three-quarters of them agreed with the statement that they felt more alone in the pandemic. The same number of them said that the state did not take care of the needs of elderly carers. Among the identified life difficulties experienced during the pandemic, isolation of older people, access to

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formal and informal support (care services, rehabilitation), and health care came to the fore. Carers took a range of measures to protect their clients from infection. The predominant strategies were increased hygiene and limiting social contact as much as possible. Another form of prevention was the use of strategies involving increased attention to hygiene and to one’s own physical and mental health. Similar approaches were used in Israel and probably in many countries around the world: “One of the new restrictions during the COVID-19 outbreak was the quarantine imposed on long-term care facilities. This was a strict precautionary measure designed to protect patients. Isolation from family and friends had a huge impact on the overall wellbeing of seniors. Moreover, dependency of residents, staff shortages, lack of clear procedures and social isolation can be factors that increase the risk of abuse” (Alon, Lowenstein, 2020, s. 38). At the end of July 2021, the vaccination status of Poles was still insufficient to achieve population immunity. As of the end of July 2021, approximately 41.47% of the population had been vaccinated, meaning that the number of all vaccinations performed in Poland since the beginning of the pandemic for every 100 inhabitants was 88.9 (https://300gospodarka.pl/live/ile-zaszczepiono-na-covid-polska). Several European countries such as Ireland, Malta, Iceland, and Portugal have already reached (or are very close to) 100% vaccination of people over 60 in the same period of time. In Poland, the percentage was 71.2%, and for people over 80 years of age—62.5%. (European Centre for Disease Prevention & Control, 2021).

Perceived Quality of Life in a Pandemic The situation of isolation, the inconvenience of the pandemic’s restrictions, resulted in a significant reduction in subjective quality of life assessment during the first year of the COVID-19 pandemic (SeniorHub, 2021). Six out of ten respondents over 60 years of age declared a deterioration in mental wellbeing. This condition was the product of a number of factors, one of which was impaired physical condition. Twothirds of the respondents had reduced physical activity, and in the case of the 70 and older age group, three-quarters indicated a reduction in physical activity. All typical activities such as walking, participating in religious worship, or pursuing educational or cultural offers were virtually abandoned. Daily activities that required any kind of activity, such as going shopping or walking the dog, were reduced to a maximum extent, and older people reduced all physical activities to a minimum. According to the study, after a year more than half of the respondents felt psychological fatigue resulting from the restrictions. The most burdensome of these were the wearing of a mask, the lack of opportunities to meet and participate in social and cultural life, difficulties in the work of offices and service points, and difficulties in accessing medical services. Four out of ten were dissatisfied with the “actions of the state” in the face of the hardships generated by the pandemic. Half of the respondents had reduced social relationships during the pandemic. The youngest of the seniors lost the most in their contact with others. Every third respondent felt significantly more

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irritable and anxious during the pandemic compared to the time before the pandemic (SeniorHub, 2021). As preventive measures, as in most countries in the world, an economic and social lockdown was introduced, the order to keep a physical distance of 2 m and to cover the nose and mouth with masks, to disinfect the hands, etc. All schools, universities, cinemas, theatres, and restaurants and some workplaces were closed. Long-distance trains were suspended, and seats for public transport passengers were rationed. People were urged to stay at home and not to receive visitors. There was an administrative ban on gatherings in churches, on family celebrations (funerals, weddings), and on rallies and protests. A quarantine order was enforced for infected people and those arriving from abroad. The service sector practically ceased to function, and so-called “hours for seniors” were introduced in open grocery shops—from 10:00 to 12:00. Research conducted by the Public Opinion Research Centre (CBOS) in May and June 2020 on a representative group of adult Poles showed that 62% of respondents declared fear of contracting coronavirus, and 21% described the level of fear as high. Pensioners (79%) and pensioners (77%) were most afraid of infection, women (68%) more often than men (56%), and less educated people (CBOS, 2020). One year later, in July 2021, concern about the possibility of contracting COVID-19 was felt by 48% of all respondents, including 58% of those in the 55–64 age group and 67% among those aged 65 and over (CBOS, 2021). It can be concluded that on an annual basis, the fear of contracting COVID-19 has decreased.

Resilience The self-reported research undertaken (more extensively: Szarota, 2020) aimed to obtain a picture of the adaptation strategies that 12 older adults (aged 60–79) adopted in the face of pandemic threats. To interpret the results obtained, the concept of resilience was used, which “focuses on explaining the phenomenon that some individuals function well despite adverse life conditions, adversity and/or traumatic events” (Borucka & Ostaszewski, 2008). “The psycho-social problems are the most complex issues in the elderly that can be represented in many hidden, direct or indirect ways that are symptomatic in their thinking, moods, and behaviour” (Diyali, 2020, p. 126). Older people in the course of the free interviews (Szarota, 2020) indicated the strong experiences and feelings they experienced in Spring 2020. They encapsulated them in the terms: horror, panic, fear, and terror. The psychological costs of social isolation were high. These included existential anxiety—for one’s own health and life, fear of terminal illness, of running out of ventilators. The narrators felt a strong fear of contact with other people (risk of infection), spoke of fear for loved ones, and a sense of loneliness caused by longing for family, intensifying during holidays. They reported deprivation of the need for security, situational anxiety, confusion in the mass of information, and distrust of the media. They perceived lowered mood and sadness and talked about sleepless nights, tears, and sympathy for the victims of the first wave of the pandemic. They

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spoke of a disturbed need for connection, contact, and interpersonal relationships. They strongly felt the reduction of direct family contacts and the lack of social life, and the disappearance of social contacts. For several of them, the reduction of participation in a religious community was painful. Equally important became the inability to participate in the offer of cultural, educational, recreational, and entertainment institutions. A few indicated a change in the quality of interpersonal relationships—from initial emptiness and silence to a slow revival of indirect contacts (telephones, instant messaging, and social media). U3A students felt acutely the lack of cultural and educational activities, which they repeatedly emphasized. Those with home-centric lifestyles did not signal such critical changes. Narrators rationalized pandemic tensions by adapting to epidemic recommendations and increased hygiene, including the space of their own homes. They maintained physical distance and social isolation, some not leaving the house for over a month. They bought more products at a time to go out shopping as little as possible. They also used public transport as seldom as possible. All interviewees indicated a need for security, certainty of living conditions, and avoidance of risk. About a month after the outbreak of the pandemic, interviewees coped by concentrating on activities for others, focusing on maintaining links with the outside world. They were sewing masks, organizing catering for health services, and joining in actions to help less able neighbours. They kept a close eye on developments. They found space for new activities on the Internet and in social media. They managed their free time, using their own resources, and their home resources, and created community groups. It can be concluded that the process of adaptation in the respondents went through specific stages of reaction to pandemic stress and physical isolation—from the phase of shock and loss of sense of personal security, through a kind of familiarization of the situation, expressed in adjustment to restrictions and finding oneself among the pandemic recommendations (maintaining hygiene, distance, and self-isolation). Discovering and taking up new forms of activity was like a rebirth. The narrators, all casual Internet and social media users, talked extensively about their interests and new activities, their intensive use of social media, and their drawing of knowledge, culture, and entertainment from Internet resources. All had been vaccinated, but some—as we know from the return interviews conducted in May 2021— did so only after becoming ill and overcoming the coronavirus. The immunity gained gave them a sense of relaxed feeling. They undertook or intensified indirect contact with family and friends. The Summer of 2020 was a time of loosening sanitary regime restrictions in Poland, so several people went on holiday, two of them abroad, others spent their canicule time in Poland, on holidays or on recreational plots, and they turned to relatives. They started to plan for the near future and made certain decisions, including those of a paid nature (returning from retirement to full-time work or, on the contrary, giving up paid work and returning to pensioner status) or of a travel nature (planning trips, including abroad). In the normalization phase, they began to function actively in their communities again, however, very much wishing for the return of the “old” pre-pandemic social order. This was particularly noticeable in the statements of those with a high level of socio-cultural activity (U3A listeners).

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These people long for face-to-face contact and want direct forms of activity. SarsCoV2 marked the narrators heavily, and although they did not suffer personal losses or have to face the bereavement of the loss of loved ones they greatly feared, the pandemic cast a shadow over their daily lives. Pandemic ‘house arrest’ vexed most, and was the cause of intrusive and gloomy thoughts. Technology became a factor in alleviating their physical isolation, their social distance. Interviewees wished to return to pre-pandemic activities, to “complete their dreams”. After an initial phase of lowered mood and anxious attitudes, older people found themselves in a pandemic-modified everyday life. The anxiety- and uncertaintyridden expressions characterizing their emotions at the beginning of the lockdown changed into statements capturing the essence of individual coping strategies. They were similar in that the narrators did not have to make significant changes to their daily rhythm, take up remote work, use public transport, or struggle for economic survival. They submitted to the sanitation regime and had a sense of community in the sense of danger and commonality of experience. The experience of pandemic closure did not significantly affect the attitudes and needs of the people in the study (Szarota, 2020). Residual strategies appeared to be similar, due to sanitary recommendations. However, they had a trait of individualism, especially when it came to the emotional and spiritual sphere. The value system of the narrators did not change. The conviction of one narrator (aged 69) was fortunately isolated: I have frozen my interests. I don’t like intermediate forms. To survive I need to go out, to be with people. I stood over the cliff. I retreated, looking for a safe place for my own existence. We can walk safely for a while, but we can’t go forward, because there’s an abyss… For our generation, time has stopped, we won’t develop, there’s no point in waiting! Arguably, the good functioning of the research participants (Szarota, 2020) is derived from their good quality of life (good economic situation, extensive social support resources, acceptance of health status, higher and secondary education, and high level of professional and social activity). The narrators’ families worked well in the coronavirus era; none of the interviewees indicated a negative change in family relationships, apart from an acute lack of physical closeness. Perhaps the results of a study conducted among people with a bad life situation, a negative life balance would be extremely different. Such research is planned to be conducted by means of interviews and expert interviews in a social welfare home for the chronically somatically ill, where the average age of the residents is 82 years.

Summary There are convergences in the conclusions of the referred reports and in the results of our own research (Szarota, 2020). The current assessment of the Polish government’s activities was ambivalent. The lack of an idea for real support for the elderly was criticized. Situational absurdities were pointed out, such as fines for going to the forest or on a bicycle, delegating the police to supervise people in quarantine, or directing

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people willing to go to vaccination centres, e.g. 188 km away from the patient’s place of residence. The innovation of a “senior citizen’s hour” in shops was dismissed with reluctance, pointing to the stigmatizing nature of this relief. The misguided decisions and misguided actions of the government regarding the purchase of masks and respirators, the misinformation and inconsistency of messages, and the chaos in the vaccination programme were widely commented upon. The attitude of certain prominent politicians who, during the first wave of the pandemic, publicly distanced themselves from attitudes considered to be rational, ignoring or even ridiculing vaccination or the wearing of masks, and making irresponsible statements about the threat of the virus deserve justified criticism. At that time, the Catholic Church (Catholicism being the dominant religion in Poland) did not yet contribute to the promotion of attitudes of responsibility for one’s own and others’ health, and in the case of elderly people who are religiously active, this could significantly contribute to shaping their positive attitude towards vaccination or preventive behaviour, ensuring a higher level of personal and social safety for all. Other aspects were also criticized. These can be summarized in several points: – The lack of systemic, compatible actions of the various actors of the care and assistance scene and from the health ministry was perceived. The consequence was that one-quarter of the residents of nursing homes contracted coronavirus. – The lack of psychiatrists, psychologists, and counsellors who would alleviate the emotional and mental effects of the crisis experienced was pointed out. – Difficulties of citizens in using medical or rehabilitation services, and problems with getting to a specialist or internist were noted. – It was noticeable that citizens were lost in the specific tasks of a multitude of ministries fulfilling service, support, care, and rescue functions (the Ministry of Health, the Ministry of Social Welfare, the Police, the Municipal Police, etc.). The administration and social services still lack a “one-stop-shop culture”, which would make it easier and simpler to solve many individual and collective problems. – Family assistants, social workers, community nurses, carers, and institutional caregivers are not a valued element in assistance and care services. They were invisible in the pandemic. This generated a total lack of support for people with disabilities, and multimorbidity. – Informal carers could not count on support, and respite care. – After months of experience, the Ministry of Health attempted systemic measures to optimize the work of care institutions. Mandatory testing of people before admission to long-term care facilities was introduced, employment of external nursing and care staff working also in other treatment facilities was restricted, an order was issued to set aside an isolation room in in-patient facilities for patients with suspected or infected COVID-19, and visits and external contacts of patients were completely stopped. At the same time, provisions were introduced to encourage nursing and caring staff to enable patients to remain in remote contact with family and other close persons (telephone, Internet—instant messenger, and e-mail) and to provide patients with the highest possible standards

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of direct care and psychological/emotional support due to their sense of loneliness (Ministerstwo Zdrowia, 2020). – In response to these proposals, the problem of preventive but unlawful confinement of residents of 24-h social welfare homes arose, the Ombudsman pointed to many other isolating directives without medical grounds and the lack of opportunities for treatment other than COVID-19 or the continuation of treatment of pre-existing diseases (especially cancer). In addition, issues were raised regarding the lack of systemic solutions to help those who cannot leave their homes, people with disabilities, and people of advanced age. The lack of counselling points available also for the digitally excluded was pointed out, and among the elderly, this is the majority, i.e. 70% (after: SeniorHub, 2021). Currently, both in Poland and worldwide, there is a rich literature on the problem, treating the conditions of individual and collective life in the pandemic. Repositories of knowledge on this topic are the free collection of the British Geriatrics Society under the collective title Age and Ageing Journal (2020) and the collection of 25 articles from German-speaking countries—Germany, Austria, and Switzerland, in the open-access publication Kompetenznetz Public Health COVID-19 (2021). Reading the individual texts makes it possible to compare problems and analyse attempts to solve them.

References Age and Ageing Journal: Free collection of COVID-19 papers | British Geriatrics Society (bgs.org.uk); Date Published: 01 May 2020. Available at: https://www.bgs.org.uk/resources/ age-and-ageing-journal-free-collection-of-covid-19-papers Alon, S., & Lowenstein, A. (2020). Nadu˙zycia i zaniedbania wobec osób starszych w społecze´nstwie izraelskim w czasie pandemii COVID-19. Exlibris Biblioteka Gerontologii Społecznej/Exlibris Social Gerontology Journal, 19(2), 32–41. https://doi.org/10.24917/27199045.192.2 Bakalarczyk, R., & Kocejko, M. (2021). Sytuacja opiekunów rodzinnych osób starszych w czasie pandemii Covid-19. Rapotr z badania. Available at: https://seniorhub.pl/wp-content/uploads/ 2021/07/Raport-Sytuacja-opiekunow-rodzinnych-osob-starszych-w-czasie-pandemii-COVID19-Raport-z-badania-5.07.2021.pdf Bł˛edowski, P. (2020). Polsenior 2. Sytuacja ekonomiczna osób starszych i ich potrzeby opieku´ncze. Available at: https://konferencjapolsenior2.pl/ Borucka, A., & Ostaszewski, K. (2008). Koncepcja resilience. Kluczowe poj˛ecia i wybrane zagadnienia. Medycyna Wieku Rozwojowego, 587–597. CBOS. (2018). Opinie na temat funkcjonowania opieki zdrowotnej. Warszawa: Fundacja CBOS. Available at: https://cbos.pl/SPISKOM.POL/2018/K_089_18.PDF CBOS. (2020). Postawy wobec epidemii koronawirusa na przełomie maja i czerwca. Warszawa: Fundacja CBOS. Available at: https://www.cbos.pl/SPISKOM.POL/2020/K_073_20.PDF CBOS. (2021). Obawy przed zara˙zeniem si˛e koronawirusem i postrzeganie działa´n rz˛adu w czerwcu. Nr 79/2021. Warszawa: Fundacja CBOS. Availalbe at: https://www.cbos.pl/PL/publikacje/rap orty.php Cierniak-Piotrowska, M., D˛abrowska, A., & Stelmach, K. (2021). Ludno´sc´ . Stan i struktura oraz ruch naturalny w przekroju terytorialnym w 2020 r. Warszawa: GUS.

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Available at: https://stat.gov.pl/obszary-tematyczne/ludnosc/ludnosc/ludnosc-stan-i-strukturaludnosci-oraz-ruch-naturalny-w-przekroju-terytorialnym-stan-w-dniu-31-12-2020,6,29.html Diyali, C. (2020). Psycho-Social problems of elderly during the time of pandemic and ways towards its solutions: A social work study on India. Exlibris Biblioteka Gerontologii Społecznej/Exlibris Social Gerontology Journal, 18(1), 123–134 https://doi.org/10.24917/27199045.181.11 European Centre for Disease Prevention and Control. (2021). Available at: https://vaccinetracker. ecdc.europa.eu/public/extensions/COVID-19/vaccine-tracker.html#age-group-tab Eurostat. (2021, 07 05). Deaths and crude death rate. Available at: https://ec.europa.eu/eurostat/ databrowser/view/tps00029/default/table?lang=en GUS. (2015). Warto´sci i zaufanie społeczne w Polsce w 2015 r. Available at: https://stat.gov.pl/ obszary-tematyczne/warunki-zycia/dochody-wydatki-i-warunki-zycia-ludnosci/wartosci-i-zau fanie-spoleczne-w-polsce-w-2015-r-,21,1.html GUS. (2019). Uniwersytety trzeciego wieku w Polsce w 2018 r. Warszawa. Available at: https://stat.gov.pl/obszary-tematyczne/edukacja/edukacja/uniwersytety-trzeciego-wieku-wpolsce-w-2018-r-,10,2.html GUS. (2020). Trwanie z˙ycia w zdrowiu w Polsce w latach 2009–2019. Warszawa. Available at: https://stat.gov.pl/obszary-tematyczne/ludnosc/trwanie-zycia/trwanie-zycia-w-zdrowiu-wpolsce-w-latach-2009-2019,4,1.html GUS. (2021). Trwanie z˙ycia—tablice. Available at: https://stat.gov.pl/obszary-tematyczne/ludnosc/ trwanie-zycia/trwanie-zycia-tablice,1,1.html Komisja Ekspertów ds. Osób Starszych. (2020). Sytuacja osób starszych w Polsce—wyzwania i rekomendacje. Warszawa: Biuro Rzecznika Praw Obywatelskich. Kompetenznetz Public Health COVID-19. (2021). Available at: https://www.researchgate.net/pub lication/341670713_Kompetenznetz_Public_Health_COVID-19_1_Soziale_Isolation_als_Ste rblichkeitsrisiko_fur_altere_Menschen. Ministerstwo Zdrowia. (2020). Zalecenia dotycz˛ace organizacji procesu udzielania s´wiadcze´n piel˛egnacyjnych i opieku´nczych w ramach opieki długoterminowej w zwi˛azku ze stanem epidemii i ryzykiem zaka˙ze´n SARS-CoV-2 i zachorowa´n na COVID-19. Available at: https://www.gov.pl/ web/zdrowie/wytyczne-dla-poszczegolnych-zakresow-i-rodzajow-swiadczen Ministerstwo Zdrowia. (2021). Raport o zgonach w Polsce w 2020 r. Available at: https://www.gov. pl/web/zdrowie/raport-o-zgonach-w-polsce-w-2020-r. Philip, J., & Cherian, V. (2020). Impact of COVID-19 on mental health of the elderly. International Journal Community Medicine and Public Health, 7(6), 2435–6. https://doi.org/10.18203/23946040.ijcmph20202513 SeniorHub. (2021). Jako´sc´ z˙ycia osób starszych w Polsce w pierwszym roku pandemii COVID-19. Warszawa: Instytut Polityki Senioralnej. Available at: https://seniorhub.pl/wp-content/uploads/ 2021/05/raport-jakosc-zycia-osob-starszych-09.pdf Szarota, Z. (2020). Indywidualne strategie adaptacyjne osób starszych w czasach pandemii COVID19. Exlibris Biblioteka Gerontologii Społecznej/Exlibris Social Gerontology Journal, 19(2), 13–31. https://doi.org/10.24917/27199045.192.1 Szatur-Jaworska, B. (2020). Polsenior 2. Sytuacja rodzinna i wi˛ezi społeczne osób starszych. Available at: https://konferencjapolsenior2.pl/userfiles/file/2.pdf Tobiasz-Adamczyk, B. (2020). Polsenior 2. Jako´sc´ z˙ycia. Available at: https://konferencjapolseni or2.pl/userfiles/file/4.pdf Uchwała nr 167 Rady Ministrów w sprawie ustanowienia programu wieloletniego na rzecz Osób Starszych “Aktywni+” na lata 2021–2025. (2020, 11 16). M. P. 2020 poz. 1125. Ustawa o osobach starszych. (2015). Dz. U. 2015 poz. 1705. Ustawa o pomocy społecznej. (2004). Dz.U. 2004 nr 64 poz. 596 ze zmn. Ustawa z dnia 27 sierpnia 2004 r. o s´wiadczeniach opieki zdrowotnej finansowanych ze s´rodków publicznych. (2004). Dz. U. Nr 210 poz. 2135 ze zmn. Zarz˛adzenie nr 2 w sprawie powołania Rady do spraw Polityki Senioralnej. (2013). Dz. Urz. MPiPS.

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Zrałek, M. (2021). Jak w warunkach pandemii realizowane jest prawo osób starszych do ochrony zdrowia pod wzgl˛edem dost˛epno´sci szczepie´n przeciw COVID 19. Available at: https://www. rpo.gov.pl/sites/default/files/Raportzbadandostepnosciszczepiendlaosobstarszych.pdf https://300gospodarka.pl/live/ile-zaszczepiono-na-covid-polska (status as of 29.07.2021).

Chapter 11

Intergenerational Family Relations in Old Age During Regular Times and in Covid-19 Period Sigal Naim, Ariela Lowenstein, and Ruth Katz

Abstract During the last few decades, we encounter a demographic revolution with increased life expectancy and a growing number of people 80+. These developments bring together several generations in families who interact in various life domains. Intergenerational family relations represent complex family interactions of solidarity. The most known model is the Bengtson one which includes six dimensions: structural solidarity—living arrangements; solidarity of contact between generations; emotional solidarity—mainly emotional support; functional solidarity—division of household chores; affectual solidarity—involvement in intimate relations with family members; normative solidarity—value transmission to younger generations. Recently another dimension—digital solidarity was added. Other researchers (Lüscher and Pillemer, Intergenerational ambivalence: A new approach to the study, 1998) added Conflict and Ambivalence. In a study comparing several countries, Israel was high in some of the dimensions: emotional, structural, contact, and functional. These data reflect the importance and strong family relations in Israeli society. All this occurs in “regular-normal” times before Covid-19. However, since the World Health Organization (WHO) instructed social distancing, in order to reduce face-toface contacts and by doing so, to reduce pandemic influence, the pandemic caused isolation for all, but impacting mostly the older population who could not meet with family and friends and being closed in their homes. To understand this special period and its impact on intergenerational relations from elders’ perspective, we interviewed 20 community-dwelling older people about their feelings, patterns of behaviour, changes, and differences they experience in their relations, in order to “validate” the Bengtson model. S. Naim (B) School of Health, Academic Center for Law and Science, Hod Hasharon, Israel e-mail: [email protected] Yezreel Academic College, Jezreel Valley, Israel S. Naim · A. Lowenstein · R. Katz Center for Research and Study of Aging, University of Haifa, Haifa, Israel e-mail: [email protected] R. Katz e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_11

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Introduction One of the most exciting scholarly debates in family research has been about the conceptualization of intergenerational relationships (Bengtson et al., 2002; Connidis & McMullin, 2002; Lüscher & Pillemer, 1998; Pillemer & Lüscher, 2004). Social gerontology has witnessed few conceptual and theoretical debates. Nevertheless, there is a growing debate regarding two paradigms of parent–child relations in later life: the solidarity–conflict model and the intergenerational ambivalence model. It would be right to say that those two models even compete between them, since they offer different conceptual lenses for understanding complex family relationships in various cultures, to understand microlevel interpersonal relations and macrolevel structural forces and the interactions between them (Lowenstein, 2007). The solidarity–conflict model suggests that parent–child relations in later life can be predicted by levels of cohesion and family conflict during younghood; the ambivalence model asserts that sociological and psychological contradictions are the centre of adult intergenerational relations Due to increase in life expectancy, more people will live longer within family structures while the structures of family are constantly changing because of population ageing, globalization that caused more diversity and complexity of family lives and intergenerational bonds (Katz et al., 2019). The article’ two main goals are (a) exploration of controversy behind the ambivalence versus solidarity–conflict models (b) comparison between the predictive adequacy of each model for the older people in Israeli society during Covid-19.

Three Conceptualizations of Intergenerational Solidarity in Later Life Intergenerational solidarity represents conceptualization of family relations in adulthood and development of a theory regarding differences between parent–child dyads in such relations. The solidarity model describes sentiments, behaviours, and attitudes within family relationships (Roberts & Bengtson, 1990) which was later critiqued, modified, and expanded. Bengtson and colleagues demonstrated six dimensions of parent–child solidarity: association—frequency and patterns of interactions in family activities; affect—type and degree of positive sentiments about family members; consensus—agreement on values, and beliefs between family members; function— assistance and exchange of resources; normative—commitment to familial roles and obligations; and family structure—number of members and geographic proximity (Bengtson & Schrader, 1982). The solidarity framework is yet a social gerontology dominant paradigm. However, some concerns have been raised about the model normativity, i.e., it instructs how family relationships should be rather than how they are. The term solidarity implies consensus, although there are always nonconsensual aspects of family

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relationships. Therefore, it was argued that the solidarity model contains normative implications that easily lend themselves to idealization (Marshall et al., 1993). Some also asserted that the model does not consider conflict and ambivalence, nor does it provide insight into conflictual intergenerational relationships (Lüscher & Pillemer, 1998).

Intergenerational Conflict in Later Life During the 1980s, the paradigm was modified to become the family solidarity– conflict model, which incorporates conflict considering the possible negative effects of too much solidarity (Silverstein et al., 1996). Solidarity and conflict are not a single continuum, Rather, family relations can include both high solidarity and high conflict, or low solidarity and low conflict, depending on family dynamics and situations. According to Bengtson and colleagues, conflict is a natural part of human life (as mentioned in the basic assumption of conflict theory) that represents a separate dimension of family intergenerational relations (Bengtson et al., 2002).

Intergenerational Ambivalence in Later Life Lüscher and Pillemer (1998) regarded ambivalence as a conceptual perspective for examining parent–child relations in later life. They proposed using the concept of intergenerational ambivalence to “designate contradictions in relationships between parents and adult offspring that cannot be reconciled” (Lüscher & Pillemer, 1998: p. 416). Thy claimed that ambivalence should be the primary topic of study of intergenerational relations, because “societies and the individuals within them are characteristically ambivalent about relationships between parents and children in adulthood” (Pillemer & Lüscher, 2004: p. 6); (Connidis, 2015; Connidis & McMullin, 2002; Pillemer et al., 2007). Bengtson and colleagues (2002) argued that the idea of ambivalence is complemented rather than competed with the solidarity–conflict framework: “From the intersection of solidarity and conflict comes ambivalence, both psychological and structural” (p. 575). They concluded that both solidarity–conflict and ambivalence models could be regarded as lenses “through which one can look at family relationships—complementary instead of competing” (p. 575).

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Intergenerational Digital Solidarity in Later Life The attempt to describe and explain contact patterns between family members (associational solidarity), especially parents and their adult children, is extended today to the digital world, using ICTs (Information and Communication Technologies). The concept of digital solidarity was recently introduced by Peng et al. (2018). According to their study, digital solidarity adds a new dimension and mean of communication to the Solidarity model components by augmenting offline and online communication. Digital communication is more accessible, while still being perceived as less intrusive than phone or face-to-face contact, and therefore may be perceived as another mean of helping older family members stay in regular contact with their relatives. Digital solidarity describes a form of communication that is instant and virtual at the same time. As such, it enhances intergenerational cohesion in ways that both complement and supplement more traditional forms of communication. Unlike traditional communication, digital communication requires less coordination, time investments, and efforts (Peng et al., 2018). As opposed to face to face or phone communication, digital communication can be more frequent, while perceived as less intrusive. This may be valuable particularly to frail older parents that wish to stay in continuous contact with their adult children. It has been found that people who are not using the internet and have children and grandchildren in their socializing support network are more likely to ask others to help them with their internet usage (proxy Internet use) (Dolniˇcar et al., 2018). Thus, at a time when digital solidarity communication with and between family members, provides new methods of contact and plays an increasing role in intergenerational family relations, it is important to understand the role of such communication in ties between the oldest and youngest generations. However, empirical knowledge about the impact of different forms of communication on family relations is sparse. Antonucci et al. (2017) analysed the positive and negative sides of new communication technologies and concluded that “the advent and evolution of these technologies provide exciting and promising new directions for how we develop, use, and experience social relations” (p. 5). The Covid-19 pandemic forced and yet forcing population to keep physical distance in order to reduce the virus spread. For now, impact of a decrease in offline, personal face-to-face interactions of older people is unclear, with some evidences for negative impact. It is known that intergenerational contacts have major implications on older adults’ mental health. Maintaining those contacts through ICT may reduce those implications and help older adults and their family members enhance their mental resilience.

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Intergenerational Relationships in “Regular” Times Family takes a crucial part of social intersection in all societies. Intergenerational bonds among adult family members may be more important today than they were in earlier decades, mainly due to longevity and the increased need for all kinds of assistance with age (Bengtson, 2001). Intergenerational family exchange is one of the main important social issues, especially in old age, because families, even in modern societies, are still the main source of care and support for older people. This is due to societies and governments inability or unwillingness to continue to meet the needs of older people, hence, placing family in a central caregiving role. The family is one of the most basic social institutions, as it is representing the very first group into which one enters at birth. In most cases, family ties remain primary throughout life (Hoff & Tesch-Römer, 2017). In today’s era of modernization and global ageing, individual life courses and family forms are diversifying (Lowenstein, 2005). Population ageing results in fewer family members and caregivers being available for growing number of older people. Parallel to ageing of populations process, changes in family structures occur. Those changes create uncertainty within intergenerational relationships and expectations (Biggs et al., 2011). Population ageing process changes balance in care provision between older and younger people and between families and the state. Fewer younger children and grandchildren mean fewer family members and caregivers looking after older people in need of care. These processes pose challenges for societies and governments, forcing them to seek new ways of generational communication, social inclusion, and social integration (Katz et al., 2019). Are there similarities/differences between different societies at different points in time? In a study (Katz et al., 2019) that explored various dimensions of generational relationships between older parents and their adult children, a comparison to Dykstra’s and Fokkema’s (2011) analyses was made. Using the intergenerational solidarity model as conceptual framework enables analyses to conclude four family relationship types emerging in all societies, albeit with different frequencies. Four conclusions were drawn: (1) importance of personal resources; (2) cultural differences and meanings for families; (3) within-country differences; and (4) strength of intergenerational solidarity. The study also reveals four types of generational solidarity common across European countries and Israel: (a) descending, (b) ascending, (c) supportive-at-distance, and (d) autonomous. Descending familialism means living close to and having frequent contact with children, parents are greater providers of in-kind support to their adult children. On the contrary, Ascending familialism is characterized by living close to children with frequent contact and belief in family norms. Where there is increase in familialism, children are the main in-kind support providers. The third term is “supportive at distance”, meaning not living close to children but having frequent contact with them, and parents are the greater providers of financial support to their adult children. Finally, autonomous, is not living near children, having a low level of

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contact. In Table 11.1, we present the distribution of family types by European countries and Israel. As can be seen, four family types distribution was quite similar across the 11 original countries. In only two countries—Sweden and Greece—there was a five per cent difference within the autonomous family type. In Israel, about a third of respondents matched descending familialism type, meaning strong family solidarity, and in-kind transfers flow downward. Another third of respondents where in the autonomous type with few support exchanges (Dykstra & Fokkema, 2011). Finally, the findings of the above-mentioned studies show that, even in the modern era, intergenerational solidarity is still strong in most European countries and Israel. Table 11.1 Distribution of late-life family types by country: Comparing SHARE wave 1 (11,181) and Wave 2 (15,975) (weighted percentages) Countries

Family type Type 1 Descending familialism

Sweden

Type 2 Ascending familialism

Type 3 Supportive-at distance

Type 4 Autonomous

Wave 1

Wave 2

Wave 1

Wave 2

Wave 1

Wave 2

Wave 1

Wave 2

34

36

19

22

12

13

35

29

Denmark

29

31

21

20

12

14

37

35

The Netherlands

36

35

28

30

9

9

28

26

Belgium

42

43

25

22

5

4

29

31

Germany

32

29

26

27

7

6

36

38

France

25

28

23

24

7

7

45

41

Austria

28

30

32

28

8

9

33

33

Switzerland

27

25

25

26

6

8

42

41

Italy

37

34

38

37

3

4

22

25

Spain

30

29

44

45

1

1

24

25

Greece

34

32

42

38

6

4

19

26

34

Israel European mean without Israel European mean (12 countries)

35

32

32

24 25

29

28

7 7

7

7

35 33

32

33

Notes Wave 1, based on the 11 European countries in the Survey of Health, Ageing and Retirement in Europe. Sample size: 11,181. Source: Dykstra and Fokkema (2011); Wave 2 based on the 12 European countries in the Survey of Health, Ageing and Retirement in Europe, including all European countries that originally participated in Wave 1, so as Israel. Sample size: 15,975

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Around half of the respondents were clustered in the descending and ascending relationship types. These types are characterized by adult children living in close proximity to their older parents, having frequent contact with them, believing in the norms of filial obligations, and providing and/or receiving in-kind support. Only a third of respondents (except for the southern countries of Greece, Italy, and Spain) were clustered in the autonomous type characterized by geographical distance between parents and children, and few support exchanges.

Family Relationships During Covid-19 Period When the pandemic started it mostly had a strong impact on community-dwelling older people who were vulnerable because of various ailments, two lockdowns and limitations on their movements, and ability to meet face to face with their families. Thus, it is important to understand the implications of such period on intergenerational family relations. To highlight the attributes of such a strange and new situation, we interviewed 20 community-dwelling old man and women 65+ years old. Some of these interviewees are still in the labour market, some are involved in volunteering work. Semi-structured interviews were focused on quality of life and family relations. Many interviewees described rich and fulfilling family relations with their children and grandchildren before the pandemic started. Regarding the pandemic period, there are different attitudes and perceptions about the impact of Covid-19 on their feelings. Some express hardships while others use various technologies to be in constant touch and feel good. They used to visit us, and many times stayed overnight. During holidays we all celebrated together, enjoying rich meals. We used to accommodate my 94 old mother and she enjoyed being with her great grandchildren. It was wonderful to see all family together, happy and healthy (R, 70).

The pandemic with the three lockdowns undermined the ability for families to get together, and of course, it had negative impacts on family relations, especially on the older population. However, some were creative and managed to find ways how to be in contact, in spite of the restrictions. The following example is of a grandmother who has 7 grandchildren: I have seven adult grandchildren and 13 great grandchildren, all of whom live about an hour away from the city I live in. Due to the Corona virus I had not seen them in about four months, and I decided to take advantage of the break between lockdowns to invite one family unit at a time for brunch on Saturday. It was wonderful. I made appointments with each several weeks in advance, and each family enjoyed the special attention. I asked the grandson who was on his own whether he wanted to come with one of his siblings, and he said “no”. What a compliment! Fortunately, there was enough time for all before the next lockdown. I am now in the middle of the next round. Maybe we will keep it up for as long as I can make brunch!! (A, 85).

Some interviewees talked about children’s concern that they might infect their older parents and especially grandparents, and thus they hardly come to visit:

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I had a conversation with my oldest son before the high holidays when we usually celebrate all family together, telling me that he would not come with his family because he cares for us and afraid and therefore he refused to come…Currently everybody is nervous because what they see on TV and thus it is a very difficult time for me (S, 70).

Some other grandparents perceived the refusal of children and grandchildren to meet “face to face” as reflecting kind of “ageism” towards them. Our children and grandchildren were supposed to come and celebrate my birthday. We both were excited about it and prepared small gifts for them and planned to have a special dinner. Several days before, our daughter told us that they consulted every family member and decided to postpone till better times. I could somehow understand them, but my husband was very hurt and did not want to see them for a while (R. 78).

Other elders mentioned that although they do not meet with children and grandchildren there is a sort of “compensation” by talking with them when they call every day: Because of the pandemic they are much more worried, care more and call every day, sometimes twice a day, to hear how I feel and if I need something (W, 86).

Some interviewees differentiate between their capacity to be in touch with older versus younger grandchildren. With their older grandchildren they can use various technological devices which is complicated to do with the very young grandchildren. During the first period of the lockdown, we suffered because we could not meet with our grandchildren for several months. We are disciplined and thus, with the older grandchildren we communicated by phone, Zoom, or WhatsApp. However, we could not do it with the younger grandchildren. Therefore, we ‘sneaked’ to see them when they were asleep (A, 86).

Some other families used other avenues to see family by “open space” meetings, like in parks or at the beach: One of our children suggested the idea of meeting in one of the city’s parks. Each family will bring small table and chairs and their own food. This way, we will follow the “keeping of distance” instructions. This what we did several times, when the weather allowed, and it was a real pleasure (D, 80).

Some interviewees mentioned the division of responsibility between the State and the family, to take care of elders. This is especially important during the difficult period of Covid-19, because they don’t trust the government to assist when they will be in need: I cannot trust the state to help if I will need it, because even if some assistance is provided it does not answer all needs. Therefore, we need to rely on the family, the children should be the first to help their parents when they need it. I am afraid though, because I know the difficult financial situation of my children (B, 88).

As the pandemic continues, its implications especially on older adults are serious. Some of the interviewees were anxious that life would never be the same: As we are facing a third lockdown. This time it would even be more difficult to meet and see the children and grandchildren. This, because we “have been there” during the last two lockdowns. Thus, we are worried for the unknown future, will there be an appropriate immunization and we can go back to our “normal life”? (N, 75).

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Discussion Intergenerational family relations represent complex family interactions of solidarity. We aimed to find out if there were differences in family relations between older adults and their children and grandchildren during two periods: Those before Covid-19 (regular times) and if and what happened during the period when we have to cope with the pandemic. The interviews conducted put a “spot-light” on the significance of intergenerational family relations with children and grandchildren on the lives of older parents and grandparents during regular times and especially during Covid-19 period. One of the interviewees expressed it. Suddenly you understand what’s really important in life. Less participating in cultural events, travelling abroad, going out to restaurants. What’s left and important is keeping the relations with family and strengthen it. This is mostly needed because we care for each other (R. 78).

Most dimensions of the model (Bengtson & Schrader, 1982; Lowenstein et al., 2003) were mentioned in the interviews. Most important were association and affectual solidarity, which emphasize closeness, warmth, and positive sentiments among family members, as well as frequency of interactions and sharing common activities. These dimensions were the first which were mentioned by many of the interviewees, expressing strong emotions of fear and hardship because meeting with family was central to their quality of life and thus, they miss it so much more. Other dimensions frequently described were normative and functional solidarity which focus on strength of commitment to familial roles and obligations, as well as exchange of assistance and reciprocity between family generations. Most interviewees talked about the centrality of the family and the importance of involvement of members in “regular times” and it being indispensable during the difficult pandemic period. Others who could not keep a constant touch with family expressed suffering because their quality of life deteriorated. Some felt that children should take care of older parents and they should be responsible to keep in contact. The interviewees were aware of their need to receive assistance from their children, especially as they do not fully trust the provision of adequate means to facilitate their needs when necessary. Some of the older adults were creative and succeeded in keeping regular contacts with family members by using meetings in the parks; at the beach; using different digital technologies, especially Zoom, where you can also see each other, to be updated; to meet only one grandchild at a time; meeting at our big terrace and enabled them to invite more family members together. Two other dimensions of family relations are conflict and ambivalence. Conflictual situation between older parents and their children/grandchildren were not revealed in our interviews. We speculate that although during “regular times” conflict does exist, however, in face of Covid-19 pandemic, conflicts are not expressed verbally, but ambivalent feelings could be “located”. Pillemer and Lüscher (2004) proposed that intergenerational ambivalence reflect contradictions in relationships between parents and adult offspring that cannot be reconciled. One of the interviewees described the mixed feelings she and her husband experienced when the children told them that

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they decided to postpone her birthday celebration. On one hand, they understood the situation but at the same time they felt that they are excluded. It is obvious that there are differences between “ordinary” days to Covid-19 time in intergenerational meetings intensity, which impose difficulties and decrease quality of life among older parents and grandparents, especially within Israeli society where family gathering with children and grandchildren are common and an essential part of aged people daily life. However, the researchers found differences even among study interviewees in their descriptions of this new situation’ consequences. Some of them find the inability to meet their family members very hard, fear for the future, and express hard feelings of helplessness. On the other side, others found alternative ways to maintain those relationships despite the pandemic. Faced the restrictions and limitations with varied ways and express more positive and even optimistic approach, relating this new and uncertain situation “only” as another life-challenge that should be crossed successfully. To sum, intergenerational family relations are especially meaningful during difficult times like Covid-19, and it was reflected in most interviews. This new, unknown, and uncertain pandemic requires re-negotiation between mutual moral expectations of older and younger generations. Thus, all efforts should be made to protect such relations together with reframing them within new modern technological abilities.

References Antonucci, T. C., Ajrouch, K. J., & Manalel, J. A. (2017). Social relations and technology: Continuity, context, and change. Innovation in Aging, 1(3), igx029. Bengtson, V. L. (2001). Beyond the nuclear family: The increasing importance of multigenerational bonds: The burgess award lecture. Journal of Marriage and Family, 63(1), 1–16. Bengtson, V., Giarrusso, R., Mabry, J. B., & Silverstein, M. (2002). Solidarity, conflict, and ambivalence: Complementary or competing perspectives on intergenerational relationships? Journal of Marriage and Family, 64(3), 568–576. Bengtson, V. L., & Schrader, S. S. (1982). Parent-child relations. Research Instruments in Social Gerontology, 2, 115–186. Biggs, S., Haapala, I., & Lowenstein, A. (2011) Exploring generational intelligence as a model for examining the process of intergenerational relationships. Ageing & Society, 31(3), 353–371. Connidis, I. A. (2015). Exploring ambivalence in family ties: Progress and prospects. Journal of Marriage and Family, 77(1), 77–95. Connidis, I. A., & McMullin, J. A. (2002). Sociological ambivalence and family ties: A critical perspective. Journal of Marriage and Family, 64(3), 558–567. Dolniˇcar, V., Grošelj, D., Hrast, M. F., Vehovar, V., & Petrovˇciˇc, A. (2018). The role of social support networks in proxy Internet use from the intergenerational solidarity perspective. Telematics and Informatics, 35(2), 305–317.

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Dykstra, P. A., & Fokkema, T. (2011). Relationship between parents and their adult children: A West European typology of late-life families. Ageing & Society, 31(4), 545–569. Hoff, A., & Tesch-Roemer, C. (2017). Family relations and aging—Substantial changes Since the middle of the last century?. In: R. Katz, A. Lowenstein, D. Halperin, & A. Tur-Sinai (eds.), New dynamics in old age individual, environmental, and societal perspectives (pp. 65–84). Routledge. (2015). Generational solidarity in Europe and Israel. Canadian Journal on Aging/La Revue Canadienne du Vieillissement, 34(3), 342–355. Katz, R., Lowenstein, A., & Tur-Sinai, A., (2019). Intergenerational family relationships and successful aging (pp. 455–474). In: R. Fernandez-Ballesteros, A. Benetos, & J. M. Robine (Eds.), Cambridge Handbook of Successful Aging. Cambridge University Press, UK. Lowenstein, A. (2005). Global aging and the challenges to families. In M. Johnson, V. L. Bengtson, P. G. Coleman, & T. Kirkwood (Eds.), Cambridge handbook on age and aging (pp. 403–413). Cambridge: Cambridge University Press. Lowenstein, A. (2007). Solidarity–conflict and ambivalence: Testing two conceptual frameworks and their impact on quality of life for older family members. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 62(2), S100-S107. Lowenstein, A., Katz, R., Mehlhausen-Hassoen, D., & Prilutzky, D. (2003). Intergenerational solidarity in a comparative cross-national perspective. Retraite et Societe, 38, 52–79. Abstracted in English in www.ladocumentationfrancaise.fr Lüscher, K., & Pillemer, K. (1998). Intergenerational ambivalence: A new approach to the study of parent-child relations in later life. Journal of Marriage and the Family, 413–425. Marshall, V. W., Matthews, S. H., & Rosenthal, C. J. (1993). Elusiveness of family life: A challenge for the sociology of aging. Annual Review of Gerontology and Geriatrics, 13, 39. Peng, S., Silverstein, M., Suitor, J. J., Gilligan, M., Hwang, W., Nam, S., & Routh, B. (2018). Use of communication technology to maintain intergenerational contact: Toward an understanding of ‘digital solidarity’. Connecting Families, 159–180. Pillemer, K. A., & Lüscher, K. (Eds.). (2004). Intergenerational ambivalences: New perspectives on parent-child relations in later life (Vol. 4). Boston: Elsevier/JAI. Pillermer, K., Suitor, J., Mock, S., Sabir, N., Pardo, T., & Sechrist, J. (2007). Capturing the complexity of intergenerational relations: Exploring ambivalence withing later life families. Journal of Social Issues, 63(4), 775–791. Roberts, R. E., & Bengtson, V. L. (1990). Is intergenerational solidarity a unidimensional construct? A second test of a formal model. Journal of Gerontology, 45(1), S12–S20. Silverstein, M., Chen, X., & Heller, K. (1996). Too much of a good thing? Intergenerational social support and the psychological well-being of older parents. Journal of Marriage and the Family, 970–982.

Chapter 12

The COVID-19 Routine: Towards Integrated Interventions in Detecting, Identifying, and Treating Elder Abuse and Neglect in Israel Tova Band-Winterstein and Sara Alon Abstract Exposure to the COVID-19 virus, which has become a global pandemic, challenges society, in general, and the older adult population, in particular. This epidemic has had a significant impact on different aspects of daily life among older adults in the community, and in long-term care facilities and institutions. In addition, it has affected the roles of professionals, formal (private/hired caregivers) and informal caregivers (family members), organizations, NGOs, government offices, and policy makers. The current chapter aims to provide professionals with the necessary knowledge needed to assess situations of suspected abuse/neglect and to provide effective interventions in the new life routine, in light of COVID-19, and in the case of future “states of emergency” or other threatening situations. Three case studies will be presented followed by principles, guidelines, and recommendations for implementing interventions regarding older adults and other target populations at risk of abuse/neglect. These guidelines are a product of the discussions held by the Inter-Ministerial Committee for the Prevention of Elder Abuse and Neglect. Keywords Older people · Abuse · Interventions · Integrated approach

Introduction Exposure to the COVID-19 virus, which has become a global pandemic, challenges society, in general, and the older adult population, in particular. This epidemic has had a significant impact on different aspects of daily life among older adults in the community, and in long-term care facilities and institutions. In addition, it has affected the roles of professionals, formal (private/hired caregivers) and informal

T. Band-Winterstein (B) Haifa, Israel e-mail: [email protected] S. Alon Tel Aviv University, Tel Aviv, Israel © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_12

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caregivers (family members), organizations, NGOs, government offices, and policy makers. The current chapter aims to provide professionals with the necessary knowledge needed to assess situations of suspected abuse/neglect and to provide effective interventions in the new life routine, in light of COVID-19, and in the case of future “states of emergency” or other threatening situations. Three case studies will be presented followed by principles, guidelines, and recommendations for implementing interventions regarding older adults and other target populations at risk of abuse/neglect. These guidelines are a product of the discussions held by the Inter-Ministerial Committee for the Prevention of Elder Abuse and Neglect in Israel.

The COVID-19 Period and Perceived Threat One of the unique aspects of the COVID-19 pandemic is that it caught everyone unawares, and rapidly developed into a global crisis. The fact that there was no time to prepare has increased the ongoing sense of threat. This situation poses immense challenges on individual, community, and organizational levels, and forces policy makers to confront and resolve a multitude of obstacles and dilemmas. Perceived threat is defined as “an event or situation in which the individual or things related to him are at risk, and the results are unknown” (Rosa, 2003: p. 56). Exposure to threatening events can influence the individual in such a way that he perceives his basic situation and living conditions as being at risk (Daphna-Tekoah et al., 2020; Lifshitz et al., 2016; Pidgeon et al., 2003; Wachinger et al., 2013). Exposure to risk may be direct or indirect. The extent of impact depends upon the extent of the threat, as perceived by the individual as well as the society, and the responses and steps are taken in an attempt to cope with this threat (Kasperson et al., 1988). The source of a perceived threat often begins with an emergency situation or event, and its accompanying chaotic response. This is followed by identifying the event’s characteristics, organizing one’s life in accordance with the new routine imposed by the event, and implementing suitable intervention methods. It is important to note that during this period, the permanent parameter of uncertainty intensifies, and rapid changes occur in accepted behaviour patterns and habits. The perceived threat of COVID-19 takes place within a “shared reality” (Baum, 2010; Echterhoff, 2012), in which the various frameworks providing treatment and care, as well as the older adult population itself, are simultaneously “at the mercy” of an event that has affected society as a whole—in Israel and throughout the world. This shared reality has several characteristics: the event is collective and affects the entire community; it is happening in the “here and now” and has not yet finished; its end is uncertain; and the event is accompanied by dramatic changes in the lives of the participants. This type of situation demands reorganization and adaption to a new and unfamiliar reality.

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Moreover, as this reality is extremely dynamic, the guidelines and instructions for how to behave also change on a daily basis. An additional complexity related to living in long-term care facilities is the shared “perceived threat” attitudes of the residents, and the staff members from various professional fields, who live and/or interact within these frameworks. Institutional environments are largely characterized by the unique life patterns of those who inhabit them. These include a narrowing of the residents’ personal space and, in certain respects, that of the staff; a hierarchical structure with a clear distinction between staff members and residents; and residents’ limited options to exert control over their daily lives (Goffman, 1961). During this threatening COVID-19 period, a lockdown order was imposed, aimed at protecting residents from further risks. Separation and distancing restrictions—from elderly residents’ family, community, and society—increased the difficulties of residents, staff, and family members (Ayalon et al., 2020). The role of various governmental offices (such as The Ministry of Health and The Ministry of Labor and Social Affairs)—the formal and administrative regulators responsible for the inspection and monitoring of such long-term care facilities—became less effective during this period. Another issue that merits discussion regarding the current COVID-19 routine is the treatment of multi-cultural groups such as the Arab, Ethiopian, Ultra-Orthodox, and new immigrant populations.

Unique Characteristics of Target Populations The Older Adult Population Israel is a democratic state which embraces a combination of modern and traditional values. On the one hand, it is a progressive country with high standards of industry, technology, and health. On the other hand, Israel has a strong, traditional, and familyoriented culture. The population is comprised of a Jewish majority, and Muslim, Christian, and Druze minorities groups which together constitute almost 20% of Israel’s population (Schnor & Cohen, 2021). The older adult population in Israel—women aged 62 and above, and men aged 67 and above, according to the Social Security, Retirement Benefits Law (1995)—is comprised of over one million people (12% of the general population) (Schnor & Cohen, 2021). Older adults living in the community are not homogenous in terms of age, health conditions, socio-economic status, etc. The majority of older adults are relatively healthy, independent, and functioning. Some still work and earn a living. Therefore, the imposed lockdown order and social distancing restrictions which have isolated older adults from their familial, cultural, and occupational circles had a negative effect on their mental wellbeing, health, and economic situation (Makaroun et al. 2020). It is important to differentiate among the various groups of older adults in accordance with diverse parameters such as health condition, belonging to a

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community/institution, personal status (single/widowed), living with family, sources of support, and social-cultural-occupational networks). During the COVID-19 crisis, older adults—along with the general population— living under quarantine, social distancing, and lockdown conditions, experience emotional distress (Lopez et al., 2021), high levels of uncertainty regarding their future. This may lead to a sense of helplessness and health concerns, due to reduced sources of assistance, lack of accessibility to services and resources, reduced formal and informal support networks, and an increase in the need to acquire new and unfamiliar skills (Kotwal et al., 2021). For example, there is currently an urgent need for older adults to acquire skills enabling them to utilize technology. Older adults who do not possess such skills may experience higher levels of difficulty and frustration regarding access to services and sources of assistance, such as banks and health clinics. Among the different groups, it is necessary to consider older adults who, as a result of their reduced functioning, receive various forms of care and assistance from Israeli or foreign paid caregivers. In accordance with the Ministry of Health’s safety regulations, these older adults must remain at home, under lockdown conditions, with their paid caregiver, 24/7. This reality may very likely increase stress among both caregivers and care recipients (Alon & Lowenstein, 2020). Another group of older adults that requires special attention is that of adults residing in assisted living and long-term care facilities. The required social distancing from families and friends imposed upon these older adults, in an attempt to protect them from additional risks, has a strong influence on their general welfare. Staff members’ daily comings and goings from the institutional setting serve to increase the fear of contagion—both among the residents as well as their families. Moreover, staff members may be afraid to work with elderly COVID-19 patients, which can lead to a lack of manpower. Over the course of the crisis, many residents in assisted living facilities found themselves on their own, under quarantine and/or lockdown conditions, with minimal human contact. As part of the new life routine during COVID-19, the restriction of movement and social distancing required by Ministry of Health policies and regulations were constantly being updated and changed, requiring increased awareness, flexibility, and adaptability from all involved parties.

Family Members The uniqueness of the COVID-19 period for family members is largely characterized by concern for loved ones and a lack/surfeit of information updates. At the same time, there is a need for general reorganization, amidst worries about making a living, being able to provide the family with its immediate basic needs, and the desire to help versus the need to separate from older parents during a time of great difficulty. All of these factors serve to intensify family members’ distress. This reality may lead to an increase in elder abuse and neglect initiated by family members. Reports from the Israeli police and other service providers indicate an increase in the number of domestic violence and elder abuse cases

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(Alon & Lowenstein., 2020). Similar reports are being published throughout the world (Makaroun et al., 2021). Research findings indicate that adult children living with their older adult parents may be fertile ground for abusive behaviours (Borenstein, 2019; Mysyuk et al., 2016). Caring for an elderly parent can be stressful, and stress was found to be a risk factor associated with abuse and neglect (DeLiema et al., 2018; Wang et al., 2019). On the other hand, the financial and emotional dependency of an adult child on an older parent was also found to be a risk factor associated with abuse and neglect. The adult child may experience a sense of loss of control, as a result of having to move back to the family home. In reaction to the perceived feeling of powerlessness, and in an attempt to regain control, he/she may act abusively towards the older parent (Band-Winterstein et al., 2016; Labrum & Solomon, 2018). As mentioned above, many adult children have returned to their parents’ home as a result of unemployment, being furloughed, or an unplanned return from abroad. Living together for a prolonged period of time, especially under lockdown conditions, can provoke many types of conflicts. In addition, the fact that the older parents have a steady income may be a source of potential exploitation. Research findings indicate that adult children’s dependency on an older parent, social isolation, and stress are among the most common risk factors associated with elder abuse (Alon & Lowenstein., 2020; Dong et al., 2014; Pillemer et al., 2016). Family members who live with people who have dementia or Alzheimer’s may also experience extreme levels of stress and burnout (Killen et al., 2020). All of the above indicate the increased likelihood of an escalation of conflict in relationships and family dynamics which may lead to the occurrence of abusive events, neglect, and the exploitation of older adults (Alon, 2021).

Paid Caregivers About a quarter of a million older adults are eligible for benefits under the Home Nursing Care Law (1995). Personal assistance is provided by 80,000 Israeli paid caregivers, some of whom are 65 years of age and above (Schnor & Cohen, 2021). As a result of the current situation, paid caregivers may experience difficulties, due to the need to utilize public transportation, and fears related to making home visits to older adults. This affects elderly care recipients, who are not receiving the proper care, as well as the paid caregivers, who may find themselves without an income. In addition, in Israel, there are over 40,000 foreign caregivers employed under the Home Nursing Care Law (1995). When COVID-19 hit, all foreign caregivers were required, in accordance with Ministry of Health regulations, to comply with the lockdown and restriction of movement orders. These new measures obliged foreign workers, by law, to remain at home with their elderly employers, 24 h a day, 7 days a week—with no possibility of leaving the house, or taking a break from their Sisyphean task.

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As a result of feeling threatened, and having to cope with continuous and rapidlychanging guidelines and restrictions, elderly care recipients—now more than ever— require close attention and assistance. However, this need comes at a time when caregivers’ freedom of movement has been heavily restricted, resulting in caregivers’ feelings of burnout, stress, and fatigue. These feelings sometimes lead to more extreme situations of mental distress, mainly because of the population under discussion—older adults—often characterized by functional limitations, including physical and/or cognitive impairment. Burnout and stress can result in elder abuse and neglect (Ayalon, 2009).

Professional Staff Health care professionals, as well as social services professionals, are currently operating in an extremely stressful and dynamic reality (Daphna-Tekoah et al., 2020). In their professional role, they must provide assistance to older adults in the community and in long-term care facilities. The changing guidelines regarding the provision of such care and assistance means that healthcare professionals must be creative, constantly adapt to the rapidly-changing reality of the moment, and ensure open channels of communication for clients and their families. Therefore, special attention must be given to staff members and healthcare professionals, to help them deal with ongoing stress and high levels of uncertainty (Band-Winterstein et al., 2010). In addition, during this time, various professionals face rapidly-shifting priorities and commitments. Some professionals have suddenly found themselves answering phones at call centres and providing emotional support for older adults; others are working hard to meet immediate and basic needs, such as providing clients with food, medication, and assistance. These types of shifting priorities in one’s professional role may be extremely challenging. At the same time, professionals must also deal with the extreme difficulties that have cropped up in their own lives at this time. They, like everyone else, must cope with risk; take care of their children, who no longer have an educational framework; care for elderly parents, etc. These professionals must often think fast on their feet, quickly find creative solutions for ad-hoc situations, and navigate between their personal life, and the professional commitments and “instructions” dictated by policy makers—no easy task (Tosone et al., 2004). Another important topic relates to a lack of coordination among and between the various government offices, organizations, and service providers. This lack of coordination has a direct influence on professionals, and their ability to function effectively and provide clients and/or their families with suitable responses. Moreover, volunteer organizations’ efforts to provide assistance are also often uncoordinated, resulting in overlapping service provision, and a general lack of efficiency. This leads to multiple frameworks operating in parallel, often working on similar, and sometimes identical, issues, but with a complete lack of communication among the various groups. As no exchange of information takes place, there is no clear distribution of responsibilities

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and tasks, any shared insights, lessons learned, or conclusions drawn among these different frameworks.

Policy Makers During times of crisis, effective coordination among the various government offices is essential. A lack of satisfactory coordination in this realm makes it difficult to see “the big picture”, share essential information, and look for and implement joint solutions. As a result of COVID-19, there was, and still is, a need to shift priorities, meet individuals’ basic needs, and respond to situations related to health and social risks, including elder abuse and neglect. Moreover, it very quickly became necessary to appoint professional and experienced teams to deal with elders at risk, in general, and elder abuse and neglect, in particular.

Summary In the current crisis situation, it is absolutely essential to establish a proper balance between the growing needs of the older adult population and their need for protection, whilst safeguarding their rights and autonomy. The prevalent feeling of ongoing uncertainty may intensify people’s sense of perceived threat and feelings of helplessness. At the same time, the resources available to target populations, policy makers, and organizations may be limited. As was mentioned above, despite the fact that all of the involved organizations and social institutions dealing with the COVID-19 challenge share the same reality, there is often a lack of coordination among these entities, resulting in an overlap of services and multiple conflicts of interest. As a result, the decision-making process and actual implementation of assistance and interventions may have a negative effect on the elderly population and their families, as well as on the formal and informal professionals who care for them. Thus, there is a clear need to strengthen collaborations and cooperative efforts in order to more efficiently cope with the new reality the world is currently facing. In order to enable effective management in today’s new and unfamiliar life routine, it is important to identify and delineate common principles and plans of action. The next section will present recommended guidelines for coping with challenges arising in the COVID-19 routine.

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Principles and Guidelines for Coping with Challenges in the COVID-19 Routine The Older Adult Population . Identify sub-groups among the older adult population—according to health, functioning, social, and occupational characteristics. In this context, it is necessary to map the different needs of each population group. . Develop immediate responses and provide basic needs in an integrative manner, including food, medication, and accommodation. These needs must be clearly defined and prioritized. . Provide responses for emotional, social, and cultural needs in different situations, including those requiring caregiving and functional assistance. If necessary, new sources of support should be created. . As a result of social distancing, many people have a surplus of leisure time. Therefore, there is an acute need to acquire and/or strengthen technological skills in order to have access to online capabilities (i.e. communication with family and friends, lectures, physical exercise videos, etc.). . Maintain a sense of continuity with formal service providers via technological access. . Keep up a sense of continuity with family members and other informal involved parties by maintaining the wellbeing of older adults, in general, and vulnerable older adults, in particular. . Increase the level of social supervision to identify potential risks associated with elder abuse/exploitation/neglect. . Provide information on legal matters such as arranging powers of attorney regarding medical matters and/or matters of property, preparing one’s last will and testament, etc. . Provide information about the possibility of receiving free legal aid services from the Ministry of Justice, for those who are eligible. . Maintain optimal and continued provision of medical services. To achieve these objectives, it is necessary to map all of the involved organizations, offices, and frameworks as well as their specific roles, by assigning each one clear areas of responsibility. It is imperative to create a mechanism of optimal coordination among these entities regarding both relevant and beneficial information exchange, as well as the planning and implementation of effective responses and interventions.

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Family Members in the Role of Caregivers . Maintain ongoing contact between close family members and older adults (in the community and in long-term care facilities). . Share information and involve family members in decision-making. Provide updated, reliable, and transparent information. . Provide families with emotional support. . Identify risk factors associated with possible abuse/neglect (such as stress and burnout) and provide suitable responses. . Provide legal counsel/assistance for relevant issues such as guardianship and end of life.

Paid Caregivers . Map the changing needs of those eligible (by law) to receive assistance. Assistance should be determined according to individual needs (for example, switching from an Israeli paid caregiver to a foreign caregiver). . Provide possibilities for foreign caregivers to “take a break” from their 24/7 work responsibilities. This is in an attempt to protect both parties. Organizations and professionals working with foreign caregivers should take measures to identify caregivers in distress. In addition, these organizations and professionals must provide foreign caregivers with the necessary assistance needed to reduce tension, in order to avoid burnout, which may result in elder abuse. . In order to reduce stress, foreign caregivers are to receive financial compensation for working on weekends. . Ensure protection of foreign caregivers’ rights, in the event that one of the family members is in quarantine or is found to be infected with COVID-19. . Help caregivers and care recipients with their basic and immediate needs, such as food, medication, etc.

Professional Staff . Enhance professional and organizational collaboration by sharing information with older adult clients and their family members. . Collect data; detect and identify situations of suspected or potential elder abuse, exploitation, and neglect of older adults in the community and in institutional settings. Information should be shared among the relevant involved service providers. . Create responses that will ensure the supervision and support of staff members (i.e. consultations and opportunities to discuss challenges, vent frustrations, etc.).

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. Create a forum to deal with professional and ethical dilemmas and discuss issues related to elders at risk. . In light of the fact that professionals and clients are currently experiencing a shared reality (due to COVID-19 risks), attention should be given to how this affects staff/team members healthcare professionals. Develop and encourage the learning of new skills, including those related to accessing technology (for example, using Zoom, and other intervention methods that enable communication whilst maintaining social distancing requirements). . Strengthen cooperation among the various organizations regarding ongoing and/or changing relationships, as well as new work relationships. . Build rapid and effective collaborations among the various responsible services and organizations (social services, health care, organizations that supply home nursing care, the police), in order to initiate beneficial information exchange and enhanced cooperation regarding older adults at risk. . Find solutions for older adults who require placement in institutional settings. . Ensure that the rights of all involved target populations (older adults, family members, healthcare professionals) are honoured and protected. . Identify new obstacles and barriers that appear in daily personal and work routines and find effective solutions. . Develop ad-hoc responses for the above situations by coordinating with the involved parties. . Increase levels of social supervision to identify potential risk factors associated with elder abuse and neglect.

Policy Makers . Map the organizations and NGOs involved in providing services and assistance for older adults. . Encourage cooperation among government offices by building a new infrastructure which makes it possible to more easily collaborate and/or enhance existing collaborations. . Design procedures and guidelines for easy and effective coordination between and among government offices and organizations. . It is recommended that the provision of basic needs, such as food and medication, will be carried out by organizations other than social services. . Raise awareness about elder abuse and neglect among multidisciplinary teams and staff members who are in contact with older adults. Create a shared database among organizations aimed at detecting and identifying elders at risk, in general, and elder abuse and neglect, in particular. In this context, it is recommended to use a screening tool to detect and identify cases of elder abuse and neglect. . Prepare a synchronized flowchart for each intervention; provide care and assistance for elders at risk within the community and in society, at large. . Offer volunteer services for older adults, in general, and elders at risk, in particular.

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. Ensure fair employment conditions for foreign caregivers working on a 24/7-basis format. . Design policies for ongoing work routines regarding coping with elders at risk, in general, and for older adults exposed to abuse and neglect, in particular. . Create a mechanism to ensure open channels of communication with older adults, in general, and especially vulnerable older adults such as people with cognitive decline, family members caring for older adult with dementia, isolated older adults, older adults with limited social networks, etc.

Challenges, Needs, and Responses for Older Adults at Risk of Abuse and Neglect Regarding the COVID-19 Routine* *Case descriptions will be presented in order to illustrate and reflect the unique aspects of the COVID-19 routine. A. When dealing with risk situations, the following aspects must be considered: . New risk factors specifically associated with older adults that emerge as a result of the changing circumstances. . The importance of identifying constantly changing needs in real time. . The difficulty to assess potential risks associated with abuse/neglect, and the difficulty to determine the extent of risk, in light of social distancing restrictions (i.e. professionals are not permitted to make home visits). . Lack of services and accessibility to existing services as a result of social distancing restrictions and regulations. . Lack of professional manpower in healthcare clinics and among the paid caregivers’ workforce. In times of crisis and emergency situations, such as the current period, service providers should improvise and find alternative solutions; a new “basket” of services, employing a variety of intervention approaches, should be proposed. B. Case Descriptions (based on real cases)—Guidelines for assessment and intervention Identification and assessment: Professionals and/or teams should examine the following questions: 1. Who are the involved parties? What is the nature of their interaction? Are they exposed to abuse/neglect? What type of abuse occurred? 2. Are the potential clients known to the formal services (health care services, social services, etc.)? 3. Was a complaint filed with the police as a result of this event? Are the clients known to the police from past events (domestic violence, substance abuse…)? 4. How dangerous is the situation? From the point of view of the older adult, a friend/neighbour/family member (subjective assessment)? From the point of

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view of the professional (even in the event that it is not possible to enter the family residence)? In such a case, the professional’s perception of his/her subjective experience is of significant importance. Despite the fact that the assessment is subjective, it is recommended to rate the risk on a scale of 0–5. It is important to note that this scale is not based on a valid tool, but rather on the subjective experiences of the involved parties. 5. Identify risk factors found in previous studies to be potential predictors of abuse and neglect. Such risk factors include cohabitation; the perpetrator’s unemployment, substance abuse, mental illness; the older adult’s health situation (functional disability, dependency, dementia, etc.). 6. The final assessment is comprised of a. a subjective assessment score (on a scale of 0–5); b. objective components: high-level risk factors such as dementia, cohabitation, psychopathology (mental illness, substance abuse), and unemployment. Each high-level risk factor receives a score of 1 point. Secondary risk factors, such as a limited support network, life crises (divorce, illness). Each subjective risk factor receives a score of 0.5 points. The cumulative total score will be a scale ranging from 0–10. 7. Which services should be involved and to what extent? (Note: The proposed scale is not based on a valid tool. The risk factor assessment is based on the study findings.) Example Subjective assessment of risk (high risk—4 points), cohabitation (1 point) + addiction (1 point) + unemployment (1 point) + a limited support network (0.5 points). Total score: 7.5 points out of 10. In other words: a high level of risk. Case 1—An adult child as the perpetrator Moses, aged 78, and his spouse, Lizzie, aged 72, live with their daughter, Rachel, aged 50, who takes care of them. Moses has been diagnosed with COPD and suffers from cognitive decline. Lizzie suffers from mobility limitations and has severe breathing problems, which require a home oxygen device. Rachel has never been married. She lives with her parents and is their primary caregiver (does the food shopping, and accompanies them to doctors’ appointments and medical treatments). She works as a kindergarten teacher. As a result of the COVID-19 crisis, she has been staying at home with her parents, due to restrictions and social distancing regulations. A few days after the crisis began, Simon—their 48-year-old son, who is divorced and has been unemployed for the past 10 years—came back to live with his parents. Simon is in debt to a lot of people. Simon expects that his family will not only take care of all his needs, but that they will also give him money for his ex-wife and children. His demands are accompanied by threats and shouting. The atmosphere at home becomes unbearable and Rachel feels that she cannot go on in this manner. Simon recently used his parents’ credit card to buy cigarettes and kosher food for himself. When Rachel discovered this, she became distraught, broke down in tears, threatened to commit suicide, and ran out of the house. Lizzie called the social services office crying for help …

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Case 1: Assessment and proposed intervention Involved parties

Directly involved Elderly parents; a son who returned to live with his parents; a daughter who is the parents’ primary caregiver

Others

Interaction and type of abuse

Interaction Type of abuse Escalating tension and conflict Financial and emotional abuse; between the son and the potential neglect parents, and between the son and his sister, based on his attempts to take control of the parents’ resources; attempts to override the daughter authority as the primary caregiver; threats and infliction of fear Cohabitating as a result of the COVID-19 crisis; undermining of the family’s previous balanced routine

Known or unknown to other Unknown service providers and (no information) agencies Filed complaint with the police

At present: unknown (no information)

In the past: unknown (no information)

Subjective risk assessment score (0–5)

5 points

Risk factors assessment: (Comprised of high-risk factors) (1 point for each factor) + secondary risk factors (0.5 points for each factor)

High-level risk factors Total Score = 10.5 points Cohabitation; unemployment (son and daughter); codependency (parents and adult children); father’s cognitive decline Total = 4 points Secondary risk factors Poor health; limited functioning; advanced age Total = 1.5 points (continued)

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(continued) Involved parties

Directly involved Elderly parents; a son who returned to live with his parents; a daughter who is the parents’ primary caregiver

Others

Sharing information and collaborating with professional partners and agencies

Mapping of services Social services; multi-disciplinary advisory team; paid caregivers’ agency; social security; healthcare clinic; legal aid; senior citizens’ call centre

Social worker + APS social worker; consultation with multi-disciplinary advisory team (comprised of a lawyer, a medical doctor, a social worker, and an APS social worker Intervention: New assessment: Geriatric medical assessment—functional and cognitive assessment; and if needed, COVID-19 testing for the entire family – Plan a combined intervention including examining the possibility of 24/7 care to be provided by a paid caregiver – Obtain the necessary restraining order to provide protection and prevent threats and harassment – Put a stop to all financial exploitation and ensure the safety of the older adults’ finances/possessions – Obtain legal aid for the son and set up a payment plan to deal with his debts.

Case 2—Escalation of IPV (intimate partner violence) Clara, aged 73, lives with her husband David, aged 80. Clara had a stroke and is paralyzed on her right side. She drags her foot and it is an effort for her to take care of her husband. Over the years, her husband routinely abused her physically after drinking alcohol. Clara and David have three adult children: a son living in the US who keeps in touch on a regular basis; another son who lives far away; and a daughter, who has marital problems, and is not in touch with her parents (her father abused her sexually when she was a child). Clara usually goes to the seniors’ day care center five times a week, and David usually spends time at the seniors’ club, where he meets his friends and plays cards. Because of the COVID-19 crisis, the couple now spends all their time together at home. One day, Clara felt sick and asked David to give her some medicine. He shouted at Clara and began throwing things at her. When Clara’s crying got louder, he covered her face with a pillow, and screamed: “When I tell you

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to shut up, shut up!” A neighbor heard the screaming and Clara’s crying and called the police… Case 2: Assessment and proposed intervention Involved parties

Directly involved Victimized wife (with health problems, functional disability); abusive spouse

Others Family members: a son in the US; another son living far away; a daughter with whom there is no contact; a neighbour

Interaction and type of abuse

Interaction Ongoing IPV, escalation as a result of prolonged lockdown and social distancing orders

Type of abuse Physical and emotional abuse

Known or unknown to other Known to services service providers and agencies Social services, home care agency, health clinic, seniors’ day care centre, seniors’ retirement club Filed complaint with the police

At present—Yes

Subjective risk score (0–5)

5 points

Risk factors assessment (Comprised of: High-risk factors = 1 point for each factor + secondary risk factors = 0.5 points for each factor)

High-level risk factors Total score = 9.5 points Alcohol addiction; dependence on spouse; increasing stress due to prolonged period of cohabitation under lockdown conditions Total = 3 points Secondary risk factors Poor health and disability; a lack of formal and informal support networks; continuous IPV Total = 1.5 points

In the past—Unknown

(continued)

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(continued) Involved parties

Directly involved Victimized wife (with health problems, functional disability); abusive spouse

Others Family members: a son in the US; another son living far away; a daughter with whom there is no contact; a neighbour

Sharing information and collaboration with professional partners and agencies

Mapping of services Social services; consultation with multi-disciplinary advisory team; police; home care agency; healthcare clinic; legal aid

– Social worker + APS social worker, to inform the parties of their rights and determine whether the woman is “helpless” (according to the legal definition based on the Law for the Protection of the Helpless) – Utilization of protection laws – Provide legal aid in order to obtain a restraining order – Find an alternative living arrangement for the husband – Referral to the Center for the Prevention of Domestic Violence Health care clinic: COVID-19 testing; obtain geriatric medical information; update functional assessment; follow-up by medical staff Provide home care for the woman

Case 3—Elder Abuse in a long-term care institution Josef has been working in an institution for the past three years, where he provides care for dementia patients. Due to the COVID-19 crisis, some of the staff members must stay at home because of exposure to a patient who tested positive for COVID19. In light of the current lack of manpower, Josef has had to carry out many tasks at the same time. Josef, who is overworked as it is, doesn’t know what to do first. One morning he has to take a resident to the shower (a task that is usually done by two caregivers). He decides to take the resident to the shower alone. He becomes impatient, pushes the elderly resident and says: “Come on, come on…”. In the process, the resident falls and is injured…

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Case 3: Assessment and proposed intervention Involved parties

Directly involved The disabled older adult (resident); the institution’s employee

Others The institution’s staff: social worker, the institution’s head nurse, director

Interaction and type of abuse

Interaction Type of abuse Mistreatment and impatient Mental and physical abuse communication, leading to the caregiver’s negligent behaviour, which causes physical and mental harm to the resident

Unknown (no information) Known or unknown to other service providers and agencies Filed complaint with the police At present—Unknown (no information)

In the past—Unknown (no information)

Subjective risk assessment score: 0–5

No score

Risk factors’ assessment (Comprised of: High-risk factors = 1 point for each factor + secondary risk factors = 0.5 points for each factor)

High-risk factors Total score Cognitive decline; complete 7 points (without subjective dependency; employee assessment) (caregiver) burnout Total = 3 points Secondary risk factors Secluded institution; Lack of manpower; Lack of formal support for the resident; lack of informal support for the resident; lack of formal support for the employee; no guidelines; lack of protective measures; lack of COVID-19 testing Total = 4 points (continued)

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(continued) Involved parties

Directly involved The disabled older adult (resident); the institution’s employee

Mapping of services Sharing information and collaboration with professional Health clinic; APS social partners and agencies worker; police The institution’s violence prevention committee (institution’s head nurse, physician, social worker); the ministry of health; the; family members; APS social worker and or the police

Others The institution’s staff: social worker, the institution’s head nurse, director – Transfer resident to E.R. – Share information with family members – Keep in touch with the hospital – Debriefing of the event, drawing conclusions and decision making (consider reporting) – Report the event to the Ministry of Health and ask for clear procedures and guidelines for emergency situations – Create a mechanism that supports staff during times of emergency

Summary and Recommendations Exposure to the COVID-19 virus, which has become a global pandemic, challenges society, in general, and the older adult population, in particular. This epidemic has seriously affected different aspects of daily life among older adults in the community and in long-term care facilities. COVID-19 has also had an impact on the roles and routines of professionals, formal and informal caregivers, organizations, NGOs, government offices, and policy makers. Three case studies were presented, followed by guidelines and intervention options associated with older adults at risk of abuse/neglect. In light of the fact that the COVID-19 virus is most likely here to stay for at least the next year, the following recommendations are suggested: . Raise awareness on the subject of elder abuse and neglect (in addition to information about domestic violence). . Professionals and service providers should focus on vulnerable older adults. . Update contact lists for organizations and relevant services. . Draw up a list of representatives/contact persons for each organization. . Strengthen collaborations among and between government offices, service providers, and NGOs in order to achieve unified decision-making. . Practice emergency situations during routine time periods.

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. Create a procedure for initiating telephone calls between older adults and their families, with the emphasis on elders at risk, in general, and elders at risk of abuse/neglect, in particular. . Initiate communication and conversations with older adults/family members for follow-up and support purposes, specifically with older adults who receive care from foreign caregivers. . Create a procedure that will make it possible for foreign workers/caregivers to take a break. . Create a list of services that can help take the place of the currently-closed day care centres and clubs for seniors, domestic violence prevention centres, etc. . Instal “panic buttons” in the homes of older adults at risk of abuse/neglect/domestic violence. . Provide isolated older adults with technological devices such as tablets, so that they can continue to be in touch with family members/professionals/service providers, especially in the case of an emergency. . Build technological infrastructures for services (to enable ease of access to online meetings, discussions, etc.). . Design clear guidelines and procedures for long-term care facilities during times of emergency. . Create a manpower pool to replace existing personnel working in long-term care facilities and in the community (paid caregivers). . Create support networks for staff members.

References Alon, S. (2021). Cognitive impairment and Dementia: A risk factor for elder abuse and neglect. In M. Kapur Shankardass (Ed.), Dementia Care: Issues, Responses and International Perspectives (pp. 269–282). Springer. Alon, S., & Lowenstein, A. (2020). Elder abuse and neglect during Covid-19 pandemic in Israel. Gerontology, 47(3–4), 87–107 [Hebrew]. Ayalon, L. (2009). Fears come true: The experiences of older care recipients and their family members of live-in foreign home care workers. International Psychiatrics, 1–8. https://doi.org/ 10.1017/S1041610209990421 Ayalon, L., Zisberg, A., Cohn-Schwartz, E., Cohen-Mansfield, J., Perel-Levine, S., & Alitzur BarAsher, S. (2020). Long-Term Care settings in the times of COVID-19: Challenges and future directions. International Psychogeriatrics, 32(10), 1239–1243. https://doi.org/10.1017/S10416 10220001416 Band-Winterstein, T., & Koren, C. (2010). “We take care of the older person, who takes care of us?” Professionals working with older persons in a shared war reality. Journal of Applied Gerontology, 29(6), 772–792. Band-Winterstein, T., Semloy, Y., & Avieli, H. (2016). Shared reality of the abusive and vulnerable: The experience of aging for parents living with abusive adult children coping with mental disorder. International Psychiatric, 26(11), 1917–1927. Borenstein, R. F. (2019). Synergetic dependency in partner and elder abuse. American Psychologist.https://doi.org/10.1037/amp0000456

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Baum, N. (2010). Shared traumatic reality in communal disasters: Toward a conceptualization. Psychotherapy: Theory. Research, Practice and Training, 47, 249–259. Daphna-Tekoah, S., Megadasi-Brikman, T., Scheier, E., & Balla, U. (2020). Listening to hospital personnel’s narratives during the COVID-19 outbreak. International Journal of Environmental Research and Public Health, 17, 1–15. https://doi.org/10.3390/ijerph17176413 DeLiema, M., Yonashiro-Cho, J., Gassoumis, Z. D., Yon, Y., & Conrad, K. J. (2018). Using latent class analysis to identify profiles of elder abuse perpetrators. Journals of Gerontology: Social Sciences, 73(5), e49–e58. Dong, X., Chen, R., & Simon, M. A. (2014). Elder abuse and Dementia: A review of the research and health policy. Health Affairs, 33(4), 642–649. Echterhoff, G. (2012). Shared reality theory. In P. A. M. Van Lange, A. W. Kruglanski, & E. T. Higgins (Eds.), Handbook of Theories of Social Psychology (p. 180–199). Cal: Sage Publications Ltd. https://doi.org/10.4135/9781446249222.n35 Goffman, E. (1961). Asylums: Essays on the condition of the social situation of mental patients and other inmates. New York: Doubleday. Home Nursing Care Law, 1995. Kasperson, R. E., Renn, O., Slovic, P., Brown, H. S., Emel, J., Goble, R., Kasperson, J. X., & Ratick, S. (1988). The social amplification of risk: A conceptual framework. Risk Analysis, 8, 177–187. Killen, A., Olsen, K., McKeith, I. G., Thomas, A. J., O’Brein, J. T., Donaghy, P., & Taylor, J. P. (2020). The challenges of COVID-19 for people with dementia with Lewy bodies and family caregivers. International Journal of Geriatric Psychiatry, 35, 1431–1436. https://doi.org/10. 1002/gps.5393 Kotwall, A. A., Holt-Lunstadt, J., Newmark, R. L., Cenzer, I., Smith, A. K., Covinski, K. E., Escueta, D. P., Lee, J. M., & Perissinotto, O. M. (2021). Social isolation and loneliness among San Francisco Bay Area older adults during COVID-19 Shelter-in-Place Orders. JAGS, 69, 20–29. https://doi.org/10.1111/jgs.16865 Labrum, T., & Solomon, P. L. (2018). Elder mistreatment perpetrators with substance and/or mental health conditions: Results from the National Elder Mistreatment Study. Psychiatry Quarterly, 89, 117–128. https://doi.org/10.1007/s11126-017-9513-z Lifshitz, R., Nimrod, G., & Bachner, Y. G. (2016). Measuring risk perception in later life: The perceived risk scale. Journal of the American Psychiatric Nurses Association, 22(6), 469–474. Lopez, J., Perez-Rojo, G., Noriega, C., Martinez-Huertas, J. A., & Velasco, C. (2021). Emotional distress among older adults during the COVID-19 outbreak: Understanding the longitudinal psychological impact of the COVID-19 Pandemic. Psychogeriatrics, 22, 77–83. https://doi.org/ 10.1111/psyg.12781 Makaroun, L. K., Bachrach, R., & Rosland, A. M. (2020). Elder abuse in the times of COVID19- Increased risks for older adults and their caregivers. The American journal of geriatric psychiatry, 28(8), 876–880. Makaroun, L. K., Scott, B., Rosen, T., & Rosland, A. M. (2021). Changes in elder abuse risk factors reported by caregivers of older adults during the COVID-19 Pandemic. JAGS, 19(3), 602–603. Mysyuk, Y., Westendorp, R. G. J., & Lindenberg, J. (2016). Perspectives on the Etiology of violence in later life. Journal of Interpersonal Violence, 31(18), 3039–3062. Pidgeon, R. E. Kasperson & Slovic, P. (Eds.). (2003). The social amplification of risk. Cambridge: Cambridge University Press. Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global situation, risk factors, and prevention strategies. The Gerontologist, 56(Suppl 2), S194–S205. Rosa, E. A. (2003). The logical structure of the social amplification of risk framework (SARF): Meta theoretical foundation and policy implications. In N. K. Pidgeon, R. E. Kasperson & P. Slovic (Eds.), The Social Amplification of Risk, Cambridge: Cambridge University Press. Schnor, J., & Cohen, Y. (2021). Aged 65+ in Israel. Statistical Yearbook. Jerusalem: Myers-JointBrookdale. [Hebrew]. Social Security Retirement Law, 1995.

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Tosone, C., & Bialkin, L. (2004). Mass trauma and secondary trauma: Issues for the clinicians. In S. L. Straussner & N. Kolko Phillips (Eds.). (2004). Understanding Mass Violence: A Social Work Perspective (pp. 158–167). Boston: Pearson. Wachinger, G., Renn, O., Begg, C., & Kuhlicke, C. (2013). The risk perception paradox— Implications for governance and communication of natural hazards. Risk Analyses, 33(6), 1049–1065. Wang, M., Huimin, S., Junjian, Z., & Juan, R. (2019). Prevalence and associated factors of elder abuse in family caregivers of older people with Dementia in central China, Cross-Sectional Study. International Journal of Geriatric Psychiatry, 34(2), 299–307.

Chapter 13

From Vulnerability to Resilience: How do Elderly Holocaust Survivors Living in a Nursing Home in Israel, Cope with the Threat of COVID-19? A Group Therapy Case Study Erga Drori Abstract In addition to being an external event, the COVID-19 outbreak is a psychological event. As such, it elicits associations, memories, and metaphors around which threat perceptions are organized. These processes are likely to be especially significant among individuals who have experienced traumatic life events. In this chapter, Holocaust survivors’, living in a nursing home in a central city in Israel reactions to group psychotherapy during the Pandemic, are discussed. Themes from two timepoints demonstrate the participants’ shift in self-perceptions—from vulnerable, helpless victims of the COVID-19 threat and its multiple and complex implications, to a more resilient, resourceful, and efficacious self-perception. The case study presented in this chapter supports previous research studies, which recommend encouraging a strength-based approach when working with survivors, in order to foster better adaptation and more effective coping. This approach is especially important during times of uncertainty and adversity. Keywords Holocaust survivors · COVID-19 · Re-traumatization · Resilience · Self-perception · Group psychotherapy · Nursing home · Israel

Introduction This chapter emerged from my psychotherapy experience with elderly Holocaust survivors (HS) during the COVID-19 outbreak in Israel. In Israel, during the first wave of the pandemic, as in many other countries, the majority of people who were admitted to hospitals as well as the fatalities were 65 This chapter is dedicated to the memory of my beloved mother-in-law, Mila Drori (1945–2020), light-spreading Holocaust survivor, whose love, kindness, and selfless devotion to her family and friends will forever remain in our hearts. E. Drori (B) Clinical and Social Psychologist, Tel Aviv, Israel e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_13

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years of age and older (Cohn-Schwartz et al., 2020). As it became clear that older people were more at-risk than other populations, they were advised to refrain from visiting others, having guests, and visiting family members—they were strongly advised to simply stay home (Associated Press, 2020; Ministry of Health, 2020a). As a result, many older adults suddenly found themselves spending their days, as well as the holidays, alone for the first time in their lives (Roth, 2020). Even as the restrictions gradually eased up (Ministry of Health, 2020b), many older adults remained—and still remain—in isolation, due to their greater risk and vulnerability (Cohn-Schwarts et al., 2020). These health policy guidelines have vast psychological implications for older people, in general. The effects of these implications are further exacerbated and complicated when it comes to discriminated elderly populations, such as Holocaust survivors (HS)—especially those HS who live in nursing homes and assisted living care facilities for the elderly. COVID-19 has been especially dangerous for residents of such care facilities, many of whom are HS. During the first wave of the pandemic in Israel, these facilities experienced high rates of COVID-19 infection and mortality (Tercatin, 2020). Specifically, 37% of COVID-19 deaths in the country have been residents of nursing homes and assisted living facilities (Freidson & Raved, 2020). Therefore, to protect residents, most facilities have imposed restricted visits from family and friends, and limited contact between residents and staff (Tercatin, 2020). All extracurricular activities, such as exercise and handicraft classes, as well as all cultural activities stopped. The main area where social interaction took place—the dining room—was also shut down. After four weeks of isolation, new guidelines were issued on 21 April 2020, which permitted short visits in residential settings, under very specific conditions, to maintain the safety of residents: One visitor at a time was permitted; the visit had to be scheduled in advance and take place separate from the other residents (Ministry of Health, 2020c). These guidelines are constantly undergoing revision, in accordance with the current COVID-19 situation in Israel. In Israel, Holocaust survivors constitute more than one-third of Israelis, aged 75+ (Cohn-Schwartz et al., 2020), many of whom cope with posttraumatic stress disorder (PTSD) symptoms and other impairments (Barel et al., 2010). The first COVID-19 death in Israel was an 88-year-old Holocaust survivor, followed by many other HS. This gave rise to the awareness that HS should be perceived as a separate group, in need of special care, protection, and understanding. This attitude may be somewhat controversial, as the media and social discourse are often rife with ageist and overprotective attitudes towards HS, who are repeatedly treated as vulnerable, weak, and sometimes helpless—an attitude which has become even more extreme during the COVID-19 pandemic (Roth, 2020; Wurgaft, 2020, in Cohn-Schwarz et al., 2020). Such perceptions about HS might seem somewhat in line with memory-based theories of PTSD (Brewin, 2014), which showed that present circumstances similar to past traumatic conditions can trigger the involuntary retrieval and reliving of intense trauma-related memories and images. The current pandemic can certainly be perceived as a situation with features that resemble some of the adverse conditions which existed during the Holocaust (Cohn-Schwartz et al., 2020). The specific threat

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to life, characteristic of COVID-19, and the social and health implications to the elderly population, might thus serve as a trigger, reactivating memories, feelings, and reminiscences of the survivors’ Holocaust experience.

Group Make-Up The present chapter is based on the experience I gained while leading two closed psychodynamic psychotherapy groups; each group was comprised of 12 HS (together, a total of 22 women and 2 men).1 We met once a week, for 90 min, over a six-year period. When the meetings started, the participants were all 80 years old and above. The mean age, at present, is 88 years (range 86−95). No payment was required from the HS. All of the participants reside in a nursing home in a city located in the centre of Israel. They are all Jewish Holocaust survivors, who were in Eastern or Western Europe as children or youth under the Nazi regime, during the years 1933−1945. All participants were admitted to the group based on the following criteria: the ability to function within the group, the ability to understand and speak Hebrew, no cognitive or psychiatric impairments, and the willingness to participate in and consistently attend group meetings. As Holocaust survivors, all of the group participants were subjected to extreme and massive psychic trauma in their childhood or youth. Despite each participant’s unique and individual Holocaust experience, the participants share traumatic events, in which the individual experienced, witnessed, or was confronted with dire situations such as hunger, separation, isolation, threat, and horrors; and experienced responses that included intense fear and feelings of helplessness, resulting, among some, posttraumatic stress disorder. Being very old people, all of the participants also cope with physical ill health; widowhood; loneliness; the loss of friends and family members (siblings, cousins); the loss of independence; the need to leave their home and their familiar environment, and move to a nursing home; and more. Now, in their late 80s and 90s, they are forced, once again, to face a frightening, negative event—the COVID-19 pandemic.

A Word About Group Psychotherapy for Elderly HS Senior Holocaust survivors and group psychotherapy might initially seem like a rather unlikely combination. The HS were profoundly influenced by the horrors they experienced during the war. During that time, the expression of feelings was not conventional; in order to survive, people tended to repress them. Moreover, after the war, people continued to repress their feelings, in order to move as quickly as possible 1

Because the make-up of the two groups was almost identical, and as the themes and processes I would like to describe, were very similar, I will relate to the groups as a single case study.

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and leave the horrors they had experienced behind, and get on with rebuilding their lives (Shanan & Shahar, 1983; Mazor et al., 1990). For many, in the 1950s and 1960s, speaking about one’s Holocaust experiences invited humiliation, ridicule, and disbelief (Durst, 2002). Thus, when they arrived to Israel after the Holocaust, the response of silence, which they lived with for many years, served to weaken their feelings of shame—of being a stranger, and of once again being rejected by their fellow Jews in Israel. (Durst, 2002). However, in later life, when many of their friends have died, their need to remember and share their past experiences with others becomes more urgent: to bear witness becomes vital (Schindler et al., 1992). Indeed it took some time for the participants to learn a “new language”—the language of group dynamics and the verbal expression of feelings. It is with this new language, and within the psychotherapeutic context, that these HS voice their concerns, share their feelings, and relate their memories—both from the past and the present, in an attempt to help themselves adapt to their present situation.

Group Meetings During COVID-19 Group meetings continued as usual until mid-March 2020, at which point the meetings stopped, due to the rapid spread of COVID-19 in Israel, and the strict restrictions and routines adopted by the nursing home. We met again about two months later, at a time when the virus was still spreading rapidly around the world and in Israel. Permission to meet was based on the understanding that the older adults’ loneliness and isolation was taking a serious toll on their mental and physical health (Simard & Volicer, 2020; Span, 2020), as well as their psychological and social well-being, and also due to the group participants’ strong desire to begin holding the meetings again. After the long break, I entered the spacious room, where we had been meeting for six years. I was eager to meet the group members again, and waited for them to join me. The chairs, arranged in a circle, which had, during all the years of treatment, been placed close to one another, were now arranged far apart (2 m)—almost double the space, compared to what we had been accustomed to pre-COVID-19. The room was flooded with the light coming from the room’s very large windows, which now, despite the scorching early-summer heat, were wide open, in accordance with the Ministry of Health’s instructions. The participants arrived, took their usual seats, masks covering their faces. The usual refreshments were absent, as well as the hugs usually given upon entering the room. Everything was the same, and yet, everything was different: The way we sat, the way we listened, the way we spoke, the way we looked. Miriam said “I can’t stand it”. Everyone asked her to speak up. It is hard to hear when you sit at such a distance, when the windows are open, and the air-conditioner is making a lot of noise. A heavy silence was present in the room. Ruth said “The fluorescent light fixtures on the ceiling remind me of the hospital to which I was admitted, after I was liberated from the camp”. I thought “Why is this

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memory surfacing now?” Surely the same light fixtures have been here for the past six years. I thought “Is this the first sign of the past penetrating the present?” Sarah, who was smuggled out of the Warsaw Ghetto as a child, hidden by a Christian family, and never reunited with her own family again, said: "How we missed each other. We thought we would never meet again. We thought this Corona would exterminate us before we’d have the chance to meet again”. I thought about Sarah’s fear, and noticed the terminology she used—“exterminate”. This is a very charged word, taken directly from “there”, from the time of the Holocaust. I wondered what else would emerge, and I waited for everyone’s thoughts and feelings to enter the room. I couldn’t remember there having ever been such a silence in the room before—such gravity, the weight of unspoken words. Although it was the same setting, the same people, and the same group leader—there was another presence in the room with us—a strange feeling of oppression, alienation. I thought about the psychological concept of “the uncanny” (Unheimlich)—a word whose most appropriate meaning, in the current context, describes a psychological phenomenon in which a situation is experienced as strangely familiar, but in which the familiar thing or event is experienced in an disturbing, peculiar, or forbidden context (Cixous, 1976). This conceptualization helped me put my feelings into words, and I said, “Here, we meet again, in the same place as always, with the same friends; and yet, how different and strange is our meeting today”. After a few more minutes of silence, the group members began to speak… From that day on, we continued our weekly meetings without fail. In the meetings that followed, the participants gradually opened up and shared their thoughts, feelings, and different points of view. I will now present the main themes that emerged and developed at two timepoints: First, I will describe the main themes that emerged during the “early” meetings, which took place shortly after the global COVID-19 outbreak. After that, I will describe the main themes that emerged and became more central during our recent meetings—almost six months later, at a time when COVID-19 is still spreading and Israel continues to have a high infection rate.

Holocaust Survivors’ Response to the Pandemic: Early Themes “Plague” is a Word From the Ghetto Yakov, who was a child when he was confined with his family in the Shavli Ghetto in Lithuania, said “For me, “plague” is a word from the Ghetto. Now, with the Coronavirus constantly on the news, I frequently recall the times when I was a child in the Ghetto. Since the outbreak of this plague, all my memories have resurrected in vivid colours. Although the Holocaust is always with me and a constant companion,

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now, when the Coronavirus is infecting the whole world, I think more than ever about what was there in the Ghetto ... I remember the hunger, the cold, the dead bodies on the streets, the fear, the sick people with nothing to do about it. I don’t know why I think about it more often now. Maybe it’s because I’m alone, maybe it’s because there’s nothing to occupy my time and I have more time to think, and maybe it’s because I live in this assisted living housing with a lot of other old people, like myself. I get really anxious when I think about what might happen if the virus penetrates [this place]. I think we will all be doomed. There’s nothing we can do about it. And there is no cure, yet. Seems like we just have to wait and see what’s going to happen. This is not a good feeling at all”. Naomi, who survived the Bergen-Belsen camp, went on to say: “I can’t stop thinking about the typhus plague that spread in the camp. Everyone got sick, I got sick too, one infected the other. Now, in the few years that I have left to live, I’m once again forced to face the danger of catching the plague. Since I left Europe, I never thought I would need to face this kind of danger again. I really thought such things could only happen then, and suddenly it’s happening now”. Malka, who was imprisoned as a teenager in the Pinsk Ghetto, added: “I remember myself being very sick in the Ghetto. I was lying next to a girl like me, and we both prayed to God to save us. The next morning, the girl died; I felt better, and recovered. Now I think about what will happen if I go to the hospital and lie down next to someone, this time as old as me, and we will both think–as we did then–that this is the end–and this time, it really will be. Back then, I was still young and innocent, believing a prayer would help. Today, the elderly have no chance to survive the plague. As far as this goes, nothing has changed–the older you were, the lower your chances of surviving the Holocaust were. If you were over 70, you had no chance at all. It’s the same now”. Sarah told her story: “I was so afraid. [Try to] picture it–so many old people, sick and weak, living together. It was enough that one of us would be infected, and we would all become sick. Here, it’s like being in a small Ghetto. Of course, it’s not the same–we have food, and no one wants to kill us, but if Corona comes here, it will be like then. We will all become infected, and we will all probably die. The worst thing is, there’s nothing we can do to protect ourselves. We are totally dependent on the staff and the other residents, regardless of whether or not we get infected”.

Just Not to Die of Suffocation “Every time I hear that people are dying of this disease from the inability to breathe, I am immediately back in Birkenau”, said Ruth. Ruth was 14 when she and her entire family arrived at the Birkenau extermination camp. As soon as the family got off the train, she was left alone on the side designated for work. She never saw her family again. “I did not think I would ever be afraid of suffocation”, she continued. “Whenever doctors on TV report that the lungs get scarred, that there is a need of respirators in order to breathe, and that people die alone because they don’t let family

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members get close and say goodbye, I am immediately there–with my mother and young sister, in the gas chambers. I can really feel the moment when they try to breathe, and they can’t”. She added: “I am willing to die of anything else: in an accident, from a heart attack, even from cancer. Just not to die of suffocation from this disease”. She coughed, and everyone looked at her. She was quick to apologize, reminding us that these were remnants of the tuberculosis that had struck her during the Holocaust, and not, God forbid, Corona. Rachel lost all of her family in the Holocaust. She herself, with great determination and resilience, managed to escape as a young teenage girl from the Nazis. She wandered from village to village in Poland, passing herself off as an orphaned Polish girl. She explained: “I have lung cancer. For several years now, I have been realizing that breathing is not a given. When Ruth talks about dying of this disease because of suffocation, I think to myself: ‘This is where Corona will get me,’ it will surely be my end. Back then, there was something I could do to survive; this time, I can do nothing. This time not my wits, not my Aryan looks, not my ability to be liked, nor the many languages I speak fluently… none of these will help me. During the war, I could encourage myself and run, when I felt things were getting dangerous. Now, nothing is up to me. I have no way of doing anything to escape Corona. I’m totally dependent on Fate”.

There is No One to Blame, But Fate Miriam opened the meeting almost with a shout. She described her anger at the present time: “I don’t understand why I deserve this! It’s so horrible! I moved to a nursing home so I could enjoy the rest of my life, so I could have some peace of mind. I hoped, at my age, that life would finally be good. But this thing–this horrible thing! It destroys death for me, not life–it destroys [the quiet life I thought I would have before my] death … What did I suffer for, make such an effort for to get into such prestigious, respectable assisted living housing? This was supposed to be compensation for everything I had suffered in my life, an opportunity to die with honour, with respect, with dignity. But now, fate have made it impossible!” Zipi who survived the Stutthof concentration camp continued: “For me it is the same thing: the way I thought the last years of my life would look–is gone. No more enjoyment, no meetings with friends and family, no cultural activities, no social encounters, no holidays with the family. They bring our food to the door of the room, and leave it there–it’s so humiliating! All we have is gornisht! (“nothing” in Yiddish). And worst of all: I have no one to blame. I do not believe in God, so I have no one to blame but Fate. At least in the war, we could blame the Nazis, the informers, the sadists who wanted to harm us just because we are Jews. Revenge could be desired. But now with this Corona, who will I blame? Towards whom do I feel a desire for revenge? No address, no name”. She sobbed. The group rushed to hand her a tissue, expressing sympathy and sorrow for Zipi’s strong emotions. Identifying with her helplessness, other participants continued to

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talk about the lack of an “address”, the absence of someone to blame, to whom and towards whom difficult feelings could be directed.

The Pain of Having to Undergo Another “Selection” The next meeting took place against the backdrop of breaking news coverage coming from Italy, reporting about the guidelines for medical ethics and for the order of treatment of patients, in light of an overwhelmed medical care system. According to the guidelines: “It may become necessary to establish an age limit for access to intensive care”. From these guidelines, one can understand that, in the event of a total saturation of resources, those who are too old to have a high likelihood of recovery, or who have too few “life-years” left, even if they should survive—will be left to die (Mounk, 2020). The group members were completely overwhelmed by this information, and reacted with intense agitation. Judith, who was selected by Mengele for his experiments, and underwent an appalling ordeal, entered the meeting very upset. Her voice trembled as she spoke: “I can’t believe I’ll have to go through a selection [process] again. I will not be able to bear the ordeal of facing death again in this manner”. Zipi continues “In the camp, there was a selection–who lives and who dies, and I was saved. This time, if the Italian ‘solution’ is adopted here, then my fate is already decided. I won’t survive this selection”. The group was silent for a moment. No one moved. I noticed the group members were all stunned. Two words bearing so many emotions, from “there” had reached us here: “Selection” and the resemblance between the phrase “the Final Solution” and the phrase “the Italian Solution” had struck home. “Where are you? Where are your thoughts?” I wondered, but I waited patiently, as always, hoping that more feelings and thoughts would transform themselves into words that could be pronounced. It seemed that silence was needed for this. Leah, who went through the selections in Auschwitz and, thanks to her resourcefulness and courage managed to survive, turned to Judith and told her: “This time, I will volunteer for the selection. I’ve already done my duty on Earth. I have a family, I have great-grandchildren, I have built this country with both hands. I lost friends, my husband, a son, and if I have to save the young people now at the expense of my old life, I’ll do it. I don’t mind dying now”. A sense of restlessness swept through the group. The thought of another selection that could come and claim their lives evoked intense emotions. Some of the group members agreed with Leah, and argued that there was no justification to hang on to life today. This selection was, for the most part, fair. Others did not agree: Judith said in an apologetic tone: “I have a very sick daughter. [She is] paralyzed. If I don’t survive Corona, I won’t be able to take care of her. Even though I’m over 90, I can still listen to her, comfort her, be with her. If I don’t survive Corona, she will be left completely alone. She has no family. I’m her only family. I still want to

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be here for her, for a few more years. I don’t want to go now, just because they prefer to save a younger person”. The group listened, and Hannah said “I also went through some selections. I didn’t think such a thing could happen to me at my age. I finally feel alive. The children have grown up, they are all fine. I am here, in this beautiful assisted living housing, free from worries, and I can enjoy life. And if I get sick, and they decide I’m not eligible for resuscitation, it would be wrong! Just because I’m old, doesn’t mean I deserve to die of Corona and not receive the best treatment”. Golda continued “I’m not ready to die, yet. During the Holocaust, I was 12 when I was left on my own, digging holes in the ground in the freezing cold, starving, wearing nothing, walking the Death March, and so on. Even at the most difficult moments, I wanted to live. I kept wanting to live. And that’s why I survived. Even now, even though I’m old, I want to live. I have a great-granddaughter on the way, and I want to live”. Esther, who escaped as a young woman from the Kovno Ghetto and joined the partisans in the forests of Rudniki, said “[The fact] that they will decide if we will live or die, is awful. But also deciding for us whether we can or cannot leave this place, is hard [to accept]. Lately, I have been imagining myself running away from the Ghetto again, joining the underground and running away, unwilling to be locked up, unwilling to let them tell me I’m not free, unwilling to be passive. All my life, I have been active. I have been a manager, I have initiated social projects, changes, even here in the assisted living housing, I constantly visit sick people, teach a Yiddish class, I can’t sit still. I can’t wait for someone else to decide what will happen to me. The idea of accepting my ‘sentence’, even if it’s for my own good, immediately makes me feel like I’m a useless human being, worthless and insignificant”. Rachel said “This is what they said about us then–that we went like ‘sheep to the slaughter’. I wonder if today at our age, in our present state of health, with our limitations, we can really do something. Today we no longer have the strength to fight for our lives”.

Being Separated From the Family is the Hardest Thing “The family I raised is my victory over the Nazis”, says Dvora, who lost almost all of her family, except for her older brother in the war. “Not to visit them, not to go with them to celebrate birthdays and holidays, nor to hug and kiss them, makes me really depressed” she says. “It’s the first time since the war that I am being separated from my family. They are in lockdown there, and I am in lockdown here. I can’t stop thinking [about it], and it constantly reminds me of how, in an instant, I was left alone in the world, without the big family I had [been used to]. I remember how I found out that my brother was in another part of the camp. I looked for him, and I saw him from afar, but I couldn’t reach him. This memory now comes back to me almost every day”.

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Shoshana says “I have one daughter. She lives in Berlin. My grandchildren and great-grandchildren are there, too. They planned to come to Israel in the summer, but because of this Corona, it’s impossible. The longing eats me up. My sleep is interrupted by the desire to see and touch my great-grandchildren. This separation sometimes seems even harder to me than the separation from my parents and brothers during the war, and it’s something I do not understand. Here, at least, I talk to them on the phone, know what’s going on with them, and where they are. I also know that it’ll all be over one day, and if I stay alive, I can meet them again…I know it’s really silly to compare it to the war, because there we lived in uncertainty about ourselves, but also about the family members who were separated from us; and yet, suddenly now, this feeling strikes me, frightens me–that I may not see them again”. Meir, who was transferred by his family to an orphanage in Budapest, and was miraculously saved together with his sister, while the rest of his family perished, says painfully: “This is the first time in my life that I will be alone on the holiday. Even during the war, I spent the holidays with the other children and friends. It’s really hard for me. How can I not be with my son and daughter? They always fly to Israel to be with me this time of year. How can I feel the holiday spirit like this? It will not be a holiday for me, celebrating alone. This bad feeling takes me back to the days of the end of the war–instead of rejoicing because I had survived, I was so distraught that I didn’t want to live at all. Sometimes, now, I also think–enough is enough. Why all this suffering? Why live again through such a difficult time? Maybe it’s better not to live”. His words agitated the other participants. A difficult discussion took place. The question of how one can go on living when everything and every minute is filled with harsh and aggravating memories of the Holocaust was raised.

Holocaust Survivors’ Responses to the Pandemic: Recent Themes Found the Strength to Die Recently at one of the meetings, Aliza said “I was 14 years old when I left home with my parents and brothers. Suddenly, the bombing started, my mother grabbed my little sister and disappeared; my father grabbed my little brother and disappeared in another direction, and I, the eldest, was left alone. I lay down on the ground, and for the first time in my life, I realized I could die. I remember the fear that went through my mind at that moment: How will I find the courage to die? I realized that strength is needed in order to die, a certain bravery, valour. From that moment something inside me changed. My face was in the dirt, but my spirit was lifted up. Amidst the screams and fire, I had this insight: I realized that if I had to die, something inside me would give me the strength to do so. It’s not exactly a belief in God, but a belief in some inherent power within me that I hadn’t know I possessed. This insight, this

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belief, also made me realize that if I have the strength to die, then I will surely have the strength to live. This understanding made me feel peaceful, serene. Now I recall this moment more often, and I know that if I am about to die now, from anything, even from this horrible Corona, I know I will have the strength to do so”.

If I Knew What to Do at the Age of 12, I Will Probably Know What to Do Now Rachel said “I took care of myself all my life. I lost my whole family, I wandered under a false identity, I had to pretend, find food, avoid death, and I succeeded. It’s true that I was young, but I feel that this experience also strengthened me to deal with old age. I still do most things by myself, and hopefully it will stay that way. As for Corona, the more I think about it, the more I realize I can protect myself from it. It’s up to me if I will survive the pandemic or not. It’s my own decision whether or not I cover my face with the mask, keep my distance, wash my hands, decide for myself who to be with, and how to be with others. It’s under my control. I think that if it comes to the point when somebody else decides whether I’ll live or die; if the doctor choose someone younger over me, I’ll be able to find a way out. Maybe I’ll buy myself a respirator; I heard there are people who have done that. I believe I can still be saved”. The other participants added to Rachel’s remarks—exchanging advice on the possibility of buying a respirator, and how to avoid the risk of contagion in elevators, and in line at the pharmacy. The members also shared information on how to enhance health, in order to be more protected from the virus. They talked about a healthy diet, physical exercise, and gave each other tips related to relaxing, and passing the time.

Everything is Predetermined, But Freedom of Choice Still Sxists This maxim, which relates to Rabbi Akiva and is found in Pirkei Avot,2 implies the dilemma between determinism and indeterminism: the option that Man has an inner consciousness or inner experience of free will, the ability to choose between different possible courses of action and make calculated judgments even when it seems that no option is available. (Alkayam, 1997). Miriam, who at first was very angry about Fate, referred to this maxim and said in one of the most recent meetings: “Even if this is fate, I can say today that even if everything is predetermined, freedom of choice still exists. I can and continue to read, knit, watch TV, and listen to the songs I love on the radio. When I think about it now, and even though the epidemic is still 2

A compilation of ethical teachings and maxims from Rabbinic Jewish tradition, which is a part of the didactic Jewish ethical literature.

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spreading and it’s scary, I realize how lucky I am here in the assisted living housing, and I can enjoy what little there is [to enjoy]. I think Fate can be cruel, but you can also appreciate that it is not only cruel–that you can find a way to get along. The grandchildren come to visit me; they talk to me from a distance, but I can hear them and see them. It’s not ideal, but this is what we have, and it isn’t so bad. There’s a phone. There’s food. There is a roof over my head. I can be thankful”. Esther (who was a partisan) said “I’d like to share a secret with you–I don’t obey all the rules here. I sometimes invite a friend of mine, someone who lives here on my floor, to my apartment. I’m not willing to sit alone and stare at the walls all day. We sit at a distance and with a mask; I am very careful. The same goes for my daughter. I know we’re not allowed to go visit our families, but she lives really close. I say that I’m going for a walk, and I go visit her. We sit outside in the garden. We can talk, and be together in private. I prefer my life to be shorter, rather than to live a longer time in solitude, or feel those agonizing yearnings”. The group members expressed various reactions to Esther’s “secret”. Some congratulated her for her brave decisions; others expressed doubts and reservations. A more general discussion then took place, about the ability and appropriateness behind such independent decision-making, in old age, and particularly, at a time like this.

My Family is Always with Me Meir said “I cannot meet my family, even from afar, because they don’t live in Israel. But I can look at the photos I have in my room, of the whole family: from the youngest great-grandson, all the way to myself. This is a thing I didn’t have in the war–no photos that could have given me strength; all I had were vague memories of my parents. The family photos I created are a consolation, a source of hope, [which makes me feel] that my family is always with me”. Malka said “I have a huge photo of my children and their families on the wall in front of my bed. When I’m in bed at night, I stare at the photo and feel so proud–all of those people are alive because of me! They were all created by me! And I think: ‘If it happened, that I, the only person from my family who survived the Holocaust was able to create such a big and beautiful family, then I will surely be able to wait as long as it takes to hug and kiss them again’”. Even Shoshana who really misses her daughter in Berlin, said she found comfort in having long phone conversations with her daughter: “I think that, in a way, Corona has made my daughter and I much closer. We now talk every day, very long talks. It never happened before. She has more time, and she talks more with me, shares more of her feelings, and I listen. She also listens more patiently to me. I feel we have become closer. I can feel her love for me more. Our phone conversations are deeper and more meaningful than before the Corona outbreak. I accept this as a gift”.

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There is Nothing to Compare Naomi said “I think this Corona is also an opportunity to understand and be proud about our selves: how we all faced horrible things and survived. I do find myself thinking more about the painful times [I experienced], during the Holocaust and throughout my whole life, but I realize that the more I think about it, the less nightmares I have. I have become less afraid to remember, because alongside the awful past, I also remember the good things that have happened…and when I think about the present situation, I can say that there is nothing to compare”. Golda said “Lately, I find myself wondering more about myself, my strength. I’m amazed–how could I have gone through such terrible things? Selections, hunger, separation from the family, terrible fear and loneliness… How did I survive? Then, I remind myself about my will power, my character. Because of this, today, I can say to myself: ‘Of course you can get through this Corona, too’. After all there is not much to compare: [Back then], I was completely alone, and here I am not. The staff in the assisted living housing takes care of us, the family takes care of us. I don’t feel for a moment that I will be abandoned or neglected. Even if the situation is difficult, I think I am in the safest and most protected place I can be right now. In these respects, there is nothing at all to compare our situation during Corona to our situation during the Holocaust”.

Discussion The aim of this chapter was to describe how elderly HS are experiencing the COVID19 pandemic, and how this experience has changed over time as a result of group psychotherapy. It is necessary to bear in mind that the participants in the psychotherapy groups represent a unique group of elderly HS, who are from a higher social and economic class, living in an assisted living facility for the elderly in the heart of Israel, who function more or less without assistance, and are cognitively intact. In addition, it is also important to remember that the two therapy groups have been operating for the last six years with the same participants and leader, meaning they are “mature” groups, characterized by cohesiveness, integration, solid group boundaries, and definitive group norms. Moreover, the interpersonal climate is such that members feel free to engage in self-disclosure, and to disagree with each other. Individual self-exploration and relating more deeply to others is also characteristic of such groups (Yalom & Leszcz, 2005).

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The Groups’ Process Dynamics At first, the group meetings held right after the COVID-19 outbreak revealed a strong comparison between negative Holocaust-related motifs and expressions, and motifs and expressions related to the COVID-19 pandemic. The comparison was manifested in a manner that primarily expressed feeling of helplessness, depression, worry, lack of trust, fear of the unknown, low self-efficacy, and anger. For example, Miriam’s reaction of anger towards Fate can be interpreted, as indicated by Ornstein, (1985), in terms of PTSD-related pathological impulsiveness or as an adaptive defense mechanism against helplessness. The strong reaction towards the lockdown and social distancing measures—especially from the family—could be the result of associating with the strong feeling of trauma engendered by being imprisoned (in the camps or the ghettos), and the subsequent separation from the family and feeling of isolation brought on by the forced lockdown. Intense memories of traumatic experiences such as the selections and epidemics raised a plethora of disturbing memories among survivors—memories of a world at war. Reactions to a traumatic experience, which is coloured, intensified, amplified, or shaped by one’s reactions and adaptational style to previous traumatic experiences is known as retraumatization (Danieli, 2010). Although exposure to the new experience may not be inherently traumatic, it may carry reminders of the original traumatic event. Retraumatization typically refers to the reemergence of symptoms previously experienced as a result of the original trauma (Alexander, 2012.) In this manner, it is important to bear in mind that the factors which activate traumatic reactions and memories were always present and openly manifested among the group members. These factors include news items about anti-Semitism, personal loss, health problems, etc. However certain features of COVID-19 have served to reactivate the memories of the past trauma in the unique way described above. With the arrival of COVID-19, the external world has once again become a dangerous place, and most of the HS have reacted to it as such—their present fears stoked by fears from the past—their memories, associations, reminiscences, ruminations, and connotations. All of these factors may lead HS to experience symptoms of depression, anxiety, and other adverse psychological outcomes (Armitage & Nellums, 2020; Brooke & Jackson, 2020), as was manifested by the participants in the early themes presented above. During this early stage, the group’s function was mostly to contain these very intense feelings of vulnerability, fear, and anger. The main treatment method involved careful listening, and making space for the participants’ feelings and thoughts, including shared reflections about the emotional meaning of the COVID-19 experience. In dynamic psychotherapy, understanding the impact of one’s experience on one’s emotions and attitudes is inherent; however, in the groups of survivors, associating the past with the present is especially important, in terms of their ability to cope and adjust. With this approach in mind, over time, the participants gradually noticed how their responses to the COVID-19 crisis were affected by their previous traumatic experience. One example of this is how their lack of a normal, safe childhood and

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youth influenced their attitudes and emotions about the COVID-19 pandemic. They also mentioned the impact of growing up in a world which could not be trusted, a world which damaged and shocked them, and how this might also be connected to their reactions toward COVID-19. As the group participants’ discussed their current difficulties to relate to the pandemic with optimism and hope, they slowly began to perceive the benefits of expressing their positive associations between their Holocaust experiences and their experiences of the COVID-19 pandemic. In line with the themes that have recently emerged, is the motif of taking premature responsibility for one’s life during the Holocaust, which relates to their ability to face situations of extreme emotional and physical difficulty when they were very young. An extraordinary example for that was described by Aliza as she was taking responsibility for her feelings of being frightened, and understanding she had the courage to die when she was 14, as the bombs fell around her. This memory and notion about her resilience helps her deal with her current emotions and fear, thus taking responsibility for her reaction to the current COVID-19 crisis. Rachel and Golda could also relate to their ability to stand alone in the world and take care of themselves relying on memories as girls during the war, in order to encourage themselves to have hope and believe in their ability to survive the present COVID-19 situation. Like Aliza Rachel and Golda, many of the participants started to express similar feelings, and to remind one another of their resources. This is where the survivors’ true strength lies—a fact which they needed to be reminded of, once again, after the COVID-19 outbreak. One of the principal objectives of psychotherapy is the reconstruction of the self: the reformulating of the negative vision of life, exposing the good that happened in the survivors’ lives, and the strength which enabled them to survive. When the participants started to focus on the memories of their own bravery and survival, they were able to perceive themselves as capable and competent, thus enhancing their self-efficacy and positive outlook. This empowered them to engage in the process of altering their own self-image: from a helpless person, a victim of circumstances, into a person who had survived the worst. This understanding could then be used to help HS more easily adapt to the difficulties imposed by COVID-19, and prevent or reduce the re-activation of the trauma triggered by the pandemic (Cappeliez & Webster, 2011). The psychotherapeutic process also allowed participants to redefine their difficult early memories as a resource, and a foundation for enhanced adaptation. Research suggests that in difficult times, Holocaust survivors may be both more vulnerable and more resilient (i.e. the wear-and-tear hypothesis). Existing research suggests that these qualities coexist (Zimmermann & Forstmeier, 2020; Lomranz (2005); Shmotkin et al., 2011). Shrira et al., (2010) contend that early-life trauma can both sensitize and buffer Holocaust survivors from new adversities, and that they exhibit general resilience, along with specific vulnerabilities. In line with this, at a recent meeting, Naomi was able to voice something that several participants had been thinking: That COVID-19 could even be an opportunity to enhance one’s self-esteem by focusing on the memories of ability and strength, and that, after all, despite the fears and helplessness, the current crisis is in no way equivalent to their wartime experiences. The participants are aware that they are not being persecuted,

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food is available, and they can still meet and speak with their loved ones, via phone or under social distancing conditions. The past has prepared them well, and they know they can cope with the current adverse situation. These positive uses of reminiscence as a coping method allow survivors to redefine their difficult early memories, and perceive them as a resource from which to draw strength and a basis for gratitude (O’Rourke et al., 2014). Without underestimating the importance of group therapy with the HS, especially in times of new threats and ordeals, this group dynamic supports studies suggesting that HS are, on the whole, an emotionally resilient group (Leon et al. (1981); Hantman & Solomon, 2007; Marcus and Rosenberg, 1988), which has been successful in resolving psycho-social crises (Suedfeld, 2000; Hartman and Solomon, 2007). Prior studies show that exposure to traumatic stress contributes to the development of coping and adaptation skills (Sadavoy, 1997; Epstein, 1983). Some studies even found that Holocaust survivors scored higher on certain aspects of social adjustment, coping, and hope than non-survivor comparison groups (Carmil & Breznitz, 1991). In other words, I believe that most survivors in the described groups were characterized by inner strength, optimism, determination, and other qualities that indicate an ample reservoir of inner resources and coping abilities. Through the sharing process inherent in group therapy, they were able to become more aware of their maladaptive tendencies, and create a new perspective about their ability to cope with the COVID-19 situation.

Summary The purpose of this chapter was to describe the reactions of elderly HS, living in an assisted living facility for the elderly, to the new threat of COVID-19, and to examine the ways in which their reactions change over time, within the group psychotherapy context. The chapter reviewed two points in time: the first time point described the themes that emerged in the group sessions that took place shortly after the COVID-19 outbreak. The second time point described the themes that emerged approximately six months later—during a period in which COVID-19 is still very much present, and the numbers of infections and deaths in Israel are still on the rise. While the early themes mainly reflected self-perceptions of helplessness, low self-efficacy, low levels of self-mastery, and victimization, all of which led to higher distress levels; later themes showed better perceptions in relation to HS’ ability to cope, overcome, and adjust to the new stress brought on by the COVID-19 pandemic. This shift in self-perception indicates the interplay between the vulnerability and resilience seen among Holocaust survivors. It is relevant to bear in mind that these case descriptions of HS participating in a psychotherapeutic process, may not be generalizable to other HS populations. The participants may not be representative of HS in other places, and may differ in their demographics, socioeconomic level, and health and mental status. However,

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the group participants described in this chapter provide significant insights about the emotional and psychological implications that HS are undergoing at the present time, as a result of COVID-19. This understanding may provide family members, social workers, therapists, assisted living facility staff members, and other relevant professionals with knowledge that can contribute to the development of intervention programmes that serve the unique needs of this specific population. My experiences with the group showed that a beneficial practice would be to help HS emphasize their strengths, rather than their vulnerabilities. Each survivor’s personal story obviously has traumatic elements, but HS can learn to focus on their positive memories, thereby engendering hope and more optimistic outcomes. Hence, practitioners are recommended to acknowledge survivors’ potential vulnerability as well as their resilience, and strive to cultivate their strengths, in order to foster better coping and overall emotional health, especially during this trying time of uncertainty and adversity.

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Chapter 14

The Effect of the Covid-19 Pandemic on Older Persons: The Reality of Turkey I¸sıl Kalaycı and Metin Özkul

Abstract The disease caused by the COVID-19 virus was defined as a pandemic by the World Health Organization (WHO) on March 11, 2020. This health problem, which is effective on a global level, has infected millions of people and many people have died. Due to the pandemic, many areas, from the way individuals interact to their daily life practices, have been adversely affected. It has caused cultural, economic, and social changes at the global level. In our country, a series of practices such as curfews have been implemented to control the pandemic. This situation has changed the course of daily life and has led to changes and transformations in the nature of many institutions in the social structure. Older persons were considered to be the most disadvantaged group in the face of the pandemic. The life of older persons who had psychological, social, and economic problems at various levels before the pandemic in Turkey, became more difficult with the pandemic and their quality of life decreased. Due to the negative effects of the pandemic, older persons have experienced various problems at different levels such as heavy illness, hospitalization, risk of death, being alone, discrimination, abuse and neglect, exposure to social exclusion, inability to reach caregivers, economic problems, and transportation. This article is aimed to reveal the problems experienced by elderly individuals in our country due to Covid19 pandemic, taking into account the scientific studies carried out by the Turkish scientific community. Keywords Türkiye · COV˙ID-19 · Pandemic · Older person

I. Kalaycı (B) Faculty of Health Sciences, Department of Gerontology, Suleyman Demirel University, Isparta, Türkiye e-mail: [email protected] M. Özkul Faculty of Arts and Sciences, Department of Sociology, Suleyman Demirel University, Isparta, Türkiye e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_14

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Introduction As in different countries, the decrease in birth rates, protective measures against infectious diseases thanks to developments in medicine, the increase in preventive and therapeutic practices against acute and chronic diseases, the emphasis on healthy nutrition and physical activity, the improvement of working conditions, and the use of technologies that facilitate daily activities have led both changes to lifestyles and an increase in the life expectancy and the proportion of the older adult population (Özkul and Kalaycı, 2020, 147). Based on the definition of the United Nations (UN), the older adult population of 8-10% in the total population refers to a country with “old population,” while the older adult population over 10% corresponds to “very old” population. The top three countries with the highest older adult population are Monaco (34.1%), Japan (28.8%), and Germany (22.7%), while Turkey ranks 66th out of 167 countries. In our country, the proportion of the older adult population out of the total population is currently 9.15% (Türkiye ˙Istatistik Kurumu “TUIK,” 2021a). It is predicted that the proportion of the older adult population will be 12.9% in 2030, which will include Turkey among countries with “very old” populations (TUIK, 2015). While the older adult population in Turkey was 6,495,239 in 2015, it reached 7,953,355 in 2020. The average life expectancy was 78.3 years as of 2019 (75.6 years for males and 81 years for males) (TUIK, 2021). The reasons, such as the growth of the ageing population, the increase in the dependency ratio, and ethnic diversity through immigration, lead to the weakening of social relations and cause older adults to experience social and economic difficulties. Older adults started to experience an increase in the quality and quantity of their problems as soon as the World Health Organization (WHO) announced the disease caused by COVID-19 virus as a pandemic (WHO, 2019).

The Pandemic and Older Adults Millions of people were infected in Turkey, and many people died from such a global health problem. The numbers of cases and mortalities so far are 5,409,027 and 49,576, respectively, while 5,275,231 patients recovered from the disease (T.C. Sa˘glık Bakanlı˘gı, 2021). The severe and fatal course of COVID-19 disease is associated with cardiovascular diseases, diabetes mellitus, hypertension, chronic lung diseases, kidney diseases, liver diseases, immunodeficiency, cancers, obesity, and smoking. While ageing, physiological changes cause various chronic diseases (Altın, 2020, p. 51; Onder, Rezza and Brusaferro, 2020, p. 1175). In our country, the majority of older adults have at least one chronic disease (e.g., circulatory, respiratory, nervous, and endocrine system diseases, tumours) affecting their lives (Engelli ve Ya¸slı Hizmetleri Müdürlü˘gü, 2020, pp. 9, 107). Older adults suffer from infectious diseases frequently due to physiological changes and chronic conditions. As individuals age, they go through illnesses

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more severely, which was doubled in older adults infected with COVID-19. Consequently, the majority of older adults were treated in intensive care units. The number of older adults who died of COVID-19 until August 7, 2020, was approximately 8000. The mortality rate in our country is lower when compared to China (Wuhan), Belgium, Scotland, United Kingdom, USA, Italy, Sweden, Netherlands, Canada, and Israel, higher when compared to Germany, South Korea, Australia, Portugal, Poland, and Japan, and similar when compared to Switzerland and India (Eser, 2020, p. 552). Many factors affect COVID-19 death tolls, including the medical care infrastructure, population, and economic power of the countries (Dikmen et al., 2020, p. 32). Turkey, as in many countries, prioritized older adults in the vaccination programme considering the risks of exposure to the disease, its severe infection and transmission, and the adverse impacts of the disease on the functioning of social life (T.C. Sa˘glık Bakanlı˘gı Covıd-19 A¸sısı Bilgilendirme Platformu, 2021). For the first time, the Turkish Medicines and Medical Devices Agency granted emergency use authorization for COVID-19 vaccine on January 13, 2021 (T.C. Sa˘glık Bakanlı˘gı Türkiye ˙Ilaç ve Tıbbi Cihaz Kurumu, 2021a). The older adult population was started to be vaccinated on February 24, 2021. Those aged 50–60 years were included in the vaccination programme on August 01, 2021. Finally, the family members of individuals aged 65 and over were started to be vaccinated on February 12, 2021. Family health centres and vaccination outpatient clinics undertook the task of public vaccination. Immobile individuals receiving home healthcare services and those residing in nursing homes were vaccinated at their homes through mobile services and care institutions. As of April 2021, vaccination rates of older adults reached 90.3% in 1 city, between 80 and 90% in 10 cities, between 70 and 80% in 27 cities, and between 60 and 70% in 22 cities. In total, 76.4% of citizens over the age of 65 in our country were vaccinated. Unvaccinated citizens did not request vaccination due to their own initiative or personal reasons. Considering the vaccination rates of older adults at the regional level, the highest vaccination rate was 84.5% in the Western Anatolian Region, while the lowest rate was 54.6% in the Northeastern Anatolian Region. It was determined that while the vaccination rate in Ankara was 90.30%, it was 33.91% in Sırnak ¸ (Eskiocak, Marangoz and Zencir, pp. 37-38). Although we have no clear data on the reasons for the inability to vaccinate the entire older adult population, the prevailing opinion is that they may have had some justifications, such as having had the disease before, believing to get sick after inoculation, fear of vaccines, problems in reaching the vaccine, and individual preferences. The Ministry of Health reports that the frequencies of infection, hospitalization, intensive care unit admissions, and deaths in the older adult population have decreased after vaccination (Eskiocak, Marangoz and Zencir, p. 54). As of December 31, 2019, when the virus was announced to the world, the Ministry of Health coordinated the protective and preventive measures to be taken in the country. March 10, 2020, when the first COVID-19 case was reported in Turkey, also brought the introduction of significant regulations across the country. In line with the recommendations of the Scientific Committee, the government implemented isolation measures to break the infection chain and protect individuals from the

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adverse effects of the pandemic. The Ministry of Interior delivered relevant circulars covering isolation measures to 81 cities in Turkey. These circulars included some restrictions for the older adult population, the most important of which were to stay at home and to go out for a limited time from the date of vaccination. While these restrictions prevented older adults from being affected by the disease, they also brought some problems, such as inability to access healthcare services, inability to meet socialization needs, and the loss of fitness. Upon the circular on “Coronavirus” issued on March 16, 2020, the Ministry of Interior suspended the activities of mosques, condolence houses, and public resting and entertainment facilities, where the population was thought not to comply with the social distance rule and get infected, (theatres, cinemas, performance centres, restaurants/cafes, wedding halls, pubs, coffee houses, open-air venues, hookah halls, cybercafes, association clubs, sports centres, Turkish baths, etc.) (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020a). Older adults, who constitute an important part of society, are those that most desire to satisfy their socialization needs by meeting others; therefore, they need various social environments to establish social relations, express their ideas, and reflect their own selves. (Özkul, Kalaycı and Atasoy, 2019, p. 88). Ultimately, the above-mentioned suspensions may have led older adults not to be able to meet their socialization needs as they could not go to shared socializing spaces they could easily reach with their own efforts. The Ministry of Interior issued a circular titled “Curfews for Those 65 Years and Over and with Chronic Disorders” on March 21, 2020. Accordingly, the older adult population was prohibited from leaving their residences, wandering in open areas, and travelling by public transport (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020a; T.C. ˙Içi¸sleri Bakanlı˘gı, 2020b). Yet, mandatory stay at home regulations based on chronological age—introduced to reduce the risk of transmission of COVID-19—caused some problems in this group (Tuna Uysal and Tan Eren, 2020, p. 1149). Even though this practice is thought to be effective in preventing the spread of the disease and reducing mortality rates, the restrictions adversely affected older adults’ mental health, functionality, and physical health. Interestingly, people developed a stigma attitude towards older adults as if they spread the virus. It was detected that older adults were exposed to age-based discrimination, ridiculed, belittled, humiliated, insulted, and exposed to hate and threatening speech. They were perceived as contagious and the source of disease rather than a disadvantaged group affected by the disease. In addition, it was determined that they were subjected to psychological and physical violence, marginalization, and exclusion due to provocative social media posts (Tuna Uysal and Tan Eren, 2020, p. 1159; Ya¸sar and Avcı, 2020, p. 1159; Akgül, 2020, p. 76; Türk, 2020, p. 37). Older adults, unfortunately, experienced problems in maintaining their social wellbeing even if having good general health conditions during curfews. The curfews also caused cognitive and behavioural difficulties in such individuals due to the lack of cognitive renewal and refreshment provided by social relations and being connected to the outside world. The compulsory home quarantine prevented them from seeing their acquaintances and led them to experience psychological problems

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˙ such as anxiety, depression, and fear of death (Ince, 2020, p. 189; Kılınçel et. al., 2020, p. 12). In the circular issued on May 20, 2020, the population excluding individuals over the age of 65 was allowed to pray in mosques (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020c). Although religious activities have an important place among the leisure activities of older adults in our country (Kalaycı and Özkul, 2017, p.104), the praying prohibition for them continued to protect their health. On the other hand, they were still adversely affected by the virus since their relatives may have prayed in mosques with others. Even though the rate of infection among older adults prohibited from leaving their homes was low, they had difficulties in fulfilling activities of daily living (bathing, dressing, feeding, etc.) and instrumental activities (using a phone, shopping, preparing food, cleaning the house, washing their laundry, using public transport, taking medicine, and doing their financial work) (Ekici, 2020, p. 147). Since older adults were restricted from going out, they could not perform activities, such as shopping, banking transactions, visiting a hospital, or paying bills, which made them dependent on others. In short, during the pandemic, some older adults became victims of elderly abuse and neglect, which is a global human rights and public health problem (Kalaycı et al., 2016, p. 233). Older adults needed solid social support to be engaged in and maintain a physically, psychologically, socially, and economically healthy lifestyle during the pandemic. For this reason, The Ministry of Interior initiated the establishment of “The Vefa Social Support Groups” under the coordination of the governors/district governors to ensure that older adults living alone not be the victims and to meet their basic needs. Hence, older adults who were restricted/prohibited from leaving their residences were allowed to report their needs via 112, 155, or 156 emergency hotlines (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020d). With the help of other regulations, older adults in need of Social Assistance (economic support) could notify their demands to the hotline (144) of the ministry (T.C. Aile, Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı, 2020a). Moreover, those using drugs prescribed for their chronic disease in the last six months could obtain such medicines directly from the pharmacy without going to health institutions (T.C. Sa˘glık Bakanlı˘gı Türkiye ˙Ilaç ve Tıbbi Cihaz Kurumu, 2021b). Besides, the taxpayer older adults’ tax statements and payments were postponed until the end of restrictions (Resmi Gazete, 2020). The minimum pension amount was increased, and the pensions of the retired ones were delivered to their homes. Older adults were allowed to stay in care institutions free of charge (T.C. Aile, Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı, 2020a). Overall, government officials took the older adult population under protection through the relevant circulars and adopted a supportive attitude towards them (Gencer, 2020, p. 39). The circular issued on May 20, 2020, allowed older adults to go to the settlements they wanted, provided that they would not return for at least one month. In this way, it was provided with the opportunity to go to different settlements for those who wanted to spend the isolation period with their relatives (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020e). Besides, the circular issued on May 29, 2020, terminated the curfews for employed older adults (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020f). Due to the low ratio of employed older

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adults out of the total older adult population (12.5%), the lifting of bans was of interest to a small number of people (TUIK, 2020). With the circulars on “Curfew Restrictions” on various dates, the Ministry of Interior implemented curfews in 81 cities on varying days. Except for older adults, other individuals were allowed to meet their needs in areas close to their homes (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020g; T.C. ˙Içi¸sleri Bakanlı˘gı, 2020h; T.C. ˙Içi¸sleri Bakanlı˘gı, 2021a). Instead, various markets served older adults online; however, due to the lack of technology literacy (72.9%) (TUIK, 2020) or being incapable of using smartphones, they could not meet their needs through online platforms and were again dependent on others. They are unable to meet their own needs during the curfews. The Ministry of Interior authorized governors/district governors to meet the basic needs of citizens in advanced age groups or those with severe illnesses and to assign the required number of personnel to Vefa Social Support Groups (T.C. ˙Içi¸sleri Bakanlı˘gı, 2021b). Due to the pandemic, older adults became much more in need of social support to meet their psychological, economic, physical, and social needs. Consequently, the most important supporting power of older adults is their social environment. However, older adults could not reach social support from their relatives and were left alone since it was mandatory for the entire population to stay at home during curfews. Recent studies have shown that measures, such as isolation, physical distance, and curfews, caused older adults to be isolated, and the resulting loneliness increased the risk of anxiety, depression, cognitive dysfunction, heart disease, and mortality in older adults (Brooke and Jackson, 2020, p. 2044). Disabled older adults in Turkey have difficulties performing their regular and instrumental activities of daily living (Ba¸salan ˙Iz, 2020, p. 128). The incidence of disabilities increases gradually with advanced age, starts to accelerate after the age of 70, and causes an increased need for assistance after the age of 80. The WHO reports that approximately 20% of people aged 70 years and over and 50% of people aged 85 years and over have problems performing activities of daily living (WHO, 2020a). According to TUIK’s 2014 data, the rate of older adults having difficulty in bathing/showering was 19.1% (22.1% in 2019), while the rate of those having difficulty in getting into/out of bed or sitting/standing on a chair was 19% (20.6% in 2019) (TUIK, 2021). It is reported that 23% of those aged 65–69 years, 31.9% of those aged 70–74 years, and 46.5% of those aged 75 years and over in the country have a disability due to various health reasons that affect their quality of life (Engelli ve Ya¸slı Hizmetleri Müdürlü˘gü, 2020, 9, 107). Due to the full restrictions during the pandemic, individuals providing disabled older adults with care were not able to deliver the necessary help and assistance to them. Older adults with disabilities were affected by the pandemic more adversely than others. The circulars issued on November 11, 2020, and November 18, 2020, allowed older adults to go out only between 10:00 and 13:00 considering the increasing trends in the number of sick, severely ill, and intubated people and the total death toll (T.C. ˙Içi¸sleri Bakanlı˘gı, 2020i). Yet, the circular on March 02, 2021, lifted the curfew for people aged 65 years and over in the cities with low and medium risk. Besides, older adults in the cities with high and very high risk were allowed to stay out for 4 hours

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(T.C. ˙Içi¸sleri Bakanlı˘gı, 2021c). However, since they were forbidden to use public transport, they could not get far from their settlements, which contributed to their dependence on others. The Ministry’s “Gradual Normalization” circular on May 16, 2021, and “Normalization Measures” circular on June 01, 2021, declared that no additional curfew would be applied for older adults having received two doses of vaccine. Nevertheless, some older adults suspected and avoided being vaccinated, or some having tested positive for COVID-19 could not be vaccinated for at least six months. Therefore, such citizens could only go out between 10.00 and 14.00 on weekdays. In addition, all older adults were subject to full-time curfews at weekends. In the relevant circular, older adults were prohibited from using public transport regardless of whether they were subject to curfews (T.C. ˙Içi¸sleri Bakanlı˘gı, 2021d). In this case, older adults continued to be dependent on others in their activities such as shopping, going to the bank, or visiting the hospital.

The Pandemic and Older Adults in Institutional Care Families in Turkey do not undertake the care of older adults anymore due to situations such as the transformation of the family structure into a nuclear family, employment or unemployment of family members, poverty, prolonged education, high care burden, burnout, and disintegration from cultural values. In this case, family members apply for formal services to meet the needs of their older adult relatives (Özkul and Kalaycı, 2018, p. 2). Hence, institutional care centres are used to meet the care needs of some older adults in Turkey. Currently, a total of 160 care centres (30 affiliated with the Ministry of Family, Labour, and Social Services, 127 with municipalities, and 3 with NGOs) serve older adults (Engelli ve Ya¸slı Hizmetleri Müdürlü˘gü, 2020, 97). Approximately 36% of the nursing homes (428) are publicly owned, and about 58% are privately owned. While 51% of older adults (27,219) receive care in public nursing homes, about 39% benefit from the services of those owned by private enterprises (Engelli ve Ya¸slı Hizmetleri Müdürlü˘gü, 2020, 96-97). Since institutional care centres (nursing homes, rehabilitation centres, etc.) host older adults with physical and mental health problems and chronic diseases, the risk of contracting and severity of the disease may be high in such places (WHO, 2020b). Thanks to the measures taken by the General Directorate of Disabled and Elderly Services for both its residents and employees during the pandemic, there was a pretty low number of cases in nursing homes (Hotar et al., 2020, p. 214). The Ministry of Health published a guide titled “Measures to be Taken in Nursing Homes and Elderly Care Centers” on May 1, 2020. In this direction, the General Directorate of Disabled and Elderly Services took some measures for older adults under institutional care. Some of the measures implemented by the Directorate are as follows (T.C. Aile, Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı, 2020b):

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– Among older adults receiving services in public and private nursing institutions, those who wanted to stay with their families were given leave before or during the pandemic for at least one month. Those who wanted to return to their institutions were required to stay in an isolation institution or a single-person social isolation room for 14 days following a COVID-19 test and were accepted to their rooms after completing the isolation process. – Those, who were treated at the hospital due to health problems and were discharged and provided for follow-up care in any isolation institutions, were admitted to their institutions following a COVID-19 test after the 14-day isolation period. – Provided that they complied with the necessary hygiene measures, it was ensured that older adults had maximum benefit from gardens and sitting areas within care institutions. – It was ensured that the products requested by older adults were purchased from markets and delivered to them following hygiene measures. – Controlled, regular, and structured physical activities and cultural and artistic activities were planned and implemented within the coordination of relevant personnel to provide psychosocial support to older adults for their adaptation to social life after the pandemic. Group activities were avoided. – Older adults were not allowed to be in shared spaces for a long time, except for compulsory situations. – Visits were suspended. – The personnel worked in fixed shifts. – PCR tests were applied to the personnel. Although the measures taken for the residents and employees of the institutions were effective in reducing the number of cases, they adversely affected the mental health and well-being of these people (T.C. Aile, Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı, 2020b).

The Pandemic and Older Adults Receiving Home Care Services Home care service is defined as “the provision of services in the home environment of individuals who cannot perform their own personal care and maintain their quality of life and who need the support of their family and relatives or specialists in medical, social, and other fields” (Balcı and Koçatakan, 2021, 189). Home care services allow older adults to benefit from the care and social support services in their living environments instead of going to an institution. In Turkey, about 500,000 older adults are provided with home care services (Engelli ve Ya¸slı Hizmetleri Müdürlü˘gü, 2020). However, the pandemic changed the quality of home care services; the rate of those applying for home care services increased during the pandemic (Anadolu Ajansı, 2020). Also, older adults infected with the virus wanted to receive home

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care services (Naharci, Katipoglu, and Tasci, 2020, p. 1195). In this case, healthcare teams coordinated and provided relevant home care services. First off, the teams contacted those they planned to visit and received comprehensive information about their symptoms. Next, they were provided with such services upon deciding they were infected. Then, their demands for home care services were re-evaluated after they completed their recovery and quarantine processes. When family members or care providers living with individuals in need of care were infected or quarantined at home, older adults were recommended to stay away from these people (Balcı and Koçatakan, 2021, p. 190). Finally, in another scenario, when a care team member was infected, other teams were deployed for fulfilling the service. It was strictly recommended that the care team would act within the daily visit plans and follow the pre-determined pandemic rules. For example, the team members must use personal protective equipment and other relevant materials.

Conclusion The pandemic still shows its devastating effects in Turkey. Yet, the number of cases varies depending on seasonal changes. Especially in the summer months, the number of cases increases due to going on vacation or visiting family members. Although vaccinated, the majority of older adults are at risk of becoming ill due to variants of the virus. Therefore, it may be necessary to maintain measures to protect their health. Though the measures have been taken to protect older adults from the disease since the beginning of the pandemic, those who are maintaining their social relations without complying with the physical distance and mask rules are still at risk of getting infected.

References Aile, T.C., & Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı. (2020a). Soka˘ga çıkma kısıtlaması bulunan/evde ya¸sayan 65 ya¸s üzeri ya¸slılarımıza yönelik koronavirüs(covid-19)bilgilendirme rehberi. https://www.ailevecalisma.gov.tr/media/44107/covid_19-yas-li-rehberi-eyhgm.pdf (in Turkish). Aile, T.C., & Çalı¸sma ve Sosyal Politikalar Bakanlı˘gı. (2020b). Kurulu¸slarımıza yönelik covıd-19 normalle¸sme rehberi. https://www.aile.gov.tr/media/50415/kuruluslarimiza-yonelik-covid-19normallesme-rehberi-i.pdf (in Turkish). Ajansı, A. (2020). Coronavirus: Turkey restrains older citizens from leaving homes. https://www. aa.com.tr/en/turkey/coronavirus-turkey-restrains-older-citizens-from-leaving-homes/1774287. Akgül, M. (2020). Hate speech in online environments: discussion of curfew for over 65 years of age in Ek¸si Sözlük. Journal of Communication Theory and Research, 51, 57–78. Altın, Z. (2020). Elderly people in Covid-19 outbreak. The Journal of Tepecik Education and Research Hospital, 30, 49–57. https://doi.org/10.5222/terh.2020.93723

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˙Içi¸sleri Bakanlı˘gı, T.C. (2021c). Koronavirüsle mücadelede kontrollü normalle¸sme süreci. https:// www.icisleri.gov.tr/koronavirus-ile-mucadelede-kontrollu-normallesme-sureci (in Turkish). ˙Içi¸sleri Bakanlı˘gı, T.C. (2021a). Kısmi kapanma genelgesi. From https://www.icisleri.gov.tr/81-ilvaliligine-kismi-kapanma-genelgesi-gonderildi (in Turkish). ˙Içi¸sleri Bakanlı˘gı, T.C. (2021b). Tam kapanma önlemleri. https://www.icisleri.gov.tr/81-il-valili gine-tam-kapanma-tedbirleri-genelgesi-gonderildi (in Turkish). ˙Içi¸sleri Bakanlı˘gı, T.C. (2021d). Kademeli normalle¸sme tedbirlerine ili¸skin genelge. https://www. icisleri.gov.tr/kademeli-normallesme-tedbirleri-genelgesi (in Turkish). ˙Ince, C. (2020). The older people as a socially vulnerable group in disasters: The case of covid-19. Eurasian Journal of Researches in Social and Economics, 7(9), 184–198. Kalaycı, I., & Özkul, M. (2017). I wish I could protect my traditional position, be modern: elderly experiences in modernization process. SDU Visionary Journal, 8(18), 90-110. 110.21076/vizyoner.308309. Kalaycı, I., Yazıcı, S. Ö., Özkul, M., & Küpeli, A. (2016). Perceptions of the elderly on elderly abuse. Turkish Journal of Geriatrics, 19(4), 232–237. Kılınçel, O., Muratda˘gı, G., Aydın, A., Öksüz, A., Büyükdereli, Y., Atada˘g, E. E., & Özen, F. (2020). The anxiety and loneliness levels of geriatric population in-home quarantine during COVID-19 pandemic in Turkey. Turkish J Clinical Psychiatry, 23, 7-14. https://doi.org/10.5505/kpd.2020. 04382. Naharci, M. I., Katipoglu, B., & Tasci, I. (2020). Coronavirus 2019 (COVID-19) outbreak and geropsychiatric care for older adults: a view from Turkey. International psychogeriatrics, 32(10), 1193–1197. https://doi.org/10.1017/S1041610220001167 Onder, G., Rezza, G., & Brusaferro, S. (2020). Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. Jama, 323(18), 1775–1776. https://doi.org/10.1001/ jama.2020.4683 Özkul, M., & Kalaycı, I. (2018). Elderly care as an informal job and employment area: The problems between the relatives of the elder and caregiver. SDU Visionary Journal, 9(20), 1-27. https:// doi.org/10.21076/vizyoner.372115. Özkul, M., Kalaycı, I., & Atasoy, M. (2019). Social relationships of the elderly: Problems and opportunities. The Journal of Social Sciences, 6(37), 77-97. https://doi.org/10.16990/SOBIDER. 5051. Özkul, M., & Kalaycı, I. (2020). Saygınlıktan günün ötelenmi¸sli˘gine ya¸slılık statüsü ve ilgili aktör rollerinde de˘gi¸smeler. In D. Say Sahin ¸ (Ed.), Ya¸slılık sosyolojisi (pp. 125-156). Ekin Yayınevi (in Turkish). Sa˘glık Bakanlı˘gı, T.C. (2021). COVID-19 bilgilendirme platformu. https://covid19.saglik.gov.tr/ (in Turkish). Sa˘glık Bakanlı˘gı, T.C., & Covid-19 A¸sısı Bilgilendirme platformu. (2021a). COVID-19 A¸sısı Ulusal Uygulama Stratejisi. https://covid19asi.saglik.gov.tr/TR-77706/covid-19-asisi-ulusaluygulama-stratejisi.html (in Turkish). T.C. Sa˘glık Bakanlı˘gı Türkiye ˙Ilaç ve Tıbbi Cihaz Kurumu. (2021b). Eczacılara ve tüm ilgililere duyurulur. https://www.titck.gov.tr/duyuru/eczacilara-ve-tum-ilgililere-duyurulur-160 32020090441 (in Turkish). T.C. Sa˘glık Bakanlı˘gı Türkiye ˙Ilaç ve Tıbbi Cihaz Kurumu. (2021a). Haberler: Kamuoyuna duyuru. https://www.titck.gov.tr/haber/kamuoyunun-dikkatine-13012021185623 (in Turkish). Türk, A. (2020). Koronavirüs (covıd-19) pandemisi sürecinde ya¸slılara yönelik uygulamalar ve ya¸slıların psiko-sosyal durumu üzerine bir de˘gerlendirme. Sosyal Hizmet, 35-46 (in Turkish). ˙ Türkiye ˙Istatistik Kurumu. (2015). Istatistiklerle ya¸slılar, 2014. http://www.tuik.gov.tr/HaberB ülteni (in Turkish). ˙sgücü istatistikleri, nisan 2020. http://www.tuik.gov.tr/PreHab Türkiye ˙Istatistik Kurumu. (2020). I¸ erBultenleri.do?id=33788 (in Turkish). ˙ Türkiye ˙Istatistik Kurumu. (2021). Istatistiklerle ya¸slılar, 2020. https://tuikweb.tuik.gov.tr/PreHab erBultenleri.do?id=37227 (in Turkish).

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Chapter 15

Mental and Physical Health of Iranian Older Adults With Positive Covid-19 Status During the Fifth Wave of Pandemic Shahram Moradi, Tahereh Sokout, Abedin Bakht Abnoos, Nobaya Ahmad, and Abdolrahim Asadollahi Abstract Background: During the five waves of the Covid-19 pandemic from January 2020 to September 2021, Iranians’ concern about the number of elderly cases that were adversely affected by Covid-19 highly increased. The present study aimed to evaluate mental and the physical health of Iranian older adults across the big waves of the Covid-19 pandemic. Methods: In an analytical and longitudinal study, the health of 517 older people with a positive test in Covid-19 disease during the fifth wave of coronavirus in south Iran. Results: The study found that the mental and physical health of older adults with positive Covid-19 status has been affected during the fifth wave of pandemic with a high effect size (Eta square ≥ 0.97, P ≤ 0.05). The majority of samples experienced high perceived stress, panic, and agoraphobia, and this condition significantly increased without change (P ≤ 0.05). Conclusions: The Covid-19 pandemic affected the mental and physical health status of older adults with positive Covid-19 status.

The original version of this chapter was revised: The family name of author Abdolrahim Asadollahi have been updated. The correction to this chapter is available at https://doi.org/10.1007/978-98199-1467-8_41 S. Moradi Department of Health, Faculty of Health and Social Sciences, Universitetet i Sørøst-Norge, Social & Welfare Studies, Notodden, Norway T. Sokout Farzanegan Daily Caring Foundation, Shiraz, Iran A. B. Abnoos · A. Asadollahi (B) Department of Gerontology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran e-mail: [email protected] N. Ahmad Department of Social & Development Sciences, Faculty of Human Ecology, University Putra Malaysia, Seri Kembangan, Malaysia A. Asadollahi Middle East Longevity Institute in Abyad Medical Centre, P.O. Box 618, Tripoli, Lebanon © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023, corrected publication 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_15

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Keywords Mental health · Physical health · Older adults · SARS-CoV-2 · Covid-19 · Pandemic

Highlights • Older people have had a difficult experience with the COVID-19 pandemic. • Their lived experience has not been able to adapt them to these new conditions. • Health policymakers have not put this vulnerable group at the centre of their interventions.

Background In late December 2019, following a report of unusual pneumonia in Wuhan, China, extensive studies was conducted on this emerging disease. On January 7, 2020, the new Corona virus was approved by the China CDC Centre, and after the samples taken from patients’ upper respiratory tract confirmed by RT-PCR WHO called the new disease as COVID-19. The disease rapid spread to several countries within a month, prompted the World Health Organization to announce a relatively high global risk of the disease in June 2020 as an epidemic (Ghajari et al., 2020). On September 24, 2021, there have been 230,418,451 confirmed cases of COVID-19, including 4,724,876 deaths. As of 22 September 2021, a total of 5,874,934,542 vaccine doses have been administered (WHO, 6 Dec 2021c). Iran is one of the countries facing a severe pandemic crisis. After a week of breaking the record for Covid-19 pandemic in Iran, it seems that the southern half of the country has passed the fifth wave and the northern half is on the decline. Each wave of coronavirus pandemic in Iran has been more widespread than ever. The fifth wave in Iran in terms of morbidity and death (709 registered deaths) peaked on August 23, 2021, which is the highest official death rate in one day since the outbreak of coronavirus (October 23, 2019). Exactly on that day, when Tehran entered a six-day official holiday, the incidence rate exceeded the previous wave, and since then, the record of new confirmed cases has been broken every day, with 50,228 new cases in one day (August 17, 2021). But for the first time in weeks, there have been 6,196,913 confirmed cases of COVID-19 with 131,680 deaths, and as of January 1, 2022, a total of 52,042,721 (65% of the population) people have been administered with both the vaccine doses (TejaratNews, 6 Dec 2021). Additionally, about 8,091,164 people (7.02% of the population) have received the booster vaccine. However, Massoud Pezeshkian, former Deputy Speaker of Parliament and a current member of the health commission, in an interview with Asr-e-Iran stated that the daily death rate is 5 times higher than the official statistics of the Ministry of Health, between 700 and 1500 deaths per day (Asr-e-Iran, 14 Sept 2021)! Some Iranian epidemiologists have estimated the sixth wave of the coronavirus pandemic in

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the 2nd half of November 2021 from the southeast of Iran, and its spread throughout the country (ISNA, 16 Sept 2021). Regarding vaccination and creating safety in citizens, at least 7.8 million have received at least one dose of the vaccine and nearly 2.4 million have been administered both doses of vaccine in Iran. Due to challenges such as the rapid growth of the ageing population (11.8% in 2021), and their vulnerability due to lack of professional health care, the outbreak of the disease coincides with the ancient celebration of Nowruz and religious holidays in Iran and the traditional culture of family gathering, health status of older adults need to be studied across the coronavirus pandemic as emergency service (WHO, 24 Sept 2021a). The psychological side effects of SARS-CoV-2 Pandemic on middle and older adults still is a point of neglect in literature, since few reports are describing the mental health status of them associated with the COVID-19 pandemic (Del Brutto et al., 2021; Fontes et al., 2020; Grolli et al., 2021; Szcze´sniak et al., 2021). This study was performed to evaluate the physical and mental health status of the 507 older people who were infected with coronavirus in the first wave of the pandemic and were screened during the next 4 pandemic waves of Covid-19 disease in Farzanegan Foundation in south Iran (March 17, 2020 to end September 2021) in the form of telephone interviews.

Materials and Methods This is an analytical and longitudinal study during the two year (2020 and 2021) to assess the mental and physical health of older people during the coronavirus pandemic in Iran. Due to the special conditions of the Covid-19 pandemic and observing the principles of the National Pandemic Control Headquarters (CRONOMY.IR), collecting data was performed from 517 older people with positive coronavirus (COVID-19) test by telephone in Farzanegan Day Caring Foundation in southern Iran during the fifth waves of the SARS-CoV-2 pandemic (March 17, 2020 to end September 2021). Using the study of Bandelow (2000) and with a mean score of 23.2 in agoraphobia index (SD = 6.4), power 95 per cent, SE = 0.05, and effect size = 0.705, the sample size was 517 (with a dropout of 13%), using PASS software version 15 (Table 15.1). Eligible samples were selected using membership numbers in their Health File Archive. The samples were the same in all 5 stages and were called between 9 am and 6 pm (see Table 15.2). Inclusion criteria: At the beginning of the telephone conversation, all the principles of professional and medical ethics, study objectives, and the elderly’s discretion not to participate in the study were announced, as well as the form of informed consent read at the beginning of the telephone call (like most telephone survey studies). He/She was asked to express his/her satisfaction by repeating the phrase “I, Mrs. / Mr. .... express my consent to participate in your study on the date ... in perfect health and interest.” The consent text was recorded and preserved as an audio message with the project interviewers. Also, the participating older samples have the physical and mental ability to answer the phones and have a positive test for Covid-19 in the National

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Table 15.1 Five waves of coronavirus pandemic in iran Waves

Beginning from …

End to …

Max. New cases in one day

Max. Deaths in one day

1st

March 17, 2020

April 10, 2020

3,186

158 (April 4, 2020)

2nd

June 25, 2020

July 26, 2020

3,574

235 (July 28, 2020)

3rd

October 23, 2020

November 27, 2020

14,051

486 (November 16, 2020)

4th

March 25, 2021

May 21, 2021

25,582

496 (April 26, 2021)

5th

June 28, 2021

September 26, 2021

50,228

709 (August 23, 2021)

Total Confirmed Cases: 6,196,913, Total Confirmed Deaths: 131,680 until January 1, 2022. Ref.: “COVID-19 kills 364 more Iranians over past 24 h”. IRNA. 17 September 2021. Retrieved 17 September 2021 and “Tejarat News”. January 1, 2021, Retreived from: https://tejaratnews.com/

Table 15.2 Data collection and analysis procedure across five waves of coronavirus pandemic

Waves

Included (Date)

Excluded (death)

1st

517 (April 12, 2020)

0

2nd

511 (July 27, 2020)

6

3rd

509 (November 29, 2020)

2

4th

509 (May 23, 2021)

0

5th

507 (September 20, 2021)

2

Analysis

507 (December 30, 2021)

0

Health Information Registration System (SiB). Exclusion criteria: unwillingness to cooperate in the study and not answering calls.

Measurement In this study, 11 valid questionnaires were used. The translation and validation of the instrument were performed according to the WHO protocol in translating and validating the research scales (WHO, 16 Sept 2021). (1) (2)

(3)

Demographic and Health questionnaire including 21 questions of demographic, family, and health components. Panic and Agoraphobia Scale (PAS), 14-items, by Bandelow (1995): the sum of scores from zero means no P and A to 52 means the existence of the panic disorder. Perceived Stress Scale (PSS, 4-items) by Cohen and hid coworkers (1983): the sum of scores from zero means no stress to 16 means the existence of a high level of perceived stress.

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225

(4)

Cognitive Impairment Test (6-CIT), 6-items (Upadhyaya et al., 2010): total score range of 0 to 28 (5) Frailty Phenotype Index, 5-items (Fried et al., 2001): total score range of 0 to 5 (6) University of Jyvaskyla Active Ageing Scale (UJACAS), 17-items (Rantanen et al., 2019): total score range of 0 to 272 and the score ranges between 0 and 272. Response options are worded to suit the item and scored from zero (lowest, e.g., least active) to four (highest, e.g., most active). (7) Intrinsic Spirituality Scale (ISS), 6-items (Hodge et al., 2015): total score range of 0 to 60 (8) Health Overall, 1-item: total score range of 1 to 4, the samples’ health status was asked on having 1 = Poor: my health significantly limits what I can do, 2 = not bad nor good: I have good days and bad days, 3 = Healthy: I have a few problems that are well-managed, and 4 = Very Healthy: I feel good. (9) Sense of Depression: Geriatric Depression Scale (GDS), 4-items (Yesavage and Sheikh, 1986), total score range of 0 to 4 (10) Sense of Anxiety: Geriatric Anxiety Index (GAI), 5-items (Heissler et al., 2018), total score range of 0 to 5 (11) Sense of Lonely: UCLA-Loneliness, 20 items (Wongpakaran et al., 2020), total score range of 20 to 80 The McDonald’s omega coefficient as a reliability coefficient for the scales was extracted which the scores of all instruments were at a valid level, ω ≥ 0.85 (P ≤ 0.05).

Data Analysis Data analysis was performed using SPSS software (version 26). Mean and standard deviation were used to describe the data, and repeated measures ANOVA was used to analyse the data. The significance level in all tests was considered 0.05. This study was approved by the biomedical ethics committee of Shiraz University of Medical Sciences with the registered code: IR.SUMS.REC.1399.474. Ethical considerations were according to Committee on Publication Ethics (COPE) in cross-sectional studies and Declaration of Helsinki (Holm, 2013) as well.

Results A population of 507 older adults who were infected during the Covid-19 pandemic (40.4 and 59.6% male and female, respectively) from urban areas during the COVID19 pandemic has participated in this study. According to the results, the mean age of participants is 76.6 (SD = 8.7), 89% have a chronic health condition (38.8 %

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cardiovascular disease), 74.6 per cent of them are not alone, 44.5 and 48.3% were widowed and married, respectively, 30.23% of sample’s education (n = 153) was in primary school level at the mid-2021. About 58.2 per cent of older samples did not receive any financial support and/or pension, which was less than 143 US$ per month (n = 295), very below than national poverty rate, and the majority of samples were supported by a social security system and insurance. The participants were inquired “How do you assess your health status?”, and the majority of them replied, “less than average!” (46.5%). Also, there was statistically a significant difference between subjects by gender in demographic characteristics (P ≥ 0.05), except for the ethnicity variable (see Table 15.3). Regarding to the main variables of research, the mean scores of them were calculated as well as significant difference between men and women and by older adults who have chronic diseases or not. As tabulated in Table 15.4, there was no statistically significant relationship between the majority of variables in the five waves of the coronavirus pandemic (P ≤ 0.05).

Results of Repeated Measures ANOVA The repeated measures ANOVAs were used to compare the means of main variables across the five waves of the Covid-19 pandemic. 1.

2.

There was a significant effect of time on health status, Wilks’ Lambda = 0.530, F (4,503) = 111.6, P = 0.000. The Mauchly’s test (0.724) indicated a violation of the sphericity assumption, χ2 = 163.2, P = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.874), Huyn-Feldt corrected results are reported (ε = 0.881). The mean reaction of health status was affected during 5 waves of pandemic, F (1, 506) = 25623.6, P = 0.000, Partial Eta Squared (effect size) = 0.981. This means that there is a difference in the health status of older samples within 5-time points. After a decline in the third wave, the health status again appears to be challenging for the older people in the next two waves, but from 3rd wave, the older samples were able to cope with their health challenges based on their lived experience (see Fig. 15.1). There was a significant effect of time on sense of lonely, Wilks’ Lambda = 0.042, F (4,503) = 2856.1, P = 0.000. The Mauchly’s test (0.152) indicated a violation of the sphericity assumption, χ2 = 951.1, P = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.523), since sphericity is assumed, Huyn-Feldt corrected results are reported (ε = 0.525). Mean reaction of lonely status were affected during 5 waves of pandemic, F (1, 506) = 162119.5, P = 0.000, Partial Eta Squared (effect size) = 0.997. This means that there is a difference in sense of loneliness of older samples within 5-time points. It seems that from the first wave, they have had problems with the isolation and loneliness index, but in the fourth and fifth waves, older samples have been able to adapt to their sense of loneliness (see Fig. 15.1).

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227

Table 15.3 Demographic characteristics of samples Variables

Subdomains

Number of Sample n

%

P valuea

Male

205

40.4

–

Female

302

59.6

Persian

367

72.4

Arab

3

0.6

Lor

64

12.6

Turk

73

14.4

No formal school

9

1.8

Only reading

42

8.3

Primary school

153

30.2

Middle school

101

19.9

High school

143

28.2

Graduated

59

11.6

Very Healthy

120

23.7

Healthy

151

29.8

Not Bad Nor Good

145

28.6

Poor

91

17.9

Divorced

2

0.4

Widowed

225

44.4

Separated

14

2.8

Married

245

48.3

Never married

17

3.4

Living with other

4

0.8

Gender

Ethnic Groups 0.533

Education

Health

0.001

Statusb 0.001

Marital Status 0.002c

Receiving any financial support and/or pension No

295

58.2

Yes

212

41.8

Yes

129

25.4

No

378

74.6

0.209

Living Lonely 0.004c (continued)

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S. Moradi et al.

Table 15.3 (continued) Variables

Subdomains

Number of Sample n

%

P valuea

No

56

11.0

0.046c

Yes

451

89.0

Having any chronic health conditions

a Using

chi-square to compare older men and women, 2-sided. four ranks with a 4-point Likert scale, the samples were asked on having Poor: My health significantly limits what I can do, Not Bad Nor Good: I have good days and bad days, Healthy: I have a few problems that are well-managed, & Very healthy: I feel good. c Fisher’s Exact Test, 1-sided b In

3.

4.

5.

There was a significant effect of time on sense of depression, Wilks’ Lambda = 0.274, F (4,503) = 332.7, P = 0.000. The Mauchly’s test (0.257) indicated a violation of the sphericity assumption, χ2 = 685.8, P = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.640), since sphericity is assumed, Huyn-Feldt corrected results are reported (ε = 0.644). Mean reaction of depression status were affected during the fifth wave of pandemic, F (1, 506) = 21461.5, P = 0.000, Partial Eta Squared (effect size) = 0.977. This means that there is a difference in sense of depression of older samples within 5 time points. It seems that up to the third wave, the level of depression in the older adults has increased, but in the fourth and fifth waves, they have been able to adapt to this feeling (see Fig. 15.1). There was a significant effect of time on sense of anxiety, Wilks’ Lambda = 0.381, F (4,503) = 204.2, P = 0.000. The Mauchly’s test (.733) indicated a violation of the sphericity assumption, χ2 = 156.8, P = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.882), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.889). Mean reaction of anxiety status were affected during fifth wave of pandemic, F (1, 506) = 13.73.1, P = 0.000, Partial Eta Squared (effect size) = 0.963. This means that there is a difference in sense of anxiety of older samples within 5 time points. The level of anxiety of the older samples in all waves of the coronavirus pandemic seems to have increased, and this increase was significant and they could not adapt to this feeling (see Fig. 15.1). There was a significant effect of time on active aging, Wilks’ Lambda = 0.699, F (4,503) = 54.1, P = 0.000. The Mauchly’s test (0.604) indicated a violation of the sphericity assumption, χ2 = 254.4, p = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.835), since sphericity is assumed, Huyn-Feldt corrected results are reported (ε = 0.842). Mean reaction of physical activity status of older adults were affected during 5 waves of pandemic, F (1, 506) = 12237.1, p = 0.000, Partial Eta Squared (effect size) = 0.960. This means that there is a difference in activity conditions of older samples within 5 time points. From the first to the second wave, it seems that a slight decrease in the measures of physical and daily living activities has been observed in the samples, but

2.4

3.7

3.4

3.4

2.3

Sense of Depression T2

Sense of Depression T3

Sense of Depression T4

Sense of Depression T5

Sense of Anxiety T1

5.70

71.1

Sense of Lonely T5

1.7

70.5

Sense of Lonely T4

Sense of Depression T1

6.27

61.7

Sense of Lonely T3

1.54

0.53

0.71

0.45

1.31

1.46

12.76

2.94

49.9

Sense of Lonely T2

2.44

3.53

3.57

3.76

2.50

2.04

70.90

70.00

62.45

50.13

1.52

0.52

0.57

0.43

1.22

1.41

5.68

6.24

12.56

3.21

2.26

3.46

3.36

3.76

2.45

1.49

71.28

70.86

61.24

49.75

45.16

Mean

SD 3.02

Mean 3.55

46.3

Sense of Lonely T1

47.99

Female

Gender Male

SD

Total

Mean

Main variables during 5 waves a SD

1.54

0.54

0.78

0.46

1.37

1.46

5.71

6.28

12.89

2.74

3.51

0.201

2.46

3.43

3.52

0.017** 0.224

4.00

0.670

2.16

1.95

0.0981

70.93

0.001***

70.43

0.460

0.129

56.70

50.63

0.541

0.001***

Mean 48.71

SD

1.59

0.53

0.66

0.05

1.61

1.58

6.29

6.17

12.79

0.48

1.71

2.32

3.50

3.43

3.73

2.51

1.68

71.15

70.52

62.35

49.81

46.00

Mean

Yes

1.53

0.53

0.71

0.46

1.26

1.45

5.63

6.29

12.63

3.11

3.65

SD

Having Chronic Health Conditions No

0.001***

Pb

Table 15.4 Statistical descriptives and differences in main variables during the fifth wave of covid-19

(continued)

0.000***

0.460

0.129

0.541

0.001***

0.001***

0.175

0.642

0.392

0.837

0.001***

Pb

15 Mental and Physical Health of Iranian Older Adults With Positive … 229

15.4

Cognitive Impairment T 3

3.9

Sense of Anxiety T5

16.6

3.5

Sense of Anxiety T4

Cognitive Impairment T 2

0.84

2.8

Sense of Anxiety T3

13.1

1.11

2.4

Sense of Anxiety T2

Cognitive Impairment T 1

3.55

46.3

Sense of Lonely T1

6.88

7.02

7.71

1.54

1.48

SD

Total

Mean

Main variables during 5 waves a

Table 15.4 (continued) Gender

16.05

16.95

13.52

3.98

3.67

2.81

2.43

47.99

Mean

Male SD

6.78

7.25

7.41

0.84

1.11

1.56

1.48

3.02

14.96

16.44

12.77

3.98

3.40

2.92

2.45

45.16

Mean

Female SD

6.94

6.87

7.92

0.85

1.11

1.53

1.49

3.51

0.084

0.441

0.279 14.73

17.73

11.93

3.93

3.30

0.008** 0.867

2.73

2.57

48.71

Mean

No

6.53

7.17

7.21

0.81

1.06

1.66

1.70

1.71

SD

15.49

16.51

13.22

3.99

3.53

2.89

2.43

46.00

Mean

Yes

6.93

7.01

7.77

0.85

1.12

1.53

1.46

3.65

SD

Having Chronic Health Conditions

0.449

0.854

0.001***

Pb

(continued)

0.449

0.854

0.201

0.224

0.017**

0.670

0.981

0.001***

Pb

230 S. Moradi et al.

3.55

46.3

15.4

15.4

Sense of Lonely T1

Cognitive Impairment T 4

Cognitive Impairment T 5

30.3

29.2

27.2

Active Ageing T3

Active Ageing T4

4.1

Frailty T5

Active Ageing T2

3.4

Frailty T4

38.2

2.9

Frailty T3

Active Ageing T1

1.09

2.4

Frailty T2

10.56

15.44

17.75

18.09

0.84

1.11

1.38

1.75

2.4

Frailty T1

4.44

3.18

SD

Total

Mean

Main variables during 5 waves a

Table 15.4 (continued) Gender

26.89

29.87

31.91

39.12

4.02

3.45

3.18

2.43

2.29

15.56

15.27

47.99

Mean

Male SD

10.28

15.31

17.53

17.82

0.84

1.15

1.36

1.09

1.75

4.55

2.84

3.02

27.48

28.73

29.23

37.59

3.99

3.49

2.84

2.39

2.59

15.38

15.56

45.16

Mean

Female SD

10.75

15.53

17.85

18.28

0.83

1.08

1.38

1.09

1.75

4.36

3.41

3.51

0.570

0.408

0.109

0.368

0.655

0.688

0.007

0.686

0.066

0.725

0.788

0.001***

Pb

28.18

28.70

31.37

40.54

4.00

3.29

2.88

2.29

3.05

15.32

14.86

48.71

Mean

No

11.05

15.94

17.98

19.48

0.78

1.12

1.34

1.12

1.76

4.60

2.80

1.71

SD

27.12

29.25

30.18

37.92

4.00

3.50

2.99

2.43

2.40

15.47

15.51

46.00

Mean

Yes

10.51

15.39

17.74

17.91

0.84

1.10

1.39

1.08

1.74

4.42

3.22

3.65

SD

Having Chronic Health Conditions

(continued)

0.491

0.797

0.639

0.303

0.941

0.167

0.587

0.369

0.007

0.867

0.008***

0.001***

Pb

15 Mental and Physical Health of Iranian Older Adults With Positive … 231

3.55

14.61 14.31

46.3

25.5

32.0

30.3

29.7

28.1

29.5

Sense of Lonely T1

Active Ageing T5

Spirituality T1

Spirituality T2

Spirituality T3

Spirituality T4

Spirituality T5

1.96 9.97

11.9

12.5

13.1

28.1

PSS T3

PSS T4

PSS T5

P & A T1

2.28

2.62

2.84

9.3

PSS T2

3.24

8.5

PSS T1

13.78

13.31

16.23

8.54

SD

Total

Mean

Main variables during 5 waves a

Table 15.4 (continued) Gender

28.24

13.14

12.59

12.04

9.42

8.74

28.04

28.57

30.06

29.92

31.07

25.13

47.99

Mean

Male SD

10.21

1.94

2.28

2.68

2.77

3.52

13.72

12.97

13.98

14.09

16.11

8.55

3.02

27.93

12.99

12.55

11.87

9.33

8.46

30.58

27.85

29.53

30.64

32.69

25.73

45.16

Mean

Female SD

9.81

1.98

2.28

2.58

2.88

3.04

13.73

13.54

14.55

14.97

16.31

8.54

3.51

0.867

0.423

0.872

0.492

0.737

26.39

12.68

12.27

11.68

9.32

8.86

30.23

0.039** 0.468

28.55

27.71

29.93

28.32

23.45

48.71

Mean

No

11.66

1.95

2.26

2.51

2.69

3.85

13.41

13.31

15.32

13.60

15.18

9.11

1.71

SD

28.26

13.10

12.60

11.97

9.37

8.54

29.47

28.09

30.00

30.40

32.49

25.74

46.00

Mean

Yes

9.73

1.96

2.28

2.64

2.86

3.16

13.83

13.32

14.18

14.74

16.31

8.44

3.65

SD

Having Chronic Health Conditions

0.562

0.666

0.571

0.272

0.426

0.001***

Pb

(continued)

0.111

0.124

0.303

0.434

0.916

0.714

0.711

0.792

0.262

0.834

0.066

0.056

0.001***

Pb

232 S. Moradi et al.

3.55

12.98 12.54

46.3

30.9

32.7

36.6

37.8

Sense of Lonely T1

P & A T2

P & A T3

P & A T4

P & A T5

Gender

38.90

36.57

32.18

30.96

47.99

Mean

Male SD

12.79

12.89

11.41

10.69

3.02

37.15

36.72

33.05

30.89

45.16

Mean

Female SD

12.34

13.07

11.45

10.41

3.51

a T1

to T5 = 5 Waves of Covid-19 across the country, b. Using Mann-Whitney U test, P ≤ 0.05, b Significant less than 0.01, c Significant less than 0.001

11.42

10.51

SD

Total

Mean

Main variables during 5 waves a

Table 15.4 (continued)

0.121

0.909

0.404

0.943

0.001***

Pb

37.63

37.62

33.34

32.77

48.71

Mean

No

12.51

12.97

11.98

10.77

1.71

SD

37.88

36.54

32.62

30.69

46.00

Mean

Yes

12.56

13.1

11.36

10.46

3.65

SD

Having Chronic Health Conditions

0.925

0.567

0.383

0.158

0.001***

Pb

15 Mental and Physical Health of Iranian Older Adults With Positive … 233

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S. Moradi et al.

Fig. 15.1 Distribution of mental and physical measures across 5 waves of covid-19

6.

from the third wave onwards, the index has increased by not observing health protocols of COVID-19 pandemic (see Fig. 15.1). There was a significant effect of time on frailty condition, Wilks’ Lambda = 0.362, F (4,503) = 221.2, P = 0.000. The Mauchly’s test (.642) indicated a violation of the sphericity assumption, χ2 = 223.3, p = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.816), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.822). Mean reaction of frailty status of older adults were affected during 5 waves of pandemic, F (1, 506) = 17533.1, p = 0.000, Partial Eta Squared (effect size) = 0.972. This means that there is a difference in frailty condition of older samples within 5 time points. The fertility

15 Mental and Physical Health of Iranian Older Adults With Positive …

235

index has been increasing since the first wave in the older population. According to the Fig. 15.1, fertility levels of older samples appear to have increased during the coronavirus pandemic. 7. There was a significant effect of time on sense of spirituality, Wilks’ Lambda = 0.963, F (4,503) = 4.8, P = 0.001. The Mauchly’s test (0.957) indicated a violation of the sphericity assumption, χ2 = 22.05, p = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.978), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.987). Mean reaction of spirituality among older adults were affected during 5 waves of pandemic, F (1, 506) = 11153.7, p = 0.000, Partial Eta Squared (effect size) = 0.957. This means that there is a difference peoplen sense of spirituality of older samples within 5 time points. From the first to the fourth wave, thendencycy towards spirituality shows a decreasing trend. But in the fifth wave, by increasing the score of this index, it shows that the aging subjects have been able to cope with the challenges of the pandemic with intrinsic spirituality by using their inner striving, motivational force, and lived experience to the current hardships of life (see Fig. 15.1). 8. There was a significant effect of time on cognitive impairment, Wilk” Lambda = 0.893, F (4,503) = 282.1, P = 0.000. The Mauchl”s test (0.619) indicated a violation of the sphericity assumption, χ2 = 242.1, p = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = 0.833), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.839). Mean reaction of cognitive status among older adults were affected during 5 waves of pandemic, F (1, 506) = 15293.8, p = 0.000, Partial Eta Squared (effect size) = 0.968. According to the Fig. 15.1, this means that there is a difference in cognitive impairment of older samples within 5 time points. Between the first and second waves, there was an increasing trend in the level of cognitive impairment of the older adults, which can be affected by the challenges caused by the coronavirus pandemic in the daily lives of the subjects. But after the second wave, the measuers of cognitive impairment decreased and its rate remained constant. This lack of significant change can indicate the older adults’ adaptation to the challenges. 9. There was a significant effect of time on PSS, Wilk” Lambda = 0.308, F (4,503) = 282.1, P = 0.000. The Mauchl”s test (0.836) indicated a violation of the sphericity assumption, χ2 = 90.6, p = 0.000. Since sphericity is violated (Greenhouse-Geisser’s ε = .917), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.924). Mean reaction of perceived stress among older adults were affected during 5 waves of pandemic, F (1, 506) = 42571.3, p = 0.000, Partial Eta Squared (effect size) = 0.988. This means that there is a difference in PSS of older samples within 5 time points. As expected, the level of perceived stress among olderpeoplee affected by the media and the unfortunate facts of Covid-19 pandemic has been increasing and they have not been able to control this fear (see Fig. 15.2). 10. There was a significant effect of time on P & A (PAS)’ Wilks’ Lambda = 0.655, F (4,503) = 66.3, P = 0.000. The ’auchly’s test (0.931) indicated a violation of the sphericity assumption, χ2 = 35.9, P = .000. Since sphericity is

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Fig. 15.2 Distribution of PAS and PSS measures across 5 waves of Covid-19

violated (Greenhouse-Geisser’s ε = 0.966), since sphericity is assumed, HuynFeldt corrected results are reported (ε = 0.974). Mean reaction of panic and agoraphobia among older adults were affected during 5 waves of pandemic, F (1, 506) = 19217.3.3, P = 0.000, Partial Eta Squared (effect size) = 0.974. This means that there is a difference in P & A of older samples within 5 time points. Like the PSS score, the older samples gradually became afraid upon hearing the unfortunate reports of the pandemic and they avoided being in public places and going out. In each pandemic wave, panic and agoraphobia level have been increasing among them (see Fig. 15.2).

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Discussion and Conclusion The SARS-CoV-2 pandemic initially manifested itself as a biological phenomenon that only threatened people’s clinical health, but has now become a multidimensional reality. The basic mental health impairments, i.e., anxiety, fear, depression, labelling, avoidant behaviours, irritability, sleep disorders, and post-traumatic stress disorder, are a set of important mental health disorders that are seen in epidemics and natural disasters (Freedman et al., 2021; Steinman et al., 2020). In this situation, maintaining the mental health of individuals is essential because people in different parts of society may experience stressful and panic experience during the Covid-19 pandemic. The psychological effects of SARS-CoV-2 are currently unclear during two years of epidemic in the Middle East and Iran. Due to the persistence of the disease, the suspension of businesses, relationships, family, and education have undergone changes. The number of unemployed is increasing, people with coronavirus due to illness experience many psychosocial consequences. The older adults are also affected by this condition, especially when it was said that the disease has a greater impact on them, their mental health was affected (García-Portilla et al., 2021; Goveas and Shear, 2020). They have a sense of fertility and vitality with the presence of their children, and in this situation, especially those who have a background of depression and Alzheimer’s and need to not be alone, this separation, limit in-person visits, and loneliness has made them sad and bored (Gorenko et al., 2021; Orhan et al., 2021). So, this study has evaluated the physical and mental health status of the 507 older people who were infected with coronavirus during the fifth pandemic wave of Covid-19 disease in south Iran. According to the results, the mean age of participants was 76.6 (SD = 8.7), 89% have chronic health condition, and majority of them have told their health status is “less than average”! (46.5%). Even though there was a significant difference in variables of study, i.e., panic and agoraphobia, perceived stress, active ageing, depression, anxiety, loneliness, during the fifth wave of pandemic using r-ANOVA (P ≤ 0.05), but these differences were not significant between elderly men and women. Recent studies indicated to this gender differences but not across the waves of pandemic (Dursun et al., 2021; Herbert et al., 2020). The r-ANOVA results indicates the most effect size of time (waves of SARS-CoV-2 pandemic) is on health (eta square = 0.98), loneliness, depression, anxiety, active aging, spirituality, cognitive impairment (Eta square ≥ 0.9, P ≤ 0.05). It means that older people suffer from a difficult situation during the pandemic; in addition to decreasing the level of physical activity, health and individual ability, and the measure of frailty, their level of stress, depression, and anxiety has also been gradually increased with being alone. The main variables of research PSS and PAS has increased so much that at each wave of the pandemic, it has become more difficult for them to cope with the new conditions (Eta square ≥ 0.97, P ≤ 0.05). Adherence to health protocols and social distancing has reduced children’s physical contact with their older parents, although in-person call and distance caring has not been able to improve the level of these indicators. At the same time, the lived experience of the older adults during this epidemic has not been able to bring them to a level of balance and coping with the challenges.

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On the other hand, social and health promotion policy-making in the country has not been accompanied by a targeted programme for older people. During the pandemic, all minority groups, i.e., indigenous peoples, ethnic minorities, refugees, migrant workers, women, children, persons with disabilities, and older persons should be considered because these groups are more vulnerable during pandemics and disasters. The crisis management test and health policy-making for these special groups should be weighed. This study was associated with problems in accessing the older samples due to pandemic conditions. Phone calls as the only solution for collecting data sometimes have unanswered from the older patients. Acknowledgements Our warm thanks go to the Research and Technology Deputy Dean of Shiraz University of Medical Sciences, as well as older adults for their participation in the study. Author’s contributions AA and AB assisted in conceptualization and design of the study, and oversaw data collection; ShM has conducted data analysis and drafted the manuscript; TS and NA has attended in data gathering and mining, study conceptualization, and reviewed the manuscript. All authors read and approved the final manuscript. Funding None. Declarations Ethical approval and consent to participate This study protocol was approved by the ethics committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1399.474). An informed consent for participation in the study was obtained from all participants. The ethics committee approved the procedure for verbal consent since the study is observational and respected the code of ethics as stated in the declarations of Helsinki. Consent for publication None. Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. Competing interests The authors declare that they have no competing interests.

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Rantanen, T., Portegijs, E., Kokko, K., Rantakokko, M., Törmäkangas, T., & Saajanaho, M. (2019). Developing an assessment method of active aging: University of jyvaskyla active aging scale. Journal of aging and health, 31(6), 1002–1024. https://doi.org/10.1177/0898264317750449 Steinman, M. A., Perry, L., & Perissinotto, C. M. (2020). Meeting the care needs of older adults isolated at home during the COVID-19 pandemic. JAMA Internal Medicine, 180(6), 819–820. https://doi.org/10.1001/jamainternmed.2020.1661 Szcze´sniak, D., Gładka, A., Misiak, B., Cyran, A., & Rymaszewska, J. (2021). The SARS-CoV-2 and mental health: From biological mechanisms to social consequences. Progress in NeuroPsychopharmacology & Biological Psychiatry, 104, 110046. https://doi.org/10.1016/j.pnpbp. 2020.110046 TejaratNews. (2021). Coronavirus (COVID-19) national report in Iran. https://tejaratnews.com/ event Upadhyaya, A. K., Rajagopal, M., & Gale, T. M. (2010). The six item cognitive impairment test (6CIT) as a screening test for dementia: Comparison with mini-mental state examination (MMSE). Current Aging Science, 3(2), 138–142. https://doi.org/10.2174/1874609811003020138 WHO. (2021a). Briefing note on addressing mental health and psychosocial aspects of COVID19 outbreak. https://interagencystandingcommittee.org/system/files/2021a-03/IASC%20Inte rim%20Briefing%20Note%20on%20COVID-19%20Outbreak%20Readiness%20and%20R esponse%20Operations%20-%20MHPSS.pdf. WHO. (2021b). Process of translation and adaptation of instruments. https://www.who.int/substa nce_abuse/research_tools/translation/en/. WHO. (2021c). Coronavirus (COVID-19) dashboard. World Health Organization. https://covid19. who.int/ Wongpakaran, N., Wongpakaran, T., Pinyopornpanish, M., Simcharoen, S., Suradom, C., Varnado, P., & Kuntawong, P. (2020). Development and validation of a 6-item revised UCLA loneliness scale (RULS-6) using Rasch analysis. British Journal of Health Psychology, 25(2), 233–256. https://doi.org/10.1111/bjhp.12404 Yesavage, J. A., & Sheikh, J. I. (1986). 9/Geriatric depression scale (GDS). Clinical Gerontologist, 5(1–2), 165–173. https://doi.org/10.1300/J018v05n01_09

Chapter 16

Mental Health and Psychological Well-Being of the Elderly During the COVID-19 Pandemic in Russia Anna Vasileva, Timur Syunyakov, Mikhail Sorokin, Maya Kulygina, Tatyana Karavaeva, Olga Karpenko, Alexander Yakovlev, Elena Zubova, Daria Smirnova, and Alisa Andrushchenko Abstract Elderly Russian people face a double burden in the COVID-19 pandemic, being at higher risk for serious infection, and vulnerable to psychiatric consequences of social isolation measures. To assess the latter phenomenon, we managed a number of studies. We undertook a number of studies. First, we enrolled a group of 456 elderly patients from general practitioners during the “2nd wave” of the pandemic. The elderly subgroup proved to have elevated levels of depression but not anxiety (measured by HADS) compared to younger adults. Higher depression scores were associated with more extensive self-isolation and the use of protective measures such as gloves. According to the COVID-19 stress scale, respondents older than 60 years experienced more intense pandemic fears including a higher perception of danger, an expectation of contamination, and xenophobia. In the second study, we compared findings in 415 elderly patients seen at the Memory Clinic during the first two waves of the COVID-19 pandemic (Spring and Autumn of 2020) with corresponding results

A. Vasileva · M. Sorokin · T. Karavaeva · E. Zubova V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, Saint Petersburg, Russia A. Vasileva · T. Karavaeva Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia National Medical Research Center of Oncology n.a. N.N. Petrov, Saint Petersburg, Russia T. Syunyakov · M. Kulygina · O. Karpenko · A. Andrushchenko Training and Research Centre, Mental-Health Clinic No, 1 N.A. Alexeev, Moscow, Russia T. Karavaeva Saint-Petersburg State University, Saint Petersburg, Russia A. Yakovlev I. I. Mechnikov North-Western State Medical University, Saint Petersburg, Russia Military Medical Academy Named After S.M. Kirov, Saint Petersburg, Russia D. Smirnova (B) International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, 78 Nagornaya Street, 443016 Samara, Russia e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_16

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from the preceding two years. Patients in the Autumn 2020 group had higher cognitive dysfunction indices on the MoCA and MMSE scales and a lower representation of vascular signs on the Hachinski scale as compared to the Spring 2020 group. The rank order of stress-related factors also differed between the mild cognitive impairment (MCI) patients and healthy participants. We performed the k-means cluster analysis on data from 55 elderly inpatients with COVID-19. We identified the cohort of patients with states of disorientation, disorders of memory, attention, and verbal fluency, as well as reduced tempo of thinking (mental speed, bradyphrenia) and low insight (Cluster 3). The representatives of this group were significantly older than mentally healthy patients (Cluster 2) and patients with other mental disorders (Cluster 1). Cluster 3 patients were characterized by a more severe course of COVID-19, with greater lung damage, higher levels of C-reactive protein, lower oxygen saturation, and higher respiratory rate. The third research study enrolled 4172 participants in a cross-sectional online cohort study design during the first months of the vaccination campaign. The strong restriction measures for the elderly subcohort were associated with a low COVID-19 rate (32.5%) compared to the young adults (40.8%) and middle-aged adults (45.5%). The elderly had a distinctly greater fear of being infected by COVID-19 (80.7%) compared to young adults (58.5%) and middle-aged respondents (72.3%). Vaccination compliance was greater among the elderly, and there were proportionally few elderly people holding vaccination to be useless, harmful, or ineffective compared to the young and middle-aged adults. Thus, the Russian experience clearly demonstrates issues of particular vulnerability related to mental well-being and its bidirectional links to somatic health in the elderly population during the period of pandemic. Our findings emphasize the importance that medical and psychosocial interventions to be well-elaborated and properly addressed to elderly people during the pandemic. Keywords Cognitive disturbances · COVID-19 Vaccines · Elderly population · Geriatrics · Mild cognitive impairment · Pandemic · SARS-CoV-2 · Social isolation · Stress

Abbreviations HADS HADS-A HADS-D MCI MMSE MoCA

Hospital Anxiety and Depression Scale Hospital Anxiety and Depression Scale—Anxiety Hospital Anxiety and Depression Scale—Depression Mild cognitive impairment MINI Mental State Examination Montreal Cognitive Assessment

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Introduction The COVID-19 pandemic continues to have multiple consequences for social life (Smirnova et al., 2021; Sorokin et al., 2021a, 2021b), psychological well-being (Karpenko et al., 2020; Sorokin et al., 2021a, 2021b), physical health (Vasileva, 2020b), and clinical practice (Sorokin et al., 2020a, 2020b). The elderly represent one of the most vulnerable population groups due to their specific somatic risks and psychological vulnerability during the pandemic (Sorokin et al., 2020a, 2020b). In addition to physical risks, elderly people have been required to meet extraordinary conditions of self-isolation (sometimes forced by the authorities) and the need for implementation of protective measures. All of these interruptions of daily routine life during the pandemic have had specific consequences for developing the state of psychological stress among elderly people. Taking into account the specific social and cultural issues, Russian gerontologists distinguish several stress factors associated with the COVID-19 pandemic. First of all, the loss of employment and income has a serious impact on well-being, especially for those on a fixed state pension income. The broader economic consequences of the pandemic made it difficult to sustain or regain the previous quality of life, and the requirements for online activity present a particular challenge to the elderly. Another important issue is the loss of leadership positions of seniors and reduced access to family and peer groups. Furthermore, the threat of infection leads to aversion and withdrawal from social contact. Russian gerontologists are emphasizing that elderly people face a double burden, as individuals at greater risk for serious COVID-19 disease, and as the population group that is the most sensitive to social isolation measures aimed to control the novel coronavirus transmission. There is, therefore, a call to enlist the elderly population into the programmes addressing to fight against the pandemic and to raise general awareness about the hardships faced by the elderly when being deprived of their usual social support environment (Bubeyev et al., 2020; Golubev & Sidorenko, 2020).

Elderly People in Outpatient Treatment: A High Psychological Risk Group The elderly show psychological and behavioural reactions to stress that differ from those of other age groups. Our sample of 456 patients was assessed in the North-West Federal district of Russia while they were seeking medical attention from general practitioners during the “2nd wave” of the pandemic. 12.5% of the sample were older than 60 years old. Surprisingly, the prevalence of chronic somatic disorders in the elderly subgroup (28.8%) was lower (χ2 = 26.3, df = 2, p = 0.00) than in young adults (50.8% of 301 respondents aged 18–44 years), but did not differ from the adults (24.5% of 106 respondents aged 45 to 59 years), possibly reflecting a bias in self-reported state of health. Only young adults (9.6%) and adults (5.7%) reported a

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history of psychiatric diagnoses which were significantly different, as compared to the elderly (χ2 = 7.2, df = 2, p = 0.03). Nevertheless, the elderly group demonstrated the highest prevalence of depression (6.9 ± 4.5 points) compared to adults (4.9 ± 4.3; p = 0.01) and young adults (4.6 ± 4.0; p < 0.01), while the anxiety scores measured by HADS (Kibitov et al., 2020) did not differ between groups. Worse emotional conditions of elderly respondents interviewed during the second wave of the pandemic in Russia were associated with more extensive use of selected protective measures. The mean nominal frequency of self-isolation on the original questionnaire (Sorokin et al., 2020a, 2020b) was higher in the elderly group (2.7 ± 1.0 points) compared to adults (2.0 ± 1.0; p < 0.01) or young adults (2.0 ± 0.9; p < 0.01). Also, the elderly reported the use of protective gloves (2.5 ± 1.1 points) more often than young adults (2.0 ± 1.0; p < 0.01), but not in comparison to the group of adults. The frequency of wearing masks, practicing physical distancing, use of sanitizers, and hand washing was equivalent among the three age groups. According to the COVID stress scale (Taylor et al., 2020), respondents at the age of older than 60 years experienced more intense pandemic-related fears. Compared to young adults, the elderly had a higher perception of danger (12.8 ± 6.0 and 9.6 ± 6.7 points; p < 0.01) and greater expectation of contamination (6.7 ± 5.3 and 4.4 ± 5.1; p = 0.00), but did not differ with respect to traumatic stress, level of ruminations, or compulsive checking about personal safety. The elderly subgroup reported a higher prevalence of xenophobia towards foreigners (8.7 ± 6.3 and 5.9 ± 6.2; p = 0.03) who, they believe, pose a higher risk of transmitting the novel coronavirus.

Dynamics of Anxiety and Depression Associated with the Pandemic Period: Focus on Patients with Mild Cognitive Impairment We placed special emphasis on the impact of the COVID-19 pandemic of associated stress factors like social isolation and health concerns on the mental health of elderly people seen at the Memory Clinic, a branch of the N.A. Alexeev Mental-health clinic No. 1 in Moscow (Grant RFBR № 20–04-60546\20). This Memory Clinic is an innovative medical rehabilitation centre for integrative care of elderly people with memory disorders or reduced cognitive and mental functions. Its rehabilitation programme includes neuropsychological sessions aimed at restoring higher mental functions, psychotherapeutic training on coping with stressful emotional experiences, and modern medication for correcting cognitive dysfunctions, along with physical exercises (Savilov et al., 2022). This ongoing study includes patients who applied to the Moscow Memory Clinic during the first two waves of the COVID-19 pandemic in 2020 (Spring and Autumn) in comparison with the preceding two years. The inclusion criteria were age over 55 years old and clinical diagnosis of mild cognitive impairment (MCI), i.e., a total score of 23–28 according to the MMSE scale (Folstein et al., 1975) and a total score of 18–27 on the Montreal Cognitive Assessment Scale

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(MoCA) (Nasreddine et al., 2005), which are generally indicative of MCI (Zaudig, 1992). The exclusion criteria were exacerbation of chronic somatic diseases or severe mental disorders, and anxiety and depressive disorders (score > 10 based on the Anxiety and/or Depression subscales of the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). At the time of writing the current report, this study included 201 patients with MCI (“MCI 2020 Autumn” group) and 49 healthy controls (“Healthy control 2020, Autumn” group), who had been examined on October 2018 (“MCI 2018, Autumn control” group), October 2019 (“MCI 2019, Autumn control” group), and May 2020 (“MCI 2020, Spring control” group). To compare with patient control groups from preceding years (“MCI 2018, Autumn control”, “MCI 2019, Autumn control”, and “MCI 2020, Spring control”), we considered only the patients from “MCI 2020 Autumn” group who were enrolled in October 2020 (n = 70). The investigative methods in all patient groups are summarized in Table 16.1. In 2020, patients additionally answered a questionnaire titled “Personal experience in connection with the COVID-19 pandemic” about their experience associated with the new coronavirus infection. The impact of the COVID-19 pandemic-associated distress in MCI patients was assessed by the data comparison between “MCI 2020 Autumn”, “MCI 2018, Autumn control”, “MCI 2019, Autumn control”, and “MCI 2020, Spring control” groups with respect to the factors of age, sex, cognitive functioning (MMSE and MoCA scales), and emotional disorders (HADS scale). This was followed by the pairwise comparison of the severity of emotional disorders on the HADS-A and HADSD subscales in four subgroups matched by age, gender, and score on the MMSE scale. We next compared the contributions of factors associated with the COVID-19 pandemic to the HADS anxiety and depression subscales between the “MCI 2020 Autumn” and “Healthy control 2020, Autumn” groups. Finally, the scores for anxiety Table 16.1 Matrix of methods used to assess study groups of elderly people during the COVID-19 pandemic Study group

Hachinski Scale (Hachinski et al., 1975)

MoCA

MMSE

HADS

Living conditions

COVID-19 associated distress questionnaire

MCI 2020, Autumn

+

+

+

+

+

+

Healthy control 2020, Autumn

+

+

+

+

+

+

MCI 2020, Spring control

+

+

+

+

+

+

MCI 2019, Autumn control

+

+

+

+

−

−

MCI 2018, Autumn control

+

+

+

+

−

−

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and depression were compared between the “MCI 2020 Autumn” group (n = 201) and the “Healthy control 2020, Autumn” group (n = 49) by the reported experience of COVID-19. We enrolled 415 patients who formed four groups depending on the time of examination at the Memory Clinic: 121 entered the “MCI 2018, Autumn control” group, 114 into the “MCI 2019, Autumn control” group, 110 into the “MCI 2020, Spring control” group, and 70 into the “MCI 2020 Autumn”. Patients in the latter group had relatively higher cognitive indices on the MoCA and MMSE scales and lower representation of vascular signs on the Hachinski scale. The female sex factor significantly influenced the severity of anxiety, but not depression in the composite group, but we did not see any group differences in anxiety and depression severity, even after matching the patient populations by age, sex, and cognitive impairment using the “case–control” study design (Karpenko et al., 2022). We also compared the impact of COVID-19-related stress factors on elderly people with versus without MCI. All patients from the total “MCI 2020 Autumn” group (n = 201) and healthy controls (“Healthy control 2020, Autumn”) completed a COVID-19 questionnaire that assessed their most influential stressful factors associated with the COVID-19 pandemic. The distribution of participants’ responses (Table 16.2) shows that the rank order of stressful factors in “MCI 2020 Autumn” group and healthy participants differed. For the MCI group, the most influential stressor was “Plans violation” followed by “Self-isolation”, “Health of loved ones”, “Poor medical support”, “Risk of being infected”, “Interaction with relatives”, “Future financial problems”, and finally “Current financial problems”. In the healthy control group, the descending rank order of stressors was “Health of loved ones”, “Selfisolation”, “Risk of being infected”, “Plans violation”, “Interaction with relatives”, “Poor medical support”, “Future financial problems”, and “Current financial problems”. Finally, in the Autumn of 2020, healthy elderly people (“Healthy control 2020, Autumn” group) had a significantly higher chance of being preoccupied with their risk of infection than MCI patients (“MCI 2020 Autumn” group) (χ2 = 4.07, p = 0.044). Table 16.2 Distribution of risk factors associated with the COVID-19 pandemic among MCI patients and healthy controls Factor attributed to COVID-19-associated distress

Response

Healthy control 2020 Autumn group (n = 49)

MCI 2020 Autumn group (n = 201)

χ2 p-value

Risk of being infected

Yes

31 (63.3%)

89 (47.1%)

0.044

No

18 (36.7%)

100 (52.9%)

Yes

22 (44.9%)

92 (48.7%)

No

27 (55.1%)

97 (51.3%)

Yes

35 (71.4%)

117 (61.9%)

No

14 (28.6%)

72 (38.1%)

Poor medical support Health of loved ones

0.637 0.216 (continued)

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Table 16.2 (continued) Factor attributed to COVID-19-associated distress Interaction with relatives Plans violation Self-isolation Current financial problems Future financial problems

Response

Healthy control 2020 Autumn group (n = 49)

MCI 2020 Autumn group (n = 201)

χ2 p-value

0.38

Yes

26 (53.1%)

87 (46.0%)

No

23 (46.9%)

102 (54.0%)

Yes

29 (59.2%)

129 (68.3%)

No

20 (40.8%)

60 (31.7%)

Yes

33 (67.3%)

121 (64.0%)

No

16 (32.7%)

68 (36.0%)

Yes

6 (12.2%)

46 (24.3%)

No

43 (87.8%)

143 (75.7%)

Yes

12 (24.5%)

68 (36.0%)

No

37 (75.5%)

121 (64.0%)

0.231 0.664 0.068 0.129

Overall, 179 individuals reported a history of COVID-19, with 29 cases (16.2%) from the “MCI 2020 Autumn” group, versus 7 cases in the “Healthy control 2020, Autumn” group (3.9%), versus no history of COVID-19 reported by 101 (56.4%) of the “MCI 2020 Autumn” group and 42 (23.5%) of the healthy control group. Anxiety and depression scores are depicted in Fig. 16.1. There were no significant differences in anxiety scores corrected for the factors of age (F = 0.537, p = 0.464 for HADS-A) and depression scores (F = 0.151, p = 0.698 for HADS-D); however, the study was underpowered for detecting any of such differences. HADS-D 9

9

8

8

HADS-D marginal Mean

HADS-A marginal Mean

HADS-A 10

7 6 5 4 3 2

6 5 4 No COVID-19 reported

3 2 1

1 0

7

MCI

Contr ol

0

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Fig. 16.1 An association of COVID-19 history with HADS-A (left) and HADS-D (right) scores in participants from MCI and healthy control groups. Note Least square Means of HADS-A and HADS-D scores are corrected to the Mean age of 71.0 years (ANCOVA); error bars denote 95% CI (Confidence Intervals)

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It is noteworthy that, despite the stress factors associated with the COVID-19 pandemic, there was a trend towards decreased mean anxiety scores in the studied sample during autumn 2021 as compared to earlier periods. Similar data were obtained by Chinese researchers when studying the psychological impact of the environment accompanying the COVID-19 pandemic on patients seen at a Memory clinic (Yuan et al., 2021). In that study, patients with neurocognitive disorders did not evince significant concern about the pandemic situation, with 22.9% of their subjects presenting clinically pronounced levels of anxiety versus 18.6% within depression, which is comparable with the results of our previous study in a similar population (14.3% and 12.9%, respectively) (Karpenko et al., 2020) Such results might reflect poor emotional stimuli processing in MCI patients (Elferink et al., 2015), and impaired awareness of emotions, including anxiety (Gigi & Papirovitz, 2021). Since our study used the subjective emotional assessment tools (HADS and COVID-19 questionnaire), a favourable emotional profile might have thus resulted from an impaired ability to recognize negative emotions and respond to environmental stressors through conscious anxiety reactions. “Plans violation” was the most influential factor in the MCI group, versus ‘Health of loved ones’ in healthy controls among the stressful factors associated with the COVID-19 pandemic in the study sample, while the second most significant factor in both groups was “Self-isolation”. The risk of being infected was a significantly overrepresented stressor in the healthy control group compared to MCI patients. Finally, financial risks were the least prominent factor in both groups, which stands in contrast to the results of a similar questionnaire among a healthy adult population in Russia (Karpenko et al., 2020).

Mental State Disturbances in the Background of COVID-19 Disease: The Factor of Age It is also well known that elderly people are at risk for a more severe course of COVID19, with a wider range of complications. To evaluate the COVID-19 consequences for elderly patients, we examined, using k-means cluster analysis, the mental health of 55 COVID-19 inpatients (Sorokin et al., 2022). Three clusters of patients were identified, without differences in gender, somatic, and mental comorbidities. The first cluster (n = 11) included patients with anxiety, disorders of fluency and tempo of thinking, mood, attention, motor-volitional sphere, reduced insight, and pessimistic views of the future. The second cluster (n = 37) consisted of patients without psychopathology, and the third cluster (n = 7) contained patients with disorientation, disorders of memory, attention, fluency, and tempo of thinking, and reduced insight into their circumstances (Fig. 16.2). Unsurprisingly, representatives of Cluster 1, in comparison with Cluster 2 (without mental disorders), had a more severe course of COVID-19, i.e., more lung lesions according to computed tomography, Median (range): 20% (6–65) vs. 15% (0–60), p = 0.018). The specific demographics of patients with mental disorders (Cluster 3)

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Fig. 16.2 Cluster analysis of COVID-19 associated mental disturbances among the inpatients of infection departments. Note the length of a bar reflects the frequency of each disturbance in the sample of COVID-19 inpatients; colours and digits in percentage reflect the fraction of patients of each revealed cluster for each disturbance

deserve special consideration. Cluster 3 patients were significantly older: Mean (SD) 76.9 (14.7) years vs. healthy patients (Cluster 2; 45.4 (17.6) years, p = 0.001), as well as vs. patients with mental disorders from the first group (Cluster 1; 55.6 (22.3) years, p = 0.027). Cluster 3 patients, in comparison with mentally unaffected Cluster 2 patients, were characterized by a more severe course of the disease according to laboratory and instrumental examination methods: they had a higher percentage of lung damage (31% (range 21–80) vs. 15% (0–60), p < 0.001), higher levels of Creactive protein (126 mg/L (range 36–298) vs. 10 mg/L (range 1.20–91), p < 0.001), lower oxygen saturation (89% (range 80–96) vs. 97% (84–99), p < 0.001), and higher respiratory rate (21 breaths per minute (range 20–28) vs. 17 (range 14–25), p < 0.001). Thus, the more complex and severe course of COVID-19 in 13% of patients (cluster 3) was associated with their older age. This result should serve for risk assessment of elderly people with COVID-19 infection with regard to their predilection for neuropsychiatric consequences in the course of the disease.

Factors of Health-Protective Behaviour During the Pandemic: The Role of Vaccination Against COVID-19 Vaccination has proved to be an effective tool in decreasing the incidence and mortality rate for COVID-19, and a plethora of infectious diseases. Nonetheless,

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mythologization and conspiracy theories are responsible for vaccine hesitancy, which has become a greater concern discussed in the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization (2015), who defined hesitancy as a delay in acceptance or refusal of vaccination, despite availability of vaccination services. Numerous studies have shown that vaccine hesitancy can differ in its intensity and involve various false beliefs, such as being a cause of autism for children or infertility for women, or even frank conspiracy beliefs such as being a pretext for mass chipping and control during the COVID-19 pandemic. The spread of misinformation affects the vaccine hesitancy, and in 2019, WHO announced vaccine hesitancy as one of the ten key global health threats and a massive obstacle for achieving population immunity due to the infodemic (Dube et al., 2013; Sallam et al., 2021; Shen & Dubey, 2019; World Health Organization, 2019, 2020). Vaccination is the key measure to stop COVID-19 community transmission, and it is the unvaccinated elderly who are greatest risk of severe illness. The alternative of waiting for herd immunity, which is estimated to be about 67% for COVID-19, would bring millions of deaths worldwide, likely with greatest impact in low-income countries. Furthermore, passive measures such as social isolation are well known as risk factors for mental disorders and dementia in the elderly. The pandemic of COVID-19 is accompanied by a massive infodemic, with the flow of misinformation perhaps spreading faster than the SARS-CoV-2 virus itself, which is proving to have a greatly detrimental effect on vaccine acceptance in certain constituencies. The general mistrust of medical guidelines has given rise to mass protests in different countries against restriction measures and compulsory COVID19 vaccination. Here, too, the elderly people are at particular risk, as they have limited access to trustworthy information sources, and a mass media campaign aimed to victimize the elderly can have a negative impact on their mental health and well-being (Vasileva, 2020a; Walsh, 2020; Webb, 2021). The rapid deployment of COVID-19 vaccines, which is unprecedented in the history of vaccinations, might raise legitimate concerns about its safety and possible adverse effects, which is indeed a key factor defining vaccine acceptance. Speculation about unforeseen immunization effects leads to underestimation of the real danger and mortality rate from SARS-CoV-2 infection, especially considering the invisibility of the virus along with psychological defense mechanisms whereby mistrust helps some individuals to regain a sense of control (Lazarus et al., 2021). We have conducted vaccination attitude research in a Russian population, aiming to evaluate the factors determining vaccination behaviour in different age groups. Elderly people were from the outset a priority, given their substantially greater health risk and mortality rate from COVID-19. This might be expected to motivate the elderly to get vaccinated, counteracted by their greater incidence of somatic disorders that might contraindicate vaccination. We conducted a cohort cross-section online study during the first months of vaccination campaign since December 2020 using a specially designed questionnaire, which included social-demographic, anamnestic, and clinical data (Vasileva et al., 2021). The separate blocks of the questionnaire described social-demographic data: age, gender, education level, social status, and

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family status. We also inquired about vaccination attitude, the occurrence of COVID19 in respondents and their social circle, the presence of mental or somatic diseases that can have an impact on the decision to receive COVID-19 vaccination, general vaccine hesitancy, and recent mental status of the respondent. The study was approved by the local ethics committee and participation was anonymous and voluntary. 4172 participants of age ranging from 18 to 81 years were enrolled in the study, of which 928 males (22.2%) and 3244 females (77.8%). The participants were stratified to the age groups according to the WHO classification: 2814 young adults (18–44 years), 1053 middle aged (45–59 years), and two subgroups comprising together 305 elderly people (>60 years). The strong restriction measures implemented for the elderly people proved to be effective, with a COVID-19 prevalence of 32.5% versus 40.8% in young adults and 45.4% in middle aged adults. There was a significant difference in COVID-19 rates between young adults and elderly (p < 0.01, ϕ = 2,638), as well as between middle age adults and the elderly (p < 0.01, ϕ = 3,867). Only about one third of the respondents (35.7%) thought immunization to be useful, while a third (32.2%) reported vaccine hesitancy, 8.7% of the respondents thought vaccination to be useless and 12.2% held it to be dangerous, while 5.9% were indifferent. 1337 (320%) respondents reported having some chronic somatic disease like arterial hypertension or obesity, and these respondents, irrespective of their age, were more likely to fear vaccination’s adverse effects (p < 0,01, ϕ = 3,918), whereas rather few of those with somatic disease (78, 5,8%) held vaccination to be useless (p < 0,01, ϕ = 4,762). In spite of measures undertaken and the decreased COVID-19 incidence in the Russian Federation in February–March 2021, about two thirds of respondents expressed some degree of fear of being infected with SARS-CoV-2, which held across all age groups. In the whole study sample, 1515 (36.3%) respondents have no fears at all, 1227 (29.4%) had some fears, 1096 (26.3%) expressed moderate concerns, 235 (5.6%) had strong fear, and 99 (2.4%) reported extremely strong fear. Elderly and very old people had greater concerns, with only 18.3% (p < 0,01, ϕ = 8,51) having no fears, while 41.5% of young adults and 27.7% of the middle-aged expressed fears (p < 0,01, ϕ = 8,055). In all age groups which included those participants having health concerns about their friends and family members, there was a higher rate of considering vaccination useful, compared to those without such concerns (p < 0.01, ϕ = 6.224; ϕ = 10.556; ϕ = 10.712; ϕ = 8.587). The strong correlation between age factor and vaccination attitude has been registered. The elderly respondents included a significantly lower proportion of those thinking vaccination to be insufficiently effective, useless, or harmful as compared to the groups of young and middle age adults (p < 0.01), and proportionally more out of elderly respondents were thinking vaccination to be useful and effective (p < 0.01). The availability in the Russian Federation of multiple COVID-19 vaccines, namely Sputnik-V (Logunov et al., 2021), EpiVacCorona (Ryzhikov et al., 2021), and CoviVac (Ishmukhametov et al., 2022) enabled starting the mass vaccination campaign without any specific need to prioritize vulnerable groups such as the elderly. Russian-produced vaccines demonstrated considerable efficacy against severe course of infection and hospitalization in real world practice, albeit with some differences

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between the three domestic vaccines (Barchuk et al., 2022). At the time of the study, 508 respondents (12.2%) were already vaccinated, 553 (13.3%) planned to get vaccine, 1449 (34.7%) were deferring their decision, 1287 (30.8%) were not planning to get vaccination, and 375 (9.0%) had medical contraindications. The elderly were more compliant towards vaccination; young adults were less likely to be planning to get vaccinated than were middle age adults (p < 0.01, ϕ = 8,664) and the elderly (p < 0.01, ϕ = 8,443), and there was a lesser proportion of the young group planning to be vaccinated in the near future (p < 0.01, ϕ = 3.332; ϕ = 4.894), and fewer who were already vaccinated (p < 0.01, ϕ = 6.45; ϕ = 3.202). We suppose that these generational differences may be related to certain advantages of the former Soviet health care system. Having grown up in the USSR, the elderly were conditioned to accept vaccination as an effective measure to fight epidemics and get protected from infectious diseases; at the time there were very strong and regular public health campaigns explaining the necessity of regular vaccination, which has carried over to present times. Results indicate that current public health programmes should address the sources of mistrust in the younger population, and educate about vaccination benefits, with attention to the favourable risk/benefit tradeoff for the elderly, including those with various medical conditions. Mental health professionals should be engaged in vaccination campaigns addressing the targets of mistrust and conspiratorial thinking, as well as other obstacles related to mental health.

Conclusions In the extraordinary situation of the COVID-19 pandemic, elderly Russian people have a double burden, being an at-risk group for a more severe course of COVID19 disease, as well as being a psychologically vulnerable group at risk to develop particular mental consequences in response to the social restriction measures aimed to control the SARS-CoV-2 transmission. Fortunately, the implementation of strong policies protecting the elderly from exposure has proven to be highly effective, as evidenced by the relatively low prevalence of COVID-19 among the elderly compared to younger age groups. The elderly demonstrated a higher level of depression, but not anxiety, compared with the groups of adults and younger adults, suggesting their particular psychological vulnerability in response to the social restrictions. Elderly patients with a history of COVID-19 showed a clear trend towards worse MMSE scores when examined in a Memory Clinic during the first two waves of the pandemic. In particular, elderly patients with infection were prone to show symptoms of disorientation, disorders of memory, attention, fluency, slower tempo of thinking, and reduced insight, all of which calls for particular attention to the risk of decompensation and needs of preventive measures. A higher percentage of elderly COVID-19 survivors had lung damage, elevated C-reactive protein, and lower oxygen saturation along with increased respiratory rate, all of which seemed to be related to their more pronounced cognitive symptomatology during and after their COVID-19

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illness. Intense pandemic fears could manifest in xenophobia and fears of contamination, while also encouraging the use of effective personal protective measures such as self-isolation and the use of gloves. Elderly people had greater concerns about being infected and were correspondingly more compliant about obtaining vaccination against SARS-CoV-2, while being less likely to think vaccination to be insufficiently effective, useless, or harmful. Results highlight the need for mental health professionals to be actively engaged in promoting the vaccination campaign, and to be mindful of the elevated risk of depression among the elderly people in the face of social isolation measures associated with COVID-19 pandemic. Acknowledgements The authors thank Professor Paul Cumming of Bern University for critical reading of the book chapter and valuable commentaries given to improve the text. Funding Results from the N.A. Alexeev Mental-health Clinic No. 1 were obtained in a study supported by the Russian Foundation of Basic Research (grant 20–04-60546).

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Chapter 17

Older Australians During the COVID-19 Pandemic: Experiences and Responses Eileen O’Brien Webb

Abstract In comparison to many nations, Australia has fared well in terms of resisting the proliferation of COVID-19 and, to date, has kept rates of infection and morbidity relatively low. Nevertheless, some perturbing issues can be identified regarding the experiences of older people living through the pandemic. These are the experience of older people in residential aged care and the increased rates of elder abuse in the community during lockdowns. This chapter will consider these issues in five parts. Part 1 will discuss Australia’s response to the COVID-19 pandemic including unprecedented state and territory lockdowns and border closures. Part 2 emphasizes the particular vulnerability of older people to COVID-19, borne out by grim national mortality rates for Australians over 65, especially for those in residential aged care. Part 3 considers the roadblocks encountered in residential aged care: a lack of training of staff and PPE equipment, orders prohibiting infected residents to be transferred to the hospital and a lack of coordinated government response. These and other factors contributed to older people in residential aged care making up most COVID-19-related deaths in Australia. Part 4 considers a rise in reports of elder abuse during the pandemic lockdowns. It seems that social isolation, in combination with increased dependence on family members or, conversely, younger family members seeking assistance from the older person, has seen many older people finding themselves in hazardous domestic circumstances and unable to access assistance. The chapter concludes by considering what the COVID-19 experience tells us about attitudes to ageing in Australia, the inadequacy of responses to the plight of older persons diagnosed with the virus, and what steps should be taken to ensure more effective and appropriate responses, should Australia be faced with such an emergency again. Keywords Residential aged care · Elder abuse · Vulnerabilities · Effective steps

In comparison to many nations, Australia fared well in terms of resisting the proliferation of COVID-19 and, until relatively recently, kept rates of infection and morbidity E. O. Webb (B) School of Law, University of South Australia, Adelaide, Australia e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_17

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Fig. 17.1 Daily new confirmed COVID-19 cases and deaths per million people—Australia. Note This figure represents Australia’s daily new confirmed COVID-19 cases and deaths per million people from January 2020 to 16 January 2023. This figure is sourced from John Hopkins University. (2023, 16 January). Australia Overview. CoronaVirus Resource Center. https://coronavirus.jhu.edu/ region/australia

low. However, with the arrival of the Omnicom variant in late 2021, the lifting of restrictions and a shift from the broad mandates and restrictions implemented during the first two years of the pandemic, there has been a significant increase in COVID-19 cases and deaths. As of 16 January 2023, Australia, with a population of just over 26 million people, has recorded 11,247, 412 confirmed cases of COVID-19 with 17,712 deaths. (WHO, 2023) Most of the cases across the wider population have occurred since the end of 2021. These statistics, and the considerable increase in cases and deaths since the beginning of 2022, are represented in Fig. 17.1. In bleak contrast, older Australians have experienced troubling rates of illness and mortality throughout the entire 3 years of the pandemic. Furthermore, the circumstances of, and responses to, the pandemic also increased the vulnerability of older people in terms of their accommodation (including in residential aged care), the risk of elder abuse, and the impact of social isolation. The pandemic also gave licence to ageist elements within the Australian population that regarded COVID-19 as a risk only to older people; blaming older people for the social and economic consequences of COVID-19 responses (Australian Human Rights Commission, 2020). This chapter will consider these issues in five parts. Part 1 will discuss the full circle of Australia’s response to the pandemic from the unprecedented state and territory lockdowns and border closures through the vaccination programme and finally to an era of “personal responsibility” (King, 2022). Part 2 emphasizes the particular vulnerability of older people to COVID-19, borne out by grim national mortality rates for Australians over 65, especially for those in residential aged care. Part 3 considers the roadblocks encountered in residential aged care: a lack of training of staff and PPE equipment, administrative orders preventing infected residents from being transferred to the hospital, and a lack of a coordinated national and government response. These and other factors contributed to older people in residential aged care making up most

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COVID-19-related deaths in Australia. Part 4 considers a rise in reports of elder abuse during the pandemic lockdowns. It seems that social isolation, in combination with increased dependence on family members or, conversely, younger family members seeking assistance, gave rise to hazardous domestic circumstances and an inability to access assistance (Collins et al., 2022). The chapter concludes by considering what the COVID-19 experience tells us about attitudes to ageing in Australia.

Part 1—Australia’s Response to COVID-19 Overview Compared to many nations, in 2020–2021, Australia avoided the worst excesses of COVID-19. However, in 2022, the Omnicom wave saw cases escalating with resultant deaths more than double the previous two years combined.

Initial Commonwealth Responses At a Commonwealth level, in February 2020, a “National Cabinet” comprised of the Prime Minister, relevant federal ministers, and the state and territory Premiers and Chief Ministers was established to oversee responses to the pandemic. At the same time, an almost complete international border shutdown was introduced. However, a truly national response was not possible because Australia’s Constitution delegates most responsibility for health care to the individual states and territories, so the Commonwealth responses were subject to sometimes differing approaches from jurisdiction to jurisdiction.

Initial State and Territory Responses State and territory governments responded to virus outbreaks with incremental measures that included internal border closures, local, and, in some cases, statewide lockdowns. For example, Western Australia imposed a “hard border” from 2 April 2020 until 3 March 2022. For the more populous eastern states and territories, a more moderate approach was taken with mask-wearing, hand sanitizing, and social distancing mandated. Surge capacity within the respective health systems increased and a contract tracing system with associated isolation protocols was introduced (Cousins, 2020). As the outbreak worsened, however, all borders were gradually closed, and cities locked down. Indeed, Victoria endured six strict lockdowns throughout 2020–2021 with

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most businesses closed, school discontinued, and citizens only permitted to leave their homes for short periods of exercise per day. Indeed, Melbourne spent more time in lockdown than any other city in the world.

Defining Moments in Australia’s COVID-19 Response While all the defining moments in Australia’s response to COVID-19 cannot be addressed in this chapter, four pivotal stages illustrate Australia’s journey through the pandemic, especially in relation to the impact on older people. (i) Some initial missteps—The Ruby Princess In March 2020, 2700 passengers on the cruise liner Ruby Princess were permitted to disembark in Sydney and return to their homes throughout Australia despite many experiencing COVID-19 symptoms. Hundreds of people throughout Australia— those who had been on the cruise or those who had been in contact with the returning passengers—were soon diagnosed with COVID-19. This led to a significant surge in the prevalence and geographical distribution of the virus. The virus then circulated within the community and made its way into aged care facilities, leading to the tragic consequences discussed in Part 3 of this chapter. (ii) Strict enforcement and lockdowns As noted above, “COVID-Safe” measures such as masking, social distancing, and lockdowns were implemented. Criminal penalties were imposed for breaches. Aged care facilities throughout Australia were locked down thus causing older people to be isolated from their families. (Commonwealth of Australia, 2020) Nevertheless, the virus took hold in these facilities, exacerbated by a lack of trained staff and PPE and the failure to transfer seriously ill residents to the hospital. Many older residents died, for example in the St Basil’s facility in Melbourne where fifty residents passed away from COVID-19. The facility is now the subject of a coronial inquest (Morgan, 2021). (iii) Vaccination Vaccination was made available to Australians in February 2021 through the Commonwealth government’s COVID-19 vaccine and treatment strategy (Australian Government, 2020d). Priority groups (including aged care residents and staff) were slated to be the first to be vaccinated. Unfortunately, the vaccine “rollout” was hampered by a lack of reliable supply and a failure to meet vaccination deadlines. Indeed, a report by Australia’s Auditor-General noted that the vaccine rollout had only been partially effective with the administration of vaccines to the general population, and in particular, priority populations, not meeting targets (Australian National Audit Office, 2022). Another issue affecting vaccination for older people was the choice of vaccine made available to them. After the discovery of a blood-clotting disorder associated

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with the Astrazeneca vaccine, and advice from the Australian Technical Advisory Group on Immunisation (ATAGI) that older people were at less risk of developing the disorder than younger people, the Commonwealth government resolved to administer Astrazeneca exclusively to older people (initially over 50 and later over 60). This led to allegations of ageism and a willingness of the government to “risk” the lives of older people with a potentially dangerous vaccine (Dow, 2021). (iv) Lifting restrictions Despite the arrival of the Omnicron variant in late 2021, rising vaccination rates amongst the wider population saw governments, arguably on economic rather than public health grounds, lift restrictions throughout 2022. As noted above, this has seen an increase in the number of COVID-19 cases with a death toll double that of the previous two years. Of these deaths, older people are disproportionately represented.

Part 2—The Disproportionate Impact of COVID-19 on Older Australians While, at least initially, Australia was spared the worst excesses of the virus, it did not emerge unscathed, especially in relation to the older population. Indeed, the statistics involving older people experiencing and dying from COVID-19 are concerning and disproportionate to those of the wider population. The median age for those who died from COVID-19 was 84.7 years (82.9 years for males and 86.7 years for females). (ABS, 2022). As can be seen from Fig. 17.2, people between 70 and over 90 years of age have experienced overwhelmingly the worst effects of the virus.

Fig. 17.2 COVID-19 Registered deaths by age group and sex to 30 June 2022. Note This figure is sourced from the Australian Bureau of Statistics and represents the registered deaths from COVID19 recorded in Australia by reference to age group and sex from the beginning of the pandemic until 30 June 2022. https://www.abs.gov.au/articles/covid-19-mortality-australia-deaths-registereduntil-30-june-2022

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Older People’s Responses to the COVID-19 Threat in the Community In some cases, COVID-19 symptoms were mild and regarded as merely a cold and “not worth seeing a doctor” (McNulty et al., 2020). Many other older people simply did their best to ignore restrictions and maintain everyday life, as far as possible (Daoust, 2020). However, it seems that for many older people, there were also issues of isolation and access to medical care resulting from the circumstances of the pandemic. For example, although testing stations were available throughout metropolitan areas, older people without access to transport were unable to be tested. Furthermore, during the lockdowns, only essential workers were permitted to travel or take public transport (Wahlquist, 2020). Seeking health care was an exception to the travel prohibitions, but it seems many older people were reluctant to venture out. Evidence of instances of elder abuse, discussed in Part 4 of this chapter, seems likely to have also prevented some older people from seeking medical assistance. It seems too many older people were fearful of presenting at a medical centre either because they may have the virus (and therefore be hospitalized and be unable to see family) or because the COVID “message” did not get through. This last instance was crucial in the spread of the Victorian second wave in relation to members of ethnic communities. Significant shortcomings were identified in relation to information provided to non-English speaking communities, especially regarding “COVID Safe” procedures, the hazards of large family gatherings when dealing with a highly infectious virus and the heightened danger to older community members (Davey & Boseley, 2020; Gray, 2020). Nationwide, presentations to hospital emergency departments and doctors surgeries were down considerably with regard to illness unrelated to COVID-19 (Mackee, 2020). A study of 4 emergency departments in Sydney found that presentations fell by over 25% during the pandemic (Kam et al, 2020) with conditions disproportionately affecting older people, such as “infectious enteric disease, pneumonia, wrist or hand fractures, stroke or intracerebral haemorrhage, and chest pain not resulting in another diagnosis” were well below 2019 levels (Swanell, 2020). There was also the complication of collateral issues associated with the pandemic such as delayed presentation at medical services for symptoms of heart attack, stroke or cancer and the postponement of elective surgery, issues that again impacted disproportionately older people (Holt et al, 2020).

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Part 3—Responses to COVID-19 in Australian Residential Aged Care Facilities—Too Little, Too Late Overview While statistics regarding the impact of COVID-19 on older people within the community are likely to be underestimated, the plight of older people in residential aged care has been well documented and has resulted in some controversy. Indeed, residential aged care has been identified as “a major weakness” in Australia’s COVID19 response with almost 50% of COVID-19 deaths in Australia in residential aged care facilities (Australian Government, 2022).

Regulation of Residential Aged Care in Australia Due to the constitutional division of powers, both the Commonwealth and State/Territory governments have significant, if not well-demarcated, roles to play in relation to residential aged care. The funding and administration of aged care is a Commonwealth responsibility, and the Commonwealth also hosts a Health Department. However, State and Territory governments for the most part oversee and regulate the health system within each jurisdiction (Webb et al, 2020). State and Territory governments also have overall responsibility for managing public health emergencies. Primarily, aged care throughout Australia is operated by private aged care providers. Some jurisdictions still provide residential aged care services, although this is relatively uncommon. The private providers are funded by the Commonwealth government and are subject to the Aged Care Act 1997 (Cth) and supporting regulations. Conduct within the industry is overseen by the Aged Care Quality and Safety Commission. Of necessity, state and territory health administration and individual medical and allied health practitioners integrate within the residential aged care system. Commonwealth and state/territory governments were well aware of the potential for the breakdown of this symbiotic relationship, but the pandemic created a “perfect storm”. Indeed, while governments were aware of failures within the aged care sector prior to the pandemic—in fact, the sector was the subject of an ongoing Royal Commission—the emergence of the pandemic saw: Confusion, poor communication and information, false assumptions…hamper important decision making and development of a collaborative approach between Federal and State regarding COVID-19 outbreaks in aged care facilities (COTA, 2020, p. 12)

Moreover, the situation was complicated by the preparedness and conduct of several aged care providers—including an unwillingness at times to comply with

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government directives—to adopt recommended responses and, in some cases, endangered aged care residents. Cousins notes that “it left families grieving and experts angry that their pleas to reform the sector had long been ignored” (Cousins, 2020).

Responses to Residential Aged Care Vulnerability Australian governments were aware of the dangers COVID-19 posed to older people and aged care facilities. News of outbreaks in nursing homes in the UK, Canada, and the United States were well known and, initially, outbreaks were contained, and the sector claimed to be well-prepared (Commonwealth of Australia, 2021b). Unfortunately, the community spread entered aged care facilities through staff and, before the lockdowns, visitors. The nature of residential aged care centres was such that the virus spread quickly amongst residents. For example, some of the first outbreaks were at Dorothy Henderson Lodge and then Newmarch House, both aged care facilities in suburban Sydney. Independent reports into the outbreaks identified a myriad of problems that hampered the response including emergency protocols, inter-agency relationships, infection control, availability of PPE, inadequate staffing and support, lack of communication with family and, concerningly, a reluctance to allow older people to be admitted to hospital in favour of an “in house” approach even when their condition was worsening due to the virus (Australian Government, 2020c). Unfortunately, these lessons were not heeded and infection in aged care ballooned. Victoria, for example, saw many residential aged care facilities overwhelmed (Davey, 2020). St Basils, a residential aged care facility in Victoria became the site of Australia’s deadliest COVID-19 outbreak with the death of 50 older residents. The circumstances within the facility were considered at a coronial inquest and a criminal investigation with the workplace regulator is underway at the time of writing. Figure 17.3 illustrates covid 19 active and recovered cases and deaths as at 17 May 2022.

Problems Experienced in Relation to Residential Aged Care (i) Lack of preparedness by government. One of the major criticisms of the Commonwealth government response to the pandemic was a lack of a “plan” in the event of the virus reaching residential aged care facilities. While there has been some pushback from the Commonwealth government on this issue, the Royal Commission noted in a special report that there was not a plan devoted solely to aged care but that there was a national COVID-19 plan—the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID19)—that the government intended to “adapt and apply” to aged care. Aged care providers were made aware of the plan in February 2020 and encouraged to use the

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Fig. 17.3 COVID-19 cases and deaths in aged care services—residential care. Note This figure adopts illustration produced by the Australian Government’s Department of Health as at 17 May 2022. The data sourced from the Victorian Public Health Events Surveillance System (PHESS) and Commonwealth sources

Plan as a reference tool to prepare emergency plans (Commonwealth of Australia (2021b). The plan was supplemented by materials provided by the Aged Care Quality and Safety Commission (ACQSC) and the Commonwealth Department of Health but providers were largely left to their own devices with several troubling omissions from government bodies such as the ACQSC permitting self-assessment by providers as to their COVID-19 “readiness” (Commonwealth of Australia (2021b). Additional Commonwealth funding was provided to aged care providers to address the virus (Commonwealth of Australia, 2021b). Unfortunately, the Commonwealth response was regarded as slow, reactive and, as noted by prominent commentator Sara Russell: While these give the impression the government is doing something, until it tackles the systemic failures that led to the deaths of …residents in aged care homes, the government is pouring our money down the drain. made to appear ‘like they were doing something’ (Russell, 2020, p.1).

Indeed, much time has been spent trying to divert perceptions of failure from the Commonwealth, with its clear responsibility to administer aged care, to the states. This was particularly the case during Victoria’s “second wave”, where, despite over 90% of COVID-19 deaths occurring in Commonwealth funded age care facilities, the blame was firmly cast on the Victorian government despite a minimal number of cases and deaths in state-managed aged care (Hoffman et al., 2020). (ii) Issues with aged care visitors, informal carers, and allied health services Access to the aged care facilities has been one of the most problematic areas in Australia’s COVID-19 experience. At the beginning of the pandemic, aged care providers implemented a blanket “no visitor” policy. In most cases, the policy was implemented without notice and

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there were complaints of a lack of communication from the providers to residents’ families (COTA, 2020).This had an adverse effect on residents in several ways. There was a considerable impact on residents’ mental health through being unable to have contact with family and friends and, where family played a role of an informal carer by assisting with the resident’s meals and care, saw some residents left “dehydrated and starving” as alternative measures were not put in place (COTA, 2020). This was particularly an issue in relation to residents experiencing dementia. Furthermore, residents were confined to their rooms, unable to access common areas, and no exemptions were granted when a resident was dying. Despite negotiations between government, advocacy bodies and providers, there was a reluctance to loosen these restrictions, even in areas where there was little to no outbreak of the virus. This “standoff” resulted in the development of Industry Code for Visiting Residential Aged Care Homes during COVID-19 (Australian Government 2021). In Australian law, industry codes can be declared to be voluntary or mandatory. Unfortunately, aged care providers as a bloc refused to agree to a mandatory code that would have ensured that all elements of the code had to be adhered to. Therefore, there are concerns that the code is not being adhered to and that many providers, being risk adverse and concerned regarding the possibility of further outbreaks, close or limit access to facilities (COTA, 2020). (iii) Clinical decision making and barriers to sending older people with COVID-19 to hospital One of the most controversial issues has been the reluctance, particularly in the early stages of the pandemic, to send older people from aged care facilities to hospital. The main exception was South Australia that introduced an automatic transfer policy for residents of aged care facilities who tested positive to the virus (Commonwealth of Australia, 2021b). In other jurisdictions, particularly New South Wales, there were a variety of reasons given for this including the use of a “hospital in the home”— treating the older person in the aged care facility. It was said that this would see less disruption for the residents, especially for those with dementia, and reduce demand on the hospital system. What became apparent was, however, that residents were simply not getting the care required to adequately treat the virus or to cope with it in circumstances when a person’s condition became critical. It was realized that aged care facilities simply did not have enough PPE, trained staff or oxygen supply, not to mention ventilators. A lack of PPE and staff being permitted to deal with other, uninfected patients, as well as caring for COVID-19 patients meant that the virus spread rapidly (Commonwealth of Australia, 2021b). Eventually, individual clinical needs overtook the blanket policy of onsite care adopted in several jurisdictions. Rising infection and death rates in aged care facilities and associated issues arising about the quality of care saw a reversal of the policy, and transfers to hospitals were made based on the older person’s clinical needs (Commonwealth of Australia, 2021a). At this point, it is instructive to consider a pertinent legal issue that arose in the course of the hospital transfer controversy. In some cases, older people had made advanced care directives that stated that they did not want to go to hospital, under

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any circumstances, in the event of illness. However, other such documents were not as clear in that an older person may not want to be taken to hospital if there is no chance of recovery, for example through a stroke or terminal cancer, but would be desirous of treatment in the event the condition could be addressed. Although aged care facilities were not equipped to adequately care for many residents stricken by the virus, admission to the hospital could result in a recovery. While there is no evidence thus far of conduct akin to that experienced in the United Kingdom and the USA regarding access to care (Human Rights Watch, 2020), it is a condition of entry to most private aged care facilities in Australia that an advanced care directive must be sought. Depending on the content of the ACD should determine the path of an older persons care and, if desired, hospitalization. However, anecdotal evidence suggests that, in some cases, an expansive view may have been taken on advanced care directives which may not adhere to the wishes of the older person. (iv) Workplace and training issues The training and skills of aged care workers have been a controversial subject for some time (Commonwealth of Australia, 2019) and the onset of the pandemic exposed existing shortcomings in the preparedness, training, and competency of the aged care workforce (Royal Commission Report, 2020: 9). While it must be said that most aged care workers make their best efforts for the older people in their care, the reality is that such workers are, for the most part, poorly trained, do not require nursing qualifications, are poorly paid and have few workers rights. Most are on casual employment and need to work across more than one aged care facility to earn enough money for a basic existence. The free-market model introduced in Australia in 1997 saw a requirement of ratios of registered nurses to less skilled assistants removed. It is now not uncommon that there may be no registered nurses on-site overnight or ratios of one registered nurse to 80 older people. As noted above, there was a shortage of PPE and other equipment required in circumstances of an infectious virus, and because private aged care facilities run on a for-profit basis, there were instances where, for example, workers were told to reuse gloves or only use one glove at a time to ration PPE (Cousins, 2020). (v) Mental health Another problematic issue arising from the pandemic was balancing the autonomy and mental well-being of the aged care residents with protecting them from the spread of the virus within facilities. At the height of the pandemic, older people were confined to their rooms 24 h per day; they were unable to have visitors and unable to leave the room for exercise. This caused an increase in depression, anxiety, and confusion for many residents. It was especially difficult for older people who were used to company or visits from family and also for dementia patients where routines were impacted (COTA, 2020: 8). Even in aged care facilities that did not experience outbreaks of the virus, residents endured months of isolation. Such isolation has seen concerning effects on physical, mental, and emotional well-being (Royal Commission Report, 2020: 25).

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The Response of the Royal Commission Although the Royal Commission into Aged Care Quality and Safety (Royal Commission) final report was not due to be released until February 2021, concern regarding the spread of COVID-19 within aged care facilities saw the Commissioners agree to produce a special report on government and provider responses to the pandemic (Commonwealth of Australia, 2020). The special report made 6 key recommendations focusing on visitors and the quality of life for residents during the pandemic, the role of allied health, the necessity for improvement in infection control expertise and PPE, and the need for a national aged care advisory body and specific COVID19 plan. The prevalence of COVID-19 in residential aged care was the subject of considerable discussion in the Final Report of the Aged Care Royal Commission in 2021 (Commonwealth of Australia, 2021a, 2021b, 2021c).

Part 4—Rising Instances of Elder Abuse in the Community During Enforced Lockdowns From the beginning of the pandemic, domestic and family violence services expressed concern regarding enforced isolation at home during the lockdowns and the likely rise in incidents of violence. It is no surprise that this concern also extended to elder abuse. Financial stress and unemployment are risk factors for domestic and family violence. As Australia went into the initial lockdown, several million people became unemployed. There was some relief through government initiatives referred to as Jobkeeper and Jobseeker that provided employees who “stood down” from their positions a living wage and increased rates for unemployed people, respectively. However, many people, including those in casual employment for less than a year, were only entitled to unemployment benefits. Older workers were especially impacted as many were in casual or part-time employment (IT Brief, 2020) In addition to the stresses caused by a sudden economic shock, initial lockdowns saw most of the population isolated at home with only essential workers permitted to leave home. With this combination of stressors, there is no doubt that this period saw, like elsewhere, a significant rise in the incidence of domestic and family violence, including elder abuse (Boserup et al., 2020; Bradbury Jones et al., 2020). In response, the Australian Government provided an additional $150 million to domestic and family violence services. However, there was little in the way of directed funding allocated to instances of abuse of older people. Furthermore, media and domestic and family violence service information was directed almost completely towards circumstances of “traditional” perceptions of family violence (Galloway, 2020). Elder abuse helplines in various Australian jurisdictions experienced an increase in the number of calls taken during the pandemic. Uniting Care in Queensland, which oversees the Elder Abuse Prevention Hotline received 2,022 abuse notification calls in

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2020–2021. This is the highest yearly total recorded since data collation commenced over 20 years ago. (Uniting Care, 2022) and accords with findings regarding increased instances of elder abuse during the pandemic in the United Kingdom and elsewhere. (Doward, 2020) What is clear is that the pandemic lockdowns created a fertile ground for elder abuse due to disproportionate social isolation of older people, troubled existing family relations being exacerbated by the all residents being ‘locked down’ at home and pressure being placed on older people by their adult children to assist financially where there had been job losses or other financial stresses brought about by the pandemic.

Social Isolation From the beginning of the pandemic, it was clear that older people were most vulnerable to the virus. This saw many older people experience even greater degrees of social isolation than before the pandemic as activities or appointments take them out of the home. Elder abuse is notoriously difficult to recognize at the best of times but the pandemic response diluted circumstances where abuse could be identified and it also meant less opportunities for older people experiencing abuse in the home to be able to escape the violence even for a few hours. And, due to concerns regarding the virus, people were reluctant to leave home anyway. As discussed above, the number of people attending medical clinics and hospitals, even for regularly scheduled appointments, decreased markedly during the pandemic. This could have the effect of undermining the older person’s physical health, thus making them susceptible to abuse. It could also result in older people, of necessity, becoming more dependent on family members. Similarly, many services were unavailable during this time meaning that support for older people experiencing isolation or abuse was curtailed. For example, some consultations could be performed by telephone but indicators of stress or abuse could not be as effectively assessed in comparison to consultations in person (Davis, 2021).

Pressure at Home During the Lockdown Where an older person is already living with one or more family members, any existing issues can be exacerbated by isolation, boredom, and financial stress. This can extend to the many forms of abuse including physical, psychological, financial, and sexual abuse. The issue of coercive control has been the subject of discussion in several Australian jurisdictions in terms of domestic and family violence. While it has not been considered in any depth, to date, in relation to elder abuse, anecdotal evidence collected by Australian helplines during the pandemic indicates the presence of controlling behaviours by family members towards older people such as exaggerating the risk of COVID-19 to the older person, thus increasingly restricting access

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to the outside world, including doctors, preventing them from using the internet or other means of keeping up contacts, and denying access to grandchildren or other (permitted) visitors because of the risk associated with them. These circumstances seem to have also led to threats such as, unless the older person provided the family member with money or other assets, the family member/s would abandon them during the pandemic.

Financial Abuse by Family Members As discussed, the pandemic saw considerable employment losses throughout Australia, many almost overnight. This saw the need for adult children, often with families, to move into an older person’s home and in some cases, the older person feeling they have no option but to support the family. Such circumstances are fertile ground for behaviour such as coercive control, exacerbated manipulation of social isolation, and psychological pressure for financial assistance (Makaroun et al., 2020; Uniting Care, 2022).

Part 5 Lessons for Australia—Addressing an Ageist Underbelly and Inadequate Responses to the Health and Safety Needs of Older People During the Pandemic This chapter has considered Australia’s responses to the pandemic, in particular, its impact on older Australians. Despite Australia’s comparative success in minimizing the worst effects of the virus—at least statistically speaking—there is no doubt that many people have been adversely affected in the wake of the virus and the extent of the harm and the virus’s ongoing implications cannot easily be assessed. Something that is already evident is the unfortunate experience of many older people during the pandemic whether in residential aged care or in the community. Another concerning issue raised during the pandemic is what appears to be a disconcerting ageist “underbelly” in Australia. While this does not come as a complete surprise, the vitriol of prominent commentators—believed in some cases to reflect a considerable segment of the public mood—was unleashed to such an extent that senior government members and social commentators felt required to make public responses (Janda, 2020). At issue was, as in several other nations, the balance between opening the economy despite the pandemic and locking down to prevent further spread of the virus. A furious media debate erupted with several economic commentators taking the view that the virus inordinately affected older people—indeed, in one notorious article, a commentator said that older people had “a good innings”—and that the economy should be reopened. Older people experienced embarrassment and, in some cases,

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verbal abuse, as the campaign gained momentum. In order to dilute the animosity, prominent Australians “pushed back” in the media and elsewhere to emphasize that it was not an either/or circumstance. Even as Australia seems to be recovering from the worst effects of the pandemic, this debate continues. Perhaps this inherent ageism makes some of the experiences of older people during the pandemic predictable. In relation to aged care, despite warnings from nations in the Northern Hemisphere about the dangers of COVID-19 to older people in nursing homes, the Commonwealth government did not have a focussed aged care plan in place and was slow to respond when the dangers of the pandemic became apparent during the first two outbreaks in aged care facilities in New South Wales. Furthermore, policies by some state health departments to adopt a hospital in the home approach to COVID-19 completely underestimated the risks of leaving people infected with the virus from being in the vicinity of other residents. The seemingly default position of several jurisdictions to simply not transfer aged care residents to the hospital is concerning, to say the least, and a uniform response of transfer on the basis of clinical need was introduced too late in the day. The shortcomings in private aged care facilities and the problematic nature of balancing an appropriate level of care with obligations to profit and shareholders were placed into stark relief. In summary, staff training, resources, emergency responses, and even the supply of necessities such as PPE were revealed, in many cases, to be completely inadequate. It is hoped that the upcoming final report from the Royal Commission reconsiders, and elaborates upon, these issues again. In comparison to the aged care “debacle” widely reported in the Australian media (Connolly, 2020), there has been a little comparative level of awareness of abuse of older people within the community. Much of the evidence of increasing levels of elder abuse is mostly anecdotal but there are certainly firm indications from helplines around Australia of an increase in calls from the beginning of the pandemic. Statistics gathered elsewhere may shed some light on the issue as it would be unusual if Australia’s position was markedly different. For example, a recent poll conducted by the UK-based Hourglass organization found that abuse of older people was at “unprecedented levels” with one in five older people being abused (Doward, 2020). It was noted that “Coronavirus has made the problem even worse as vulnerable people lose contact with friends, neighbours, and the outside world” (Doward, 2020). As Australia emerges from the pandemic, more information on the experiences of lockdown on older people will be revealed, and it is likely to be confronting. So, what can be learned from the COVID-19 “experience”? The Final Report of the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia, 2021a, 2021b, 2021c) was released in February 2021 and was, in parts, scathing regarding the government and regulatory responses to COVID-19 in residential aged care. Indeed, it was noted: The tragic impact of the COVID-19 pandemic highlighted weaknesses and shortcomings in the system, especially the reactive nature of its governance. (Commonwealth of Australia, 2021a: 62)

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Regarding the abuse of older Australians within the community, as the economy and society open up and “normal” life resumes, more instances of abuse are likely to be revealed. However, the prevalence of elder abuse is always problematic, and the invisible nature of elder abuse means that any statistics obtained will undoubtedly be inaccurate. In the wake of the 2017 Australian Law Reform Commission inquiry into elder abuse (Australian Law Reform Commission, 2017), a National Plan to address the abuse of older Australians was introduced in 2019 (Australian government, 2019) and is gradually rolling out across the country. As yet, it has not addressed the pandemic in any comprehensive way, though itsanticipated data and local experiences and responses will be the subject of significant consideration in the coming months. Ideally, the National Plan could pay more heed to national emergencies of all kinds and the effect such events can have on the older population. Finally, as a society, there is no doubt that Australia needs to consider its attitude to ageing and the considerable contribution older people have made during their lives and continue to make as they age. Sadly, COVID-19 revealed an ageist underbelly throughout Western societies (Fraser et al., 2020), including amongst the Australian population (Hausknecht et al., 2023).

References Australian Bureau of Statistics. (2022, July 29). COVID-19 Mortality in Australia: Deaths registered until 30 June 2022. ABS. https://www.abs.gov.au/articles/covid-19-mortality-australia-deathsregistered-until-30-june-2022 Australian National Audit Office. (2022). Australia’s COVID-19 Vaccine Rollout (Auditor General Report No 3 2022–2023). Australian Government. https://www.anao.gov.au/sites/default/files/ 2022-10/Auditor-General_Report_2022-23_3_0.pdf Australian Government. (2019). Protecting the Rights of Older Australians: National Plan 2019–2023. Attorney General’s Department. https://www.ag.gov.au/rights-and-protections/pro tecting-rights-older-australians Australian Government. (2020a). COVID-19 deaths by age group and sex, Department of Health Australian Government. https://www.health.gov.au/resources/covid-19-deaths-by-agegroup-and-sex Australian Government. (2020b). Covid 19 cases in aged care services—residential care. Department of Health Australian Government. https://www.health.gov.au/resources/covid-19-casesin-aged-care-services-residential-care Australian Government. (2020c). Independent Review: Newmarch House COVID-19 Independent Review. Department of Health, Australian Government. https://www.health.gov.au/sites/def ault/files/documents/2020/08/newmarch-house-covid-19-outbreak-independent-review-new march-house-covid-19-outbreak-independent-review-final-report.pdf Australian Government. (2020d). Australia’s COVID-19 vaccine and treatment strategy. Department of Health, Australian Government. https://www.health.gov.au/resources/publications/australiascovid-19-vaccine-and-treatment-strategy Australian Government. (2021). Industry code for visiting residential aged care homes during COVID-19. Department of Health, Australian Government. https://www.health.gov.au/resour ces/publications/industry-code-for-visiting-residential-aged-care-homes-during-covid-19

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Australian Government. (2022). COVID-19 outbreaks in residential aged care facilities. Department of Health, Australian Government. https://www.health.gov.au/sites/default/files/documents/ 2022/05/covid-19-outbreaks-in-australian-residential-aged-care-facilities-13-may-2022.pdf Australian Human Rights Commission. (2020). Ageism and COVID-19 Australian Government Canberra. https://humanrights.gov.au/about/news/ageism-and-covid-19 Australian Law Reform Commission. (2017) Elder Abuse—A National Legal Response. Report No 131. https://www.alrc.gov.au/publication/elder-abuse-a-national-legal-response-alrc-report131/10.1111/jocn.15296 Bradbury-Jones, C., & Isham, L. (2020). The pandemic paradox: The consequences of COVID-19 on domestic violence. Journal of Clinical Nursing, 29, 2047–2049. https://doi.org/10.1111/jocn. 15296 Boserup, B., McKenney, M., & Elkbuli, A. (2020). Alarming trends in US domestic violence during the cOVID-19 pandemic. American Journal of Emergency Medicine, 38(12), 2753–2755. https:// doi.org/10.1016/j.ajem.2020.04.077 Collins, M., Crowe, M., Cleak, H., Kallianis, V., & Braddy, L. (2022). The effects of the COVID-19 pandemic on patients experiencing family violence presenting to an Australian health service. British Journal of Social Work, 00, 1–22. https://doi.org/10.1093/bjsw/bcac184 Commonwealth of Australia. (2020). Royal Commission into Aged Care Quality and Safety. Special Report: Aged Care and COVID-19. https://agedcare.royalcommission.gov.au/sites/default/files/ 2020-10/aged-care-and-covid-19-a-special-report.pdf Commonwealth of Australia. (2019). Royal Commission into Aged Care Quality and Safety. Interim Report https://agedcare.royalcommission.gov.au/publications/interim-report Commonwealth of Australia. (2021a). Royal Commission into Aged Care Quality and Safety. Final Report Volume 1. https://agedcare.royalcommission.gov.au/publications/final-report-volume-1 Commonwealth of Australia. (2021b). Royal Commission into Aged Care Quality and Safety. Final Report Volume 2. https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-rep ort-volume-2_0.pdf Commonwealth of Australia. (2021c). Royal Commission into Aged Care Quality and Safety. Final Report Volume 3A. https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/ final-report-volume-3a_0.pdf Connolly, A. (2020, August 25). Coronavirus is devastating the aged care sector, and it all feels shockingly familiar. Australian Broadcasting Corporation. https://www.abc.net.au/news/202008-25/coronavirus-aged-care-australia-crisis-feels-shockingly-familiar/12592178 Council on the Ageing. (2020). Lessons of the COVID-19 crisis for aged care reform (Submission 2) COTA Australia. https://agedcare.royalcommission.gov.au/sites/default/files/2020-09/RCD. 9999.0507.0001.pdf Cousins, S. (2020, October 24–30). Experts criticise Australia’s aged care failings over COVID-19. Lancet, 396(10259), 1322–1323. https://doi.org/10.1016/S0140-6736(20)32206-6 Davey, M., & Boseley, M. (2020, June 28). Corona Virus Experts warn against blaming migrant communities for spreading misinformation. The Guardian. https://www.theguardian.com/aus tralia-news/2020/jun/28/coronavirus-victoria-experts-warn-against-blaming-migrant-commun ities-for-spreading-misinformation Davey, M. (2020, 15 October). We learned the hard way inside the war room to contain Victoria’s aged care Covid outbreak. The Guardian https://www.theguardian.com/australia-news/2020/ oct/15/we-learned-the-hard-way-inside-the-war-room-to-contain-victorias-aged-care-covidoutbreak Daoust, J.F. (2020). Elderly people and responses to COVID-19 in 27 Countries. PLoS ONE, 15(7). https://doi.org/10.1371/journal.pone.0235590 Davis, S. (2021). Response to NSW Department of Communities & Justice Consultation Paper on Remote Witnessing via Audio-visual Link. Justice Connect. https://justiceconnect.org.au/wpcontent/uploads/2021/08/Justice-Connect-response-to-NSW-Department-of-Communities-Jus tice-remote-witnessing-consultation-paper-June-2021.pdf

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Doward, J. (2020, November 29). One in five older people in the UK have been abused, poll finds The Guardian (UK). https://www.theguardian.com/society/2020/nov/29/one-in-five-older-peo ple-in-the-uk-have-been-abused-poll-finds Dow, A. (2021, June 22). Is Australia’s vaccine rollout ageist? The Sydney Morning Herald. https:// www.smh.com.au/national/is-australia-s-vaccine-rollout-ageist-20210622-p58385.html Fraser, S., Lagacé, M., Bongué, B., Ndeye, N., Guyot, J., Bechard, L., Garcia, L., Taler, V.; CCNA Social Inclusion and Stigma Working Group; Adam, S., Beaulieu, M., Bergeron, C. D., Boudjemadi, V., Desmette, D., Donizzetti, A.R., Éthier, S., Garon, S., Gillis, M., Levasseur, M., Lortie-Lussier, M., Marier, P., Robitaille, A., Sawchuk, K., Lafontaine, C., Tougas, F. (2020). Ageism and COVID-19: What does our society’s response say about us? Age Ageing, 49(5), 692–695. https://doi.org/10.1093/ageing/afaa097 Galloway, A. (2020, July 13). Domestic violence on the rise during pandemic. The Sydney Morning Herald https://www.smh.com.au/politics/federal/domestic-violence-on-the-rise-dur ing-pandemic-20200712-p55b8q.html Gray, A. (2020, June 29). Multi-lingual Australia is missing out on Covid-19 information. The Conversation https://theconversation.com/multilingual-australia-is-missing-out-on-vitalcovid-19-information-no-wonder-local-councils-and-businesses-are-stepping-in-141362 Hair, J. (2020, August 14). Ruby Princess inquiry slams ‘inexcusable mistakes’ made by NSW Health. Australian Broadcasting Corporation. https://www.abc.net.au/news/2020-08-14/rubyprincess-coronavirus-inquiry-findings-handed-down/12557714 Hausknecht, S., Clemson, L., O’Loughlin, K., McNab, J., & Low, L. F. (2023). Co-designing alternative frames of ageing and experiences of challenging ageism in Australia. Educational Gerontology., 49(1), 48–59. https://doi.org/10.1080/03601277.2022.2070347 Hoffman, R., Neelim, A., Elkins, & Khezr, M. (2020, August 12). Playing the COVID-19 blame game may feel good, but it could come at a cost—The Government’s Credibility. The Conversation. https://theconversation.com/playing-the-covid-19-blame-game-may-feel-goodbut-it-could-come-at-a-cost-the-governments-credibility-144120 Holt, N., Neumann, J., McNeil, J., & Cheng, A. (2020). Implications of COVID-19 on an ageing population Medical Journal of Australia, 213(8), 242–244. https://www.mja.com.au/journal/ 2020/213/8/implications-covid-19-ageing-population Human Rights Watch. (2020, April 7). Rights risk for older people during Covid-19 response: Combat Ageism; Ensure Access to Health Care, Services. Human Rights Watch. https://www. hrw.org/news/2020/04/07/rights-risks-older-people-covid-19-response IT Brief, (2020, November 25). 42% of Australia’s older workers have lost their job or had hours reduced amid pandemic. IT Brief Australia https://itbrief.com.au/story/42-of-australia-s-olderworkers-have-lost-their-job-or-had-hours-reduced-amid-pandemic Janda, M. (2020, April 14). Coronavirus risks widening intergenerational wealth divide. Australian Broadcasting Corporation https://www.abc.net.au/news/2020-04-24/coronavirusrisks-widening-intergenerational-economic-divide/12178410 John Hopkins University. (2023, January 16). Covid-19 deaths by age and sex (Australia) John Hopkins University. https://coronavirus.jhu.edu/region/australia Kam, A. W., Chaudhry, S. G., Gunasekaran, N., White, A. J., Vukasovic, M., & Fung, F. T. (2020). Fewer presentations to metropolitan emergency departments during the COVID-19 pandemic. Medical Journal of Australia, 213(8), 370–371. https://doi.org/10.5694/mja2.50769 King, E. (2022, July 17). COVID mantra of personal responsibility is fine—In theory. The Age. https://www.theage.com.au/national/victoria/covid-mantra-of-personal-responsibility-isfine-in-theory-20220717-p5b26q.html Makaroun, L. K., Bachrach, R. L., & Roslind, A. M. (2020). Elder abuse in the time of COVID-19increased risks for older adults and their caregivers. American Journal of Geriatric Psychiatry, 28(8), 876–880. https://doi.org/10.1016/j.jagp.2020.05.017 Mackee, N. (2020, May 4). Covid fears drive patients to avoid doctors, hospitals. Insight. https:// insightplus.mja.com.au/2020/17/covid-19-avoiding-doctors-clinicians-brace-for-wave-of-sev ere-illnesses/

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McAnulty, J. M., Ward, K. (2020). Supressing the epidemic in New South Wales. New England Journal of Medicine, 382 Middleton, K. (2020, June 13). NSW lays blame for Ruby Princess on Feds. The Saturday Paper. https://www.thesaturdaypaper.com.au/news/politics/2020/06/13/nsw-lays-blame-rubyprincess-feds/15919704009963 Morgan, D. (2021, December 11). Family mourns as inquest into St Basil’s aged care Covid 19 outbreak reveals ‘missed opportunities. Australian Broadcasting Corporation. https://www.abc. net.au/news/2021-12-11/st-basil-aged-care-covid-outbreak-inquest/100690396>2021 New South Wales Government. (2020). Report of the Special Commission of Inquiry into the Ruby Princess. New South Wales Government. https://apo.org.au/sites/default/files/resourcefiles/2020-08/apo-nid307566.pdf Rosenbaum, L. (2020). The untold toll: The pandemic’s effects on patients without Covid 19. New England Journal of Medicine, 382(24), 2368–2371. https://doi.org/10.1056/NEJMms2009984 Russell, S. (2020, December 4). Coalition Spin Kings: Real reform in aged care trumped by reannouncement and a deluge of cash. Michael West Media. Swanell, C. (2020). Worrying drop in emergency department presentations for non-COVID conditions. Medical Journal of Australia Published online: 28 September 2020 https://www.mja.com. au/journal/2020/worrying-drop-emergency-department-presentations-non-covid-conditions Towell, N. (2020, September 22). Acute phase of states aged care crisis ends. The Age. https://www.theage.com.au/national/victoria/acute-phase-of-state-s-aged-care-covid-19crisis-ends-20200922-p55y4l.html Uniting Care (Queensland). (2022). Annual Report 2022. Uniting Care. https://cdn-ucq.datawe avers.io/-/media/project/ucq/public/unitingcareqld/files/annual-reports/unitingcare-annual-rep ort-2021-2022-2.pdf Wahlquist, C. (2020, May 2). Australia’s coronavirus lockdown: The first 50 days. The Guardian. Webb, E., Somes, T., & Gardiner, C. (2020, October 21). Despite more than 30 major inquiries, governments still haven’t fixed aged care. Why are they getting away with it? The Conversation. https://theconversation.com/despite-more-than-30-major-inquiries-governments-still-hav ent-fixed-aged-care-why-are-they-getting-away-with-it-147736 World Health Organisation. (2023, January 16). WHO Emergency Dashboard. https://covid19.who. int/region/wpro/country/au

Chapter 18

Governing Risk and Older Age During COVID-19: Contextualizing Ageism and COVID-19 Outbreaks in Australian Aged Care Facilities During 2020 Peta S. Cook, Barbara Barbosa Neves, Cassie Curryer, Susan Banks, Annetta H. Mallon, Jack Lam, and Maho Omori Abstract The infectious spread of the novel coronavirus (COVID-19) has generated numerous media and political responses that bring together health, risk, and age. Within these responses, older people have been cast as “the vulnerable elderly” who are less socially worthy and valuable than younger people, in poor health, and considered to be automatically at risk of COVID-19 due to their age. This simplistic connection between older age, frailty, and ill-health reduces older age to a medical and health problem, which perpetuates and deepens ageism. The implied connection has been particularly evident during the coronavirus pandemic through the imposition on older people, who are living in aged and long-term care facilities, of severe lockdown P. S. Cook (B) Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, TAS, Australia e-mail: [email protected] P. S. Cook · S. Banks School of Social Sciences, University of Tasmania, Hobart, TAS, Australia e-mail: [email protected] S. Banks University of Tasmania, Tasmanian Policy Exchange, Hobart, TAS, Australia B. B. Neves · M. Omori School of Social Sciences, Monash University, Clayton, VIC, Australia e-mail: [email protected] C. Curryer School of Nursing and Midwifery, University of Newcastle, Newcastle, NSW, Australia e-mail: [email protected] A. H. Mallon School of Social Sciences, Western Sydney University, Penrith, NSW, Australia e-mail: [email protected] J. Lam Institute for Social Science Research, University of Queensland, St. Lucia, Brisbane, QLD, Australia e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_18

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restrictions enforced through the processes of risk governmentality and authoritative control. These socio-political and institutional regulations have heightened the isolation from society that older people living in such environments already face, ironically further threatening their health and wellbeing. Drawing on Australian media reports and specific institutional responses imposed on or emerging from residential aged care that occurred during 2020, our theoretical examination reveals how ageism, risk discourses, and risk governance during the coronavirus pandemic jeopardized older Australian’s health, wellbeing, and dignity of risk, while also reinforcing barriers to social inclusion. We conclude with suggestions for dealing with ageism including challenging the medicalisation of older age, promoting and supporting older people’s dignity of risk, and radically changing our attitudes towards, and language regarding, ageing. Keywords Ageism · Older people · COVID-19 · Residential aged care facilities · Long term care facilities · Risk · Governance · Australia

Introduction Some of the stories we’ve seen are unacceptable and I wouldn’t want my mum in some of these places [aged care facilities] (Daniel Andrews, in Topsfield, 2020). I can’t see my kids, I feel like I have got nothing. It’s no life for anybody, just locked in a room 24/7. There’s no end to it for us (Cheryl Mcqueen, in Topsfield, 2020).

The above quotes from Australia, one from the Premier of the state of Victoria (Andrews) and the other a person living in residential aged care (Mcqueen), emerged at a time when coronavirus was spreading across Victorian residential aged care facilities (RACFs) in 2020. In Australia, the COVID pandemic coincided with intense scrutiny from the Australian Royal Commission into Aged Care Quality and Safety (henceforth, “the Royal Commission”). In its interim report, the Royal Commission (2019) noted the significant failures of the aged care sector to meet the needs of older people including through service shortages, inadequate social and medical care, the difficulty of navigating and accessing aged care services, a failure to support meaningful social relationships for those who live in aged care, and systematic underresourcing (including low staffing levels). They further noted the aged care system had become “a signifier for loss, abandonment and fear” (2019, p. 61), and that societal attitudes towards aged care and older people including ageism—“discrimination based on age” (Gendron et al., 2016, p. 997)—may be contributing factors.1 These factors were not adequately considered by government policymakers and officials as COVID-19 hit Australian shores. In this chapter, we examine how Australian socio-political structures arising from (and contributing to) the devaluation of older people manifested during the 1

The final report of the Royal Commission (2021) was released on 1 March 2021; it contains 148 recommendations for comprehensively reforming Australia’s aged care system.

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COVID pandemic in 2020. We include media commentary on the pandemic and examine socio-political risk management related to preventing coronavirus infectious spread, particularly in relation to and within Australian RACFs. We argue that risk discourses propagated during the COVID pandemic perpetuated ageism and contributed to restricting the rights of older people, particularly those who live in RACFs, to make their own decisions regarding their care and social participation. We begin our examinations by exploring the concept of risk.

Risk and COVID-19 Risk management has been at the forefront of political responses to COVID-19. In 2020 and into 2021, this was witnessed in health testing, restrictions on human movements and gatherings, internal and external border restrictions, physical distancing, and “lockdowns” or “shutdowns” (see Cheng et al., 2020; International Monetary Fund, 2020); measures which were significantly eased in late 2021 when the Australian COVID vaccination rate was very high (89.7 percent of people over the age of 16 in Australia had had two doses of a COVID vaccine as of 14 December 2021) (Australian Government, 2021). These approaches frame risk as dangerous and containable through timely and “right” decision-making, enabling control over “future events that may occur, that threaten us” (Beck, 2009, p. 9). While health risks might be real, they are also constructed (Beck, 2009), with experts, public health, security, and political actors each having their own risk interpretations and evaluations. How such risks are identified, framed, and represented to the public during pandemics reveal exercises of power, authority, and control (Abeysinghe & White, 2010; McCormick & Whitney, 2013). Understandings of risk are therefore contested and subject to change. The global spread of COVID-19 has revealed the difficulty of managing risk. In his risk society thesis, Beck (1992) defines risk as “a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself” (p. 21). Beck (1992, 2009) argues that, in contemporary society, risks are a defining feature. They are the unintended consequence of human decisions and associated with modernization and techno-scientific developments. Unlike in pre-industrial societies where risks were localized and thus geographically and temporally contained, risks in modern society can be spatially and temporally fluid, threatening the environment broadly or humanity particularly. As an example of this contemporary experience of risk, the emergence and spread of COVID-19 is compelling: a range of human activities have blurred the divide between the social and natural worlds and have enabled coronavirus transmission. Among these are the frequent contact between humans and animals, human destruction of natural habitats, “risky” food production systems (bushmeat and wet markets), globalization, and human international travel (Rose et al., 2020; Waitzkin, 2020). Human decisions are increasing and intensifying risks. While political responses

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seek to manage these risks, the consequences of the COVID-19 pandemic illustrate that risks are uncertain. Central to government decision-making on risk management strategies are risk calculations. These risk calculations are informed by large volumes of information including epidemiological data that guide the practices and techniques of governing—which Foucault (1991b) termed governmentality—to avoid risk. Risk management by governments involves state apparatuses such as police, state media, and the public healthcare system. These institutions generate strategies that encourage or legally require individuals (and populations) to direct their conduct towards desired set goals (Foucault, 1991b), as informed by risk calculations. The strategies involve experts applying their “disciplinary power”, which is a form of social control that shapes the conduct of others towards desired outcomes and produces norms (Foucault, 1991a, 1991b). Amid this, individuals are expected to manage risks irrespective of structural and institutional inequalities such as class, gender, living conditions, accessibility and affordability of healthcare, disability, age, and race/ethnicity. As risk is globalized, it is framed as affecting everyone equally; risk is democratized and universal (Beck, 1996). Solidarity discourses during the COVID-19 pandemic have claimed “we’re all in this together”; a slogan repeated by celebrities, experts, political leaders, and brand marketers (Hewett, 2020; Hornery, 2020; Morrison, 2020a; Sobande, 2020; World Health Organization, 2020). These messages are at odds with the increased discrimination certain individuals and populations have experienced during the pandemic (IFRC, UNICEF, and the World Health Organization, 2020). One such group is older people (Carrieri et al., 2020; Cook et al., 2021; Curryer & Cook, 2021; Previtali et al., 2020), who are the focus of this chapter. We are specifically interested in how risk management and calculation have intersected with age in COVID-19 discourses and political strategies, and how this fostered ageism.

The Intersection of Risk, Health, and Age in COVID-19 Amid the panic induced by the COVID-19 pandemic, chronological age was factored into decision-making and used to define “normality” and “health” (Previtali et al., 2020). Those people considered to be the “norm”, the “ideal”, and the “safe” have high social value: that is, the youthful and the young (Featherstone & Hepworth, 2005). In contrast, older age has been equated with being “elderly” and “vulnerable”. This created a “them”/ “us” dichotomy based on socially perceived generational differences that helped to foster “othering” (Cook et al., 2021; Curryer & Cook, 2021). These notions were apparent in Australian media reports that simplistically connected

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age, risk, individual social value, blame, and COVID-19, and which appeared during Australia’s first and second waves2 of the coronavirus pandemic: What is the value of a 90-year-old’s life versus the value of the continuing livelihood and happiness of a 25-year-old? (Maskell, in Le Grand, 2020). […] if you are going to throw a ring of steel around anything it should be around aged care homes […]. The rest of the population should be liberated to get on with their lives while taking sensible health precautions (Uhlmann, 2020). If you’re in an aged-care facility you’re not waiting to be discharged and sent home in a few weeks. You’re on your way out, and the exit’s probably not that far away. Coronavirus is speeding up the process […] (Waterson, 2020).

While the risk of becoming seriously ill or dying from COVID-19 increases with age, this risk varies greatly among the older population. Those most susceptible to COVID-19 infection include people (of any age) with pre-existing comorbidities and people in dense living conditions such as RACFs (Banerjee et al., 2020; Gardner et al., 2020; Perrotta et al., 2020). It is ageist, however, to conflate older age with vulnerability, frailty, disability, and poor health, or to cast age as a predictor of COVID-19 recovery or fatality (Rahman & Jahan, 2020): “A 70-year-old patient may have a better chance of survival and benefit more from intensive or other forms of medical treatment than a 30-year-old one” (Carrieri et al., 2020). Ageism manifests when age alone is used as a determinant of social, political, and medical worthiness of treatment and care. The focus on chronological age and age groups in risk governance smooths the way for implementing differential population control restrictions that medicalise ageing. Biomedicine as a disciplinary regime regulates how bodies are perceived and understood (Foucault, 1991b) and has reshaped how the ageing body is conceptualized. As such, the medicalisation of ageing shapes older age reductively as a problem requiring medical intervention and control (Estes & Binney, 1989). Older bodies therefore become a “bad” social burden that supposedly demonstrate “a process of inevitable decline, disease, and irreversible decay” (Estes & Binney, 1989, p. 594), and which contrast unfavourably with the “good” and “normal” (youthfulness) (Gendron et al., 2016). As seen in moralistic and value-laden policies of active, positive, healthy, and successful ageing, older individuals are expected to be responsible by engaging in preventative measures that enable them to age healthily and independently (that is, to be ageless). A failure to “age positively” is blamed on the individual as an irresponsible and morally deviant citizen who made “poor choices” and did not exercise “self-care”. This discourse diverts attention from social and power inequities (Asquith, 2009; Foucault, 1991a, 1991b; Kane & Jacobs, 2018; Rose, 2007) and, during the COVID-19 pandemic, how risk governance creates inequalities (Cook et al., 2021; Curryer & Cook, 2021).

2

The first wave of coronavirus reportedly occurred from March to April 2020. The second wave of coronavirus—from June to September 2020—was caused by community transmission and was primarily experienced in the state of Victoria, and heavily localized to its capital city, Melbourne (Australian Institute of Health & Welfare, 2021).

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These attitudes influence policymaking and public perceptions of ageing (Estes & Binney, 1989), and act to reinforce negative views towards older people, particularly those who live in RACFs. In 2020, the then Australian Prime Minister Scott Morrison (2020b) described RACFs as “pre-palliative care”, which constructs RACFs as medical facilities, reduces older age to being a medical problem, and objectifies those who live in RACFs. This is despite the Australian Aged Care Act 1997 reframing of RACFs from medical facilities to “homes” for the people who live there; a political strategy to reduce medical and staffing costs (including the removal of minimum staffing ratios) and positioning the people who live in RACFs as consumers (Eagar et al., 2019; Morton, 2020b). By delineating people based on their chronological age and where they live, Australian political risk responses to coronavirus have exhibited ageism, imposing a heavy burden on older people particularly those living in RACFs. We now turn to examining the socio-political risk governance of Australian RACFs during the COVID-19 pandemic in 2020.

Political Responses to COVID-19: The Situation in Australian Aged Care In Australia, aged care services are available to support older people to live at home in the community, in short-term care, or in a RACF. The subsidization and regulation of aged care, including standards of care, are the responsibility of the Australian federal government rather than state and territory governments3 (Australian Government, 2019). The political responses to the coronavirus and its spread in Australian RACFs during 2020 provide clear examples of ageism through the applications of risk governmentality and the medicalisation of ageing. This can be seen in (i) the requirements imposed on or by RACFs and to those living in them, which were radically different from those applied to the wider population, and (ii) the differences between the federal government’s approach to pandemic management and that of state/territory governments and aged care providers. In this section, we detail these risk management strategies to provide an insight into the governance of those living in RACFs,4 which reinforce assumptions about ageing and its medicalisation. To achieve this, we will outline the spread of COVID-19 in Australian 3

Australia has eight internal state and territories that form the Commonwealth of Australia (Queensland, New South Wales, the Australian Capital Territory, Victoria, Tasmania, South Australia, Northern Territory, and Western Australia). In this chapter, we collectively refer to these as “states”. Based on geographical size, Australia is the world’s smallest continent and largest island (Geoscience Australia, n.d.). It is also the world’s sixth largest country, with a land mass approximately 50 percent larger than Europe and 32 times greater than the United Kingdom (Australian Government, n.d.; Geoscience Australia, n.d.). It is the only nation to govern an entire continent. 4 Australian aged care policy focuses on ageing-in-place (in one’s own home or in the community). RACFs mostly provide care for older people who have higher and complex needs (Eagar et al., 2019; Ibrahim, 2020). The underfunding of and significant waitlists for home and community care,

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RACFs during 2020, with a specific focus on the federal government’s response as well as some discontinuities between the federal government requirements and what was occurring in specific states and territories (herein collectively referred to as the “states”). The first known death from COVID-19 of a person living in an Australian RACF occurred on 4 March 2020 (Han, 2020); it was the second death from COVID-19 in Australia. The RACF, Dorothy Henderson Lodge in Sydney (New South Wales), became the site of the first Australian COVID-19 cluster. Risk management involved shutting Dorothy Henderson Lodge to visitors, and COVID-19-free residents were restricted to their rooms for more than three weeks to prevent and contain infectious spread (Gilbert, 2020). Personal care staff who had had close contact with those living in Dorothy Henderson Lodge were quarantined in their home and out of fear some personal care workers stopped coming to work, a combination of which created staffing shortfalls. By 11 April 2020, six people living in Dorothy Henderson Lodge had died (Gilbert, 2020). The next day (12 April 2020), a person living at Newmarch House—a RACF in western Sydney (New South Wales)—was diagnosed with COVID-19. By 15 June 2020, 34 staff and 37 people living in Newmarch House had tested positive for COVID-19, and 19 people had died; this was a fifth of all deaths at that time from COVID-19 in Australia (Connolly et al., 2021). On 22 April 2020, following information from the Australian Health Protection Principal Committee (AHPPC),5 the Australian Government (2020a) recommended a suite of RACF restrictions that were subsequently updated on 19 June 2020 (see Table 18.1), but there were no outbreak plans for RACFs despite what had occurred at Dorothy Henderson Lodge and Newmarch House. The Committee’s statements, however, did recognize that while Australian states/territories and aged care providers might implement other restrictions, there remained a need for person-centred care, visits from family and friends, and compassion (Australian Government, 2020a, 2020b). During March and April 2020 (the first Australian wave of COVID-19), Australian states started to implement containment and “state of emergency” measures in response to the growing spread of coronavirus. These measures varied across the states but included restrictions on intra- and inter-state travel (except for essential workers and the movement of goods), postponements to elective surgery, suspensions on indoor and outdoor public gatherings, physical distancing rules, temporary closure of public places such as playgrounds and skate parks, suspensions of visits to prisons and RACFs, and requirements not to leave one’s primary place of residence unless an essential worker (or if working from home is not possible), getting essential supplies (such as medicines or grocery shopping), or for compassionate reasons (such as care provision) (for example, see Australian Institute of Health & Welfare, 2021; Storen & Corrigan, 2020). however, have led some older people to die while waiting for such services or to prematurely enter RACFs (Royal Commission into Aged Care Quality & Safety, 2019, p. 158). 5 During health emergencies, the Australian Health Protection Principal Committee (AHPPC) is Australia’s key decision-making committee.

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The response of Australian states and aged care providers to coronavirus varied significantly (Guardian, 2020). There were significant (and confusing) local and national inconsistencies in COVID-19 risk management strategies of and for RACFs. Here, we briefly examine two states as examples that are both located in south-eastern Australia: Victoria and Tasmania. In the state of Tasmania,6 a COVID-19 outbreak associated with a rural hospital in April 2020 led to a state-wide limit on visitors to RACFs, with only medical staff and visitors for compassionate and end-of-life reasons permitted (Gutwein, 2020b). This was driven, at least in part, that some staff working at the hospital also worked in some local RACFs. These restrictions were eased on 11 May 2020 but did not match the Australian government’s recommendations on entry and visitations until 22 June 2020 (Gutwein, 2020a, 2020c) (see Table 18.1). Table 18.1 Minimizing the impact of COVID-19 on RACFs—Recommendations from the Australian Health Protection Principal Committee (AHPPC) (information from Australian Government, 2020a, 2020b) Date

Restricted entry into RACFs

Those who have 22 April 2020 . In the last 14 days, (Australian returned from Government, 2022a) overseas or been in contact with a confirmed COVID-19 case . Fever or symptoms of acute respiratory infection . Not been vaccinated against influenza

6

Visitors

People who live in RACFs

. “Limiting visits to a . Active screening for short duration”, and symptoms of “a maximum of two COVID-19 of people visitors at one time entering or per day” inclusive of re-entering from family, close friends, other settings . No entry for people and professional with COVID-19-like services symptoms . Visits to be . No external conducted in the excursions person’s room, outdoors, or a designated area within the RACF . “No large group visits or gatherings, including social activities or entertainment” . “Children aged 16 years or less must be permitted to visit only by exception” (continued)

Based on geographical size, Tasmania is Australia’s second smallest state/territory. Tasmania is an island state located 240 kms off the southern eastern end of Australia. The physical separation between Tasmania and the rest of Australia allowed Tasmania to implement a hard border rule during 2020 and for most of 2021.

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Table 18.1 (continued) Date

Restricted entry into RACFs

19 June 2020 Those who: (Australian . In the last 14 days Government, 2022b) returned from overseas or been in contact with a confirmed COVID-19 case . “Are unwell, particularly those with fever or acute respiratory infection” symptoms . “Have not been vaccinated against influenza”

Visitors

People who live in RACFs

. “Limiting visits to a maximum of two visitors at one time per resident” . “Children of all ages be permitted to enter RACFs” . Visiting service providers “be permitted to enter RACFs when their services cannot be provided via” other means . “Spouses or other close relatives or social supports are not limited in the number of hours that they spend with their spouse/relative” . Visits to be conducted in the person’s room, outdoors, or a designated area within the RACF . “No large group visits should be permitted” . Gatherings of those who live in the RACF in communal or outdoor areas are permitted

. Active screening for symptoms of COVID-19 of people entering or re-entering from other settings . No entry for people with COVID-19-like symptoms, unless they have recently tested COVID-19 negative . “Residents admitted from other health facilities should be assessed by appropriate medical staff prior to admission to the facility” . “Appropriate infection prevention practices should be implemented for residents returning from treatment or care at other facilities” . Permitted to leave for small family gatherings . Collective external excursions are not permitted

In the state of Victoria,7 a second wave of coronavirus caused by community transmission led to a second lockdown8 and the reintroduction of tight restrictions on RACF visits with suggestions from the state Premier, Daniel Andrews, these 7

Based on geographical size, Victoria is Australia’s third smallest state/territory. It is located north of Tasmania, from which it is separated by the Bass Strait. Based on population size, Victoria’s capital city, Melbourne, is the second largest city in Australia. Victoria is Australia’s second most densely populated state/territory in Australia (28 people per square kilometre) (Australian Bureau of Statistics, 2020). 8 As of 25 February 2022, Victoria has had a total of six lockdowns since March 2020. As of 22 October 2021, people who were living in Melbourne had experienced the longest length of lockdowns in the world at 262 days since the start of the coronavirus pandemic.

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would remain in place into 2021 or until a rapid antigen test or a COVID-19 vaccine became available (Department of Health & Human Services, 2020; Towell, 2020). In addition, some RACFs implemented their own entry rules that went beyond federal or state government guidelines such as lockdowns that banned all visitors (including those that supplement care responsibilities) or allowed one visitor only per visit (Henriques-Gomes, 2020). Some families were not only stopped from visiting their relatives in RACFs but also denied (or provided incorrect) information about the health and care of their relative/s (Ibrahim, 2020). It was also reported that some Victorian RACFs had restricted older people to their rooms for over two months without visitors (Davey, 2020b). As such, there were significant (and confusing) local and national inconsistencies in COVID-19 risk management strategies for and in RACFs. In Royal Commission (2020) hearings examining the impact of COVID-19 on aged care, numerous governmental and institutional failures were identified including an unwillingness to move older people with COVID-19 from RACFs to hospitals, the reservation of hospitals “for the young” (Morton, 2020a), substandard care, and a lack of staffing and infection control measures (Topsfield, 2020). It was also noted that many aged care homes across Australia had not experienced COVID-19 outbreaks, but residents nonetheless “have endured restrictions for most of this year [2020] that go beyond those endured by the general community” (Royal Commission into Aged Care Quality & Safety, 2020, p.7). Of these restrictions, Melbourne barrister Fiona McKenzie noted: Somehow the COVID reign ushered in a new world where we pretended the law didn’t exist, at least for older people. But fear of an infectious disease does not suddenly give property managers the right to detain people, ban them from seeing their families or prohibit them from getting exercise or fresh air (McKenzie, 2020).

Furthermore, the Royal Commission noted that the AHPPC: Provided no written guidance to the aged care sector in the period between 20 June 2020 and 3 August 2020. During that time, the number of daily infections in Victoria grew from 25 to 413 and the number of active cases in residential aged care facilities grew from zero to over 500 (Royal Commission into Aged Care Quality & Safety, 2020, p. 15).

During a Federal Parliamentary Inquiry held in August 2020 (Senate Select Committee on COVID-19), the then Minister for Aged Care and Senior Australians, Senator Richard Colbeck,9 did not know how many residents of RACFs had died due to COVID-19 and Professor Brendan Murphy, the then Secretary of the Department of Health (Australian Government), refused to publicly release a list of Victorian RACFs with COVID-19 infections to protect the “reputational” interests of the aged care sector and to avoid distress for families and care providers (Karp, 2020; Murphy, 9

Minister Colbeck came under scrutiny in 2022 when he chose to attend three days of a cricket match between Australia and England in Tasmania rather than attend a Parliamentary Enquiry into COVID-19. Minister Colbeck, however, cited the reason for his absence was due to “The Covid-19 pandemic … [being] at a critical point with the onset of numerous Omicron outbreaks” (Colbeck, in Karp, 2022). Minister Colbeck has appeared at the inquiry twice: 4 August 2020 and 21 August 2020 (RMIT ABC Fact Check, 2022).

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2020; Norman, 2020). This lack of transparency was questioned given the information needed by families, the public funding and federal regulation of aged care, and concerns regarding accountability (Grattan, 2020). The potential risks from staff working across multiple RACFs for individuals living and working in aged care, also appeared poorly understood: “We [the Australian government] did not anticipate that the entire management structure and the office structure, cleaning, catering staff would all be regarded as close contacts as part of an outbreak” (Colbeck, in Tillett, 2020, p. 3).10 In response to criticisms, the Australian government eventually released, from 12 September 2020, a weekly snapshot of COVID-related infections and deaths in RACFs (Australian Government, 2020d). The first release included the names of 115 aged care providers with more than two cases of COVID-19 but failed to include the names of 98 providers that reported just one case of COVID-19 (Karp, 2020). The Australian Institute of Health and Welfare (2021) reports that in 2020, 7 percent of all COVID-19 cases and 75 percent of all deaths from COVID-19 in Australia were people living in a RACF. During 2020, Australia’s COVID-related death rate in aged care was amongst the highest in the world (Power, 2020). The number of deaths of people living in aged care internationally, along with the isolating consequences of lockdowns, led some to liken RACFs to “besieged castles” (Trabucci & De Leo, 2020). Australian governments (at the federal and state levels) and RACFs differentially evaluated risk and translated this into policy and institutional decisions in and for RACFs. These risk management strategies have been based on the premise of looking after and protecting “vulnerable” older people living in RACFs. These measures did not prevent COVID-19 infections and spread in RACFs, though they may have reduced the number of infections. One shortcoming was the failure to consider how the heavily casualised aged care workforce could spread coronavirus in and between RACFs (Wahlquist, 2020), with only visiting family and friends considered an infectious risk. Through lockdowns, RACFs operated as a risk containment field of power and control that, in the desire to protect those who live inside—the “at risk” population—from the external danger of coronavirus, resulted in the lesser treatment of older people living within them. While governments and RACFs have a duty of care to maintain the health and wellbeing of those living (and working) in RACFs which includes implementing measures to prevent the spread of COVID-19, the prolonged lockdowns and highly restrictive visitation practices risked compromising that duty, were paternalistic, medicalised ageing, and did not prevent COVID-19 transmission. Totalising risk management strategies in RACFs such as lockdowns have had negative effects on older people’s mental and physical health (including deconditioning from lack of physical exercise), their wellbeing, and quality of life, as well as contributing to increased feelings of hopelessness and suicidal ideation (Ibrahim, 10

RACFs are precarious workplaces—care staff are often employed casually, work across multiple sites, and are undervalued and poorly-paid (Royal Commission into Aged Care Quality & Safety, 2019), factors which have created heightened risks (to themselves and others) during the COVID-19 pandemic (Wahlquist, 2020).

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2020; Plagg et al., 2020; Royal Commission into Aged Care Quality & Safety, 2020). This includes exacerbating the health and social risks that people living in RACFs already face: frailty, depression, social isolation, and loneliness (Neves et al., 2019). Lockdown strategies failed to enable the continual face-to-face support provided by family and friends that includes physical and emotional care (Hado & Feinberg, 2020), as well as holding RACFs to account for possible neglect and elder abuse (Han & Mosqueda, 2020). At one private RACF, for example, staff shortages, a lack of staff training, and deficiencies of medical supplies during the COVID-19 lockdown meant the facility was not adequately cleaned (e.g. faeces being left on the floor). Those living in this RACF missed out on medication, food and water, hygiene support, and bandage changes, with one person having ants crawling from a wound (Davey, 2020a). Other reports suggested that people living in RACFs were refusing to eat or take their medication (Robb, 2020), that chemical restraints were being used to manage behaviours (such as wandering), and that there were staff shortages; all of which are a direct response to or result from coronavirus risk management strategies (including hospitals not admitting people with COVID-19 from RACFs) (Markson, 2020).11 These risks have been exacerbated by risk governance—strategies that forced people living in RACFs into physical isolation while failing to account for the chronic lack of resources and staff to support people living in RACFs and to manage any COVID-19 outbreaks. RACFs thus become “risky places” with “differential rights” instead of safe places that empower residents. As noted by Beck (2009), “risk divides, excludes and stigmatizes” (p. 16). By further segregating people living in RACFs from their families and wider society, responses to the coronavirus pandemic have made visible the existing (and normally unacknowledged) barriers that RACFs create between older people and the rest of the community. Goffman’s (1961) concept of a total institution as a place where “inmates […] live in the institution and have restricted contact with the world outside the walls” (p. 18) holds true for how Australian RACFs are conceptualized and the experiences of those people living in them. People living in total institutions are viewed as incapable, disempowered, and dependent, and are subjected to bureaucratic management of their daily lives. This includes being marginalized or excluded from decision-making that impacts upon them (Goffman, 1961), evident in the ubiquitous lack of consultation on the design and implementation of risk management responses to coronavirus between governments, those working in RACFs, and those living in RACFs and their families (Ibrahim, 2020). This lack of consultation served to silence older people and undermines their agency, autonomy, and dignity (Ibrahim & Davis, 2013). These uneven power relations are structural, diminishing the social worth and value of those who live in RACFs and, by removing or reducing contact with 11

In Australian RACFs, some of these issues were already known problems including incidents of sexual and physical assault, poor pain management, and the overprescribing of antipsychotics and benzodiazepines (Ibrahim, 2019). There is chronic under-resourcing and under-staffing of RACFs, which includes a dearth of staff expertise on high and complex health needs (Eagar et al., 2019; Ibrahim, 2020). These are structural problems that compromise optimal care and quality of life for people who live in RACFs, and which have become more visible and profound during the coronavirus pandemic (Zhuang, 2021).

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wider society, eroding their community connectedness and belongingness. Tellingly, the initial Australian Health Sector Emergency Plan for Novel Coronavirus did not recognize the ongoing concerns within the aged care sector or the interim findings of the Royal Commission (Ibrahim, 2020). Socio-political contexts, language, and governmentality shape how risk is understood and acted upon (Gendron et al., 2016) and are exercises in authority and power (Abeysinghe & White, 2010; Beck, 2009; Cook et al., 2021; Foucault, 1991b; McCormick & Whitney, 2013). Understanding these responses to the pandemic sheds light on age-based discrimination and on broader societal notions of older people and aged care. We now turn to making some suggestions for how ageism may be challenged within and beyond the COVID-19 pandemic.

Conclusion: Challenging Ageism in the Context of COVID-19 As “an ageism-related focusing event” (Reynolds, 2020, p. 502), political and media responses to coronavirus have drawn attention to the devaluation and differential treatment of older people. Based on the risk governmentality and risk framings discussed, we argue that challenging ageism in the context of the pandemic should focus on two primary areas, 1) the links between risk management and the simplistic and reductionist ideas of capacity, agency, and social worth as connected to chronological age, and 2) challenging language that labels all older people as “vulnerable”. Regarding our first point, it is vital to recognize that older age does not reduce individual or population diversity of life experiences, health status, capacities, and social circumstances. While people with comorbidities are more susceptible to serious illness, this does not necessarily apply to all—or only—older people. Risk-averse strategies based on chronological age alone that make assumptions about an individual’s health and wellbeing are problematic. Age-related segregations also foster an us-versus-them mentality and undermine intergenerational relations (Cook et al., 2021; Curryer & Cook, 2021). Using older age or living in a RACF as criteria to deny hospital access for COVID19 treatment presumes that there is little gain from it whether that be for the individual (in terms of life expectancy and quality of life) or society (in terms of social productivity and worth). People living in Australian RACFs are susceptible to COVID19 if they have comorbidities (just as are people in the general community), but they are made more susceptible by the living conditions in most Australian RACFs. Restricting admission to hospital treatment and care based on chronological age because it would be a “waste” of resources—such as saving hospitals for the young (Morton, 2020a) and not transferring older people with COVID-19 from RACFs to hospitals or, as in Italy, the use of age to determine entry into intensive care or access to mechanical ventilation (Trabucchi & De Leo, 2020; Vergano et al., 2020)—and

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failing to recognize that RACFs are not medical facilities,12 are forms of discrimination that compromise a population’s dignity and human rights to health and wellbeing (Carrieri et al., 2020). Such approaches are paternalistic, ethically unsound, and place undue burden on older people who, in a climate of pandemic-panic and ageism, might feel compelled to refuse medical care. Understanding that older people are diverse and have different needs and preferences is important to support dignity of risk and choice (Ibrahim & Davis, 2013). As such, risk governance should be underpinned by an inclusive approach that acknowledges that risk-taking can be positive for individuals; it can enhance quality of life and enables active citizenship. COVID-19 management strategies should actively balance duty of care with dignity and involve consultation with those who live in RACFs and their families. This can pose challenges with balancing quality of care with quality of life, but one size does not fit all. In addition, RACFs should not be experienced or treated as prisons or total institutions where the “provider knows best”, and those who live there should not experience their home as “inmates”. The evident link between ageism and COVID-19 risk management approaches highlights how older people living in RACFs have been distinguished from the rest of the population and socially marginalised. Second, a concerted policy commitment towards addressing ageism and the unequal treatment of older people is needed, including scrutiny of language and its use. This is because language (and therefore attitudes) persists when crises (such as pandemics) end, informing socio-cultural perceptions (Gendron et al., 2016; Kane & Jacobs, 2018) that can foster marginalisation and stigmatization. We need to challenge language that labels all older people as “vulnerable”. Moralistic and valueladen, “vulnerability” is used to classify individuals and populations to justify social control mechanisms. Being labelled as vulnerable is disempowering and stigmatizing; implying deficiency and dependency (Brown, 2011). As noted by Brown (2011), “like its conceptual cousin ‘risk’, ‘vulnerability’ has close links with choice, responsibility, blame and legitimacy” (p. 319). Labelling individuals or a population as vulnerable undermines their agency and fails to account for structural causes of “vulnerability”. In the case of older age, we add that it also medicalises. The language of lockdowns when applied to RACFs has policing connotations with the resultant actions serving to limit internal and external movements in the interests of social order and control, which deepens structural inequalities. Therefore, while risks are universal (Beck, 1992, 2009), risks—and who and what is considered “risky”—must always be understood as culturally, historically, and politically constructed (Abeysinghe & White, 2010; Fogarty, 2011; McCormick & Whitney, 2013). Risk governmentality applied to and within RACFs is ageist, creating conditions that have undermined the safety, wellbeing, and lives of those who live there, 12

Australian RACFs are defined in the Australian Aged Care Act 1997 as people’s homes. This fostered “the development of a workforce that is less clinically skilled and oriented with greater reliance on lower skilled personal care workers” (Eagar et al., 2019: 4). Even though there is an obligation for RACFs to “provide safe, respectful and quality care and services” (Standard 7, Aged Care Accreditation Standards, in Eagar, 2019, p. 4), they are not medical facilities and do not have the associated material and human resources including highly trained medical specialists.

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even though risk governmentality is implemented in the interests of “care and protection”. We call for a radical reframing of pandemic risk discourses, particularly those which serve to marginalize populations considered to be “at risk” and whose lives are deemed “less worthy”. The differential framing of risk and the treatment of older people living RACFs outlined in this chapter highlights the role of power, medicalisation and risk governance in perpetrating inequality and ageism during the 2020 COVID-19 pandemic. The impact of COVID-19 on older people and those living in RACFs—whether that impact be from the virus itself or risk governance strategies—has undermined the social inclusion and health and wellbeing of older Australians, and deepened simplistic beliefs that equate older age to vulnerability, unworthiness, and incompetence. In addition, while the socio-political risk strategies appear to some as only being in the interests of protecting “the elderly” (as witnessed in the quotes earlier in this chapter), the outbreaks in RACFs and the resulting deaths of people who call these places home highlights structural problems within the aged care sector. The desire to retain RACFs as “risk-free” spaces did not eventuate; they became “risky places”. And it seems that no lessons have been learnt by the Australian Federal Government from the 2020 COVID-19 outbreaks in RACFs. As we write this (February 2022), Australia is dealing with an outbreak of the coronavirus variant, Omicron. This came to Australia at a time when travel restrictions were being lifted (December 2021), but no planning was made to protect those in RACFs. As such, COVID-19 has again spread into RACFs—this time, not limited to Victoria but across the country— and again RACFs are applying rolling lockdowns and restricting residents to their rooms. From 1 January to 18 February 2022 (48 days in total), 742 RACF residents died from COVID-19; more than in 2020 (n = 685) or 2021 (n = 282) (Australian Government, 2022a, 2022b). With RACFs battling these outbreaks and staff shortages from people needing to isolate or leaving the industry, the Australian Defence Force is being used to fill the gaps (Daniel, 2022). There have been numerous unknowns during the coronavirus pandemic including how to control COVID-19 transmission, what are appropriate public health responses, timing and availability of a vaccine, allocation of material and financial resources, and when to implement and lift human movement restrictions. Regardless of these unknowns, we know that responses based on presumptions regarding chronological age and the failure to protect those living in Australians RACFs are ageist and undermine human rights. This is unacceptable. It is not just the RACFs that need “transformation” (Ibrahim, 2020, p. 2)—so do our attitudes towards and treatment of older people.

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Chapter 19

United States Treatment of Older Adults During the COVID-19 Pandemic Pamela B. Teaster and Manasi Shankar

Look, I’m sure she would have declined somewhat, but I know in my heart, the isolation in the facility accelerated it. She’s collateral damage of this COVID-19 seclusion, passing away because of a broken heart (Paulin, 2020).

Abstract The COVID-19 epidemic took the United States by storm, creating widespread upheavals starting in mid-March 2020. The coronavirus, with its genesis in Wuhan, China, spread rapidly and devastated many parts of the world, with the U.S. experiencing the highest number of cumulative deaths of any country. Eighty percent of deaths due to COVID-19 were of people aged 65 and older with multiple chronic conditions. Over 30% of all COVID-19 deaths were of people living in longterm care facilities, although only 0.5% of all older adults in the U. S. reside in them. Available scientific data reveal that the virus spreads from person to person, mainly through exposure to respiratory droplets produced by an infected person. From March to December 2021 the U. S. experienced several waves of the virus, with over 77.5 million persons infected and almost a million dead. Controversies have raged over lockdowns, the wearing of masks, cumulative disadvantage, racism, health disparities, distribution of the vaccine, and politics. Swift yet extensive research on hundreds of potential vaccine candidates resulted in three that were approved by the Food and Drug Administration. The Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen vaccines served an instrumental role in the containment and spread of the virus in the U.S. and globally. This chapter addresses the crucial aspects and effects of COVID-19 on older adults living in the U. S., including efforts to mitigate the

We gratefully acknowledge the assistance of Jacey Jarrell, Public Health/Psychology Undergraduate and E. Carlisle Shealy, Ph.D., MPH, Assistant Director, Center for Gerontology, Virginia Tech. P. B. Teaster (B) Center for Gerontology, ISCE, Virginia Tech, Room 105, 230 Grove Lane, Blacksburg, VA, USA e-mail: [email protected] M. Shankar Department of Counseling Psychology, University of San Francisco, San Franciso, CA, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_19

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spread of the disease as well as strategies to support older adults should a pandemic strike again. Keywords COVID-19 · Older adults · Politics · Pandemic · U. S. · Masks · Social distancing · Vaccine

Introduction As of this writing, there are more than 410 million cases of COVID-19 worldwide, and over 77.5 million of those cases are in the United States (U.S.). The pandemic resulted in approximately 5.8 million deaths globally, with over 918,000 deaths in the U.S. alone (World Health Organization, 2022). According to the Centers for Disease Control (CDC), the risk for severe illness from COVID-19 increases with age. Adults aged 65 and older with other chronic conditions are at the highest level of risk of infection and death (CDC, 2021). In addition to advanced age, certain medical factors increase a person’s risk for severe infection, particularly those with underlying medical conditions, including asthma (mild-moderate), obesity, chronic heart conditions, cystic fibrosis, liver disease, chronic obstructive pulmonary disease, and/or immunocompromised state (CDC, 2021). Other than medical conditions and age, the CDC also addressed demographic factors that increase some people’s risk of infection, including but not limited to racial and ethnic minority groups, pregnant and breast-feeding women, people with disabilities, people living with substance-related issues, people experiencing homelessness, refugees, and people residing in nursing homes (CDC, 2021). Severe illness for persons infected with COVID-19 may require that they are hospitalized, receive intensive care, and even be put on a ventilator to help them breathe (CDC, 2021). Of the 0.5% of Americans living in nursing homes, most of whom are older adults (Grabowski & Mor, 2020), over 30% were COVID-19 fatalities (CDC, 2021). A disease barely known in February 2020 has wreaked havoc on governments, economies, lives, and livelihoods, with the most deleterious effects on older adults and their families. This chapter describes the treatment of older adults in the U.S. during the period from March-December 2021.

A Brief History of the Spread of the Coronavirus and Treatments On 31 December 2019, China reported a cluster of cases of pneumonia among people associated with the Huanan Seafood Wholesale Market in Wuhan in Hubei Province. A week later, on 7 January 2020, Chinese health authorities confirmed the association of the cluster with a novel virus, 2019-nCoV, which came to be known as COVID-19

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(Chaplin, 2020). By the end of January 2020, nearly 10,000 cases were reported in 21 countries, including the U.S., which confirmed its first known case on 20 January 2020. The case was in Snohomish County, Washington and involved a 35-year-old symptomatic man who had recently visited his family in Wuhan, China, and returned to Washington State on the 15th of January. He presented with a four-day history of coughing and fever and checked into an urgent care clinic. He was subsequently admitted to a hospital, and the CDC was notified (Holshue et al., 2020). On 30 January 2020, the World Health Organization (WHO) declared a public health emergency of international concern, and the U.S. State Department warned against travel to China and limited other international travel (World Health Organization, 2020). On the 13th of March, former President Trump declared a national emergency and made funding available to states and territories to assist with treatment. By the end of March, the U.S. became the country hit the hardest by the virus with more than 81,321 infections, overtaking cases in China, Italy, and all other countries. To stem the spread of the virus, states and localities began to lock down, closing schools and businesses for weeks that stretched into months. Elective surgeries were put on hold, and local and state governments released statements limiting gatherings of people to small numbers and restricting travel in and out of the country as well as within and across state lines. Thousands of people in the U.S. lost their jobs and their health insurance benefits, increasing fear among many, especially among older adults and their families. Responding to the capricious spread and surge of the virus, countries worldwide regulated lockdowns, lifted restraints, and then re-instituted them (Calderón-Larrañaga et al., 2020; Garnier-Crussard et al., 2020; Morley & Velas, 2020; Shahid et al., 2020).

Early Treatments In the beginning of 2020, more than 70 companies worldwide commenced research on vaccines and efficacy. The irreparable harm caused by the pandemic resulted in the acceleration of clinical trials to discover a vaccine that could be distributed globally. Later in 2020, the FDA issued an emergency use authorization (EUA) for the drug Baricitinib in combination with Remdesivir for the treatment of suspected or laboratory-confirmed COVID-19 in hospitalized adults and paediatric patients two years of age or older requiring supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). In a clinical trial of hospitalized patients with COVID-19, Baricitinib, in combination with Remdesivir, reduced time to recovery within 29 days after initiating treatment compared to patients who received a placebo. The safety and effectiveness of this investigational therapy for use in the treatment of COVID-19 continued to be evaluated. Chloroquine and Hydroxychloroquine, drugs approved by the FDA for malaria and other autoimmune diseases, demonstrated some efficacy against SARS-CoV2. However, their use was discouraged within days of the announcement (U.S. FDA, 2020). Remdesivir was also believed to be helpful in treatment, but by late October

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2020, clinical trials revealed that it was ineffective in prevention and treatment (Cohen & Kupferschmidt, 2020). One promising drug that many hospitals with COVID-19 patients used was Dexamethasone, a steroid that reduces inflammation by mimicking anti-inflammatory hormones produced by the body and works by dampening the body’s immune system. Sometimes the immune system goes into overdrive (as with COVID-19), and it is this reaction that can prove fatal, the same reaction that attacks infection but attacks the body’s own cells. Dexamethasone is believed to calm this effect. However, the drug is suitable only for patients already in hospital and receiving oxygen or mechanical ventilation—those who are the most unwell. For those with no respiratory-related issues, the drug was not beneficial (BBC News, 2020). Since the early months of the virus, treatments improved significantly (Le et al., 2020; Wu & Kolata, 2020).

The Emergence of Vaccines On November 9th, Pfizer Pharmaceutical Company, who collaborated with German company BioNTech, announced that early analysis of their COVID-19 trial suggested that their vaccine was robustly effective in preventing infection, with more than 90% proven effectiveness. Pfizer stated that by the end of 2020, the vaccine could immunize 15 to 20 million people (Thomas et al., 2020). On 20 November 2020, Pfizer sought emergency approval by the FDA so that distribution of the two-sequence inoculations could begin in December for front-line workers and those people deemed most vulnerable to infection and death. In December 2020, the Pfizer-BioNtech vaccine became the first FDA-approved vaccine approved for emergency use (FDA News Release, 2021). Moderna, another drug company with funding from Operation Warp Speed, the drug initiative instituted in spring 2020 by the Trump administration, pronounced in the same week that its double-blind trials also had shown 95% efficacy in its research subjects (Chagla, 2021). In February 2021, the Johnson & Johnson vaccine was also granted emergency use authorization by the FDA. By 19 April 2021, all states had opened vaccine eligibility to residents 16 and above, regardless of citizenship status. The U.S. government initiated vaccine distribution under the presidency of Donald Trump. In January 2021, President Joe Biden was elected, beginning his term with a goal of administering over 100 million vaccine doses within his first hundred days in office. On 19 March 2021, this goal was met, with 67% of the country’s population receiving at least one shot of an approved vaccine (Allegretti, 2021). Distribution and proven effectiveness of the vaccines provided a sense of hope to people across the world. However, despite treatment improvements, mitigation protocols, and vaccinations, older adults living in long-term care facilities remained uniquely vulnerable due to the unchecked ease and rapidity of the viral spread, explained below.

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Progression of the Virus When an infected person expels virus-laden droplets and someone else inhales them, SARS-CoV-2 can opportunistically enter through the nose, throat, and/or eyes. The virus finds its home in the lining of the nose, where cells are rich in the cell-surface receptor angiotensin-converting enzyme 2 (ACE2) (Wadman et al., 2020). ACE2, which usually helps regulate blood pressure, marks tissues vulnerable to infection and enables COVID-19 to find a ready receptor to enter a cell. Once inside and taking over the cell’s machinery, it replicates itself and attacks new cells. Its reproduction enables an infected person to shed vast amounts of the virus, especially during the first week of infection. For many, symptoms are non-existent, while others may develop symptoms such as a fever, dry cough, sore throat, loss of smell and taste, or head and body aches (Menni et al., 2020). For the immune system fails to arrest the virus early, it progresses down a person’s windpipe and attacks the lungs, where it can quickly become deadly. In the lungs, branches of the respiratory tree end in small air sacs (alveoli), which are lined with a single layer of cells rich in ACE2 receptors (Wadman, 2020). Normally, oxygen crosses the alveoli into the capillaries, tiny blood vessels next to air sacs carrying oxygen to the body. As the immune system fights the virus, oxygen transfer is disrupted. On counterattack, white blood cells release inflammatory molecules (chemokines) that enlist more immune cells to target and kill virus-infected cells, leaving behind fluid and dead cells. Such is also the pathology of pneumonia, symptoms that include cough; fever; and rapid, shallow respiration (Gattinoi et al., 2020). At this point, while many COVID-19 patients recover with little support beyond oxygen delivered through nasal prongs, others deteriorate rapidly, developing a condition called acute respiratory distress syndrome (ARDS). Oxygen levels in the blood crash, and those afflicted struggle to breathe, their lungs filled with white opacities where black space (air) should be. This is the trajectory of patients who are placed on ventilators, many of whom die. Autopsies reveal that their alveoli were full of fluid, white blood cells, mucus, and dead lung cells (Wu et al., 2020). In addition to lung damage, the virus and the body’s response to it can injure other organs. Some researchers suspect that many seriously ill people experience an overreaction of the immune system known as a “cytokine storm”, which causes other viral infections. Typically, cytokines are chemical-signalling molecules that guide healthy immune responses. In a cytokine storm, levels of certain cytokines spike, with immune cells attacking healthy tissues. Blood vessels leak, blood pressure drops, clots form, and catastrophic organ failure may ensue (Dance, 2020). Infection may also lead to blood vessel constriction, including ischaemia in fingers and toes. Blood clots appear to increase disease severity and mortality (Helmy et al., 2020). Occasionally, at some stages, the virus alters the balance of hormones that help regulate blood pressure and constricts blood vessels going to the lungs. Oxygen uptake becomes impeded by constricted blood vessels rather than by clogged alveoli. Also, COVID-19 may directly attack the lining of the heart and blood vessels, which,

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like the nose and alveoli, are rich in ACE2 receptors (Wadman, 2020). The virus can also target the kidneys, also abundantly endowed with ACE2 receptors (Frontera et al., 2020). In addition to the virus’ heavy impact on the lungs and kidneys, research demonstrates neurological injuries in 1 out of 7 infected patients, with some effects lasting for months. Researchers claim that these neurological injuries can lead to confusion caused by low blood-oxygen levels, resulting in stroke and/or seizures (Aghagholi et al., 2020). Although largely unexplored until recently, neurological complications can significantly increase the risk of death in patients by 38% because of low oxygen for prolonged periods of time (NYU Grossman School of Medicine, 2020). Neurological complications may also be the result of secondary effects from being severely ill and suffering from low oxygen levels for prolonged periods of time (Frontera, 2020).

The Impact of COVID-19 on Older Adults in Long-Term Care Facilities From the known history and biological explanation above, an early instance of rapid and deadly virus transmission occurred in Life Care Center of Kirkland in Washington, one of the first nursing homes known to be hit hard by the virus. As early as 2 April 2020, at least 37 of its approximately 120 residents died due to complications from COVID-19. Moreover, despite a surge in respiratory illness and COVID-19 cases in its resident population, the facility continued to accept new residents. The State Department of Social and Health Services halted new admissions to the facility after a spike in cases that affected staff, physicians, and residents. The five-starrated care facility significantly fell in ratings—with the biggest drop because of their insufficiency in health inspection (Sacchetti, 2020). The Centers for Medicare and Medicaid Services (CMS), which regulates long-term care, fined the facility, citing that for two weeks the nursing home failed to report an outbreak of respiratory illness, failed to provide adequate care to its residents, and failed to provide 24-hour emergency physician care (Sachetti, 2020). On the other side of the country, an early site of rapid infection was at Canterbury Rehabilitation and Healthcare Center in Richmond, Virginia. After the first resident showed symptoms, 60% of residents tested positive but were asymptomatic. Although health officials ordered more testing, not until the end of March were all residents screened. By that time, 92 of approximately 160 residents had tested positive (Freger et al., 2020). By May 2020, 50 residents died from COVID-19, with more than 100 residents and staff testing positive. These events represented a philosophy, termed “treating in place”, espoused by regulatory agencies, health care providers, and academics arguing that hospitals were inhospitable environments for vulnerable older adults and that they would benefit more from getting treatment at the facility to which they are accustomed

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(Englund, 2020). Unfortunately, many long-term facilities were without the staff or the expertise to attend to older residents with COVID-19 in addition to other problems with which they were already afflicted. As with the U.S. as a whole, residents and staff of minority status (e.g. Black, Hispanic) suffered more from the deleterious effects of the virus than their White counterparts (Calderón-Larrañaga, et al., 2020). Some nursing homes transported patients only when they were close to death rather than sending them to the hospital before they were actively dying.

Strategies for Safety Facial Coverings/Masks. Much discourse ensued concerning older adults and their use of facemasks, particularly older adults who are hard of hearing. Older adults with dementia can simply forget or refuse to wear a mask. Some have difficulty comprehending the importance of mask usage and comply only when recommended by someone they trust. Caregivers have noted that people with dementia will often pull down the face covering, refusing to wear it for long periods of time (Nelson, 2020). Although the CDC has made some medical exemptions, caregivers and care facilities working with older adults were required to encourage and positively reinforce mask usage and to provide up-to-date information to residents so that they could make the choice to wear a face covering when necessary and appropriate. Though mask mandates shifted and varied by state, overall, a decreasing number of cases resulted in less stringent mask mandates. While states like New York required proof of vaccination to allow the removal of masks while entering some businesses, other states like California enforced consistent mask usage in public buildings, regardless of vaccination status (The New York Times, 2021). Quarantine in Long-Term Care Facilities. For the first half year of living with the virus, long-term care facilities maintained a state of lockdown. Many residents were quarantined in their rooms with little contact with the outside world (Flint et al., 2020). Family members’ visits were limited to telephone and Zoom calls where and when possible. Many visits were made only through windows, leading to a significant increase in feelings of loneliness and isolation among residents. An image widely publicized was that of residents and family members long pressing their hands against panes of glass (Schepisi & Teaster, 2020). For many older adults, a decline in mental health led to a decline in physical health, making them even more vulnerable to the illness (Luo et al., 2020). Experts report a withdrawal from care, resulting from the isolation, leading to a refusal to eat, to take medication, or to engage in other forms of self-care. This behaviour resulted in increased weakness, placing the older adult at heightened risk. Besides this issue, many long-term care facilities were attempting to find solutions to safety with minimal support and assistance (Paulin, 2020). In response to Paulin’s (2020) interview about the plight of care in long-term care facilities, Perissinotto, Associate Chief of Geriatrics Clinical Programs at the University of California stated, “I don’t

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envy them at all. They are trying to keep the virus out of the facility, but in doing so, they are worsening mental health. There’s no winning”. Besides limiting visits from friends and family in order to reduce the possibility of infection, many facilities discontinued group activities and interactions with other residents, another way residents were socially isolated (Chu et al., 2021). For older adults who contracted the virus, their sense of isolation was increased and carried over to the hospital setting in which they were forced to combat the illness with minimal psychosocial support. One older adult stated, “I feel like I am in prison, and there’s no getting out” (Graham, 2020). After six months of strict visitation restrictions in nursing homes, the Centers for Medicare and Medicaid Services (CMS) released a memorandum that significantly eased previous mitigation restrictions. The new guidance permitted outdoor and indoor visitation, encouraged compassionate care visits, and specified a framework for resident visits in an attempt to reduce the significant feelings of isolation (CMS, 2020). However, by November 2020, cases around the country and world were spiking again, and new problems were emerging in long-term care facilities.

A Tandem Wave of Neglect While more than 90,000 of U.S. long-term care residents died in the pandemic, a tandem waive of death began, claiming thousands more people due to neglect. According to Sedensky and Condon (November 2020), advocates received reports of residents whose diapers had not been changed, who had not had a bath in months, and who had died due to neglect because in many instances, staff were simply overwhelmed. In addition, and less obvious was the possibility of resident deaths fueled by prolonged isolation and listed on some death certificates as “failure to thrive” (Sedensky & Condon, 2020). In a study by H. Stephen Kaye, in nursing homes where at least 3 in 10 residents contracted the virus, the death rate for reasons besides the virus was double that of pre-pandemic levels (Spanko, 2020). Safety was compromised due to inadequate staff mitigation practices and staff shortages in general. With the Omicron variant that surged in December 2021, concerns regarding increased transmissibility resurfaced. To limit the infection of residents, health care personals, and visitors, the CDC recommended newly admitted residents and those who were in contact with an infected person to quarantine, if they were not fully vaccinated. Self-isolation was no longer required for fully vaccinated adults, unless they were tested positive, and were symptomatic (CDC, 2022a).

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Impact on Older Adults Living in the Community Like residents living in long-term care settings, older adults living in the community were also highly impacted by Sars-Cov-2. As mentioned above, many states imposed lockdowns or stay-at-home orders, some of which resurfaced due to spikes in numbers in November 2020. Restrictions meant that for a time, depending on the state, only businesses and agencies deemed essential were operating, and for many, hours and protocols related to entry were significantly altered. Also, supply chains were impacted, meaning that commodities such as personal hygiene products were unavailable for weeks at a time, and when they were available, they were in short supply, leading to significant challenges for older adults with limited resources, as well as their families. Many older adults encountered difficulties finding transportation to procure goods and services, as ride-hailing services were stopped or decreased in frequency, and public transportation such as buses, subways, and trains significantly reduced and restricted their hours of operation (Ewoldsen, 2020; U.S. Department of Transportation Services). Stores motivated to assist older adults in acquiring basic necessities instituted early morning “elder hours” whereby older adults could more safely shop and thus reduce vectors of transmission. Even so, due to disruptions in markets, the prices of many items, even when available, increased significantly (Suneson & Stebbins, 2020). To support the vaccination of people in the community, businesses such as Uber and Lyft offered free commutes to vaccine appointments, increasing vaccine accessibility for numerous older adults (NPR, 2021a, 2021b). Social Distancing. Around March 2020, the CDC issued guidelines for mitigating the virus. An early and oft-repeated form of mitigation was referred to as “social distancing”, although the term “physical distancing” more accurately reflected the advice. Social distancing referred to the practice of keeping a safe space between individuals, especially when people were not a part of the same household. People were advised to stay at least six feet away (about two arms’ length) from those not from the same household in both indoor and outdoor spaces. The CDC also advised practicing social or physical distancing in combination with other behaviours to reduce the spread of the virus, including wearing masks as discussed above. Related to the discussion of virus transmission earlier in the chapter, increasing physical distance was an important way to reduce the spread by aerosol. Despite their being critical for the health safety of older adults, suggestions by the CDC and others—making additional preparation for transportation, reducing contact when running errands, selecting safe social activities (e.g. telephoning, Zoom, and Facetime), limiting social gatherings, maintaining a distance of six feet or more at events both indoors and out—proved difficult if not impossible for many older adults. Restrictions created challenges for people living in close quarters, care providers, those living in shared housing, persons with disabilities, and those who were homeless. Towards the end of 2021, guidelines for social distancing eased, as CDC encouraged physical distancing when appropriate and limited travel for essential purposes only (CDC, 2021).

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Enforcement of Wearing Masks Related to the admonition to distance physically, one of the most visible reminders of living in the pandemic was the donning of masks, more accurately referred to as face coverings. As with the necessity of physical distancing, the U.S. was largely unprepared for the urgent need to acquire and then wear masks. At the beginning of the pandemic, facial coverings were in short supply, and many people were unaware of how to effectively purchase and wear them. It took time for supply to meet demand, especially because of the number of masks required. It also took time to enforce mask wearing, which by September 2020 became an item of apparel that, in some settings, rose to the level of a fashion statement. To maximally impede the spread of COVID-19 to others, the CDC (2020) provided the following advice: • • • •

Wear masks with two or more layers Wear the mask over the nose and mouth and secure it under your chin Masks should be worn by people two years and older Masks should NOT be worn by children younger than two, people who have trouble breathing, or people who cannot remove the mask without assistance • Do NOT wear masks intended for healthcare workers, for example, N95 respirators • CDC does not recommend the use of gaiters or face shields alone. Evaluation of these face covers is ongoing, but effectiveness is unknown at this time. Wearing masks also quickly became a flashpoint for the 2020 presidential election. Two camps emerged, largely along party lines—those who adopted the wearing of masks and those who rejected it, dubbed “antimaskers”. While many U.S. Republicans assiduously wore face coverings, many of the party’s more libertarian members rejected wearing them. States wrestled with the wearing of masks as a requirement, as many insisted that a condition of riding on conveyances and entry into healthcare offices, stores, and events was contingent upon patrons wearing them. The requirement was enforced unevenly, although people generally complied. Former President Trump himself appeared in public more often without a mask than with one, as did many members of his inner circle. Many of his in-person political rallies were attended by people without masks, possibly producing super-spreader events. In midSeptember 2020, ostensibly at a Rose Garden event to promote the nomination of Amy Coney Barret as a justice on the Supreme Court, former President Trump and a number of attendees, including his wife, contracted the virus. In contrast, members of the Democratic Party urged the public to wear face coverings, and President Joe Biden was seen in public usually wearing (but sometimes not wearing) a face covering. Mandates for wearing masks aligned with state policies concerning lockdowns, also a political flashpoint. Particularly in the early months of the pandemic, older adults were challenged by where and how to procure face coverings, their expense, and how and when to wear them. For older adults with breathing and hearing problems, masks created yet another way to separate them from others in the community. Towards the end of 2021, while some mask mandates

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were lifted, students were mandated to wear masks at schools and federal rules still required masks on all forms of public transportation (The New York Times, 2021). Quarantine in the Community. To mitigate community spread, quarantines were enforced to keep someone who might have been exposed to COVID-19 away from others. For those suspected of contact with a person testing positive, the CDC recommended that people stay home (even if family members were in the same residence), monitor their health, and follow directions from their state or local health department (CDC, 2020). The CDC also made a distinction between quarantine and isolation, the latter being a practice that keeps an individual with the virus or possible infection completely separated from others, even family members and/or caregivers. As with older adults in facilities, research on impacts of quarantines and isolation of older people in the community suggests an increase in depression, poor sleep quality, and physical inactivity during the isolation period (Sepúlveda-Loyola et al., 2020). During the course of the pandemic, U.S. states varied and vacillated in policies and responses related to quarantines. For example, early in the pandemic, in California, the health department permitted only outdoor gatherings with no more than three households attending and with a space large enough to permit social distancing. Restrictions across the country eased somewhat in the summer, but by November 2020 the virus came roaring back and restrictions resumed, many even more stringent than before. By mid-November 2020 when there were more than 150,000 cases daily, the country experienced a resurge of lockdown restrictions. California, Washington State, Michigan, and Oregon ceased indoor dining. In Chicago, a new stay-at-home advisory went into effect in mid-November as the country began preparations for the Thanksgiving holiday. In Philadelphia, Mayor Jim Kenney introduced a sweeping new set of coronavirus rules, including a ban on most indoor private gatherings, with a plea for understanding: “We do not take any of this lightly”, he said. “Believe me, more than anything in the world, I wish none of this was necessary”. However, the new restrictions met with resistance that was especially fierce in Michigan, where Governor Whitmer, a Democrat, announced on a Sunday evening that she would shut down indoor dining, shutter casinos and movie theatres, and halt in-person learning at high schools and colleges for three weeks. A Republican state legislator quickly called for her to be impeached, and Dr. Scott Atlas, former President Trump’s coronavirus adviser, urged people in the state to “rise up” in protest (Mervosh, 2020). Since then and as the number of cases plummeted, mandates related to quarantine, testing, mask usage, and social distancing shifted to accommodate for the economical, sociocultural, and health-related needs of the country. Though state-specific differences continued to exist, overall federal regulations were more structured with policies in place for travel, vaccinations, social distancing, and testing procedures. Testing Availability and False Positives. In the high-stakes world of coronavirus testing, one mistake took centre stage: the false negative, wherein a test mistakenly deems an infected person to be virus-free. According to experts, such results can deprive a person of treatment and embolden him or her to mingle with others, thus hastening the spread of infection. However, false negatives are not the only errors bedevilling coronavirus diagnostics. False positives, which incorrectly identify a healthy person as infected by the virus, can have serious consequences as well,

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especially in places where the virus is scarce. Health officials report numerous issues related to false positives—psychological, financial, and physical. Psychologically, a misdiagnosis can cause severe anxiety and stress over infecting others, although unwarranted. Financially, there are numerous potential losses for a person who falsely tests positive and may cancel travel plans, reserve isolation centres, pay for additional medical opinions, or even buy medications before they are prescribed. There are also potential health side effects of a false positive. A person who is misdiagnosed and instructed to seek medical care might be exposed even more to infection during hospital visits or admissions (Healy et al., 2021).

Seeking Out Health Care The pandemic and accompanying restrictions also affected how older adults and their families accessed healthcare. Particularly during the lockdowns, nonessential healthcare was temporarily discontinued, meaning that elective procedures had to wait. Scheduled surgeries were pushed out, along with checkups and other procedures. Physicians’ offices adopted new hours and new protocols, most of which elongated visiting times due to the need to sanitize more thoroughly between visits and to screen each patient, including the now-normative questions/temperature checks—presence of a fever, interactions with persons having COVID-19 or suspected of having the virus, loss of the senses of taste and smell, and travel history. Many members of health care staffs were deployed to take care of urgent cases while others were furloughed due to low patient volumes. New York City was the site of the most dramatic initial surge of the virus, but as the weeks and months of the virus spread continued, areas all across the country were surprised and often ill-prepared to address the surge in patient volumes. The result was that nearly every area of the country was affected; those that appeared to dodge exposures early on fell victim later to spikes in positive testing, with the same scenario playing out when a new and highly transmissible variant, the Omicron variant officially arrived in the US (first reported in California) in December 2021 (Keating et al., 2021). These factors above had the unfortunate result of older people delaying appropriate healthcare. What was once considered nonessential care over time devolved into essential care, and, sometimes, care sought too late (Castellano & Plummer, 2020). Other older adults were unable to access care due to a lack of available transportation, and still others who received care in the home either saw their care discontinued or were exposed to the virus due to transmission by unwitting, COVIDpositive care providers. Many older adults hunkered in their homes, fearful of going to appointments with care providers, believing that the exposure risks were too great. Some fortunate older adults were able to receive care via telehealth, a tremendous boon, while others did not have the bandwidth, the required technology, the requisite technological skills, or a combination of these. The spectre of a second wave loomed large in the summer months, with healthcare experts equivocal as to whether the U.S. ever really escaped from the first wave of

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the virus. A predicted respite from the viral spread resulting from warmer climates failed to emerge, and by late summer 2020, a new concern arose that there could be a twindemic—a one-two punch of high rates of COVID-19 virus transmission in addition to high rates of seasonal flu. The CDC urged that people, especially older adults, be vigilant in getting a flu vaccination as soon as it was available. The agency warned against “COVID fatigue”, a term coined to reflect population weariness with keeping up with necessary precautions against community spread. The CDC cautioned that cooler weather in many parts of the country would allow fewer opportunities to stay comfortably outdoors and result in more people gathered closer together in spaces where virus droplets would remain in the air longer, driving up exposures. In November 2020, the dire predictions became the new reality as cases of the virus soared to heights greater than at any time in the spring and did so again in December 2021, when the Omicron variant again blew up COVID numbers (Rattner, 2021). There were bright spots, however, as the typical numbers of seasonal flu were far lower than predicted due to the precautions that people were taking to avoid COVID. The vaccine rollout, which began in late 2020 and continued into 2021 reduced the numbers of deaths and hospitalizations. In May 2021, children between ages 12 and 17 also began to receive the two shots of the vaccine, and in November of 2021, children ages 5–11 could receive the vaccine. Additionally, in November of 2021, the FDA authorized the administration of a single booster of the Pfizer-BioNTech COVID-19 vaccine for persons 18 years of age and older (CDC, 2021).

Racial and Ethnic Disparities Racial tensions were already simmering related to people of colour who, as a demographic, were disproportionately affected by the virus. At least two events that occurred during the pandemic further ripped apart an already fragile nation. The first occurred just as awareness of the pandemic was growing. On 13 March 2020, Breonna Taylor, a 26-year-old African-American woman who worked as a full-time emergency room technician for the University of Louisville Health, was fatally shot in her Louisville, Kentucky apartment when three White, plainclothes police officers from the Louisville Metro Police Department forcibly entered her apartment during an investigation of drug dealing operations (BBC News, 2020). Ms. Taylor’s boyfriend, inside the apartment when officers knocked on her door and then forcibly entered, thought they were intruders and fired a warning shot. The officers said that they announced themselves as police before forcing entry, but her boyfriend said that he did not hear them announce themselves. One of the officers was supposedly hit in the leg, which resulted in the officers’ firing 32 shots. Although Ms. Taylor’s boyfriend was unhurt, she was struck by six bullets and died. According to police, Ms. Taylor’s home was never searched (Lovan, 2022). In September 2020, the city of Louisville agreed to pay Ms. Taylor’s family $12 million and to reform police practices; a state grand jury indicted one of the officers on three counts of Wanton

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Endangerment of Taylor’s neighbors. As of December 2021, a jury had not been chosen in the trial of one officer charged with the endangerment (Lovan, 2022). On 25 May 2020, a store clerk in Minneapolis, Minnesota, alleged that George Floyd, a 46-year-old Black man, passed a counterfeit $20 bill. When police officers arrived at the scene, they apparently undertook a series of actions that violated policies of the police department, actions that left Mr. Floyd unable to breathe as he and onlookers called out for help. Officer Derek Chauvin, the White male officer seen most clearly pinning Mr. Floyd to the ground, kept his knee on Mr. Floyd’s neck for at least eight minutes, even after Floyd lost consciousness and paramedics arrived. Videos of the death of George Floyd went viral, the country erupted in both peaceful and violent demonstrations, and an already-fractious political divide deepened. Chauvin and three other officers who were also present faced murder charges of varying degrees (Hill et al. 2020). Mr. Chauvin’s trial was held during March and April of 2021. Mr. Chauvin was then convicted of second-degree murder and sentenced to 22 ½ years in prison (Chappell, 2021a, 2021b). These horrific events were not lost on older adults of all races and ethnicities. Thousands of individuals of all ages across the country marched, largely peacefully, against such treatment—the masked and unmasked. Such events created even greater fear for a number of older Americans who, in addition to an already uncertain environment due to disparities in health care, a roller-coaster economy, and exposure dangers for older people with chronic conditions, were confronted, once again, with injustices due to their own identities related to the intersectionalities of race and socioeconomic status. In July 2020, the CDC released a statement about Health Equity Considerations and Racial and Ethnic Minority Groups (CDC, 2020). The CDC addressed long-standing, systemic health and social inequities that put many racial and ethnic minorities at increased risk of contracting the virus and eventually dying from it. The statement also outlined factors contributing to increased risk including discrimination in the healthcare context, housing, criminal justice and finance, healthcare access and utilization, occupational resources, and educational, income, and wealth gaps (CDC, 2020). Young/Old Divide. Although people of all ages contracted COVID-19, older people, particularly those with underlying health conditions, were most susceptible to its effects. In March 2020, awareness of the virus and its spread across the country began as many public schools, as well as institutions of higher learning, were involved in or were soon to experience a March spring break holiday. The new and evolving information led educational institutions, from pre-schools to graduate schools, to announce virtual classes that continued well into the summer. Developing over the late spring and summer were looming questions concerning the fate of fall 2020 classes. As with lockdowns and the donning of masks, plans for education varied. Some schools remained entirely virtual through 2021, others opened with distancing guidelines and protocols, and still others adopted a hybrid model. Protocols attempted to quell transmission by students going back and forth to classes. Their practices concerned many people in the community, especially older adults, who feared that community spread would worsen when students returned to campus. A dance of

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dollars ensued. Not surprisingly, the economies of many cities and towns are highly dependent on students. Colleges and universities require a steady infusion of students and their tuition dollars. In some instances, budget shortfalls created a domino effect of losing outstanding students and outstanding faculty. The concerns of people living in the communities in which colleges or universities were located were not unfounded, since just as they feared, diagnosed cases in those towns increased, at least for a time, particularly in college towns that had managed to keep their numbers low while the students were away. When students returned, many older adults went further underground, reducing their grocery/merchandise shopping times or eliminating it altogether and decreasing other potential exposures such as trips to medical providers. While many older adults flourished, restrictions on social contact amplified social isolation and loneliness for others.

The Spectre of Elder Abuse Social distancing and stay-at-home orders enacted to protect the public against infection were critical for the safety of older adults and their families. However, these same policies and protocols also placed some at heightened risk for elder abuse (D’cruz & Banerjee, 2020; Elman, et al., 2020; Han & Mosqueda, 2020). Increased social isolation and reduced access to care and services also placed some older adults in even more vulnerable circumstances than they were previously. A number of family members and their formal and informal caregivers were at heightened risk of abuse due to COVID-19 consequences, including loss of jobs, financial stress, and conflicting home and work responsibilities. Moreover, closures of adult daycare programmes, senior centres, and places of worship, combined with reduced contact with service providers including doctors, nurses, mental health professionals, social workers, and ombudsman made preventing and discovering elder abuse more challenging than prior to the pandemic. The result of fewer eyes and ears meant that, for most states, reports alleging abuse, neglect, and exploitation declined, ironically at a time when mistreatment was on the rise, in frequency and intensity. Many of the very organizations and programmes charged with addressing abuse, neglect, and exploitation had to pivot from their hallmark face-to-face investigations and conduct them virtually. These operational changes resulted in many instances of elder abuse going undiscovered (Teaster et al., 2020).

Primary Resources and Organizations Supporting Older Adults Support for Older Adults in Long-Term Care Facilities. Given their congregate nature and the populations they serve, residents of long-term care facilities were at higher risk for contracting COVID-19. Older adults in care facilities are seldom

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contactless, often requiring support from staff, particularly caregivers or nurses at the facility, increasing the risk of contracting and spreading infection. The CDC released information, recommendations, and policies to support facilities and their residents by providing resources such as control measures, plans for testing residents and staff, visitor restrictions, new admission policies, and safety of healthcare personnel and recommendations to control and prevent infection within the facility. The CDC also advised caregivers, residents, and long-term care staff by providing up-to-date information on safety and precautionary methods. In addition, the CDC provided testing resources, including step-by-step guidance, considerations for the use of SARS-CoV-2 antigen testing, guidelines for collecting, handling, and testing clinical specimens from older adults, and the reporting of COVID-19 laboratory data (CDC, 2022b). Another form of testing especially common in care facilities and hospitals was point-of-care testing, which increased free, accessible testing with rapid results so that appropriate treatment procedures were completed quickly in the place where the older adult resided. The Institute of Healthcare Improvement (IHI) provided a consolidated list of national resources with updated information for residents, caregivers, and facility staff for supporting the health of older adults and their caregivers. The Long-Term Care Ombudsman. Long-Term Care Ombudsmen (LTCO) are advocates for residents in nursing homes, board and care homes, and assisted living facilities. LTCO provide information concerning locating an appropriate facility and how to access quality care. Trained in problem resolution, LTCOs also assist in complaints made concerning the long-term care facility in which residents reside. Authorized under the Older Americans Act, each state is required to have an Ombudsman Programme, which is administered by the Administration on Aging (AoA)/Administration for Community Living (ACL) and includes more than 6,000 volunteers and more than 1,200 paid staff. Most state LTCO programmes are housed within their State Unit on Aging (ACL, 2020a). During the pandemic, LTCOs amplified the frequency and quality of care they provide to older adults and care facilities. As an example, an Idaho Ombudsperson, Tera Fellow, began pairing up pen pals in facilities across the county from which she operated. Fellow matched 16 sets of pen pals from different care facilities as of November 2020 in the hope that feelings of loneliness were decreased, if not mitigated (Pfannenstiel, 2020). LTCOs have also been engaging the community, older adults, and care facility staff to provide resources, specifically information related to appropriate care of older adults through a trauma-informed and disaster relief perspective when appropriate, usually via free webinars (Wehry, 2020). The National Long-Term Care Ombudsman Resource Center (NORC) is a valuable resource supporting care providers, both formal and informal. The NORC provides staff and caregivers with resources, tips, and examples to promote effective communication between the Ombudsman programme and residents, families, providers, and the public when in-person visitation is limited (What is the Long-Term Care Ombudsman Program? 2021).

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Support for Older Adults in the Community Research has consistently demonstrated the value of community support for older adults, leading to reduced levels of isolation, feelings of depression, and healthrelated anxiety (Harrington et al., 2019). Throughout the pandemic, some organizations took the initiative to develop novel and context-specific strategies to support older adults and facilities working with this population through innovative and reliable resources. In the U.S., community-based organizations such as the National Council on Aging, the Eldercare Locator, AARP, and the American Society on Aging all played an instrumental role in supporting older adults in the community through outreach and advocacy. COVID-19 significantly altered their functionality, purpose, funding, and for some, even sustenance for these programmes. As a part of the nation’s ageing network, several of these organizations provide support through meals, housing resources, financial aid, benefit enrollments, caregiver support, transportation, and more. During the pandemic, traditional organizations and their missions were no longer able to meet some of the increased and changing needs of older adults. By 2021, the primary needs of many older adults shifted from food, housing, and supplies to staying socially connected, with 72% of older adults reporting social isolation as the most imperative issue (Wu, 2020). The National Council on Aging (NCOA) has historically supported organizations that work with the older adult population through funding, providing free resources for education associated with policy, health benefits, and insurance. During the pandemic, NCOA took steps to provide relevant resources to older adults and organizations providing care. Examples included information about healthy voting during the pandemic so that older adults felt safe while practicing their power in the election, since many of these adults have been voting for most of their lives (NCOA, n.d). Area Agencies on Aging. Authorized by the Older Americans Act and administered by the Administration for Community Living, an Area Agency on Aging (AAA) is a public or private non-profit agency designated by the state to address the needs and concerns of older adults at regional and local levels. “Area Agency on Aging” is a generic term; specific names of local AAAs vary. AAAs are primarily responsible for a geographic area, also known as a Planning and Service Area (PSA), which is either a city, a single county, or a multi-county district. AAAs may be categorized as county, city, regional planning council or council of governments, private, or non-profit. AAAs coordinate and offer services that help older adults remain in their homes by making a range of options available. AAAs make it possible for older individuals to choose the services and living arrangements that suit them best (ACL, 2020b). Presently, there are 622 AAAs distributed around the U.S. One of the most well-known activities of many AAAs is Meals on Wheels, which enabled 221 million meals to be delivered to 2.4 million older adults annually and throughout the pandemic.

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Adult Protective Services. Adult Protective Services (APS) is a social services programme provided by state and local governments serving older adults and adults with disabilities who need assistance because of abuse, neglect, self-neglect, or financial exploitation (adult maltreatment). In all states, APS is charged with receiving and responding to reports of adult maltreatment and working closely with clients and a wide variety of allied professionals to maximize client safety and independence (ACL, 2020c). During COVID-19, in general, after appropriate training and support, staff were able to conduct investigations, relying upon collaterals for information in ways that they might not have earlier. They learned to use personal protective equipment (PPE) appropriately, although its use was already familiar to many. The COVID-19 emergency revealed the distinctive role that APS programmes play in their communities and the importance of APS staff to ensuring the health and safety of vulnerable adults (Han & Mosqueda, 2020; Teaster et al., 2020). AARP. Formerly the American Association of Retired Persons, AARP is an interest group and insurance company that addresses issues that affect adults aged 50 and over. AARP boasts over 38 million members (FastCo Works, 2020). For its membership, AARP produces a magazine and bulletin—publications that enjoy some of the largest-circulation in the U.S. Since the onset of the pandemic, AARP, specifically its charity-based sub-section AARP Foundation, raised critically needed funds for allocating resources to low-income families.

Observations, Conclusions, and a Way Forward in the Midst of a Pandemic Since March 2020, the lives of people living in the U.S. were fundamentally altered to address the effects of COVID-19. For some, the virus ravaged them and then took their lives—the fact that 31% of total COVID-19 deaths were people living in long-term care settings remains inexcusable and unconscionable (Chidambaram & Garfield, 2021). Many deaths were preventable and represent an important opportunity for policy and procedural changes to change the manner in which older adults in longterm care and their caregivers are treated. Too many older adults living in community settings also died needlessly. Some perished due to unintended exposures while others died from complications arising from an inability access needed healthcare— whether precluded by lockdowns, because of fear, or both. In addition to the deaths of thousands of older adults were the deleterious effects of depression and loneliness. For some, the virus lockdowns and staying at home promoted a time of flourishing. Many older (and younger) adults experienced a slowing of overall life pace and a time to reflect and renew. For some, the virus engendered occasions to be out in nature, to pause from a schedule previously and needlessly frenetic, and to reach out to people in ways that had not occurred in the past. Accommodations in commerce created ways of reaching out, of being mindful, and of being kinder to others overall because time allowed for it.

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As we write this chapter at the end of December 2021, due to the Omicron variant, the numbers of COVID-19 deaths and infections are again rising at an alarming rate in the U.S. and abroad. During nearly all of 2021, President Biden oversaw the vaccine rollout and confronted vaccine hesitancy and the political eruptions concerning mask mandates. Thus, at a time of renewed hope for some, dashed hopes for others, we provide observations related to the treatment of older adults (and their families and caregivers) in the U.S., offer conclusory remarks, and offer a way forward, one that involves lessons for living with the virus. Enable and Encourage Medical Care. Described throughout this chapter and in line with statements set forth by the CDC, the risk for severe illness from COVID19 increases with age (CDC, 2022a). This reality means that, to save the life of an older adult, immediate access to medical care including hospital beds, ventilators, intensive care units, and accessible hospitalizations had to be prioritized. The onset of the pandemic led to upheavals in health care systems nationally and globally. Some researchers stressed the importance of proactive assessment by medical providers to be able to detect and treat infection (Bianchetti et al., 2020; Gan et al., 2020). Within geriatric hospital wards, protocols established the prognosis of the patient upon admission. Asymptomatic residents with confirmed diagnoses were isolated and periodically checked for specific and nonspecific symptoms. Increasingly, hospitalizations were limited to cases that could not be managed in long-term care facilities and considered only after assessing their general health, cognitive, and functional status (Bianchetti et al., 2020). Timely and specialized healthcare for older adults was especially crucial; caregivers, healthcare providers, and family members needed to assiduously support patient rights and autonomy like never before. The pandemic revealed that telemedicine represents an important avenue for preserving and protecting the health and well-being of older adults. In learning to live with COVID-19, it is vital that renewed efforts related to telemedicine become a reality, including assuring adequate broadband available for older adults living in rural areas. It is equally critical that older adults have access to technology that allows them to connect to telemedicine (e.g. computers, smart phones, notebooks). Providing access will be meaningless without appropriate and consistent technological support mindful of the learning patterns and needs of older adults and their caregivers. Intergenerational Integration—Not Divide. Researchers, caregivers, and healthcare providers consistently emphasize the benefits of intergenerational care (McGuire, 2019). In a generationally segregated society, activities, care, and services for older adults that are integrated with those for younger generations decreases feelings of isolation and increases levels of happiness alongside sustaining a sense of purpose in people’s lives (McGuire, 2019; Requena et al., 2018). Older adults have been discriminated against in numerous contexts. Some researchers found that the pandemic led to an increased level of maltreatment of older adults and a parallel outbreak of ageism, especially from younger generations (Ayalon et al., 2020). Ayalon et al. (2020) recommend reducing the intergenerational gap and fostering solidarity between generations in a way that benefits older adults and younger people. The researchers argued against age cut-offs, explaining that they lead to prejudicial

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treatment of older adults and stressing that chronological age cannot be the sole determinant of risk. It is important to reframe discourse that refrains from using broad age-based categorizations that increase ageist prejudices and stereotypes (O’Neil & Haydon, 2015). Some private organizations and groups made efforts to reduce the intergenerational divide and to increase collaboration through unique and novel strategies to support older adults during the pandemic, primarily through an increase in social engagement. One notable example was Big & Mini, brainchild of Allen Zhou, a college student majoring in electrical and computer engineering at the University of Austin, Texas. Allen and colleagues created a website connecting older adults— “bigs”—with teenagers—“minis”—to provide older adults and adolescents a way to connect virtually and to battle social isolation (Koshy, 2020). Support Business Efforts to Help Older Adults. Amidst the increased risk that older adults experienced during the pandemic, small businesses took the initiative or continued their mission to support older adults. For example, the National Institute of Aging (NIA) supports the efforts of entrepreneurs and small business owners who work to improve the lives of older adults. The Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) helps companies commercialize products and technologies aimed at extending active, healthy lives of older adults (Haim, 2020). During the mandated closure of restaurants and bars, older adult food service professionals were hired to supplement existing staff and likely interested vendors whose businesses were affected by the shutdown (Harvey, 2020). An example of a small business to support that also aimed to assist older adults through the pandemic is ClearMask. Because traditional face coverings block faces, facial expressions and visual cues can easily be missed, adding to the confusion for many older adults. To combat this issue, ClearMask created FDA-approved transparent face coverings that caregivers can wear when they visit the older adults or interact with them (Williams, 2020). During these still-unprecedented times, it is crucial that small business owners, companies, and organizations that help older adults are supported through funding, access to healthcare information, and additional resources from the government and non-profit organizations. Encourage Creative Ways to Mitigate Social Isolation and Loneliness. The unexpected onset of the pandemic, its unpredictable course, unknown trajectory, and significant impact on society, including sheltering in place, quarantines, and physical distancing, were challenging for most but were significantly impactful upon older adults. Research since the inception of the pandemic demonstrated that older adults reported higher levels of depression and loneliness with the onset of COVID19, which in turn affected their well-being and physical health (Krendl & Perry, 2020). The same study also found that increased levels of loneliness were directly proportional to feelings of depression, and for some, to tendencies toward self-harm (Wand, 2020). In 2020, Schepisi and Teaster addressed the problem of rapidly increasing feelings of isolation for older adults living with dementia. As mentioned in a previous section of this chapter, the authors described an image commonly used—that of older adult

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residents in long-term care facilities and family members pressing their hands against panes of glass, which represented an impermeable barrier between them and their loved ones. The authors proposed that older adults should be offered autonomy to make choices related to quality over quantity of life and called for the creation of innovative new plans to be taken seriously, rehearsed, ready, and in place so that better options are available for current and future emergencies. By developing efficient plans, the authors emphasized that it was possible to reduce the traumatic image of older adults’ hands pressed against glass. Simultaneously, individuals, private organizations, and businesses developed novel and creative ways of combating isolation and loneliness in older adults. One positive aspect of the quarantine was the adoption of technology. Many care facilities, hospitals, and families utilized technology to stay in touch with older adults. Virtual visits supported many older adults and their families by providing emotional and relational support (Russell, 2020). The AARP Foundation developed an example of an initiative: Connect 2 Affect, which provides a free self-assessment tool and resources to help older adult’s battle feelings of isolation. Similar to Big & Mini described above, “Assistance from a Distance” is a companionship tool offered by Papa. A family-run organization founded in Miami, Florida, Papa focuses on supporting older adults in battling feelings of loneliness and isolation through social connection initiated by Papa volunteers, often referred to as “family-on demand.” During the pandemic, this team addressed active and ongoing disease surveillance, workforce protection, and management (Parker, 2020). De-Politicize the Virus and Redress Injustice, Including Ageism. The virus, which knew no boundaries, quickly became political, especially occurring during the year of a presidential election and its volatile aftermath. Political divisions became as fractious as racial inequities. First, alarm bells rang related to anticipated shortages of hospital beds, the supply of ventilators, adequate PPE, and of basic goods and materials (e.g. toilet paper, paper towels, sanitizer, sanitizing wipes, alcohol, meat and poultry, peanut butter). Some shortages were short-lived, others persisted, and yet others re-emerged. Second, arguments erupted daily, sometimes hourly, concerning who was to blame for the spread of the virus; who was to pick up supply shortages, if, when, and who should lock down and for how long; and who should be mandated to have vaccines and wear masks. Dividing lines were drawn between liberal versus conservative, Democrat versus Republican, rural versus urban, White versus Black, elites versus the working class, young versus old, and so on. When the ugly head of racism reared again, the politicization and polarization gathered size and speed like an avalanche careening down a mountain. Spring 2020 turned into summer, then into fall, and the animus continued into 2021. A presidential election, clouded by allegations of election fraud, was uncertain due to threats of legal battles and requests for recounts. The unrest erupted on 6 January 2021, when opponents stormed the Capitol of the US. The virus, which over time morphed into the Delta Variant and later, the Omicron Variant, was wholly unimpressed by demarcations and raged, even with renewed vaccines, vaccine boosters, and mask mandates in 2021. Early in 2021, the

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widespread administration of the vaccine allowed gradual re-openings for celebrations, business, and the like. However, some openings were short-lived, as breakthrough COVID-19 cases increasingly occurred. In reaction, in the fall of 2021, the CDC strongly advised people to have a booster shot to reduce infections overall and severity of the disease. By November 2021, a new and highly transmissible variant, the Omicron variant, emerged in South Africa (Mallapaty, 2022). In late 2021, parts of Europe again locked down, as did parts of the U.S. Flu Shots, Masks, and the Vaccine. Early in the summer of 2020, public health authorities, most notably the CDC, implored the public to get a seasonal flu vaccine as quickly as possible. The genesis of the campaign arose from concerns that colder weather would result in greater community spread. It was feared that those who contracted COVID-19 and those who contracted the seasonal flu would create an unprecedented healthcare challenge, one that for many would not end well. Pleas increased for members of the public to wear face coverings when six feet apart from or in the company of a person who might have been exposed but was asymptomatic. By the fall of 2020, compliance with wearing masks was visibly greater, although pockets of a lack of compliance were on public display, particularly when former President Trump and his wife contracted the virus, ostensibly during a plane trip with an infected but unsuspecting consultant. Over the summer of 2020 and into the fall, special committees were offering guidance and making decisions about the vaccine rollout. One notable committee was from the National Academies, which formed a working group charged with producing a consensus study to help policy makers in the U.S. and abroad concerning equitable allocation of the vaccines (National Academy of Sciences, n.d.). Foundational ethical principles that undergirded deliberations were maximum benefits, equal concern, and mitigation of health inequities. Procedural principles upon which the committee relied were fairness, transparency, and an evidence base. Cognizant that vaccines would be in short supply in the beginning of administration and considering both needs and a “worst off first” approach, the committee recommended a phased approach for administration. Upon FDA approval, the committee recommended that Phase 1a include high-risk health care workers involved in patient care; Phase 1b involved people 18 years of age and older with two or more comorbid or underlying health care conditions, as well as older adults living in long-term care and other congregate settings. Phase 2 involved K-12 teachers, child care staff, and people whose work put them at significant risk of exposure and harm. Phase 3 opened up access for children, and Phase 4 included all others (Framework for Equitable Allocation of COVID-19 Vaccine, 2020). The Pfizer/BioNTech vaccine was approved by the US Food and Drug Administration under an Emergency Use Authorization on December 11, 2020, and administration of the first of two doses commenced in the U.S on December 14th (Pfizer, 2020). Although the rollout marked a major turning point in the battle against COVID-19, there emerged significant groups of people of all ages who were either hesitant to be vaccinated or who refused to be vaccinated. Some individuals could not be vaccinated because they were immuno-compromised; others refused on religious grounds. The vast majority who refused did so for political reasons, citing that forcing people into

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vaccine administration was overreaching by the government. Like lockdowns, the controversy fell along political lines, with conservatives less supportive of vaccine administration than liberals. Vaccine administration and mask wearing evolved to vaccine and mask mandates for professions and groups, which again polarized the county and opened the door for increased transmission, hospitalizations and deaths, and for new variants to emerge more rapidly, as it did in late 2021 (Gerretsen et al., 2021). Reduce Exploitation. The spectre of elder abuse loomed large through 2021, even though it will take years to disentangle the extent to which it increased during the time of the global pandemic. Certainly, the alchemy was right—a toxic brew of isolation, reduced access to medical care for people with dementia, and loss of jobs or other sources of income for many. While predictions of abuse, neglect, exploitation, and self-neglect were forecast (Han & Mosqueda, 2020; Giwa & Teaster, 2020), for many states, APS, the LTCO, and concerned others were unable to report what they could not see or hear. Results of large-scale, longitudinal studies of mistreatment during the pandemic and its effects will be published at some future date.

A Way Forward—Envisioning a Future Reality We end this chapter, one that grew ever larger as more and more history was added to lives increasingly enmeshed with COVID-19. We acknowledge that while this chapter represents our present reality, it quickly becomes our commentary on a fixed period in the past. Our observations on the present have implications both for looking backward and forward. Below, we propose a path forward. We emphasize that the virus should be what it is—less a political football game and more of a health event. The virus offers an opportunity for long-needed and oftendelayed improvements in long-term care. The pandemic makes possible a renewed appreciation for a nation diverse in age, gender, race and ethnicity, education, income, and geography. While we wish to preserve our differences because many make us collectively stronger, it is incumbent upon us to make more equitable the presently stark disparities in income, access to healthcare and technology; reduce isolation and loneliness, and reform the criminal justice system’s treatment of (even alleged) offenders. We as a nation are obliged to restore our faith in institutions such as the CDC and government in general and to recognize that mask wearing and vaccine uptake are means by which to mitigate a virus, not to extinguish freedoms. We conclude our chapter at the end of December 2021 with COVID-19 numbers once again spiking around the country. Hopeful signs nearly two years later are that the Omicron variant is more transmissible but less severe than early strains. More of the public is vaccinated and boosted, including vaccinations for children ages five and up. For 2022, a hopeful path forward is tempered by the knowledge that COVID-19 will now and in the foreseeable future be added to the international list of diseases for which there is no cure, only prevention, one that is endemic rather than pandemic. The path forward includes opportunities for revision of programmes and

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policies to redress past inequities—particularly racism and ageism. Also on the path forward are opportunities that are individually oriented. The time afforded by staying close to home has created for some a time to remember that a less hectic, quieter life is possible, that outdoor activities can be accommodated more easily than first imagined, and that traditions may be altered yet still enjoyed. Finally, the people of the U.S., as well as those around the world, should emerge from a long and painful pandemic wiser, stronger, and now more than ever, appreciative of the possibility and potential to grow old.

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Chapter 20

Daily Life Among Adults in a Maryland Condominium During the Early Stages of the COVID Pandemic Cynthia Thomas

Abstract Semi-structured interviews were conducted with 36 residents in a Maryland condominium, ranging in age from the late 30’s to the mid 90’s, nearly half of them over the age of 80, between July 8 and September 17, 2020. The condominium is located in the most populous county in the state, and one of the wealthiest and best educated in the country. There are large proportions of Hispanics, Blacks and Asians as well as 43% who identify as white. During this time period, there was alarming news about the progress of the epidemic in the U.S and within Maryland, nearby Virginia and the District of Columbia. Respondents for the most part were paying close attention to the news about the epidemic and were following guidelines about mask wearing and social distancing. Most had adjusted their daily activities to comport with a restricted environment. They missed social interactions with family members and friends, the freedom to travel, and access to restaurants, entertainment and the arts. On the upside, many were becoming more introspective and appreciative of their surroundings, or had begun to acquire new skills. Keywords COVID 19 · Perspectives on the Pandemic · Patterns of daily activity · Social contacts · Medical care · Outlook for the future

National Context By January, 2020, health professionals in countries around the world began to be aware that a highly contagious virus originating in Wuhan China was likely to spread rapidly across the globe. Around that time, officials in the White House in Washington DC became aware of the potential for serious infections to spread to millions of US citizens, although most citizens themselves were unaware of the potential threat until mid-March, if then (Wright, January 4 & 11, 2021). The virus spread rapidly in a few western states such as Washington and California, and even more forcefully in several states in the Northeast. During the first three months of the pandemic, New C. Thomas (B) International Network for the Prevention of Elder Abuse (INPEA), Rockville, MD, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_20

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York City, then the epicentre of the disease, had over 200,000 confirmed cases, with a fatality rate of over 30% among those hospitalized and a nine percent fatality rate overall (Centers for Disease Control, February 29-June 1, 2020) (Later on, fatality rates were closer to two percent). Hospital beds in the city began to fill up rapidly, necessitating the conversion of convention centres and other places into emergency treatment centres. Surrounding states such as New Jersey also had large increases in the daily number of cases. At this point, much of the country figured that the most serious centre of this epidemic was pretty much confined to the northeastern US, and perhaps California. Other areas of the country were slow to react and take precautions, especially states in the midwest. By July 8, however, there were almost three million confirmed cases, and nearly 125,000 deaths (Lutton, July 8, 2020). During this first major wave of the virus, many people were expecting the daily number of new cases to begin to decline by September or October, and there was hope that by that time, there might be a vaccine. Nonetheless, people were already becoming tired of staying at home most of the time, of being asked to wear masks and keep a social distance of at least 6 feet from others, and of such cumbersome tasks as washing off groceries after they were delivered or on their return from a quick visit to the grocery store. There was confusion about who if anyone needed to take responsibility for coordinating a strategy for responding to this emerging medical crisis. The President indicated that for the most part each of the the 50 states should take responsibility for addressing the virus by acquiring their own supplies of personal protective equipment (PPE), including masks, gowns, and face shields, and even medical equipment such as ventilators, referred to as “state authority handoff” (Shear & Weiland et al., 2020). Seven northeastern states banded together to make purchases, attempting to avoid a free-for-all competition that would likely lead to scarcity and higher prices (Klar, May 3, 2020). However, despite efforts by the various states to search for sources of supplies in the US and abroad, ventilators and PPE remained difficult to acquire throughout this period.

Events in Maryland As the virus continued its spread in the northeast, Maryland, by July 10, was averaging over 400 new cases a day, and rates were starting to increase even more (New York Times, July 10, 2020). The Governor proposed measures to control the virus, requiring retail establishments to close, making plans to limit contagion in schools by requiring on-line learning, and urging the use of masks, social distancing, crowd avoidance, hand washing, and other safety measures. With over 6 million residents, Maryland is the 19th most populous state in the country. Located approximately 24 miles north of Washington DC., the state is home to a substantial number of Federal employees, businesses in fields of information technology, aerospace and defence, as well as some of the best medical facilities in the country.

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There are 23 counties in the state, the most populous being Montgomery County (MoCo), located in the west central part of the state. According to Census.gov, the county had over a million residents by 2019. The racial and ethnic composition of MoCo includes approximately 43% who identify as white, 20% Hispanic or Latino, 18% Asian, and 20% Black or African American. The county is ranked as one of the most affluent in the US, and has the highest percentage of residents over 25 years of age who hold post-graduate degrees—nearly 30%. The median annual household income in MoCo is more than $108,000, approximately $27,000 higher than the median for the state as a whole. Despite the overall affluence of county residents, there are significant pockets of low income households. A community food distribution centre has a steady stream of customers, and the numbers requiring food assistance have been increasing during the epidemic (Martin, September 27, 2020).

Context for Interviews with Residents in MoCo Between July 8 and September 17, 2020, the number of cases continued to increase rapidly in the northeast but more modestly in Maryland. During this time period, thirty-six residents of a two-building condominium in Rockville, Maryland, the county seat for MoCo, were asked in a series of semi-structured interviews to express their concerns and experiences regarding the first four to six months of the Coronavirus epidemic. During this time period, cases in MoCo were increasing more rapidly than in any other county in the entire state except for one. Residents in the condominium are typical of affluent, well educated members of the community. One to three bedroom apartments in the two connected buildings have recently sold for average prices over $450,000. Building amenities include a 24 hour front desk attendant, an outdoor swimming pool, a gym, and a roof garden. The residences are located within easy walking distance of grocery stores and a Metro station with a train line that travels directly into the District of Columbia. Initial interviews with building residents occurred in the context of alarming news about the continuing progress of the epidemic nationally, and within Maryland, nearby Virginia and the District of Columbia. (This triumvirate of jurisdictions is known locally as the DMV). Nationally, the number of new cases on July 8 was 59,455, declining somewhat to 45,310 new cases on September 17 (New York Times, updated December 28, 2020). There were similar patterns in Maryland, with the two largest counties, Prince Georges and Montgomery, leading the state in both the number of cases and deaths from the epidemic. In Montgomery County, an article in the Washington Post on August 26 highlighted the problem in nursing homes, where at this point approximately 40% of the cases had occurred, including staff as well as residents. The article indicated that the state had levied large fines against three nursing homes in MoCo, for “infection control deficiencies” that inspectors claimed had placed residents in “immediate jeopardy” during the epidemic (Tan & Chason, August 26, 2020). At that point, nearly 15,000 residents in nursing homes and assisted living facilities had tested positive for the virus; two thousand of them

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had died, more that half of the deaths in the entire state. The fines levied in MoCo were especially noteworthy, given that fines in senior living facilities throughout the DMV had been relatively rare. At this time, however, virtually no one expected that the virus would later become difficult if not impossible to control (as was feared by mid November, 2020).

Respondents’ Characteristics Respondents to the survey ranged in age from late 30’s to mid 90’s, with nearly half over the age of 80. All but four were 60 years or older—the most vulnerable age group for serious complications from COVID. Many were long-term residents of the buildings, which opened in the mid 1980’s. Fourteen respondents had lived in one of the buildings for 20 years or more, while only 10 had been in residence for three years or less. Thirty respondents were women. Most lived alone, or with one other person, but nearly everyone had family members in the area. They were asked whether they had pets, how they rated their health, whether they were working or retired, and their most recent occupation. Eight had professional positions either now or in the past with Federal, state or county agencies. Six had been or were still school teachers, of English, special education, or nursery school. Three held senior administrative or teaching positions at universities. Three were artists or designers. Several others owned or managed businesses ranging from a travel agency to a cemetery company. One person had organized a laundry workers union and had served as its president. Others worked for the airlines, in publishing, as freelance writers, as financial planners, or as religious leaders. Interviews lasted anywhere from 30 min to over an hour, and were conducted wearing masks and social distancing, either outside in the roof garden, by the swimming pool, in the terrace meeting room, at a nearby park, or occasionally in residents’ apartments. Respondents were asked to assess how serious they judged the pandemic to be: very serious, somewhat serious, or not too serious. No one thought the pandemic was not too serious, and only a few respondents indicated that it was only somewhat serious. Already in what turns out to have been an early stage in the development of the pandemic people in the building were taking it seriously. During the time period of the interviews, from four to seven months after epidemiologists had begun to sound alarms about the potential for rapid spread of the virus, little was known about the characteristics of the illness, effective treatments, likely duration once infected, risks of dying, and who might be most vulnerable, in addition to nursing home residents. Nonetheless, virtually all respondents thought it important to wear masks when close to other people, to practice social distancing, and to wash their hands frequently.

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Perspectives on the Pandemic Most residents claimed to be paying close attention to the news and to the advice of public health officials, including Dr. Anthony Fauci, the foremost epidemiologist on the President’s Coronavirus Task Force. In fact, several respondents had worked with or personally knew Dr. Fauci, having been employed at one time at Fauci’s organization, the National Institutes of Health, located less than a mile from the condominium. Primary sources of information about the virus varied. Several residents had physicians as family members or close friends, and consulted them for updates and advice. Others relied on newspapers such as the Washington Post or network or cable television channels, physicians in their medical practice, the Centers for Disease Control, or state or local public health authorities. Some residents paid attention to social media such as Facebook. Almost everyone consulted multiple sources when weighing how to respond to the epidemic. Although no one mentioned it specifically as a reason for their concern about the seriousness of the pandemic, twelve respondents said that someone they were close to, such as a family member or a close friend, had contracted the virus. Seven people knew someone close who had died, and several others knew of someone—such as a friend of a friend—who either had a mild case or had died. Since these interviews took place only 4–7 months into the epidemic, the fact that over a third of these residents already knew someone who had suffered or died is noteworthy. The weather in spring and early summer in MoCo was pleasant, with temperatures on most days in the 70’s, not yet too hot to spend time outdoors. In fact, at least 20 building residents spent time at the outdoor pool, some even congregating in the water without masks. Perhaps because of the nice weather, even many of the residents who were not pool goers were somewhat skeptical of the necessity for such precautions as mask wearing outdoors. Others were especially cautious and had food delivered to avoid visiting grocery stores, washed their groceries before putting them away, and wore gloves when outside the home to avoid touching potentially contaminated surfaces. Ultimately, the latter two precautions were deemed unnecessary by most public health officials. Given the overall levels of concern about the potential for contracting the virus, it was interesting to note that as time progressed—from early July to late August or September—the respondents in the later weeks seemed to be weighing cautiously whether they could venture more widely from their home base. For example, most early interviewees stayed home exclusively, having their groceries delivered, and refrained from visiting nearby family members including their grandchildren. Later interviewees were beginning to visit grocery stores cautiously but infrequently, and arranging social distancing gatherings with family outdoors, in order to see their grandchildren, although still avoiding close contacts such as hugs. During this early period of the epidemic, most people—over 20—had felt little or no financial impact. People who were employed were working from home, meeting with colleagues over Zoom. One person had not expected to be able to work effectively from home, but found that he could accomplish almost as much as he had in the office. Now he thinks

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it will be difficult to return to the office given how comfortable it is to work from home. Those needing close contact with others, such as dentists, were finally able to see patients while limiting the number in the waiting room and requiring masks as feasible. Five or six people had suffered reductions in income, due to decreases in the value of their investments, real estate losses due to renters moving away, or the state’s requirement that they close their businesses. On the other hand, several respondents noted that they now had more money to spend, since they were not traveling or shopping as they had before. They were able to save money and make more contributions.

Patterns of Daily Activity Respondents were asked how their daily activities had changed since March, when they were first urged by the Governor and local health officials to stay home with only infrequent visits outside the home to buy food or for other emergencies. Almost everyone now spent time differently, at a slower pace, in contrast to more varied activities during normal times. Often, people slept late—several as late as noon. One person said that she often gets up at 7:00, as in the past, realizes that she has no place to go, and gets back into bed and sleeps until 10:00. Eating a leisurely breakfast while reading the newspaper was a common activity at the start of the day. Many spent more time on the telephone than they had in the past, either after breakfast or during the afternoon. “I eat whenever I’m hungry, and I like to putz around during the day,” said one. Often, people followed a routine, such as in one case watching tv from 4:00 until 4:30 every day, and then the news for an hour starting at 7:00. Someone said: “It’s not a productive routine, but I’m good at making lists.” Most found time to exercise, either in the morning or late afternoon, often walking for one-two hours. “I’m not as active,” said one person, “but not inactive, either.” Those who were working from home found that they were spending much more time seated in front of a computer, often attending Zoom meetings most of the day. Before the epidemic, while in the office or at work, they had walked around, attended meetings, or talked with colleagues in the hall. Respondents were asked to address the following topics, comparing their regular activities before the onset of the virus, with current activities, at the time of the interview. Topics included: . Getting together with family or friends, either in person, or via telephone, face time, Skype, Zoom, or some other type of connection . Grocery shopping or eating out . Watching television, reading, or similar activities . Getting exercise

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. Visiting doctors or dentists for either routine or emergency care . Traveling or vacationing, either in the US or abroad . Or any other activity or plan that might have been affected by the virus?

Contacts with Others Activity patterns for most residents had changed considerably from a pre-COVID norm by the time of the interview. In-person gatherings were extensively curtailed for most people, while other forms of contact increased. Telephone calls were preferred by some of the oldest respondents, while those in their 70’s or younger had been spending more time on face time or Skype. Zoom, a virtually unknown form of communication before the Pandemic, had quickly become popular with most people, regardless of age, as a way to communicate with groups of family members, with organizations and religious groups, and with clusters of friends. For most, however, personal connections with others could not be adequately replaced by such distant forms of communication. People missed playing cards every day with friends, tennis matches, going out for lunch, taking walks with a grand daughter, taking tap dancing lessons, frequent dinners with colleagues from work, trips around the area sponsored by a Senior Center, Bible study groups, talking with strangers, watching a toddler develop and learn to walk and talk, holding babies, yoga classes, attending theater productions and going to the movies. One person, however, noted that video communications, despite their limitations, “have been a tremendous aid in dealing with isolation.”

Time at Home The amount of television watching was way up, even for those who normally never watch television. The most popular type of program was the national news. Many people seemed to prefer watching the news rather than reading about it in a newspaper, although the local newspaper, the Washington Post, was a favourite source for information in print. Reading books was also a popular activity. Many preferred to read books in hard copy rather than electronically. One person indicated that she kept three books in a pile, so that the next book would be ready at hand as soon as she finished reading each one. Another woman who said she loved to read indicated that the day was not long enough for all of the reading she wanted to do. By evening, however, she preferred to watch a movie. Someone else indicated that he preferred to watch movies and avoid the news altogether, since the news broadcasts always “hype everything.” Reduced opportunities for exercise provoked concern and led respondents to search out other ways to stay fit. The majority of respondents—20 of them—indicated that they were getting about as much exercise as they had before, even though they

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were exercising differently. Before the stay at home recommendation, 5–6 people had been going to a gym several times a week, and two of them belonged to more than one gym. Others had been taking tai kwon do lessons, going to exercise classes, exercising with a personal trainer, biking, hiking, or playing soccer or tennis regularly. Several indicated that they were continuing to run several times a week. Many were substituting more walking for their exercise, and/or taking classes on Zoom. One dog walker was continuing to walk dogs for 3 miles a day. Several used to walk daily while shopping and now had to find different destinations since most stores at this point were closed. People who were still employed and spending time in the office took to walking up and down stairs at work. Others were walking up and down the driveway, in the building’s halls or around and around their apartments. One found a friend to walk with in the neighbourhood for two hours every evening. Several people thought they were actually exercising more than they had before, mainly by walking or taking classes at home on Zoom. At least 10 people, however, admitted that they were exercising less, having found no satisfactory substitute for exercise classes or lengthy shopping trips. One person who complained about a lack of opportunity for exercise at least was able to continue taking bone building classes on Zoom.

Medical Care In the early months of the stay-at-home directives, in-person visits to doctors were limited. Many doctors, if available at all, at least were able to see patients virtually, with the exception of dentists. The American Dental Association instructed dentists not to see any patients for at least six weeks, beginning in March. After that, extensive precautions were put in place to protect both dentists and their patients, including the use of various procedures to improve ventilation in dental offices. There was concern that limited access to health care would compromise health, especially of older people. Only two respondents seemed relatively unconcerned about access to medical care, one of whom had no health issues, and a second who distrusted doctors because of a previous bad experience. Fifteen respondents, however, had been able to make one or more in-person medical visits since the crisis began in March, although for several of them the visits had initially been delayed. Five people had had their scheduled visits canceled altogether. Others were still waiting for a routine in-person or virtual visit to be scheduled. Ten respondents had mainly experienced virtual visits or telephone calls with their providers. Respondents reported delays in needed blood work, eye exams, or cataract surgery. One person waited 3 weeks after a temporary crown fell out before he could be seen by a dentist; after similar delays, another was hospitalized for emergency dental surgery. Overall, respondents seemed to have access to some level of medical care, although few of them found it to be adequate to their needs.

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Coping with Limitations Most respondents were unhappy about their inability to travel. Travel by air, train or bus was deemed risky. Travel to distant destinations by car would have necessitated an overnight stay along the way in a hotel or Air BnB, with exposure to surfaces that might not have been disinfected, not to mention the people one might come in contact with. Only a handful of respondents indicated that they rarely or never traveled anyway at this time in their lives. People especially missed seeing close family or friends who lived in other places in the U.S. Approximately 15 people would have visited their families in Chicago, New Mexico, California and elsewhere if they could have–trips they were used to taking several times a year. Some respondents typically spent winter months is warmer locations such as Florida or California, but were not planning such trips this year. Several people in the past had travelled frequently for business as well as pleasure, often several times a month, to destinations all around the country. Summer vacation plans were abandoned. Trips in the coming months to Australia, Africa, Switzerland, Zimbabwe, Mexico, Israel, India and Japan were cancelled. A visit to Glimmerglass State Park in New York for three opera performances was postponed until another year. One person had resorted to taking local trips around the area, bringing a lunch of coffee and sandwiches to eat while remaining in the car. There were some things no one seemed to miss, however. People were happy to be be avoiding the heavy traffic, especially around rush hour. Streets were nearly deserted, but most people were not going any where any way. Being able to avoid the packed metro every morning was also a plus. One person was delighted not to have to be in the office every day with a new boss she didn’t like. Several liked the slower pace of life. As one said: “I’m not running around like a crazy person now.” Some were surprised that they were happy to stay home for dinner rather than eating out so often. Women were pleased not to have to put on make up every day, to stop colouring their hair, or to be able to wear slouchy comfortable clothes all the time. Also, the living room no longer had to be neat, since no one was coming over for a visit, and papers could pile up on the dining room table, with no one around to notice. COVID provided an easy excuse to avoid commitments or events that people preferred to skip. “I don’t have to go anywhere I don’t want to anymore.”

New Interests and Activities Given the inability to travel and being confined to their homes, people have been creative in filling in the extra hours of the day. Many were able either to spend more time on activities they had previously neglected, had found new ways to connect to others, or had taken up new interests. Some were industriously taking on household projects or acquiring new skills. Popular at-home activities included sorting through paper files, cleaning out closets and drawers and throwing things away, and digitizing or organizing photos.

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One photo buff was sending favourite photos to a company to be made into jig saw puzzles. As noted, many were reading more. Topics might focus on self-improvement or learning something new, such as art criticism and art history, for example. People were watching more movies on Netflix, the Hallmark Channel, or other streaming services. A woman took up needlepoint again. Many were doing more home cooking, taking a course in gluten-free baking, learning to make brownies, or making more labour intensive recipes with lentils, chopped liver, desserts with walnuts that required whipping egg whites, or simply “trying to make dinner more interesting.” One “chef” was asked by a friend (jokingly?) to bake a tuna bundt cake. She baked the cake with a can of tunafish hidden in the centre. When her friend cut into the cake, the knife hit the metal can, provoking laughter. Someone else indicated that he had more time for healthier eating—no more donuts at the office—and had thereby lost weight. Some found time to upgrade or conduct repairs in their apartments. One person was hanging paintings more artfully, and had also ordered a bed by mail. Another purchased a day bed to be located in a separate room for a snoring husband. Someone else did touch up painting around all the light switches. Still others simply found more time to clean. Many had more time to spend with family members or friends, in person at home or via social media. Others were able to connect with people from their past. One person reconnected with friends from high school. Someone else expanded the information on a family tree, zooming with people in California, Sweden, New York and Georgia to fill in the tree’s branches. Another takes part in a coffee chat with friends on line every Friday; still others play bridge or mah jong on line. Grandmothers have been able to participate at least as spectators on Zoom in their grand children’s high school graduations. Many are spending more face time with friends they don’t see often. Several people had children at home, who otherwise would have been away at college or in school during the day, and were enjoying a closer relationship than they had had before. A mother was pleased to have young teenagers around all day, where they could ask her questions about topics they might otherwise have discussed with kids at school.

More Time for Reflection Some people had become more introspective. As one put it: she was creating her own world, in ways she never had before. An older woman now talks to herself out loud, to clarify her thoughts, and writes comments in the margins of books she is reading. Another plays scrabble against herself. Someone else plays solitaire on the computer; another plays super Sudoko, which involves putting 4 × 4 blocks together instead of 3 × 3 blocks. A woman has started listening to Zen Buddhist philosophers and practices mindfulness and stress reduction techniques; another has begun meditating more regularly. Still another spends time listening to TED talks. Someone else has taken to writing three pages of a diary every day, to learn more about herself. Another enjoys the peacefulness of staying at home, where she has more time to think. She

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used to go out frequently and had little time alone. A woman was able to travel to North Carolina before the lockdown where she quarantined with her sister. They had not spent much time together since high school. They renewed their relationship, sitting on the porch, watching the cardinals and the humming birds at the feeder, reminiscing and forming a new togetherness.

Religion and Learning as Sources of Comfort Some are finding ways to be more closely connected to their religious beliefs. Synagogues and churches have developed on-line programs and services in which many participate; even the high holidays in September could be celebrated on line. As one person said, regarding the absence of in-person services: you now don’t have to show up (a good thing), but I miss the contact with others (a disadvantage). Several people are taking Bible study classes, participating in on-line discussions on the Bible, or reading the Bible more frequently on their own. One person has started writing prayers on such topics as healing, posting them on the internet, and sending them to friends. People are taking advantage of their free time to learn new skills or upgrade current ones. One woman is learning to play the violin, taking lessons regularly on Zoom. Another has taken up dancing on Zoom. Others are pursuing language lessons, in one case, beginning to learn French. On-line classes are popular, on topics such as accounting, managing social media, or how to make a mask. People have been enhancing their professional skills in fields such as engineering, or learning how to rebuild a computer.

Outlook Toward the Pandemic and Beyond While many have found meaningful activities to occupy them during a typical day, and throughout the repetitious weeks, they were concerned about the quality of their important relationships, especially close friends and family. As one person said: “Praying together is different from praying alone. One of the subtleties of prayer is being in a congregation.” People were taking advantage of quiet times to pay more attention to their surroundings, and to consider how their futures might be different once the virus was under control. Virtually no one had any confidence that the Federal government would quickly find ways to control the virus, although many believed the Maryland governor and key health professionals might be able to exercise leadership and help slow the spread of the infection. Several, especially those with compromised immune systems, were anxious about catching the virus, whereas others felt they were taking adequate precautions to avoid contagion. Respondents were asked to choose which of the following statements best applied to them:

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a. b. c. d.

The virus has had minimal effect on my daily life so far. The virus has had a moderate effect, but I’ve been able to adjust. The virus has had a moderate effect and I’ve had trouble adjusting. The virus has had a large impact on my daily life so far, but I’ve been adjusting to it. e. The virus has had a large impact on my life, and I’ve found it difficult to adjust.

Almost everyone thought the virus was having a moderate effect on their lives, and most thought they had been able to adjust so far. On the other hand, when asked about their mood, people were often less positive in describing their mental state. One remarked: “When you’re 20, 3–4 months is nothing at all. At my age (late 70’s), 3–4 months is a major chunk of the time I have left.” Some felt no difference in mood or were trying to remain upbeat, saying: I feel peaceful…I’m not affected. It’s had no effect. I don’t get depressed. I’m trying to stay positive. I’m glad I live alone. Families being confined together are going up the wall. I feel blessed, when I see what others are going through.

Others were resigned to whatever might happen, or felt things were out of their control. I’m accepting it, though I’d prefer to have my life back. It’s worrisome, but there’s nothing we can do. An overpowering feeling of helplessness. It seems to go on and on. I’m a cancer survivor—it puts things in perspective. Life is like being on a treadmill going nowhere. I’m in a perpetual state of uncertainty. I’m a control freak, and don’t have control of what’s going on.

Those who were sad, depressed or up and down in mood depending on the circumstances made the following comments: I need rest—I get emotionally tired. It’s harder to sleep—weird dreams. Bored and lonely, occasionally. Depressed. Feel fearful…I’m in a high risk category. Feel sad, especially for other people’s struggles. My husband died and now I have to get used to the Pandemic as well as his death. Anxiety when out. Feel more isolated. An overwhelming feeling of grief.

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The whole world is changing for the worse. In addition to the Pandemic, age takes its toll. Mini meltdowns.

What About the Future? How does everyone see their lives changing, if at all, when the Pandemic ends? Many hoped after the end of the Pandemic to get back to normal, as they put it, resuming life where they left off. This might mean once again spending time with family members living nearby, going to concerts, attending happy hours, shopping, traveling for vacation in the US or abroad, or visiting grandchildren and relatives in other states. Someone merely expected to resume work in the office instead of continuing to work from home. One person hoped to be able to use the basketball tickets he had already purchased for the current season. Another hoped to find a part-time care taker for her ill husband so that she could get out of the house from time to time again. Others feared that residue from the current situation would remain. “I don’t see life changing…” One member of a “loving church” did not think that members of the congregation would ever go back to hugging and kissing again. Travel to anywhere outside the US in the future seemed problematic to one person, who did not know what new diseases might be encountered in a foreign country. Several people were concerned about the future for students at school and in college, fearing that such factors as unequal access to computers, and the handicaps of learning remotely, would result in permanent harm for entire generations of students, especially those who are poor or minority. The pandemic, some believe, has permanently changed their approach to living. “I’m more mindful of little things, and I’m not worrying as much.” “I now appreciate essential workers.” It’s important to “live for today.” One person plans to change professions, and move to a warmer location. Others feel that they have “learned to live with the unknown,” have re-evaluated goals and values, don’t feel the need to impress friends any more, or will now appreciate living at a slower pace. “If left in a desert by myself, I would be fine.” Instead of constantly shopping for something new, someone claims she will ask first, “Do I really need that?” A man realized that things he enjoys are just “icing on the cake.” A woman feels that her life does not have enough purpose, that going to concerts and movies is not enough. She hopes to find the energy to do something more important, such as supporting organizations such as Black Lives Matter. One person couldn’t cope with getting older before, but now is embracing the changes that life brings, finding that “aging is a secondary issue now.” Another woman would like to meet a man—someone she could invite over for dinner.

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Implications Past pandemics have had lasting effects on societies. Recent studies have demonstrated the differential impact of the 1918 influenza Pandemic on the health of adults who were born to mothers who were sickened by the virus either at the beginning of the Pandemic, in the middle, or towards the end. Adults whose mothers had become ill early on were more likely than their peers to have diabetes, to be shorter or poorer when their mothers were sickened mid-way through the Pandemic, or to be prone to kidney disease following later-stage infections (Mann, June 2020). Sometimes widespread diseases can “permanently alter society, often for the best, by creating better policies and habits,” (Foss, April 1, 2020). Such changes, the author notes, occurred after the 1793 yellow fever pandemic, which led people to be come more altruistic, developing lasting habits of volunteering as they supplied clothing and food to those afflicted. During the tuberculosis epidemic of the 1890’s, a new technique of documentary film making was developed to show how to prevent transmission of the disease, a technique that gained widespread use. Pandemics have frequently transformed economies as well. During the Black Death of the middle ages, survivors saw wages rise over a 20 year period from the 1340’s to the 1360’s (Yao, ed., April 22, 2020). Men ages 18–40 were most vulnerable to the influenza Pandemic of 1918. Their early death led to a decrease in the GDP in the US by 6–8%. As early as four months into what was not yet recognized as the early stages of the US coronavirus epidemic, upper middle class residents of a condominium in Maryland’s largest county were concerned about the contagiousness of the disease and were prepared to follow guidance from healthcare professionals. No one had any idea that the worldwide pandemic would continue to become more severe, taking hundreds of thousands of lives in the US alone and many millions across the globe. It is too soon to predict what the outcomes might be for individuals or for society overall when the Pandemic is under control. One hopes that there will be at least some positive impacts as there have sometimes been after past Pandemics. It was common for people in the Maryland condominium to begin exploring new approaches to living and to have attained a greater appreciation for their immediate surroundings. Many claimed already to have experienced changes in ways of connecting with others, using social media, internet-based apps and even phone calls more frequently. New skills and interests developed with more time available may enrich people’s lives in the future. Until there are widespread inoculations against the virus, there will continue to be instability and uncertainty everywhere. But then, even so, as one person noted: “This may not be the last Pandemic.”

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References Centers for Disease Control. (2020). www.cdc.gov. Foss, K. A. (2020). How epidemics of the past changed the way Americans lived. Smithsonian Magazine. Smithsonian.com. Klar, R. (2020). Northeast states band together to buy protective gear. The Hill. Lutton, L. (2020). Coronavirus case numbers in the United States: July 8 update. Medical Economics. Mann, C. C. (2020). Pandemics leave us forever altered. The Atlantic. Martin, M. (2020). The coronavirus crisis: in affluent Maryland county, pandemic exacerbates food insecurity. 5 minute podcast, NPR: All Things Considered. New York Times. (2020). COVID -19 alert: coronavirus Maryland. New York Times. (Updated December 28, 2020, 2:11 PM ET). Coronavirus in the US: latest map and case count. Shear, M. D., Weiland, N. W., Lipton, E., Haberman, M., & Sanger, D. E. (published July 18, 2020, updated September 15, 2020). Inside Trump’s failure: the rush to abandon leadership role on the virus. The New York Times. Tan, R., & Chason, R. (2020). These nursing homes failed to isolate covid-19 patients. Now they face six-figure fines. The Washington Post. Wright, L. (2021). The plague year: the mistakes and the struggles behind an American tragedy. The New Yorker, 22–59. Yao, A, Ed. (2020). A brief economic history of pandemics. Berkeley Economic Review.

Chapter 21

Challenges Faced by Institutionalized Elderly in COVID Era—Insights of a USA Doctor Ruchika Kuba and Chandini Sharma

Abstract With the greying of the human population, institutionalization of elderly is on the rise all over the world. The different living arrangements to accommodate the spectrum of functional abilities have mushroomed. As if this transition was not already hard, it has become more burdensome during this Pandemic. Patients, families, care givers, health care workers and administrators have all felt the impact. Resilience, care giving, abuse, psychological issues, social concerns, technological and medical challenges with special emphasis on patients with dementia all have been affected. COVID 19 has stretched the meagre resources of Elder Care to its limit. Everyone has struggled to find ways to cope up and devise innovative strategies to meet the challenges. The pandemic has brought about new issues and concerns that need to be looked and addressed. Some of these are ethical issues, and rights of elderly, testing human relationships. With it’s unfolding, a new normal is evolving. Stories are based on the personal experiences and case studies in various continuing care retirement institutions where the coauthor is working as a geriatrician in a city in Oklahoma State in USA as a consultant. These institutions include assistive living, long-term care, nursing home and dementia units. Keywords Elderly · Older persons · COVID · Institutionalized · PPE · Pandemic · Nursing homes

Introduction As life expectancy increased, the proportion of elderly making it to ‘Senior years’ increased. Most of these seniors were independent and demonstrated healthy ageing. The catch phrase’50 is the new 30’s’ came about. On one hand we have growing R. Kuba (B) School of Health Sciences, Indira Gandhi National Open University, New Delhi, India e-mail: [email protected] C. Sharma OSU Health Science Center, Hospice of Green Country, Covenant Living Inverness Village, Sapulpa, OK, USA © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_21

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proportion of healthy ageing seniors and on the other hand the number of seniors who were increasingly dependent on care and caregivers is exponentially on the rise. Care may include some assistance in medication management or even help needed to perform activities of daily living (ADL’s). Caregiving, provided initially for the most part by family, falls on the shoulders of the adult children. Overtime the adult children are unable to provide the increasing needs of the seniors. The caregivers at times are long distant and are located in different towns. The caregivers are themselves the ‘sandwich generation’, having dual responsibility for their ageing parents and their own dependent children in school, while themselves still working fulltime. Such a full schedule of a caregiver lends to burnout and excess stress. Some caregivers might be knocking at the doors of being seniors themselves of old-old parents. Industry responded to this growing need by providing alternative living arrangements. Senior housing for independent seniors who required some assistance in cooking and driving mushroomed. Congregate living with common kitchen and transportation was provided and paid for by the senior or their family. Other seniors who were in need of more help, for example, with their medication administration and vital assessment, or help of one person to perform their ADL’s went to the Assisted Living residence. Assisted Living Centers were consequently the fastest growing segment of the housing market. While seniors with higher level of dependence and need of care went to Long Term Care. All these congregate living environments may have varied in the level of care provided but they all had one common aspect. Importantly they all provided for socialization. This is such a vital aspect in senior life. Many seniors experience loss of family, peer, friends, independence, job, financial stability etc. All these contribute to a mounting burden on mental and physical health. Socialization as evidenced in the ‘Blue zones’ of the world, is one of the strongest predictors of positive outcomes. Congregate living provides a rich opportunity for socialization with activities directors, social workers and even happy hours. Mealtimes are times for seniors to engage in conversations with friends and swap and share old time stories and goings on of family members with each other. With all its benefits and burdens the nursing homes were a ‘way of life’ for many a seniors. March 2020 was a landmark day in the history of senior lives. Due to the COVID-19 pandemic overwhelmingly affecting seniors and causing upward of 40% deaths, the nursing homes went into LOCKDOWN. This meant families were now not allowed to come visit their loved ones. Seniors were required to stay in their one room accommodation. Food water snacks were brought to their rooms. Seniors requiring assistance were frequently toileted and cleaned. All these measures were implemented to help keep seniors safe from the SARS Co V2 virus and to mitigate it’s spread. It worked to a large extent. However, another silent epidemic was unleashed. Of declining mental health, of depression and of social isolation. As is the nature of any hardship, it provides an opportunity of growth and innovation. COVID-19 in the nursing homes has caused lot of death, despair and despondency. It has also offered glimpses and examples of great compassion, love and creativity.

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Methodology The stories are based on the true incidences in institutions like assistive living, longterm care, nursing home and dementia units in an Oklahoma City, where the coauthor is working as a consultant geriatrician. The situations which were confronted and managed by these institutions during the COVID pandemic period have been documented. The names of characters and institutions in the stories have been changed to maintain confidentiality. The problems and solutions in these institutions have also been compared with the available literature on the subject as addressed in other countries of the world.

Stories 1 Family Support to the Institutionalized Elderly in COVID Times Ms KT 95 year old, on hospice for terminal illness residing in Happy Nursing Home looked forward to the visits of her daughter with grandchildren religiously at 11 am every day. On March 15th morning Sister Mary came to Ms KT’s room and broke the news that the nursing home had gone into a “Lockdown” owing to the spread of a strange new infectious disease, until further notice. Family visits for all patients had to be curtailed. Ms. KT believed (like the rest of the world) that this restriction would probably last a month or so only. Each day when Sister Mary would come to give her, her medicines at 10 am, she would eagerly ask if the Lockdown had opened up yet? Her enthusiasm was met with disappointment. Her simple normal routine of life, and bare aspirations were suddenly very distant and she longed to see her family. As days passed into weeks, her terminal disease progressed and she slipped into increasing frailty and despondency. Sister Mary was distraught. Mary loathed at the predicament of this 95 year old passing away without having contact with her loved ones. Mary approached Dr. Susan urging her to come up with a compassionate solution to this very complex and sensitive issue surrounding end of life. This pandemic had altered the usual processes of End of Life management where teams of people would surround the patient and family, and work at alleviating the pain and suffering related to death and dying. This “Lockdown” was a devastating blow to the very essence of hospice philosophy of loving kindness. Authorities in the hospitals too were forced to isolate the infected patients, even at the end of their lives, to protect the uninfected family and to cut down the community transmission of the novel virus. This was done at a huge emotional cost to the family and the patient. The family may have seen their loved one for the last time in the ER as the patient was whisked to the medical floor. The next time the family was in contact was with the ‘urn of ashes’ of their loved ones. Emotional toll of these events

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was staggering. While these steps were logical from the Public health standpoint they were devastating on an individual basis. Dr. Susan, was a doctor who based her decisions from her empathetic heart and scientific mind. She came up with a compassionate approach to this dilemma. She arranged a meeting between Ms KT with her family outside the nursing home building in a sheltered enclosure. As KT could no longer walk, due to her frailty, she was transported on a gurney in full PPE to the sheltered enclosure where her family members were eagerly waiting for her. PPE was provided to several family members so that they could see and physically bond with KT. Tears of happiness flowed down KT’s cheeks as her grandchildren held her gloved hands. Next day KT passed away with a sense of peace and contentment. Time and again it has been documented that family and other unpaid care givers which may include friends, neighbours or relatives are the most preferred and trusted source for providing emotional and practical support for individuals living in longterm care facilities (National Academies of Sciences, Engineering, and Medicine, 2016; Reinhard et al., 2019; Whitlatch & Feinberg, 2007). The elderly falling into the high risk and vulnerable group were badly affected by the spreading COVID pandemic and more so were the residents residing in the long-term care facilities (Barnett & Grabowski, 2020). Mos of the long-term facilities issued COVID 19 strict restrictions for visit to these facilities by friends and families to slow the spread of the disease to the residents (Centers for Medicare Medicaid Services, 2020a). Hado and Feinberg point out that it was important at this juncture that the health care providers and authorities strengthen the communication channels between the elderly in these facilities with their families as well as the health care staff. Initiatives to keep the connection between the patients and nursing homes going, were undertaken by people across the globe. Nursing homes in Brazil are privately owned and many of these closed for visitors during the COVID19. However the families were kept informed and their doubts cleared while also explaining them the reasons for the measures being adopted by them (Blasco et al., n.d.). They suggested to continue to convene family councils; and mobilize gerontological social work students and other trainees to help provide social support (Hado & Komisar, 2019). Others have suggested that institutions should indulge in regular phone calls, virtual visitation through various web conferencing tools to facilitate conversation between the residents and care givers (Lynn, 2020). COVID era has made difficult situations, like family support in the end of life, even harder. This story highlights that thinking outside the box to find solutions have resulted in unusual strategies to emerge, without violating scientific principles, and patient safety. The decisions taken by the health care staff made them feel that ethical justice had been upheld. The ‘personal touch’ helped provide a sense of closure to both the family and the patient during this tumultuous time.

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Story 2 Elder Abuse in COVID Times On April 5th, The EMSA team received a call from a home stating that an 85 year old lady in the house was experiencing frequent falls. When EMSA arrived, Betty was found on the floor with a bedsheet on her. The family agreed to transfer Betty to the hospital for evaluation. In the emergency room comprehensive assessment was carried out by the ER nurse. She observed multiple bruising all over her body which appeared to have been sustained over a period of time. Several of the bru Nursing homes in Brazil are privately owned and many of these were closed for visitors during the COVID19. However the families were kept informed and their doubts cleared while also explaining them the reasons for the measures being adopted by them (National Academies of Sciences, Engineering, and Medicine, 2016). Bruises were in areas that do not bruise in a usual fall. Raising the concern for abuse, the patient was extensively questioned, but she emphatically denied any violence, abuse or neglect on the part of any family member. This is not an uncommon phenomenon. Patient also had an exacerbation of her asthma due to COVID pneumonia. She was appropriately treated in the hospital in the next few days. At the time of discharge from the hospital, the family strangely was unable to be contacted. In this predicament, the patient was transferred to a rehabilitation centre for physical strengthening and safe keeping until further discharge arrangements could be made. Social services from the Rehab subsequently sought out the family after continued effort, and counselled them regarding the needs of the senior. Social services outlined the responsibilities of the caregivers for the care of the senior and clarified that when requisite care needed by a senior was not provided by the responsible caregiver that could be deemed as neglect and could be a legal issue. These caregivers were being paid by the State to take care of Betty at her home. These caregivers who lived with her, were her son and daughter in law. Having had the respite and the ‘talking to’ by the social services, the family was more than happy to have the elder back home after she was no longer contagious. Elder abuse is the outcome of many factors which may be related to the older adults, their care givers and the society in which the elderly lives or interacts (Mosqueda et al., 2016). COVID 19 resulted in recommendations for social distancing and instructions for not to leave the homes especially for the elderly and people with co morbidities across the globe. Thus lockdown during COVID era has caused unprecedented psychosocial burden by one and all young and old. This has stressed the interpersonal relationships more than ever before, resulting in increased vulnerability of the already vulnerable elderly. A rise in the elder abuse living in the community with family and consequent depression has been a distressing fallout. This abuse could be physical, mental, financial or emotional. On the other hand caregiver stress also has been on the rise as the emotional state of the caregiver too is fragile and unsupported. Studies have documented an increase in family violence in general during the COVID 19 era (Xue et al., 2020). WHO has also

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reported a surge in the number of older adults facing violence in their homes and long-term care homes (https://www.who.int/publications/m/item/covid-19-and-vio lence-against-older-people). Violence against the older adults has also been reported mainly attributed to the lockdown measures (Sajan, 2020). Respite in the everyday care of the elderly for any brief period mitigates some of the psychosocial stresses. This scenario story increased the use of social services and heightened awareness of Elder abuse in this COVID era.

Vulnerability of a Dementia Patient in Memory Unit—Care Giving/Health Care Staff Challenge Ms PB an 87 year old lady who had been living in an assisted living memory unit for the last three and a half years. Assisted Living memory unit patients are ambulant and require one person assistance to perform their ADLs. Cognitively they are comparable to less than five year old. They have lost their safety awareness and many a times even their Self awareness. However they look forward to their simple structured daily routine like walks outside the memory unit to not only maintain their activity level but also as a means of socialization. One day in early April 2020 the memory unit nurse reported that PB was running low grade fever, dry cough and had developed mild shortness of breath. Soon she was pacing incessantly and there was no calming her down. The nurse was also exhausted physically and of ideas trying to redirect the patient and to keep her safe. With these symptoms the patient was isolated and a COVID test was imperative. It was positive. The only COVID test available in those days was the PCR which took about 3 to 4 working days to result. Even one positive case is termed an ‘Outbreak’ in a Nursing home, and sets of series of algorithmic steps were recommended by CDC for the team including the Administrators. Their greatest concern was containment now that the patient with dementia had been roaming all over the memory unit and exposing all other residents and staff during her presymptomatic phase. While PB was transferred to the hospital for evaluation and management, a contact tracing analysis was undertaken to identify the source of infection. The source would have to be external as the members of the memory unit had not left the unit (even for their scheduled daily walks) due to COVID Lockdown. Research early on informed us that Covid infection was brought in to a facility by asymptomatic or pre-symptomatic health care workers. Contact tracing is impossible within the confine of a memory unit. Residents cannot give an accurate account of where and who have they been in contact with due to their memory impairment. These residents cannot socially distance nor can they adhere to a mask wearing for more than a few minutes. They cannot remember to wash their hands often. Keeping these residents within their rooms is also a monumental challenge. Recognizing these limitations the executive director of the memory unit John Saska didn’t stop at reporting this outbreak to the health department promptly but sought best practices for mitigating the spread of the virus in memory units. Mr. Brown

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Director of the Health Department suggested that one successfully implemented option was to house the teams of nursing staff working the memory unit on campus. That way staff movement on and off campus was limited. As staff were now residing on campus their own exposure during trips to grocery store/errands, for example, was reduced. This reduced the risk of exposure of the staff to outside the campus environment. If staff were infection free the likelihood of infection amongst residents was significantly lowered. Staff buy-in, participation and commitment was essential for the success of this plan. Four CNA’s agreed to participate in this plan doing two on and two off. They stayed at the nursing home for a whole month until the outbreak was cleared. Added COVID pay and monetary reimbursement alone was not why the staff bought into such a plan. Their commitment to their residents, their genuine concern for their residents, their commitment to their own families safety, and not exposing their families to the virus all together made this an appealing plan. Reference: Leading age Georgia member Park Springs nursing home innovation. COVID 19 brought with it challenges for all institutionalized elderly. However these challenges were much more pronounced in the dementia units. Recent data suggest that persons affected by dementia face a greater risk of having severe COVID19 than just old age or people suffering from other comorbidities like hypertension or diabetes) (Aggarwal et al., 2019; Atkins et al., 2020; Verity et al., 2019; Williamson et al., 2020; Zhou et al., 2020). Reasons for greater vulnerability of people with dementia to get infected by and spread COVID-2 can be enumerated as given below (Mok et al., 2020). (a) These people may not be able to understand, follow or even recall any of the instructions given to them for containing the disease like social distancing, use of face masks, hand washing etc. (b) The individuals suffering from agitation, wandering, or disinhibition are also at a greater risk of contacting as well as spreading the infection (c) Many of the elderly suffering from dementia may not be able to carry out their basic activities of daily living and are dependant on others for the same thus increasing the risk of infection to both themselves as well as their care providers, even higher risk of catching and spreading the infection. Many of these may also be suffering from physical disability and thus require assistance making social distancing impossible. (d) The memory units in which the elderly reside share common areas like living rooms or dining rooms thus increasing the chances of contacting infection. (e) The fact that elderly do not usually present the illness with the commonly experienced symptoms like fever, cough and difficulty in breathing, are often not suspected of having the illness and thus increase the chances of them infecting others (Nguyen et al., 2020). Coupled with the fact that the elderly in the dementia units are more vulnerable, challenges are faced by the health came staff in managing these patients. Some of the challenges that can be identified are (Mok et al., 2020).

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(a) There is a risk of increasing the chances if delirium when attempts are made to isolate the people with dementia in an unfamiliar environment for extended period of time especially when there is no contact with the relatives or familiar care givers (LaHue et al., 2020). (b) Simple infection control measures like wearing masks, avoiding contact with high risk surfaces, keeping social distancing are not possible for patients with agitation or wandering. (c) Occult infection as well as non-specific or altered presentation of COVID is common at this age and hence delayed diagnosis could result in spread of infection (d) Moving patients from their familiar environment increases chances of delirium as well as continuity of care (e) Isolating the positive cases increases the chances of other preventable harms like falling inadequate nutrition, and pressure sores. (f) The risk of spread of infection would result in the care homes to not be so forth coming in taking back their patients. A number of measures could be adopted to meet these challenges (Mok et al., 2020). (a) Trained health care providers should be placed to look after the older patients with dementia suffering from COVID. (b) Social distances lead to dementia units not to allow relatives and friends to visit the elderly. However online video interactions could be facilitated to mitigate delirium and patient distress. (c) It is important to keep a close watch on the reversible factors of delirium like common reversible factors for delirium hypoxia, electrolyte disturbance, pain, constipation, visual or hearing problems, sleep disturbance etc. This story highlights the extraordinary challenge that memory units pose to caregiving in a nursing home as these patients are unable to provide self-care and are dependent for their basic ADLs on staff. Care giving in these units is ‘high touch’— requiring frequent contact by staff for hands on care including toileting, dressing and even feeding which are very intimate caregiving activities. With Covid restrictions of attempting confinement to individual rooms, the staff grapple with constant redirection of these patients. The best practice of providing accommodation to staff on campus, not only protected the patients and staff but also the staff families.

Stresses of Long Distance Elder Care Givers in COVID Era 91 year old P.K had developed pneumonia and was transferred from her assisted living apartment to the hospital. She tested negative for COVID but had bilateral pneumonia. She developed respiratory failure and was intubated in the ICU, treated with appropriate antibiotics and ventilator support. After a long stay in the ICU, she

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was stable enough to be discharged to the medical floor. By about now, the case management started working on the discharge plan. It was evident that return to the pre-morbid functional level was no longer possible. At this time, discharge to a skill nursing facility for short-term rehab was optimum. By the time she arrived at the skill nursing facility, she had lost 15 pounds of weight and had very poor appetite. She was now two persons to assist (baseline function was independent ADLs). With the rehab programme, Ms P K slowly gained some energy and came to a new baseline of requiring long-term care placement. Even though she gained her pre-morbid cognitive function, her weight loss continued. Two months in the long-term care and on going weight loss, she now began meeting criteria for hospice. At this time, a phone call to update the son, her care giver, was made. During the phone call, it was discovered the stresses that the son was himself going through. The son’s was in direct line of the hurricane that was to make landfall in one or two days. They were in the process of boarding their house, packing their things to move to safer grounds. As if this was not stressful enough, the son’s wife’ mother who was in hospice was actively transitioning during the same period. The complexity created by COVID in this life event of the care giver was that even if he wanted to drop everything, sit in the car and drive over night to see his mother, he couldn’t because of the lockdown. Long-distance adult caregivers need to provide different kinds of support for their aged parents. These could be for just financial support or regular visits. At times the other family members or local care giving families may need to be relieved by these distance care givers. Others may visit irregularly or keep in touch with their older parents or with the professional care givers through phone or email to remain involved and informed (Cagle & Munn, 2012; Zentgraf et al., 2019). Care givers must understand that to be able to provide support and help to their elderly, they must themselves be mentally and physically healthy. This is all the more relevant to long distance care givers who face a much greater level of stress, being away from their loved ones and trying to balance their responsibilities for caring with their own social, work and personal obligations. COVID brought with it restrictions imposed on travel and social distancing. Although circulation for family caregivers of elderly with dementia was allowed by some governments (Ministerio de la Nación, 2020), many family members did not want to visit their relatives out of fear of spreading the disease (Donohoe & Winker, n.d.). The care givers need to understand that they should keep a positive outlook since a lot that happens is outside their control, but they need to react appropriately. In the pre COVID era also various strategies have been adopted by care givers to avoid stress like avoiding isolation, taking part in family and group support meetings, and sharing the burden of care with other family members (Hughes et al., 2014). The stress in the care givers, especially the long distance ones got heightened even more due to COVID and many ways have been suggested for the long distance care givers (Donohoe & Winker, n.d.). To reduce their stress they can indulge in yoga, listening to music and meditation. Since they may not be able to get in touch physically with the elderly, they can always connect virtually through online platforms or emails. They can also resort to writing letters or make long distance calls, They could also send photos, deliver grocery, food items

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medicines etc. Another strategy could be to reach out to local support groups who could fill in the gap for them. Other suggestions have been to locate suitable nursing home discussion forums in the residential municipalities of the long distance care givers and to help fulfil different requirements from those of local caregiving relatives, particularly with regard to purpose and scope (Fischer & Jobst, 2019). This story highlights that care givers can themselves be elderly and stresses that they go through are often over looked. Senior care givers are facing multiple challenges, existential, financial, emotional, social and functional in their life stage. When a doctor or a care provider is opening a sensitive conversation about a loved one, it is imperative to be mindful of the emotional state of the senior, prior to declaring the bad news. This not only helps soften the blow but also allows the senior to brace the bad news better. The empathy provided by the health care provider helps the elderly care giver to visualize himself outside the crises and prioritize his actions in a logical sequence.

Instilling and Spreading Positivity in the COVID Era “Even at 96, I need to look forward to every morning.” “I never thought my life would end isolated in a room even after I have survived the COVID infection.”

Human strengths have been challenged by COVID in more than just illness. We witness this through the experience of Ms. M.E. Ms. M.E is a Vietnam Veteran, who worked as a nurse in the army. She single handedly ran a farm, survived a farm accident resulting in hip fracture where she dragged herself half a mile to get help. None of this brought her spirits down. Then at the age of 96 when she contacted COVID, even than did not bring spirits down. The back breaking fatigue also could not incapacitate her mentally. She smiled through the six weeks of tough rehab where she relearnt how to walk with a walker. However when she came back to her assisted living apartment, with the lockdown and confinement to her one room apartment, the social isolation ragged its gnawing tentacles around her and left her with severe depression. She kept saying “I have made it this far, but I don’t want to die alone in this room. “The health care team taking care of her, responded to her repeated requests and carved out a role for her. She became the ambassador of positivity for the entire 250 residents in the assisted living. While she brought the mails and magazines to the residents, she took a few minutes for the one on one conversations with each resident addressing their fears and apprehensions about COVID and debunking the myths surrounding the illness while sharing her experiences with the disease. Depression among older adults is one of the most serious public health problems facing modern societies (Chapman & Perry, 2008). Many of depressed older adults are also lonely, and a correlation has been found between depression and loneliness (Sayied et al., 2012). A study was undertaken in Israel in 2020 assess the effect of loneliness feelings on depressive symptoms. Although the study was on elderly

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patients staying at home, it brough out a connection between loneliness feelings, depressive symptoms, and malnutrition (Schorr et al., 2020). Similar studies have also reported that loneliness feelings are associated with mental wellbeing (Armitage & Nellums, 2020; Gonyea et al., 2018). As evidenced in M.E’s story, physical disability from COVID, sometimes is not the bigger issue. Impact on quality of life from the lockdown and hence exacerbation of the social isolation can lead to an emotional burden that might outweigh the physical disability. Providing a purpose and hope to such seniors who have survived the infection is vital. While M.E grew out of her shell, she also brought cheer to the residents in assisted living.

COVID Wing During early COVID era patients who contacted COVID were to ‘shelter in place’. However soon the nursing home administrators recognized that the very scarce PPE burnt through, so rapidly leaving them very uncomfortable. Hence for patient safety and PPE preservation, the administrators collectively decided that just as soon as a patient was diagnosed or suspected, the patient would be transferred to the hospital. This rapidly led to heightened bed occupancy in the hospital. Many of these patients who were still COVID positive, but were stable and no longer required the hospitalization had no place to go as the nurses were reluctant to accept them back. This dilemma was overcome by the creation of the ‘COVID wing”. Sections of the nursing home were walled off with plastic walls creating an outdoor entrance and designating it the COVID wing. This wing provided several advantages. First and fore most it led to decompression of the hospitals and vacated the much needed beds for more serious patients. Secondly the PPE burn rate was reduced. How the staff did not need to change their gowns between patients as everyone was positive. Unintended consequence that emerged to everyone’s delight was the ‘socialisation in isolation’. Patients in the wing no longer needed to confine themselves in the rooms and could walk in the halls with physical therapists allowing them to gain strength. These wing residents were able to play games, eat together, watch TV together, thus socializing, allowing them to forget the COVID fears and restrictions as they all were positive. Estimates of the mortality due to COVID in countries of Europe and North America have revealed that up to half of those who died from COVID-19 were residents in long-term care facilities (Declercq et al., 2020). Although various categories of institutional care are existing in the developed countries, the middle and low income countries are also beginning to have day care centres, old age homes and long-term care facilities for the older persons. Many of these institutions faced the vulnerability of their residents to the COVID pandemic and attempted to draw out broad frameworks for guiding emergency interventions to handle this vulnerability (Lloyd-Sherlock et al., n.d.). COVID 19 and the deaths associated with them also brought out the fact that many of these institutional centres were running without authorization (the alarm goes off in the GBA nursing homes,

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n.d.) and there was a need to regularize the institutions before they could be provided the standard infection control protocols and the associated resources to manage the pandemic situation (http://www.ciudadyderechos.org.ar/derechosbasicos_l.php?id= 21&id2=101&id3=66). There are several reasons why the institutions housing the elderly had difficulty dealing with the outbreaks and protecting their older persons from the same (Declercq et al., 2020). One of the reasons was characteristics of the population. Nursing home residents have high degrees of frailty, could be suffering from one or more comorbidities, requiring close contact with the health care staff, indulge in collective activities like eating together (Xiang et al., 2020), recreation, difficulty in identifying cases because of atypical presentations and dementia and maintaining infection control protocols and social distancing by the residents because of their neurological deficits or other co-morbidities. Another reason is that the primary focus of most governments was on hospitals, rather than the institutional facilities for the elderly especially so in the high income countries, and hence resources like PPE or protocols for managing outbreaks and catastrophic events were not in place (Ashwell et al., 2021; British Geriatrics Society. Coronavirus & Older People, 2021). Lack of trained staff was also a contributing factor (Bradshaw et al., 2020). Monitoring systems are also required to be strengthened to evaluate the compliance of these centres with the national guidelines for preventing spread and managing the infected cases. One of the greatest challenges of the pandemic highlighted in the above story is the scarcity of the PPE for both patients as well as workers faced during this pandemic. The administrative mastermind of creating the COVID wing helped tide over the scarcely available resources including PPE and mitigating the financial burden of individual ‘shelter in place provisions’. Secondary benefits were better patient outcomes due to social interactions, increased physical activity and elevated mood.

Conclusion Through the above stories we have tried to address the various facets that COVID has touched in the lives of the institutionalizd elderly and the challenges faced by the institutions in handling the same. Many innovative solutions used can be carried forward even in the period after COVID also since they provide better coping mechanisms and management techniques for improved health care of the elderly.

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Chapter 22

Global and U.S. Policy Perspectives on COVID-19 and Impacts on Older Adult Care and Older People of Color: Syndemic Theory and Public Health Strategies for Palliative Care Mary Beth Quaranta Morrissey and Patricia Brownell Abstract The COVID-19 pandemic has foregrounded pre-existing inequities in older adult care, both in the United States and globally, and heightened risks of suffering, serious illness, elder abuse, and death in older adult communities and populations, especially among older Black and Brown people and Latinx living in nursing home settings. The dual lenses of public health and syndemics provide a structural perspective on social and economic determinants of health and multiple disease epidemics that have contributed to older adult vulnerability and detrimental health outcomes during the pandemic, including policy and government failures. This chapter will examine both global health and U.S. health policy in pandemic contexts, as well as the roles of U.S. federal and state governments in the public health and long-term care policy making process. The implications of policy failures for older people of colour and vulnerable older communities and populations will be addressed, especially for nursing home residents who have been disproportionately impacted by the pandemic. Keywords COVID-19 · Public health policy and ethics · Social and economic determinants · Structural racism · Ageism · Age discrimination · Palliative care

Introduction The global reach of the COVID-19 pandemic and its human devastation, particularly in older adult populations and communities, has left virtually no corner of the world unscathed. The United States has suffered over one million deaths as a result of the M. B. Q. Morrissey (B) Wurzweiler School of Social Work, Yeshiva University, New York, NY, USA e-mail: [email protected]; [email protected] P. Brownell Graduate School of Social Service, Fordham University, New York, NY, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_22

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pandemic, approximately forty percent (40%) occurring in nursing homes (Eaton, 2020). This unthinkable loss of life imposes an ethical imperative upon all global actors, nation states, and professions to undertake the important work of assessing the experience of older people and their families and communities who have been disproportionately impacted by the pandemic. In understanding the social, economic, and public health challenges presented by the pandemic and their historical contexts, one must take into account the interconnectedness of age, chronic illness, disability, and income inequality as seen among older populations who are also affected by place of residence, neighbourhood, race, and ethnicity (1)MS. There is a broad consensus that pre-existing structures have significantly contributed to the catastrophic nature of the pandemic as it has unfolded since its first onset. The history of public health threats and crises is explicated well by Anthropologist Clarence Gravlee (2009), who first developed his conceptualization of syndemic theory in 1990 during the AIDS crisis in the United States. Advanced in the more recent contexts of the pandemic, Gravlee’s syndemic theory (2009, 2020) is relevant to the contemporary public health crises wrought by COVID-19, helping to illuminate the complex nature of the pandemic that was unforeseen both in its scale and consequences and for which the global world was wholly unprepared. The syndemic lens brings into focus the interaction of social and economic forces that heighten the interactions and impacts of multiple diseases or epidemics. In this framing of the pandemic, pre-existing structural conditions, such as racism, poverty, housing, income and food insecurity, and neighbourhood disadvantage, lay the groundwork for the cataclysmic exchange occurring when existing and new diseases converged in the contexts of economic and social deprivation. In the current pandemic, for example, pre-existing disease burdens in communities of color and amongst vulnerable populations have interacted with the COVID virus and deeply entrenched systems of racial disadvantage, contributing to detrimentalities and heightening risk of serious illness and death for such communities and populations.

COVID 19 and Older People: International Policies, Programs, and Issues The COVID-19 pandemic has inflamed panic and exacerbated suffering for older people around the world. As stated by Who Health Organization (2020), while the virus can infect individuals of all ages, older people and especially those above 80 years are more likely to die than those who are younger. (2)MS The intersectionality of gender, minority status, older age, and vulnerability caused by underlying conditions all conferred greater risks upon certain segments of the global population. The United Nations (2020) reported that for people over 70 years of age, about 66% were at a higher risk of experiencing negative impacts from the virus, especially if they had any underlying health problems. (3)MS This was exacerbated by limited access to needed health care for older adults due to lack of mobility and age discrimination

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in decisions on medical care triage and life-saving interventions. The impact of COVID 19 is more serious for rural older people, those belonging to lower economic groups, and those who are homeless, or living in crowded areas, in poor sanitary circumstances, and with limited access to health facilities and transport (4) MS. Older people faced vulnerability to abuse and neglect with well-meaning quarantine and shelter-at-home policies especially targeting older persons. Those older people who were locked down with abusive family members or caregivers faced added risk of abuse, and the risks were intensified by lack of contact with service providers, faith community members, neighbours and ombudsmen. It is public knowledge that care of ill individuals is undertaken primarily by older women in both home and institutional settings. These carers are themselves at greater risk of being affected by the virus. In addition, the fact that among older women of 80 years and over, a majority of whom live alone, enforced isolation due to COVID 19 is a matter of serious concern (United Nations, 2017) (5)MS. Isolation is known to adversely affect the mental health of older people, particularly those who are not digitally linked. The impact on older adults is visible also in terms of loss of income and employment opportunities as noted by the International Labour Organization (2018). Due to COVID 19, food insecurity among older people also increased. (6) MS Income and food insecurity have also heightened the suffering of older people during the COVID-19 pandemic. Long and short-term remedies require a rights-based approach to ensure health, safety, an inclusive perspective, and life of dignity for older people. This has long been recommended by the United Nations (1991). While certain precautions for distancing older people are necessary during COVID 19, these cannot override the need for their care and for provision of social support. Such support services must be integrated into more humanistic socioeconomic development plans inclusive of older people from rights-oriented national and international legal frameworks that protect their interests now and in the future (7)MS. Full integration of a focus on older people into a socio-economic plan must be sought through “strengthening the national and international legal framework to protect the human rights of older persons” (United Nations, 2020, p. 4). (8/9) MS Ensuring that older people participate in the shaping of a plan is necessary to ensure the dignity, safety, and well-being of all.

Abuse, Neglect, and Violence Against Older Adults and the Decade of Healthy Ageing It is no accident that the United Nations Decade of Healthy Ageing was announced during the COVID pandemic. The alarming impact of COVID on the most vulnerable older citizens around the world dramatized the need to strengthen protections against older adults everywhere.

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In December 2020, a resolution was adopted by the United Nations General Assembly to declare 2021–30 as the Decade of Healthy Ageing. This resolution recognizes that the coronavirus pandemic poses a particular threat to older adults around the world, and necessitates a coordinated, and comprehensive response that is inclusive of all people (United Nations, 2020). This resolution also recognizes that to promote healthy ageing, measures are needed to combat age discrimination, neglect, abuse and violence, and inequality in accessing needed healthcare services (United Nations, 2020).

New York Case Study: Nursing Home Experience During the Pandemic–Narratives of Loss, Inequity, and Systems and Infrastructure Failures The COVID-19 pandemic highlights the confluence of macro-structural inequities in the society that have marginalized Black and Brown and Latinx older adults. We turn now to the United States and take a look at the experience in New York State during the pandemic. While all U.S. health and hospital systems have been taxed beyond measure by the pandemic, nursing homes in particular have dealt with unprecedented levels of suffering, deaths, and losses of those loved. Health care workers have also died, or experienced concomitant moral injury and distress as they have borne witness to massive suffering. In these circumstances, we must ask whether the nursing home residents and workers who lost their lives to the pandemic might have survived had we been able to correct the unrelenting course of history in the punishing treatment of vulnerable older adults, including all those older persons living with disabilities. As further context for understanding the impact of COVID-19 on older adults in New York State, recent population studies in New York cities and counties point to older adult population growth and diversity (González-Rivera, Bowles & Dvorkin, 2019: Morrissey, Brownell & Caprio, 2020). For example, as Gonzalez Rivera et al. (2019) point out, there is an increase in the population of older people to the extent of 26% in the years from 2009 to 2019 among New Yorkers in age group 65 years and above, and also an increase of 41% in the growth rate of the older immigrant population (González-Rivera et al., 2019; Morrissey et al. 2020). 10 MS. Thirty-one percent of U.S.-born older adults in New York are non-white (González-Rivera et al., 2019; Morrissey et al. 2020). Poverty rates are higher among Black/African American, Latinx, Asian American and immigrant older adults than non-Hispanic whites, and overall poverty rates approach 1 in 7 among older New York residents (Gonzalez-Rivera, et al. 2019; Morrissey et al. 2020). Disturbingly, as data from Department of Health, New York City (2020) indicate, among older populations there was a disproportionate impact of COVID 19 on New Yorkers of color who have experienced cumulative disadvantages due to race, ethnicity, gender and poverty and as compounded by pandemic devastation. Sadly, the pandemic also detrimentally affected older people residing in nursing

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home and assisted living facilities, living in shelters for the homeless, those who are noncitizens, and essential workers, all categorized as Black/African American and Hispanic/Latinx (New York City Department of Health, 2020) (11) MS. It is observed (NYSBAHLS, 2020) that among nursing home populations in particular racial inequities and discrimination became more prominent during the COVID 19 pandemic. It has been reported that about 40 percent of U.S. COVID-related deaths occurred in nursing home and assisted living facilities, with New York experiencing over 15,000 nursing home resident deaths (Gebeloff et al., 2020). Various inequities affecting older people in minority groups were heightened in institutions providing health care access across the continuum of care (Bouie, 2020). In particular, Black African American older people who experience cumulative disadvantages were disproportionately subject to COVID19 related infections, illnesses and death compared to other groups. In sum, the pandemic had a disproportionate impact on older Black/African Americans, including those residing in long-term care facilities (Gebeloff et al., 2020) (12–16) MS.

Structural Racism and Inequities: Changing the Paradigms Neoliberal paradigms of ageing dominant in the last decades have contributed to notions that older adults who are not ageing well perhaps because of illness compromise, disability, or dementia, are individually responsible for their failures, and to boot, are dispensable (Morrissey, Lang, & Newman, 2019a, 2019b; Morrissey, Zimmerman, & Lively, 2022). A structural perspective is helpful in piercing the veil of such myths and highlighting the inherently racist underpinnings of frameworks that exclude black and ethnic minorities and persons with disabilities from the envisioning of opportunity in society. Negative cultural attitudes toward older adults and more virulent forms of age and other types of discrimination, hatred, and violence such as that seen in some examples of allocation of resources during the pandemic (Fins & Miller, 2020), have been wildly propagated under this brand of neoliberalism. It is now well recognized that making any sense of the experience of older adults during the pandemic, especially for socially and economically and disadvantaged older people and communities, involves going beyond measurement and understanding of risk at the individual level and choices or decisions made by individuals. A public health approach to the social problem of struggle and precarity among older adults calls for serious study of social structural factors that are influencing and to a large extent determining health outcomes for older people (17) MM. This includes many older people of color, the growing population of older immigrants in New York (Center for an Urban Future, 2017) and older inmates who experience accelerated ageing, older adults living with disabling conditions, and older adults with dementia residing in nursing homes. Older people living in institutional settings experienced unprecedented levels of suffering during the pandemic. A history of federal and state policy failures over decades played a significant role in shaping structural vulnerability for these older adult communities (18) MM.

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There is a clear relationship between the study data on nursing home resident mortality during the pandemic and the history of structural racism in the United States. This includes how long-term care policy has been designed and implemented (19) MM.

Federal Policymaking: and Policy Failures Older persons living in institutional settings experienced unprecedented levels of suffering during the pandemic. A history of federal and state policy failures over decades played a significant role in shaping structural vulnerability for these older adult communities. In particular, the historical failure to enact comprehensive longterm care policy, including long-term care financing, in the United States has affected the vulnerable nursing home population during the pandemic (20) MM. The structural forces that converged leading up to and during the pandemic served to heighten the vulnerability of the nursing home population (21/22) MM. The magnitude of the failure of the federal government in the United States to enact any form of long-term care policy in the course of its history has come to the fore during the pandemic. This policy failure has contributed significantly to structural vulnerability for people who are ageing and heightened their risk of detrimental outcomes during the pandemic (23) MM. The last attempt to correct this gap, at least in piecemeal fashion, was made by Senator Edward Kennedy with the enactment of the Class Act, standing for the Community Living Assistance Services and Supports Act. This legislation would have created a government-run long-term care insurance program. The Class Act was repealed after Senator Kennedy’s death due to lack of success in crafting a viable funding plan to support it. Shortly thereafter a Long-Term Care Commission was appointed. While the Commission did issue a comprehensive report, the report failed to address a plan for financing long-term care (Hudson, 2014) (17–19) MM. The United States continues to stand out on the global stage as having the highest healthcare spending among developed nations, but worse health outcomes than other developed nations with lower spending (Tikkanen & Abrams, 2020). The highly fragmented U.S. healthcare delivery and financing systems are no less catastrophic because of the glaring absence of a constitutional right to health care in the United States, further undermining the access to needed long-term care for those vulnerable and older adult populations left behind. The obligations of the United States under international conventions to ensure the availability, accessibility, acceptability, quality, affordability and nondiscriminatory access to health systems (Gostin, 2014) have not had the legal force or political power to alter ingrained patterns of inequity and injustice in the United States for vulnerable populations and older persons (López & Gadsden, 2016). Other major federal policy gaps, including in the domains of public health and emergency preparedness and workforce, compounded these failures. While certain steps had been taken at the federal level post-Katrina to strengthen preparedness, including The National Response Framework; The Post-Katrina Emergency

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Management Reform Act, and the Pets Evacuation and Transportation Standards Act(Morrissey, 2020), it is clear these frameworks did not go far enough in strengthening the public health infrastructures needed to deal with a pandemic of the magnitude we have experienced in the last year. This has been all too evident, for example, in breakdowns in the supply chain and vaccine distribution. Underinvestment in public health workforce education and training, as well as appropriate education and training for other health care workers, has also been detrimental and left the workforce ill-equipped to respond to the public health crisis. The direct care workforce, for example, has historically been marginalized through both low wages and lack of training.

State Policymaking Funding, Emergency Preparedness and Crisis Standards, and Public Health Infrastructure (26). MM The New York State Bar Association (NYSBA) adopted a set of COVID-19 Resolutions in November, 20201 (NYSBA, 2020; Morrissey & Rivera, 2021) that made specific recommendations to address the challenges New York faced as a result of the pandemic, as well as the threats posed by future public health emergencies and disasters. The recommendations made by NYSBA included a call for enactment of crisis standards of care and the adoption of triage guidelines that would govern during prevailing crisis conditions of scarce resources, as experienced during the COVID pandemic. The NYSBA recommendations themselves date back over a decade, documenting the work done by the NYSBA Public Health Law Committee and other public health law scholars, advocates, and bioethicists in calling for action by state government to strengthen the state’s emergency health powers and assure uniform guidelines for the allocation of scarce resources (NYSBA, 2020). The state’s reluctance to take timely steps in some cases, such as in failing to adopt uniform triage guidelines for allocation of scarce resources in crisis conditions, and in other cases to exercise its proper constitutional authority to regulate public health, plan and build adequate public health infrastructures, and equip New York with clear statutory authority to meet the threat of a well-foreseen pandemic, are now welldocumented. Nothing short of such clear authority, such as in the example of New York’s use of executive orders during the pandemic, proved to be adequate enough to respond to the magnitude and seriousness of the pandemic (NYSBS, 2020). New York’s nursing homes have been beset by crisis through ongoing patterns of historical underfunding (Eaton, 2020). Many nursing homes in New York operate in a survival 1

Mary Beth Quaranta Morrissey, PhD, JD, MPH, served as chair of the NYSBA’s Health Law Section Task Force on COVID-19 and played a lead role in the conceptualization, writing, and editing of the COVID-19 Task Force Report and Resolutions approved by the NYSBA House of Delegates on November 7, 2020. Morrissey also served contemporaneously as co-chair of NYSBA’s Health Law Section Public Health Law Committee. The full September 2020 Task Force Report, drawn on for the purposes of this chapter, is available at: https://nysba.org/app/uploads/2020/09/ Health-Law-Section-COVID-19-Report-September-20-2020.pdf.

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mode, assessing month to month whether they will be able to continue to stay afloat and serve disadvantaged resident populations who are dependent on government funding. Nursing homes capitalize to the extent possible on subacute rehabilitation programs for those who have no place else to go to live out their later years are deeply underfunded. The consequences of underfunding have been evident across every level of service in the nursing home industry, ranging from staffing and staff training to infection control, virus testing, personal protective equipment (PPE) and provision of essential palliative care services. These systems-wide deficiencies compromised quality of care and contributed to heightened suffering among nursing home residents (29) MM. These are required resources to prevent spread of infection and to ensure compassionate care (29) MM to those who must be isolated and have no meaningful access to their loved ones, sometimes even as they lay dying. The absence of any comprehensive long-term care policy in New York State thus mirrors the policy failures at the federal level and the downstream consequences of such policy failures (Grabowski & Mor, 2020).

Public Health and Palliative Care in Pandemics Palliative care is central to the public health response to pandemics, as framed in The Institute of Medicine (IOM) Crisis Standards of Care (2012) (IOM Crisis Standards of Care). (30) PB. Palliative care is critical in disasters and emergency situations related to public health according to the crisis standards of care. As both a philosophy of medical and social care and a delivery system, palliative care provides service that utilize practices known to relieve pain and manage symptoms (Morrissey et al. 2020). (31) PB In pandemic crisis conditions, such as have obtained during COVID-19, and if the need for services is greater than what is available, ethical standards require that all older adults are provided with treatment for pain and suffering, and no one is abandoned. Palliative care must be available to meet not only physical but also psychological and social needs as well (Morrissey et al. 2020) (32)PB. The right to high standards of health care for older adults is reaffirmed by international frameworks including the United Nations Committee on Economic, Social and Cultural Rights and Comment 14 (United Nations, 2000) and is spelled out in the Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (Hunt, 2007. p. 2; Morrissey et al. 2020). (33) PB. Comment 14 as cited by Hunt (2007) and Gostin (2014) emphasizes that health care including palliative care is a right. This means that palliative care, incorporating pain management, must be accessible, meet ethical and cultural standards of accessibility and be of high quality. Health facilities, services and goods must be provided without discrimination (34) PB (Morrissey et al. 2020). While Comment 14 does

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not refer specifically to palliative care, The Global Care Atlas (Conner & Bermedo, 2014) states that the right to health includes palliative care and is obligatory for all member states regardless of national resources: (35) PB “access to health facilities, provision of goods and services on a nondiscriminatory basis, the provision of essential medicines as defined by the WHO, and the adoption and implementation of a public health strategy” (Morrissey et al. 2020). The U.N. Special Rapporteur on torture has cognized that, “denying access to pain relief can amount to inhuman and degrading treatment” (Connor & Sepulveda Bermedo, 2014 (36) PB, p. 9; Morrissey et al. 2020). Many older adults regardless of race/ethnicity and place of residence may find themselves at risk of lacking sufficient food, income, housing, and experiencing neglect, abuse and violence and other social and material threats to wellbeing (Morrissey et al., 2015, 2020). They must be guaranteed access to healthcare delivery systems that are free of all forms of discrimination in order to ensure they are provided equitable and equal health care for all. (37) PB (Morrissey et al. 2020). A systems approach proposed to relieve pain and suffering of older adults, especially during crises like pandemics, requires a palliative care approach that leaves no vulnerable adult, including older adult, behind (Morrissey et al., 2015, 2020; Morrissey & Rivera, 2021). (37) PM. During pandemic crises, palliative care must be made available to all older adults as a right (Morrissey et al., 2015). This is particularly critical in nursing home environments (Morrissey et al. 2020). Strong evidence exists that demonstrates the impact of COVID 19 on marginalized older adults in the Black and Latinx communities. The IOM’s Crisis Standards of Care (2012), and the New York State Bar Association (2020) recommend availability of palliative care and relief of pain and suffering to all older adults and in particular those representing vulnerable populations. (38) PB. The WHO Resolution WHA 67.19, “Strengthening of palliative care as a component of comprehensive care throughout the life course,” advances the WHO and Public Health Strategy frameworks in the realization of palliative care as a right (World Health Organization, 2014; Morrissey et al. 2020). The 2017 Lancet Commission report (Knaul et al., 2017) on palliative care calls attention to the ethics and morality of a public health system that is global in scope, especially for low- and middle-income countries (Morrissey et al. 2020). The Commission calls for worldwide recognition of palliative care and pain relief as essential components of universal health coverage and social provision, and progressive realization of these goals, and identifies a new measure of suffering called “serious health-related suffering” associated with illness or injury and physical, emotional or social suffering and that cannot be relieved without medical intervention. These recommendations to relieve the suffering of older adults (Morrissey, 2011, 2015), including nursing home residents must be prioritized. This includes a comprehensive palliative care program that includes but is not limited to COVID-19 testing and treatment. Palliative care policy as a part of a comprehensive public health plan is an ethical imperative that also requires meaningful implementation of policy that mitigates risk and suffering of older adults (Morrissey et al., 2015).

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Ahman et al. (2020) also emphasize that for both health policy and front line practice, vulnerable groups must be prioritized both in the aggregate as well as individually (Morrissey et al. 2020). Addressing older persons’ needs in the context of their lived experiences, cultures, communities, and social groups is imperative (Ahman et al., 2020; Morrissey et al. 2019a, 2019b; Morrissey et al. 2020). Such a shift will necessarily demand transforming the conditions of older adults’ embedded environments, strengthening public health, and eliminating systemic discrimination and racism.

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International Labor Organization. (2018). Spotlight on work statistics. Retrieved May 20, 2020, from www.ilo.org/stst/Publications/WGMS-629567/land-en/index.htm Knaul, F. M., Farmer, P. E., Krakauer, E. L., et al. (2017). Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: The Lancet Commission report. Lancet, 391(10128), 1391–1454. López, N., & Gadsden, U. L. (2016). Health inequities, social determinants and intersectionality: NAM perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. Retrieved February 20, 2021, from https://doi.org/10.31478/2016/12a Morrissey, M. B. (2015). Suffering narratives of older adults. Routledge. Morrissey, M. B. Q., & Rivera-Agosta, J. L. (2021). Protecting the public’s health in pandemics: Reflections on policy deliberation and the role of civil society in democracy. Frontiers in Public Health, 9, 678210. https://doi.org/10.3389/fpubh.2021.678210 Morrissey, M. B., Caprio, T., & Reid, C. (2019a). The palliative turn in person-centered care: Public health and human rights-based approaches to interdisciplinary palliative care. Health Law Journal, 24(1), 52–60. Morrissey, M. B., Lang, M., & Newman, B. (2019b). A public health strategy for living, aging, and dying in solidarity: Designing elder-centered and palliative systems of care, environments, services, and supports. Routledge. Morrissey, M. B., Herr, K., & Levine, C. (2015). Public health imperative of the 21st century: innovations in palliative care systems, services, and supports to improve health and well-being of older Americans. The Gerontologist, 55(2), 245–251). https://doi.org/10.1093/geront/gnu178 Morrissey, M. B. Q., Brownell, P., & Caprio, T. (2020). Intersectionality of race, ethnicity, and culture in neglect, abuse, and violence against older persons: human rights, global health, and systems approaches in pandemics. In R. Geffner, J. W. White, L. K. Hamberger, A. Rosenbaum, V. Vaughan-Eden, V. I. Vieth, (Eds.), Handbook of interpersonal violence and abuse across the lifespan. Cham: Springer. https://doi.org/10.1007/978-3-319-62122-7_337-1 Morrissey, M. B., Zimmerman, A., & Lively, C. (2022). Psychology’s contribution to radicalizing aging theory for a participatory democracy. In B. D. Slife, S. C. Yanchar, & F. C. Richardson (Eds), Routledge international handbook of theoretical and philosophical psychology: critiques, problems, and alternatives to psychological ideas (pp. 552–576). https://doi.org/10.4324/978 1003036517-34552 Morrissey, M. B. (2011). Suffering and decision making among seriously ill elderly women. Doctoral dissertation, Fordham University. Retrieved from http://fordham.bepress.com/dissertations/AAI 3458134/ Morrissey, K. (2020). Extending emergency preparedness to farm animals. Unpublished Paper. New York City Department of Health. (2020). Covid-19: Data. NYC.gov. Retrieved May 23, 2020, from https://www1.nyc.gov/site/doh/covid/covid-19-data.page New York State Bar Association (NYSBA). (2020). Report of the New York State Bar Association’s Health Law Section Task Force on COVID-19. https://nysba.org/app/uploads/2020/09/HealthLaw-Section-COVID-19-Report-September-20-2020.pdf Stjernswärd, J., Foley, K. M., & Ferris, F. D. (2007). The public health strategy for palliative care. J Pain Sympt Manag, 33(5), 486–493. https://doi.org/10.1016/j.jpainsymman.2007.02.016 Tikkanen, R., & Abrams, M. K. (January 2020). U.S. health care from a global perspective, 2019: Higher spending, worse outcomes? The Commonwealth Fund Data Brief . United Nations. (2000). Committee on Economic, Social and Cultural Rights (CESCR), general comment No. 14: The right to the highest attainable standard of health (Art. 12 of the Covenant). Retrieved from http://www.un.org/documents/ecosoc/docs/2001/e2001-22.pdf United Nations. (2020). Policy brief: the impact of COVID-19 on older persons. Retrieved May 20, 2020, from https://unsdg.un.org/sites/default/files/2020-05/Policy-Brief-The-Impactof-COVID-19-on-Older-Persons.pdf

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United Nations. (2017). World population agency, department of economic and social affairs. https://www.un.org/en/development/desa/population/publcations/pdf/ageing/WPA2017-Highli ghts.pdf. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA 2017_Report.pdf World Health Assembly, 67. (2014). WHA67.19—Strengthening of palliative care as a component of comprehensive care throughout the life course. Sixty-seventh World Health Assembly, Geneva,: resolutions and decisions: annexes. World Health Organization. Retrieved May 19–24, 2014, from https://apps.who.int/iris/handle/10665/260211 United Nations Office of the High Commission on Human Rights. (1991). UN principles for older persons. Retrieved May 15, 2020, from https://www.ohchr.org/en/prfessionalinterest/pages/old erpersons.aspx World Health Organization (1990) WHO Definition of palliative care. Retrieved from https://www. who.int/cancer/palliative/definition/en/ World Health Organization. (2016). Planning and implementing palliative care services: A guide for programme managers. World Health Organization. https://apps.who.int/iris/handle/10665/ 250584 World Health Organization. (2020). COVID-19 strategy update 14 April 2020. Geneva: Switzerland. Retrieved May 20, 2020 from https://www.who.int/default-source/coronavirus/covid-strategyupdate-14april2020.pdf?sfvrsn_19download=true World Health Organization. (2022). Tackling abuse of older people: five priorities for the United Nations Decade of HealthyAgeing (2021–2030). Geneva: World Health Organization; Licence: CC BY-NC-SA 3.0 IGO

Chapter 23

In Praise of Older Canadian Indigenous Peoples Elizabeth Podnieks

Abstract This chapter will discuss older Canadian Indigenous peoples (First Nations, Métis and Inuit): their experience with COVID-19, their profound sense of isolation, and their demonstrated strength. The basic framework is a human rights filter that states that everyone has the right to be free from harm. In this context, elder mistreatment, long-term care facilities, Indigenous peoples, prison sentences, residential schools, problems, possibilities, resources, and stories will be reviewed. This ode to Indigenous older peoples is also a call to caring communities and elder abuse prevention networks to reach out and be more inclusive, compassionate, and loving. Keywords Isolation · Strength · Human rights · Elder mistreatment · Long term care

Setting the Scene Canada has usually been seen as a friendly country. People are generally calm and make good neighbours. Often, the worst thing said about Canada is its weather: the cold. The truth is that Canada’s relationship with its Indigenous population has been described as “cultural genocide” (Rees, 2018), and recent generations have tried to not only forget the past but also atone for it through reconciliation (Moran, 2020). This is an important time for Canada: pain and shame of how the Indigenous peoples were treated remains one of the darkest and ugliest parts of our history. This chapter lays the ground for a conversation on the incredible resilience of older Indigenous peoples to not only cope, but survive and even thrive. Indigenous peoples came to Canada thousands of years before the arrival of Europeans and with them, they brought their own cultures. Canada, a former British colony Appreciation to Sara Pomper B.A for assistance. E. Podnieks (B) Ryerson University Professor of Emeritus, Toronto, ON, Canada e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_23

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left the UK in 1867, inheriting treaty obligations previously held between the UK and First Nations. Self-governance by Indigenous peoples was lost along with their land control and the services they used, including education and health care (Government of Canada, 2017). Indigenous peoples today still face the consequences of colonialism: they have little to no power (Rees, 2018). They experience overcrowded housing, unemployment, mental health issues, food insecurity, and account for 25% of homicide victims (Department of Justice, 2017). The Canadian justice system also overlooks the exploitation of Indigenous lands by lucrative businesses (Rees, 2018).

Canada’s Shame: Residential Schools Most of Canada’s people react to the term ‘residential schools.‘ The Indian Residential School system is Canada’s greatest embarrassment, and had a continuing effect on its former students lasting well into their senior years (Truth & Reconciliation Commission of Canada, 2015). From the 19th to the late 20th-century residential school education was provided through the Government mandated Indian school system. The schools were first run by religious denominations, and then laterally by the state. In 1930 there were eighty active residential schools in Canada, and the last one closed in 1996 (Truth & Reconciliation Commission of Canada, 2015). Indigenous children were forcibly separated from their families and taken to these schools where they were required to give up their language and culture. The residential schools were also known for physical, emotional, spiritual, sexual abuse, and even deaths (Truth & Reconciliation Commission of Canada, 2015). The result was irreparable, leaving the children with a compromised identity, which they carried into later years. One child explained, You don’t speak anything but English. You went to white man’s school. You went to white man’s church, wore white man’s clothing. All those were built in. It wasn’t a classroom-type lecture. It was ingrained in the system (Rees, 2018).

The idea was to alienate the children from their Indigenous identities and deliberately prevent the cultural values to be passed from one generation to the next.

Seeking Truth and Reconciliation Survivors of the Indian Residential Schools have come forward and engaged in what became Canada’s largest class-action lawsuit (Government of Canada, 2019a, 2019b). One of the settlement agreements from the lawsuit was the creation of the Truth and Reconciliation Commission of Canada (Moran, 2020). Its role was to document the historical record of the residential schools and offer a meaningful

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voice to Survivors. When data was being gathered for the commission, the Indigenous victims of the school scandal showed their courage, strength, and honesty in sharing memories of those terrible days. They described their anguish of being deprived of a cherished culture (Truth & Reconciliation Commission of Canada, 2015). The stories struck a chord with the Canadian people who realized just how brutal Canada had been; they wanted to show remorse. A frenzy of action reflected these feelings. Statues were torn down, and prominent buildings were renamed (Zimonjic, 2017). This could be a time of reflection to identify teaching opportunities. Statues could have Indigenous art incorporated into their design. Discussions could be held with Indigenous peoples to learn how they would like to see Canada acknowledge their past pain, and how it could be turned into a peaceful future for everyone. To redress the past harm, Canada’s recent governments, schools, churches, and civil service groups along with all Canadians were called to take action on the Truth and Reconciliation Commission’s 94 recommendations (Government of Canada, 2019a, 2019b). The federal government also planned to reimburse the Indigenous Residential School Survivors and their families in hopes of recognizing rights, respect, cooperation, and partnership among all people in Canada (Moran, 2020). Further shame and embarrassment came recently to Canada with the discovery of over 4000 children who were abducted from residential schools, killed and buried in Unmarked graves across the country… The National Truth and Reconciliation Commission of 2008 refers to Canada ‘s “ cultural genocide “ and resulted in Canada changing the way Canadians think about their history: now with grief and sadness. There were 94 recommendations emerge from that commission deliberations. Among those were $ 238 billion in search and commemoration activities be awarded to the indigenous people. It is still unclear whether this will carry forward. The government has been organizing searches of land, now covered with trees, soccer fields, and gardens but this is of little solace for those parents whose children never came home from school. The unspeakable grief, loss, and shock will be their life forever.

Intergenerational Trauma and Elder Abuse One consequence of both colonization and the residential school system is intergenerational trauma. Children in residential schools were punished, abused, coerced and controlled and shown violent parenting models in the process (Menzies, 2020). The abuse and lack of a nurturing environment did not prepare many Survivors for adulthood or parenthood, We were taught not to show love or affection to our own kids. (Bear Paw Media & Education, 2015).

There are multiple generations of residential school Survivors who suffer from the emotional, psychological, physical and spiritual effects of intergenerational trauma.

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The trauma and associated coping methods contribute to a high occurrence of violence within Indigenous families (Menzies, 2020). Older Indigenous peoples are likely to experience health issues, and may have to be transferred out of their communities for care. They often need to travel with an escort or translator, potentially putting the senior at risk for financial abuse and neglect (Health Council of Canada, 2013). There are stories of younger relatives disappearing into town with the money intended for essentials like meals, accommodations and other expenses (Health Council of Canada, 2013). Family members are often the abusers, and those experiencing abuse may be reluctant or afraid to report it, because they don’t want their loved one to end up in prison. An alternative to being sent to a correctional institution is to handle the issues in a Peace-making circle (Bear Paw Media & Education, 2015). The year 2020 was known for being the year of COVID-19. The modern-day plague that ravaged our world affected lives everywhere. When a crisis occurs within society there is often a coming together of citizens to share, connect, and support each other. It was affirming to see how all generations were united in a strong commitment to see this pandemic be challenged with all the resources available (CBC News, 2020). Many people worked together in tandem, with a spirit of giving and protecting others. Unfortunately, there is usually a dark side in these circumstances—one that causes the rest of the population to react with shock and disbelief. In this case, it was seeing the incidence of elder abuse escalate and increase. In order to provide the reader with an understanding of how COVID was addressed in the province of Ontario, the following data describes some of the short falls and in so doing shows how the government failed many Canadian people.

Ever-Present Financial Abuse Citizens were urged by the government and other social services to pay special attention to older people during COVID. Some neighbours were particularly observant and concerned for homebound people and others who could not get food or needed supplies. These were often the individuals targeted for pandemic abuse (Hill, 2020). Older people were so happy when someone came to their door and offered to do some shopping for them, but there were people who would take the money and never come back with the groceries (Hill, 2020). There was a significant increase in reports of all types of financial abuse of seniors during COVID-19. Whether it was from door-todoor or email, it was hard to distinguish trustworthy sources of help from malicious attempts to gain confidential information and access to finances (Amin, 2020). In 2015, the financial abuse rate was 2.6% representing 244,176 older Canadians (National Initiative for the care of the Elderly, 2015). Worldwide in 2020, it is estimated that 6.8% of seniors aged 60 and over are financially abused in their community, and 13.8% of older adults experience financial abuse in retirement and in long-term care settings, which is of particular concern (World Health Organization, 2020). Victims need to understand the importance of reporting the abuse. Elder abuse

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prevention and awareness networks can detail the benefits of describing abuse to the police for many reasons, such as considering potential remedial action, creating statistics for government intervention and aid, and destigmatizing the situation of being a victim of abuse. During the pandemic, the Canadian government generously funded citizens (Snyder, 2020); however, the management of these funds has often been uneven, so it may not have reached the older people that most need it (Gilmore, 2020).

Ageism in Healthcare Health care is a human right, and every life has equal value (World Health Organization, 2017). The shortage of resources during COVID-19 included limited hospital beds and few ventilators and equipment (Nasser & Crawley, 2020), all of which caused anxiety among many to the risks of discrimination and actual refusal of services for older persons. The protection of human rights is fundamental for older persons in every country, especially those in poverty. Presently, there are more than 700 million people living in poverty globally and this number is expected to double in the next three decades. This includes older people who will represent the largest growth in population in less developed countries by 2050 (United Nations Department of Economics & Social Affairs, 2019). In Canada, it has been noted that 81% of deaths from COVID-19 have been among the elderly (CIHI, 2020). This has caused unbearable distress for decision-makers who are faced with the question of: who gets the ventilator (Zafar, 2020)? Indeed, there have been examples of physicians committing suicide due to their crushing life and death role (Zaminpeyma, 2020). Some older people were refused a ventilator, citing the need elsewhere (Wallace, 2020).

A Flawed Long-Term Care System The pandemic exposed years of inadequate long-term care in Canada. The horror of the conditions resonated across the country and across the world (Szklarski, 2020). The government called in the Canadian Forces to help with the situation, and it was revealed that Canada had long been not only below par—but actually abusive in caring for older adults in nursing homes and care facilities (Brewster & Kapelos, 2020). The absence of quality care extended to patients in acute care hospitals where older people were referred to as “bed blockers” (Sibbald, 2020). Patients and residents were stigmatized, discriminated against, neglected, and blatantly abused (Brewster & Kapelos, 2020). Workers were burned out, and didn’t have proper protective equipment, and were ill-prepared to prevent COVID from spreading (Brewster & Kapelos,

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2020). Additionally, staff members were poorly paid, which caused some individuals to leave as soon as they had some training only to be replaced by similarly prepared people. Staff members were hired part-time, necessitating them to hold several jobs, increasing the risk during the pandemic of cross-infection and spreading the disease (The Canadian Press, 2020). The very serious outcome of this situation—8 months into the pandemic—was that no action had been taken or implemented to address the poorly run health system. A committee was formed to develop plans of action, but there was no reporting; no discussion of potential outcomes and no social media posts showing government action. The most tragic consequence of COVID-19 for older people was not the disease itself, but rather the restrictions placed on facilities by the government. Older people were deprived of contact with their loved ones for weeks, and the toll was unbearable for the elderly. Many were deprived of caregivers, of daughters, of sons, and especially their beloved grandchildren. There were window visits, Skype and Zoom calls, but they were in no way a replacement for the personal contact of a hug or kiss. The effect was long lasting as the quarantine dragged on from weeks to months only to be repeated when the second wave arrived. It was also observed that the number of requests for Medical Assistance in Dying (MAID) increased during this period of time (McCue, 2020). Canada needs a universal health care strategic plan; this is long overdue. Even the embarrassment of Canada being tagged the worst in the world (CIHI, 2020) has gone unchallenged.

The Vulnerability of Older Adults in Indigenous Communities In addition to being one of the most vulnerable populations overall, Indigenous communities are particularly at risk of transmitting COVID-19 in their community. Multi-generational housing conditions, poverty, food insecurity, and unclean water increase the risk of being infected (Northern Policy Institute, 2020). There are associated respiratory illnesses, and a high rate of type-2 diabetes, making Indigenous peoples more susceptible to the severe symptoms and complications of COVID-19 (Crowshoe et al., 2018). Furthermore, to access many healthcare-related needs, older individuals are required to travel outside their communities, often to urban centres (Northern Policy Institute, 2020) (Fig. 23.1). In 61 Indigenous communities there is a “boil water” advisory, and therefore challenging to obtain or prepare water sources that don’t promote illness (Thomson, 2020). Many Indigenous communities do not have the resources to follow all recommendations set out by Canada’s public health officials, and COVID-19 cases continued to rise (Alhmidi, 2020). Some reserves were closed off, and some had the support of the Canadian Forces to address heath needs (Aiello, 2020).

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Fig. 23.1 Canada’s Indigenous population percentages shown by province including seniors over the age of 65, and women over the age of 65 based on Canada’s 2016 Census

Restrictions on close contact and gathering during the COVID pandemic meant that community celebrations were cancelled (Lee and Huynh, 2020). A powwow is an Indigenous celebration that welcomes all. Indigenous people dress in beautiful elaborate costumes and dance, sing, drum, socialize, and honour their cultures. The events stimulate the Indigenous economy and provide income that helps communities through the winter (Chidley-Hill, 2020). Poverty can often include lack of access to technology and infrastructure, which could otherwise offer connections to Elders and remote healthcare. Another risk factor for COVID-19 is not having a home. Indigenous peoples experience homelessness at a much higher rate than non-Indigenous peoples. In Toronto, Canada’s largest city approximately 15% of the homeless population is Indigenous, even though they represent only 0.5% of the total population (Homeless Hub, 2019).

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A 2013 study of Canada’s urban centres found that 1 in 15 Indigenous individuals experience homelessness compared to 1 in 128 people in the general population (Homeless Hub, 2019). Toronto’s Our Health Counts, an inclusive community-driven health survey for Indigenous peoples in Toronto reported that over 90% of Toronto’s Indigenous population live below the poverty line (City of Toronto, 2016).

Ageing as a Federal Offender A population that often goes unconsidered are people who live in Canada’s federal prisons. Indigenous peoples were overrepresented in federal prisons at an all-time high in 2020, at 30.04% and Indigenous women make up 42% of the population (Canada Office of the Correctional Investigator, 2020). For many years, Indigenous peoples have been disproportionately placed in maximum-security institutions receiving more forceful harm and more time in solitary confinement (Canada Office of the Correctional Investigator, 2020). Offenders can serve long sentences in these crowded institutions and develop healthcare needs that are beyond the capacity of the system. The infrastructure to help older and ill individuals with mobility impairments and chronic, painful diseases is substandard. Supplies for incontinence are not provided, and pain management is not available—it is inhumane. Older people make up 25% of federal prisoners, and 5% are terminally ill (Chattopadhyay, 2020). Palliative care doesn’t exist, and being let out on compassionate release almost never happens; it’s easier to receive Medical Assistance in Dying (MAID) (Mahboob, 2020). Every year in the province of Ontario, about 30 older and sick individuals die in federal prisons, and this expected to increase (Chattopadhyay, 2020). Unsurprisingly, three-months into the pandemic, measures to prevent COVID-19 cases in these crowded institutions were not being addressed. Supplies like hand sanitizer and additional soap were not being provided, and sick individuals were being placed in solitary confinement. Physical distancing wasn’t being practiced or enforced, and new arrivals were not required to isolate. Canada’s mainly smaller institutions released approximately 6,000 offenders to help prevent COVID from spreading (Bradley, 2020).

Social Isolation as an Indigenous Senior Indigenous seniors are at risk of experiencing social isolation due to racism, culture, language, poverty, and all of the negative experiences from their past (Truth & Reconciliation Commission of Canada, 2015). There are far too many reminders of the oppression experienced in the residential school system still present. Addressing social isolation became an enormous focus during the COVID-19 crisis. Many attributed its consequences to deteriorating wellbeing even leading to death. This

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section will build awareness of the risks and protective factors for social isolation, and outline suggestions of successful tools. They can be utilized in different settings such as reserves, rural or remote areas, and large or small urban environments.

Risk Factors for Social Isolation COVID-19 has revealed the extreme danger that social isolation places on older people. Vulnerable to begin with, the government-imposed restrictions mandated for older people can even take lives. The situation in long-term care facilities has revealed the extent of poor and cruel treatment that is the norm, and not the exception. Life transitions may trigger social isolation, including: retirement, illness, death of a spouse, loss of caregiver, moving, and loss of access to health and social services. One loss may be bad; however, when they are multiplied it may result in a failure to cope. Indigenous older people may be isolated because of poverty, especially women (Employment & Social Development Canada, 2018). Other common risk factors for social isolation among Indigenous seniors include food deprivation and chronic health conditions (Tables 23.1 and 23.2). Case Study The following case study describes a common story. Try to identify risk factors and protective factors that occur in older Indigenous peoples’ lives. Use this as a basis for discussion.

Table 23.1 Key risk factors associated with social isolation for ALL seniors Demographic

. Living alone . 80 + years old . Being a caregiver

Health

. . . .

Poor physical or mental health Mobility issues, poor eye sight and hearing Frailty Victim of older adult abuse, neglect, and financial abuse

Social and cultural

. . . . . . . .

Loss of a spouse Absence of friends or family Unsupportive families Lack of access to transportation Loss of independence Lack of communication access, such as no telephone or cell phone Discrimination Inability to afford essentials (healthy foods, medication)

Economic

. Poverty

Note Reprinted from Social Isolation of Seniors–A Focus on Indigenous Seniors in Canada, by Employment and Social Development Canada, retrieved from https://www.canada.ca/ Copyright by Her Majesty in Queen and Right of Canada, 2018

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Table 23.2 Additional risk factors for INDIGENOUS seniors . . . . . .

Racism Living in communities with high crime rate Past institutional experience Residential school trauma Living in overcrowded housing Moving into the city or town from a rural reserve . Insufficient or remote family supports

. . . . .

Cultural differences Language differences Political/jurisdictional isolation Lack of access to services Lack of culturally appropriate activities and/or ability to access activities . Lack of appropriate health care and community services on reserves

Note Reprinted from Social Isolation of Seniors–A Focus on Indigenous Seniors in Canada, by Employment and Social Development Canada, retrieved from https://www.canada.ca/ Copyright by Her Majesty in Queen and Right of Canada, 2018

Mary lives on a small rural reserve, with the closest town three hours away. She is 84 years old and has been widowed for many years. She speaks Cree fluently and understands enough English to get by. She is afraid to go shopping alone or go into town because she has experienced racism. She sometimes feels powerlessness and shy or fearful about being alone among “white” strangers and not being able to speak English very well. Mary attended residential school as a child and remembers being punished for speaking Cree, and while she later forged a good life with her late husband, she was still dealing with some old fears. She has eight children and many grandchildren. Mary has a pension and continues to live in her own two-bedroom house. Her granddaughter, Josie, and her two children live with her. Josie works part-time, helps Mary around the house and sometimes takes her shopping or blueberry picking in the summer. However, Josie has a boyfriend who is disrespectful toward Mary, which leads to disagreements between Mary and Josie. Things are getting increasingly difficult. Mary has poor eyesight and a heart condition, is diabetic, and needs a walker because of her arthritis. A home-care nurse makes regular visits on weekdays, and sometimes the home health aides will drive her to her medical appointments in the city or take her to the Elder suppers and occasional community events. Mary loves being active this way, but it is becoming more of an effort because she needs more help to get anywhere. Mary feels increasingly isolated and anxious. She overheard the nurse and her granddaughter talking about her poor health and the possibility of moving her to a long-term care home in the city (there are none on the reserve). She wants to stay in her home. She is afraid of being alone in some long-term care home where no one speaks her language, no one understands her culture, and traditional foods are not available. She anticipates an experience much like her experience in residential schools, and is worried that they might not treat her well because she is Indigenous. She wants to die at home when her time comes (Employment & Social Development Canada, 2018, p. 15).

Protective Factors of Social Isolation Indigenous culture serves to protect people in a variety of ways, including connecting with the land, traditional medicine, spirituality, traditional foods, traditional activities, language and humour. These themes provide insights into the meaning held by seniors (Employment & Social Development Canada, 2018). An understanding of the nature of these concepts is necessary for planning strategies in a holistic way.

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Activities and programs that provide social support by way of help, kinship or friendship can be seen as mitigating social isolation. Health research has shown that social support is a key determinant of health. Traditional values of Indigenous peoples have always included helping, caring, and being kind to each other. Elders are known for their wisdom and knowledge, and this is respected (Employment & Social Development Canada, 2018). Providing translation in non-Indigenous settings is a protective factor for at-risk Indigenous older peoples who need to comprehend the interactions involved in social settings. If not provided, many Indigenous individuals are excluded from important conversations (Employment & Social Development Canada, 2018).

Youth and Generations Together Grandparents in Indigenous cultures have had essential roles within families and communities for generations. They mentor grandchildren in traditional knowledge and cultural practices, and remain integrated in their children’s and grandchildren’s lives (Silvey et al., 2019). In non-Indigenous families it has become less common for grandchildren to spend time with their grandparents. The transition to single-family homes and the increase in seniors’ homes has created an unintended separation and the disconnection has led to social isolation for older individuals and also missed opportunities for learning about each other (BC Care Providers, 2009). In 2020, the pandemic demonstrated the need for generations to work together. With two consecutive lockdowns people were not supposed to mix households (Newton, Silverman, & Joseph, 2020) and this is where technology became important. Younger people helped with digital communications, and this was possible because they have the patience and energy to teach, help, and encourage older people to become more technical. Younger individuals may be able to adjust settings to make devices easier for the older person to use. While communications technology can be expensive, younger people are well placed to source what is needed through donations of unused iPads, and other tablets and laptops. It was helpful when some hospitals made iPads available to patients during COVID to prevent social isolation and encourage family communication. This is an example of where funding should be directed in nursing homes. There needs to be the incentive to provide the technology and skills for older people. It is the link to communication and the outside world. When the young help the elderly, the benefits flow both ways. One of the most powerful outcomes of the pandemic has been the change in relationships. From the beginning, family and friends reassured us we would work together to help each other stay connected. This is something we should hold onto tightly. With all generations working together we can eliminate social isolation: we can become the caring people we were meant to be.

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The Dimensions of Indigenous Spirituality and Religion Indigenous spirituality is deeply linked to the land, the very land the people themselves are being owned by. This philosophy proposes that all things are living and share the same soul or spirit as the people. The Indigenous spirit is a feeling of oneness and belonging (Mudrooroo, 1995). Everything else is secondary; intrusive awareness, elements of the Earth are interconnected with people, plants, animals, land forms and celestial bodies: everything is related to each other. Thus, Indigenous spirituality has a oneness with all living things, and things that do not breathe (Mudrooroo, 1995). Indigenous peoples were significantly influenced by government policies and missionaries from the late 19th to the mid = twentieth centuries. More recently, there has been a return to practicing traditional spirituality. Non-Indigenous lives are seen to be ruled by planning and future thinking, whereas Indigenous peoples live in the present mindset. Indigenous peoples now make plans according to what their own beliefs are. There is no definitive religion: there is agreement and acceptance of commonalities among traditions which include: creation stories, the role of tricksters, folklore and the need for sacred organizations, Spiritual meaning permeates most activities of life (Smith, 2018). Creation Stories describe the origins of the cosmos and the interrelations of the elements. One story talks about Earth being formed on the back of a turtle, which some refer to as the land for North America. Trickers, Transformers and Culture Heroes may take on many forms of Indigenous cultures, they can be male or female, foolish or helpful, hero or troublemaker, human or animal. Transformers or Shape-Shifters can change shapes, from human to animal to inanimate object (Religion and Spirituality of Indigenous, People in Canada, 2018). Celebrated Indigenous musician, storyteller, and eternal optimist, Thomson Highway, describes how the Cree Nation describe the death experience. After death, there is no heaven or hell, “there is the circle of life and death that interconnect, and when we pass away, we leave this planet, we don’t go up or down. We stay [in] another part of the circle” (CBC News, 2020). Figure 23.2 represents Indigenous support systems and how they are interrelated based on individual wellness, shared responsibility shared care, family, and friends. The layers represent spheres of responsibilities that extend beyond the individual. The layers are interconnected and foster harmony by promoting responsibility (Employment & Social Development Canada, 2018). Indigenous cultures are diverse; they share the belief in the interconnectedness of living things Employment & Social Development Canada, 2018). The circles represent interaction and interdependence. Within the circles and between circles there are reciprocal relationships: individual to family, and family to community. These are principles that interventions for abused seniors can build on to encourage healing from challenging situations.

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Fig. 23.2 Indigenous interrelated support system. Note Reprinted from Social Isolation of Seniors– A Focus on Indigenous Seniors in Canada, by Employment and Social Development Canada, retrieved from https://www.canada.ca/ Copyright by Her Majesty in Queen and Right of Canada, 2018

Resources and Interventions Support Groups: A Chance for Human Connection Support groups are important in the mental health community and can help many seniors address psychological, emotional and spiritual challenges in an accessible way. They offer a safe environment where participants can express the feelings associated with elder abuse, such as sadness, anger, frustration, guilt, resentment, stress and hopelessness (Podnieks and Thomas, 2014). Participants are encouraged to talk about their challenges and coping mechanisms, and they can ask any questions like, “why does my son abuse me?” Support groups also help victims navigate health, legal, and social systems and build awareness, confidence, and the tools to assist victims in developing and asserting more control in their lives (Podnieks and Thomas, 2014). It is important to establish support groups made up of individuals who have similar challenges and experiences. As expected, support groups for Indigenous populations are most helpful when they too are designed for individuals with similar community challenges (Podnieks and Thomas, 2014), and it is highly recommended that they be centred in Indigenous communities. Indigenous elders have a variety of traditions

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and may speak a number of different languages depending on where they are located in Canada. It is valuable to know that “Indigenous peoples get their strength from connecting to their land, culture and languages” (Alhmidi, 2020) and to run a support group outside Indigenous communities, the awareness, appreciation, and knowledge of Indigenous culture and practices need to be developed. Responding effectively to the cultural and linguistic needs of Indigenous elders is crucial to helping victims (Betancourt et al., 2003). Below is a list of organizations that provide holistic healthcare services for Indigenous peoples (Table 23.3). Table 23.3 Shows a selection of resources, programs and services, which strive to provide holistic health services and equalize healthcare for Indigenous seniors in Canada

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Empowerment In addition to the formal intervention modules that are recommended and used to assist Indigenous peoples to address situations of mistreatment, discrimination, or other forms of inappropriate behaviour, practitioners are directed to inexpensive, innovative practices. The first step is to help the older person feel some sense of empowerment, some sense of being in control. Those who are empowered often share the same core concepts of resilience and hardiness, which are strengths in the Indigenous population. History has been brutal with Residential schools, and systemic racism and poverty are still obstacles to overcome to this day. Some communities have found a way to adapt to the new and persisting challenges of COVID-19 restrictions by learning to use iPads. One Ontario Reserve with 500 people have been helping each other stay safe by adhering to stay-at-home orders to prevent the spread of the virus (Skead, 2020). A way to empower people to pay attention to a cause is to start a group. Students at a British Columbia school joined to form their group using the namesake CNPEA— The Canadian Network for the Prevention of Elder Abuse. Starting with five group members, they made posters to advocate for elder abuse awareness and it quickly helped them grow to 12 members with students and teachers cared deeply about the cause (CNPEA, 2018). Each new member has different skills to help spread awareness. Crafts, word-of-mouth, stories, songs, dance and more can all be transformed into a meaningful act of self-advocacy. Small initiatives can grow and develop and help members build a sense of control, willingness, courage and spirit to stand up to politicians.

Humour: A Strength in the Indigenous Community It is not often commented on, but Indigenous peoples have a well-defined sense of humour (Smith, 2018; Public Health, 2022). This can help promote healing and unity as it is rooted in life lessons providing a healthy escape from still vivid memories held over from colonization. Indigenous peoples have had much experience at being teased, taunted, and ridiculed in school onward. Somewhere along the line, they learned a healthy escape—giving back. They soon realized that stereotypes are erased by laughter; humour brings energy to which people respond positively. People discovered they were popular, and they liked being funny. Scientific research demonstrated that laughter was actually good medicine. This was documented in the thirteenth century when it was noted that laughter eases tension, anxiety, grief and depression. Humour also releases endorphins, boosts the immune system and lowers blood pressure. Indigenous humour is unique and as such is the heart of resilience and survival ability. Moral lessons and social order are embedded in storytelling, especially in trickster stories. Humour helps foster understanding and change, making people want to do better and be better.

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Leadership Challenge for Prevention and Awareness Advocates The pandemic of COVID-19 emerged as a worldwide catastrophe, which suddenly made elder abuse awareness and prevention and other senior organizations, groups, advocacy centres, and senior clubs uncertain of their role. Everyone wanted to help, but how? The Canadian government was quick to respond with leading government officials issuing public statements at appropriate times. Ministers of health appeared calm and informed, and ready to give the public information that was needed for their protection. However, it became clear very quickly that this was a senior crisis: long-term care was the target, and deaths occurred immediately. How terrifying for those older people to be captive care recipients within those facilities. The news only kept getting worse as families and loved ones were excluded from seeing, being with, or communicating with their family members when they needed them the most. Networks, groups, and organizations must now pause to reflect and consider how to help in emergency situations like these. Addressing what could have been done, if more consolation could be offered to those who needed help so desperately. They need to come up with a plan to be prepared for the next time, and decide if a corps of volunteers should be briefed for such occasions, and if materials should be preprepared for circulation. It’s also time to determine how families can be prepared in advance, and consider the roles of faith leaders in an emergency such as the pandemic. In 2021, virus mutations emerged to further demonstrate the need to leverage knowledge and resources to provide the needed help. There are many answers, but it does seem there could and should be a conversation leading to a strategy that addresses the issue of older people, Indigenous peoples, immigrants, incarcerated individuals and any person who is faced with dying alone. World Elder Abuse Awareness Day (WEAAD) was designated by the United Nations 15 years ago as a day to honour and respect older people—all older people. There have been ideas expressed over time that perhaps the concept of WEAAD could be extended over the year. People want to show respect for older people more often. The pandemic could be used as an example of a possible innovation that would challenge people to see a situation, and have an immediate response of “what can I do?” It might be a time for action and advocacy, and this is an opportunity for Indigenous peoples to participate.

Building on the Future This chapter has been a call out to the research community: the voices of indigenous people have not been heard and have not been listened to. Existing literature outlines their high risk of poor health resulting from the historical and structural factors in their past (Pace and Grennier, 2016). Despite the hardship endured, Indigenous people have demonstrated enormous strengths which enable them to age successfully and this should be examined by researchers. Examples of resilience resonate throughout

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this paper: humour and laughter have healing properties and can bolster resilience and are strongly connected to the maintenance, restoration and empowerment of older people. These concepts must be further examined, tested and applied in successful aging. Indigenous people as a marginalized group, should be at the scientific table and contribute their lived experience to better support ageing well among other diverse groups. It is inspiring to note the contribution of Indigenous peoples to the artistic community: the world of art, music, literature, dance, sports. The success in these areas speak again to the untapped future and potential of Indigenous peoples.

Closing Thoughts The purpose of this chapter was to explain how Indigenous older people in Canada coped with the COVID-19 pandemic and what were some of the cultural and situational challenges that were faced. The paper also addressed the surge of incidence of elder abuse that was experienced. The response to unfortunately resulted in financial scams, which left the older person perplexed and saddened. The chapter is framed in a human rights model highlighting the premier principle that every person has the right to be free of harm. A Convention for Older People initiated by the UN has been in development for the past ten years, and is expected to be unveiled shortly. It is noted that such a document has been available to protect children for many years. The chapter describes the Indigenous peoples being excluded, abused, vilified, and victimized ever since colonization. However, building on traditional knowledge, Indigenous peoples have developed collective, community-based programs, and strategies. Advocates encourage communities and individuals to leverage these and develop more. Readers of this chapter who belong to abuse prevention networks or other senior organizations are asked to encourage Indigenous peoples to join their membership. If there is to be a sense of cooperation, and collegiality, contact must be established and nurtured. The pandemic has been called the great equalizer. This is an opportunity for caring people to mobilize share resources, share the wisdom and culture that many did not realize we had in common. The pandemic showed how helpless we are when alone and how strong we are together. As we offer praise to Indigenous older peoples, we also look to melding our two cultures in praise of all older people.

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Alhmidi, M. (2020, September 30). COVID-19 cases rising at an alarming rate in Indigenous communities. Retrieved from https://www.theglobeandmail.com/canada/article-covid-19cases-rising-at-an-alarming-rate-in-indigenous-communities/ Amin, F. (2020, April 17). Coronavirus scams targeting seniors on the rise. Retrieved from https:// toronto.citynews.ca/2020/04/17/coronavirus-scams-seniors/ BC Care Providers. (2009 Spring). Creating caring communities: A guide to establishing intergenerational programs for schools, care facilities and community groups. Retrieved from http:// www.bccare.ca/wp-content/uploads/BCCPA-Intergenerational-Toolkit.pdf Bear Paw Media and Education. (2015, April 30). Hidden–elder abuse in aboriginal communities [Video file]. Retrieved from https://www.youtube.com/watch?v=5AZjMe970w8 Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118(4), 293–302. https://doi.org/10.1093/phr/118.4.293 Bradley, J. (2020, August 14). Canada’s correctional institutions released thousands of inmates in the early days of COVID-19. National Post. Retrieved from https://nationalpost.com/news/can adas-correctional-institutions-released-thousands-of-inmates-in-the-early-days-of-covid-19 Brewster, M., & Kapelos, V. (2020, May 26). Military alleges horrific conditions, abuse in pandemichit Ontario nursing homes. CBC News. Retrieved from https://www.cbc.ca/news/politics/longterm-care-pandemic-covid-coronavirus-trudeau-1.5584960 Canada Office of the Correctional Investigator. (2020). Annual Report in the midst of the third wave of the global COVID-19 pandemic. https://www.oci-bec.gc.ca/cnt/rpt/annrpt/annrpt20202021eng.aspx CBC News. (2020, March 16). How Canadians are helping each other amid the COVID-19 outbreak. Retrieved from https://www.cbc.ca/news/entertainment/community-support-coronavirus-1.549 8521 Chattopadhyay, P. (Host). (2020, November 15). Sunday Edition [Radio broadcast]. Location: Toronto, Ontario: CBC Radio. Chidley-Hill, J. (2020, May 25). Powwow circuit disrupted by COVID-19. Retrieved from https:// www.cbc.ca/news/canada/ottawa/powwow-cancel-2020-covid19-1.5583452 CIHI: Canadian Institute for Health Information. (2020, June). Pandemic experience in the long-term care sector. Retrieved from https://www.cihi.ca/sites/default/files/document/covid-19-rapid-res ponse-long-term-care-snapshot-en.pdf City of Toronto (2016). Indigenous people of Toronto. Retrieved from https://www.toronto.ca/ city-government/accessibility-human-rights/indigenous-affairs-office/torontos-indigenouspeoples/#:~:text=Toronto%20has%20the%20largest%20Indigenous,increase%20of%2025% 20per%20cent CNPEA: Canadian Network for the Prevention of Elder Abuse (2018, March 9). High school student founds elder abuse awareness school club in BC. Retrieved from https://cnpea.ca/en/ about-cnpea/blog/796-high-school-student-founds-elder-abuse-awareness-school-club-in-bc? highlight=WyJzdHVkZW50Il0 Crowshoe, L., Dannenbaum, D., Green, M., Henderson, R., Naqshbandi Hayward, M., & Toth, E. (2018). Type 2 diabetes and indigenous peoples, 42, S296–S306. Retrieved from https://guidel ines.diabetes.ca/docs/cpg/ch38-type-2-diabetes-and-indigenous-peoples.pdf Department of Justice. (2017, January 2). Indigenous overrepresentation in the criminal justice system. Retrieved from https://www.justice.gc.ca/eng/rp-pr/jr/jf-pf/2017/jan02.html Employment and Social Development Canada. (2018). Social isolation of seniors–a focus on indigenous seniors in Canada, 1999. Ottawa: Author. Gilmore, R. (2020, May 27). We’re trying to survive’: Seniors grow frustrated over slow rollout of COVID-19 financial aid. Retrieved from https://www.ctvnews.ca Government of Canada. (2017, May 2). First Nations in Canada. Retrieved from https://www.rca anc-cirnac.gc.ca/eng/1307460755710/1536862806124 Government of Canada (2019a, February 19). Truth and reconciliation commission of Canada. Retrieved from https://www.rcaanc-cirnac.gc.ca/eng/1450124405592/1529106060525

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Government of Canada (2019b, September 5). Delivering on truth and reconciliation commission calls to action. Retrieved from https://www.rcaanc-cirnac.gc.ca/eng/1524494530110/155751 1412801 Health Council of Canada. (2013, November). Canada’s most vulnerable improving health care for First Nations, Inuit, and Métis seniors. Retrieved from https://healthcouncilcanada.ca/files/Sen ior_AB_Report_2013_EN_final.pdf Hill, A. (2020, March 21). Coronavirus scammers targeting vulnerable older people, say police. In The Guardian. Retrieved from https://www.theguardian.com/society/2020/mar/21/coronavirusscammers-targeting-vulnerable-older-people-say-police Homeless Hub. (2019). Indigenous peoples. Retrieved from https://www.homelesshub.ca/abouthomelessness/population-specific/indigenous-peoples Lee, H. O., & Huynh, D. (2020, May 25). Long-term social distancing during COVID-19: A social isolation crisis among seniors? CMAJ News. Retrieved from https://www.cmaj.ca/content/192/ 21/E588 Mahboob, T. (2020, November 17). Compassionate release should be prioritized over MAID in Canadian prisons, says expert. Retrieved from https://www.cbc.ca/radio/sunday/the-sundaymagazine-for-november-15-2020-1.5801033/compassionate-release-should-be-prioritizedover-maid-in-canadian-prisons-says-expert-1.5801035 McCue, D. (2020, April 19). ‘I choose to be in control’: Some seniors weighing medically assisted death because of COVID-19. Menzies, P. (2020, March 25). Intergenerational trauma and residential schools. In The canadian encyclopedia. Retrieved from https://www.thecanadianencyclopedia.ca/en/article/intergenerat ional-trauma-and-residential-schools Moran, R. (2020, October 5). Truth and reconciliation commission. In The canadian encyclopedia. Retrieved from https://www.thecanadianencyclopedia.ca/en/article/truth-and-reconcili ation-commission Mudrooroo. (1995). Us mob: history, culture, struggle: an introduction to indigenous Australia. Angus & Robertson. Nasser & Crawley. (2020, Mar 19). Ontario could run out of ICU beds, ventilators in 37 days even if COVID-19 rates cut in half: study. CBC News. Retrieved from https://www.cbc.ca/news/canada/toronto/ontario-could-run-out-of-icu-beds-ventilatorsin-37-days-even-if-covid-19-rates-cut-in-half-study-1.5503333 National Initiative for the care of the Elderly. (2015). Into the light: National survey on the mistreatment of older canadians. Retrieved from https://cnpea.ca/images/canada-report-june-7-2016pre-study-lynnmcdonald.pdf Newton P., Silverman H., & Joseph, E. (2020). Toronto begins a four-week lockdown–its second of the pandemic - as Covid-19 cases surge. CNN. Retrieved from https://www.cnn.com/2020/ 11/23/americas/toronto-coronavirus-lockdown-monday/index.html Northern Policy Institute. (2020, July 30). Can the government help Canada’s most vulnerable population amid a pandemic? Retrieved from https://www.northernpolicy.ca/indigenous-peo ples-covid-19 Pace, J. E., & Grenier, A. (2016). Expanding the circle of knowledge: reconceptualizing successful aging among North American older indigenous peoples. Journals of Gerontology Series B: Psychological Sciences and Social Sciences. Retrieved from http://hdl.handle.net/11375/20842 Podnieks, E., & Thomas, C. (2014). Preventing elder abuse–Hope springs eternal in elder abuse and its prevention. In Elder abuse and its prevention: Workshop summary (pp. 95–100). Institute of Medicine and National Research Council. Rees, W. (2018, September 9). Canada’s First Nations: Canada’s treatment of its indigenous peoples has been described as ‘cultural genocide’. History, 68 https://www.historytoday.com/historymatters/canada%E2%80%99s-first-nations Sibbald, B. (2020, May 15). What happened to the hospital patients who had “nowhere else to go”? CMAJ News. Retrieved from https://cmajnews.com/2020/05/15/covid-alc-1095873/

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Silvey, L. A. E., Bailey, S. J., & Ponzetti, J. J. (2019). Understanding the role of grandparents in indigenous families: principles for engagement. Retrieved December 1, 2020, from https://www.researchgate.net/publication/336240379_Understanding_the_Role_of_Gran dparents_in_Indigenous_Families_Principles_for_Engagement Skead, Z. (2020, November 27). Resilience on reserve: How my First Nation and my family have endured this pandemic. The Globe and Mail. Retrieved from https://www.theglobeandmail.com Smith, D. G. (2018). Religion and spirituality of indigenous peoples in Canada. In Z. Parrott, & M. Filice (Eds.), The Canadian encyclopedia. Retrieved April 19, 2018, from https://www.thecan adianencyclopedia.ca/en/article/intergenerational-trauma-and-residential-schools Snyder, J. (2020, November 14). Canada’s ‘generous’ COVID-19 income supports vastly outpaced other developed nations: OECD. National Post. Retrieved from https://nationalpost.com/news/ canadas-generous-covid-19-income-supports-vastly-outpaced-other-developed-nations-oecdreport Sue Craig Consulting and the CLRI Program. (2017, March 27). Supporting indigenous culture in ontario’s long-term care homes needs assessment: Needs assessment and ideas for 2017–18. Retrieved from https://the-ria.ca/wp-content/uploads/2018/10/Supporting-Indigenous-Culturein-LTCH-Report-Final-March-31-2017_updated_A.pdf Szklarski, C. (2020, June 25). Canada’s proportion of COVID-19 deaths in long-term care double the average of other countries, study shows. CBC News. Retrieved from https://www.cbc.ca/ news/health/coronavirus-canada-long-term-care-deaths-study-1.5626751 The Canadian Press. (2020, October 30). Coronavirus: Front-line workers who left LTC homes in May won’t come back, commission hears. Retrieved from https://globalnews.ca/news/7433503/ coronavirus-ontario-long-term-care-homes-commission/ Thomson, N. (2020, October 23). Trudeau won’t commit to meeting promised deadline to lift all boil-water advisories on First Nations. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/politics/article-trudeau-wont-commit-to-meeting-pro mised-deadline-to-lift-all-boil/ Truth and Reconciliation Commission of Canada. (2015, July 23). Honouring the truth, reconciling for the future: Summary of the final report of the truth and reconciliation commission of Canada. Retrieved from http://www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_ the_Future_July_23_2015.pdf United Nations Department of Economics and Social Affairs. (2019, June 17). Growing at a slower pace, world population is expected to reach 9.7 billion in 2050 and could peak at nearly 11 billion around 2100. Retrieved from https://www.un.org/development/desa/en/news/population/worldpopulation-prospects-2019.html Wallace, D. (2020, March 31). Belgian woman, 90, with coronavirus dies after telling doctors to save ventilator for younger patients. Fox News. Retrieved from https://www.foxnews.com/world/bel gium-woman-coronavirus-ventilator World Health Organization (2017, December 29). Human Right and Health. Retrieved from https:// www.who.int/news-room/fact-sheets/detail/human-rights-and-health World Health Organization. (2020, June 15). Elder Abuse. Retrieved from https://www.who.int/ news-room/fact-sheets/detail/elder-abuse Zafar, A. (2020, March 31). What is a ventilator and who gets one if COVID-19 turns catastrophic in Canada? CBC News. Retrieved from https://www.cbc.ca/news/health/covid19-ventilators-1. 5515550 Zaminpeyma, R. (2020, July 13). Physician suicide: A hidden epidemic. Retrieved from https://sci encewriters.ca/blog/9099528 Zimonjic, P. (2017, August 18). Buildings renamed, monuments fall in recognition of oppression of Indigenous people. Retrieved from https://www.cbc.ca/news/politics/canada-monuments-bui ldings-legacy-1.4248680

Chapter 24

“Initial Responses to the Impact of Covid-19 on Older Persons in Argentina” Lia Susana Daichman and Rosa Ana Silberman

Older persons are important and valuable members of Society who are entitled to an effective and efficient Health Service and to promote not only Health but a minimization of disability in later life. Argentina has a rapidly ageing population, total of 44,50,000 inhabitants, 14.3% 60 years old and over. Buenos Aires is the third aged capital town in the Latin American and Caribbean Region.

L. S. Daichman · R. A. Silberman (B) ILC Argentina, Buenos Aires, Argentina e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_24

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By 1/07/2020 Argentina had 90,680 Covid-19 confirmed cases and 1720 patients have died. Mortality in females and males was 49/51 percent, rate of death in those over 65 was increasingly high, reaching 15–17% in 80 + year. Average age of positive cases in the total population was 42 year and at the beginning of the pick of the pandemic crisis, it spread mainly in the poorest neighborhoods of the country, as poverty appears to be a crucial risk factor that increases the contamination. In general, these people live in overcrowded areas (“villas”), with limited access to services, inter-generationally, many times no running water is available and if they wouldn’t get assistance from the government during all these months, they couldn’t afford enough food or medications either, according to their needs. Argentina has 3,800 Old People Homes, representing 1.3% of the total population of older persons. We don’t have a reliable data for the national level of elders living in Nursing Homes, but in Buenos Aires City we have about 18,500 older persons living there, already 80 deaths and about 650 positive cases. The average mortality in all cases in the city is 2%, and in the older population in Nursing Homes 13%. 80% of the casualties were over 80 year and their average age was 74.9 years old. The Covid-19 pandemic has starkly revealed many sad truths about the inadequate health system, social circumstances, and well-being of older adults around the world mainly in long-term care and nursing homes.

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The National Direction of Policies for Older Adults (DINAPAM), under the Ministry of Childhood, Adolescence and Family of the Ministry of Social Development of the Nation.1 Jose Ricardo Jauregui MD

Update Situation (26/10/2020) Confirmed cases 1,090,589 Recovered patients 8,94,819 Deceased Cases 28,896 M = 51% F = 49% 60 and over 10.5% Active Cases 166,874 ICU occupancy beds:–Nation: 63.5% There are 2,462 Covid-19 Cases every 100,000 inhabitants Death Rate 3%.

Long-Term Care Residences in Buenos Aires City Confirmed Patients 5,198 Deceased 917.

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Economical Impact During the first month of preventive and compulsory social isolation, the Argentina economy fell unprecedentedly, reaching 26.4%, according to INDEC data. For example, the fall it experienced during the month of April exceeded that observed in December 2001 and January 2002 (big Argentinean economic crisis) in full convertibility. In this sense, the National Institute of Statistics and Census INDEC, using data provided by the Monthly Estimator of Economic Activity EMAE, that this institution builds shows us disaggregated and that the contractions which mostly affected this final figure are represented by the manufacturing industry with a drop of 34.4%, commerce with 27% and building that fell by 86.4%. Those three sectors as a consequence of having been declared “non-essential” were the most affected. In relation to commercial premises, according to figures from the same body, only a third were able to function during the month of April compared to the month prior to the arrival of the coronavirus. In some areas such as the automotive, textile, and non-metallic mineral sectors, a certain percentage of the companies did not produce anything during this period; this added to the historical drop in building construction that produced a direct effect on the demand for industrial products such as cement, plaster, steel or iron. According to the seasonally adjusted INDEC index, the drop compared to March was 17.5%. By way of comparison, in the same period it was verified that the Mexican economy contracted by 17.3%, the Colombian by 14.4%, the Brazilian by 9.7%, and the Chilean by 8.7%. The decline in local economic activity was greater than that expected by the majority of private consultancies, notwithstanding the fact that for the next few months it is expected that the declines will ease and that economic activity will show some recovery given that at the beginning of the June 21 provinces already had more than 75% of private employment enabled to work and industry and commerce were already functioning normally in most provinces, the difficulties persisting in the Buenos Aires metropolitan area called AMBA. The EMAE brings together several of the components that make up the Gross Domestic Product (GDP). According to the consultants and financial entities that participated in the latest Survey of Market Expectations (REM), Argentina’s GDP will contract by 9.5% in 2020 due to the pandemic. In a similar vein, the International Monetary Fund (IMF) expects a drop of 9.9%. The newly announced restrictions, related to the extension of the quarantine until July 17, worsen the forecasts for the year and the fall of the economy could deepen to 12%. In addition, the primary fiscal deficit would exceed the record 7% of GDP, given the need to extend aid programs for the payment of wages and assistance to the most vulnerable sectors (the $ 10,000 of the IFE).

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According to data from the Ministry of Labor, in March registered employment had an interannual reduction of 1.7%, with 209,000 fewer workers than in the same month of 2019, with casualties in all sectors, except for public employment.2 At the present time, even if the lockdown is not so strict but continues in several areas, the unemployment rate is 13%, the highest in 15 years.

Long-Term Care Residences for Older Adults in Argentina Throughout the Long-term care Residences, comprehensive care is provided to older people who do not have medical assistance or financial resources. Older people receive what they need and is available and have the rights to an active life which are promoted through different activities. Likewise, institutions and Day Centers are strengthened economically so that they can improve their building facilities and conditions, equipment, and the services they can offer. (Day Centers are not opened since the end of March). Regarding Long Term Care Facilities DINAPAM (National Direction of Policies for the Aged) has 7 Older People Homes in the Province of Buenos Aires and 1 in the City of Buenos Aires. According to the last Census, 2010 in Argentina, there were 3,584 institutions categorized as long-term care residences (3800 at the present time).In the Inter-American Convention on the Protection of the Human Rights of Older Persons approved by the OAS in 2015, the scope and meanings of the LTC facilities are established. In reference to institutionalized older people, the 2010 Census informs us that 76,627 people aged 60 and over were living under this modality, which means 1.3% of the total population for 2010 over the total of older people. (5.725.838). This percentage could be considered low if we take into account countries such as Spain 4.4%, the United States, 5%, and other European countries that have around 4 or 5%, which also present a high rate of population ageing. The accelerated ageing of Latin America and the Caribbean is bringing us closer to the ageing rates of those European countries, so it is logical to think that long-term care residences are increasingly necessary and that neither their regulation nor careful control can be left out.3 In the context of the Covid-19 pandemic, the National Direction of Policies for Older Adults (DINAPAM) has been implementing actions based on gerontological policies to promote, protect, and guarantee the fundamental rights of older people. It has been articulating interdisciplinary and inter sectors with the technical teams of the different provincial, municipal, and civil society organizations. It is a joint effort with the reference centers of each locality. The work of the “Plan Argentina against hunger” was also integrated. Responses are provided to the spontaneous demands that come from older people who are in a situation of social, preventive, and compulsory isolation. Continuing with the activation of protocols and preventive procedures for direct assistance to residents, according to updates from the Ministry of Health of the Nation, in the 8 (eight) LTC residences dependent on this Agency.

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Regular visits are made to see how they work and provide necessary supplies and resources for safety and protection. Weekly meetings of the Emergency Committee (Covid-19) of DINAPAM directors and coordinators are being held. Also, participation in virtual meetings with different International Organizations (ECLAC, OISS). DINAPAM was part of the “Inter Ministerial Round Table of Care Policies”. The 9th National Campaign for Good Treatment towards the Elders is articulated with PAMI. DINAPAM also continues with the inscriptions in the National Registry of Home Caregivers and receives new proposals that come from different NGOs and National Universities. Gerontological webinars are developed on the zoom platform with the participation of renowned national and international professionals in the gerontological field.4

City Government of Buenos Aires General Direction for Dependencies and Primary Care Epidemiological Situation Covid-19 Permanent Residence Households In the four Permanent Residence Homes live 1,318 Residents. Unified protocols were fulfilled, according to the directives of the National Ministry of Health with strict preventive measures in relation to the Visiting regime (none), Health control of residents, Cleaning and disinfection service, Food service, and Case Management of Covid-19 suspects.5

National Institute of Social Security for Retirees and Pensioners (INSSJP) Comprehensive Medical Assistance Program (PAMI). PAMI is the largest medical-social insurance in Latin America which provides Medical and Social Care to 5,000,000 Retirees and Pensioners, their dependents, and Malvinas Veterans.

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Communication in Times of Covid-19 Comprehensive Medical Assistance Program (PAMI) National Protocols and measures were implemented that facilitated communication and care. All other procedures can be managed via the PAMI website. A PAMI application that allows them to call Urgencies and Emergencies. . “PAMI listens and responds” enabled an exclusive line for inquiries: . Automatic renewal of medicines with new modality of electronic medical prescriptions, simple and fast dispensing of medicines in pharmacies, etc. . Physical, socio-recreational, and cultural activities for people affiliated with Social Networks. Nursing Home Programes (PAMI). . . . .

5 Own LTC Residences 563 Agreed Private Residences 95 persons provide Services in Own Residences 22,000 affiliated people across the country living in Long Term Care Residences.

An economic reinforcement was granted for long-term care residences. PAMI created a commission of experts and activated health protocols in order to monitor the course of the disease and take care of the health of their members. Said protocols include strict sanitary measures in the 5 own long-stay residences and the 563 private ones with which PAMI has an agreement. Its mission is to supervise the work of the medical and psychosocial teams in these establishments, such as visits, reception of packages, care, and containment of personnel, among other actions.6

Measures and Socioeconomic Impact on Older People To mitigate the socio-economic impact caused by Covid-19 and in order to preserve access to basic goods and services for the most vulnerable population, which includes the elderly, the unemployed, and informal workers, measures and aids have been implemented economic from the National Social Security Administration (ANSES). . The return of 15% of the value of purchases made with a debit card by all those retirees and pensioners who receive the minimum pension (200us$) and by the beneficiaries of the Universal Child Allowance, Universal Pregnancy Allowance, and non-contributory pensions. . Extraordinary bonus of 3000 pesos (37us$) only once in March for OP. . Exemption and postponement of ANSES Credits from the quotas corresponding to January, February, and March.

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. Tablets were delivered with instructions to promote connectivity and social contact. . Bank hours were later extended temporarily, but one have to make an appointment to get into the bank, if you have to solve a problem, or only who have to charge for Social Security are attended personally. To facilitate the completion of the procedures and the collection of assets or subsidies, protocols were implemented that authorize it to be carried out through proxies or virtual As mentioned in the beginning, all these measures that were applied alleviated the situation but were not sufficient to cover the needs of retirees, pensioners or the elders in general for different reasons. We can mention some: . They do not reach people who are not registered or who live in unfavorable or high-risk areas. . At first they were unable to collect their pensions because for various reasons, they usually used to do so through the cashier, and the banks were closed. . Half of the retirees did not have their debit cards, and this enabled them to collect their money and many who do have, did not know how to use the ATMs. Retirement issues, pension mistakes, or else cannot be managed because the ANSES is closed and only exceptional procedures are carried out.7

Government of the Autonomous City of Buenos Aires–Covid-19 Programs Implemented . Main Older Care It provides telephone assistance to people over 60 years of age or with risk factors and offers help to make purchases in pharmacies, groceries, and local shops, the walking of their pets, among other needs, during preventive and compulsory isolation. (With a network of Volunteers). The Buenos Aires Ministry of Health launched a vaccination plan for people over 65 years. 80 fixed points were enabled to vaccinate against the influenza from April 9th, 2020, days depending on their gender and the latest number of the National Identity Card) (DNI). Contact numbers for prevention and reporting in cases of institutional violence and gender violence are promoted by all possible means and repeatedly. Benefits were granted in relation to the payment of basic services. Workshops, trainings, recreational and cultural shows are offered through all social networks and virtual platforms. Recommendations related to healthy, eating, online physical activity classes, and prevention measures to take care of the body and mind are included.

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. #More Respect for Older Persons It is the campaign against the Mistreatment of older people that from the Ministry of Human Development and Habitat, the City of Buenos Aires promotes an active and productive approach for the more than 650 thousand older adults in the Buenos Aires neighborhoods, which represent approximately 25% of the total population. This approach and actions are also promoted to eradicate abuse and mistreatment.8 The lines of action for people over 70 in very poor neighborhoods were as follows: OP (older people) without symptoms (>70): Social distance with effective support

A. Single or couple households about the same age: Assisted self-distance (500 neighborhood ‘s assistants) B. Multigenerational households: Physical distance with specific care facilities. Other Vacancies (1) 1000 Beds in community centers (2) 500 Bed in specific hotels (3) 100 Bed long-term care residence.

GENERAL DISTANCING FLOW CHART FOR OLDER PERSONS

CESAC (*)

*MEDICAL EVALUATION *VACCINATION

CONTACT WITH TERRITORY AND PREASSIGNMENT OF CENTER

TRANSFER to the CESAC

* DELIVERY OF MEDICINES * CONFIRMATION OF DISTANCE CENTER

TRANSFER AND ENTRY TO THE CENTER

HEALTH MONITORING

* SIGNATURE OF CONSENT

(*)CESAC: Community health center Of all the proposed lines of action were used: assisted self-distancing (500 neighborhood promoters) and Community Centers (7 in total, 2 in very poor Neighborhoods “Villa 15”, 2 in “Villa 21-20”, 2 in Villa“31” and 1 in the Neighborhood “Rodrigo Bueno”). The centers were chapels that were conditioned for this purpose,

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and biopsychosocial assistance was provided through an interdisciplinary team, from person-centered care. The results were very satisfactory, providing older people with constant support throughout the pandemic, learning new trades, meeting new people, exchanging cultures (many people from these neighborhoods are immigrants), and acquiring new tools for health care. Different problems of housing, retirement, and adequate documentation were also addressed, for a better post-pandemic quality of life, always from a human rights perspective.9 Related information of how and how many older people asked for assistance, help, or presented complaints during the pandemic crisis in Argentina from the Government of the City of Buenos Aires, and more precisely from the Secretary of Social Integration for older persons. Considering that this population is more vulnerable to Covid-19 and the mortality rate is higher at this stage of the life course, being the City of Buenos Aires one of the cities in the country with the highest rate of older people (21% according to the projection of statistics and censuses of the City), a comprehensive Plan for Assistance to the elders was developed with three pillars, territorial, personalized attention, through the exclusive telephone line, where queries are answered and assistance is provided in food, psychological support, care, and general health. From the beginning of the crisis, health emergency decisions were taken, working to raise awareness of the risks that this pandemic entails and the preventive measures that should be taken. An exclusive care channel for the elders was launched: line 147 option 2. This channel operates 24 hours per day, seven days a week. To this end, a team was created to answer to the telephone queries that arrive every day regarding different circulation procedures, vaccinations, pension payments, and health consultations. From a diagnosis of the consultations and requests of the first two weeks of the quarantine, a care circuit was developed through which advice and assistance in different matters are provided. On one hand, with a team of professionals and in coordination with NGOs and volunteers. Psycho-emotional support is provided to those who request it. Also, advice and referral for admission to the City Government programs, for example in cases requiring food assistance. Related to health benefits, an articulation channel was created with the Ministry of Health. Regarding care, advice and assistance were provided in cases where home geriatric care was required through the AGDH program. (Domiciliary Assistance Program). To date, July 2020, 52,000 requests were for people over 60 years of age, but some of them called more than once and for different reasons. More than 60 % of the calls were related to alimentary matters. There is a pressing need throughout the world to expand educational opportunities in the gerontological field and especially for elder’s caregivers. The actions of education and training in the discipline invoked are essential elements to promote healthy behaviors and habits to maintain autonomy and the best possible quality of life for older people. At this point, it is Law 5671/16 GCBA, in its article 4 and through its enforcement authority. It is the Secretary of Promotion and Social Integration for the Elderly, who sets this type of educational activity with the objective of training qualified human resources

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in gerontological matters to be able to aid, support, and comprehensive care to vulnerable older adults. It was designed and dictated, from the enactment of the law, the initial training course of gerontological assistant in its two modalities, domiciliary and institutional. Measures were also taken from the pandemic, which is why a platform was generated to continue training gerontological human resources in a virtual way. At the present time not only, the initial course is offered, but also specializations and forums for gerontological assistants. It should be noted that Law 5671/16 also created the Single Public and Official Registry of Gerontological Assistants of the City, which today has 5,000 enrollees whom they train and assist through the Advisory Gerontological Assistant system.10

Complaints of Older Adults

Office of Domestic Violence The Office of Domestic Violence (OVD) was created in 2006 by the Supreme Court of Justice of the Nation with the aim of facilitating access to justice for people who, affected by acts of domestic violence, are in a particularly vulnerable situation. In 2016, the Supreme Court began handling cases of trafficking in persons for the purposes of sexual exploitation and/or exploitation of prostitution. In these cases, the Supreme Court indicated that affected persons and also persons who have a family and/or affective link with the affected persons can file complaints. Usually, between 70 and 80 complaints are received monthly. In 108 days from the start of the pandemic, the number of complaints, due to confinement, fell in a very worrying way… 9 out of 10 victims had a family relationship with the person reported (the subsidiary represents 56% of those over 75 years of age). The people reported, mostly men (70%), were between 22 and 59 years old (71%). The types of violence reported were psychological (96%), physical (46%), domestic environmental (43%), and financial property (39%), among others. It is also noted that 92% of the cases were referred to criminal justice; 90% to legal advice; 49% to the Health system; 49% to the Protect program of the Government of the City of Buenos Aires.11

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New Types of Elder Abuse Among the various forms of abuse and mistreatment against older people, we have financial abuse that consists of inducing by means of abuse of trust, that a person give us their property or take possession of it without the person noticing this criminal action. The Covid-19 pandemic represented an opportunity for those who abuse and economically mistreat older people, as well as the vulgarly called “uncle’s tales”; thus referring to deceptive stories to make people fall into the cheating new forms of abuse were added. On the one hand, these malicious tales or stories were adapted to the new circumstances that generated new Social Security benefits for the elderly. They enter the home for criminal purposes depriving them not only of their property but in many circumstances also of their life. In other circumstances, the scammers make a phone call in which, using data obtained from the systems and through false promises to grant an advance on pensions or a loan as financial aid, they tell the person to go to the ATM and they are summoned there so they can empty their bank account. In addition, a considerable increase in the so-called long-standing cybercrime was detected, but during the pandemic, it appeared as a new form of financial abuse against older people, whom these cybercriminals were able to identify a new vulnerable group to attack. Screens at this time are the window to the world and to being able to communicate and contact loved ones, but according to data provided by the Argentine Social Debt Observatory of the Argentine Catholic University (UCA) according to a survey conducted before the pandemic, the use of networks and technological connectivity was much lower in the elderly population compared to the under-60 population. Why then quarantine is an opportunity? Because by being isolated in their homes, many people who previously did not habitually use new technologies, social networks, smartphones, or did not do it so regularly - among them many older peoplenow do, but they are not so familiar with the care that must be taken with the handling of their personal data. Isolation is necessary to point out the loneliness that generates anguish and despair. All these ingredients, a person unaccustomed to the use of the networks, isolated, distressed, and with economic problems is the propitious scenario for cybercriminals to put into practice a set of deceptive maneuvers, so that people fall into the trap, which it is called SOCIAL ENGINEERING. The social engineering techniques that criminals use are called baits, they offer something that most people want, for example, a sophisticated cell phone, this is the bait, to get it you must click on a certain link that will download a so-called “file malicious” or from a fake email, or pretending to be someone else, using text messages or tricks to make you believe that your computer is infected with a virus and the respective antivirus will be on that site. All these social engineering strategies aimed at committing fraud can be generically called PHISHING.

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Phishing is one of the oldest and best-known internet scams, we can define it as a type of fraud in telecommunications that, using social engineering tricks, obtains private data from its victim. In order to combat these new forms of financial abuse, the official bodies, the National Institute of Social Services for Retirees and Pensioners, PAMI, and the National Social Security Administration, ANSES, issued warning messages indicating the lines of complaints.12 For their part, various NGOs that work for older people provide permanent informative talks on these new forms of financial abuse, and videos have been produced in order to disseminate official data to prevent older people from being victims of these new crimes.13

Accountability and Justice 1. So far, the health and care system for elders and people with disabilities has not collapsed, so coverage of Covid-19 has been achieved. The main problems presented in the health field are: compliance with protocols for prevention and action against Covid-19, sufficient access to test detection, and suitable equipment for the staff mainly working in long-term care and persons with disabilities. Also, the conditions of structural inequality in which older people with disabilities live in vulnerable neighborhoods. The most important trigger factor has been the lack of economic resources and, to a lesser extent, the delay of the enforcement authorities in implementing the protocols and the development of the audits required to ensure compliance with all standards of prevention. 2. About situations of abuse or violence, Domestic Violence Office (OVD) of the Supreme Court of Justice of Argentina reported that during the first quarter of 2020, 6% of the victims were elders (over a total of 2,664 cases treated of whom 3,665 people were affected). Due to the mandatory quarantine-imposed form on March 20, a fall of 13% of reported cases was registered with respect to the same period of the previous year. In addition, according to the report made by the Femicide Observatory in Argentina, coordinated by the Association La Casa del Encuentro, between March 20 and June 11, there were 11 gender-based killings whose victims are adult women over 60 years old.14 What measures have been taken by public and judicial authorities to address such allegations and to establish accountability, if applicable? Have any disciplinary, public inquiries, or court cases been initiated, including against managers of the institutions concerned? The American continent was the first region worldwide to draw up a Human Right Treaty for the elderly within the frame of the Organization of American States (OAS).

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On June 15th, 2015, the General Assembly approved the “Inter-American Convention on Protecting the Human Rights of Older Persons”, which establishes a new paradigm of ageing, old age, and fundamental rights for the older persons. As mentioned, it has been in force in the regional system since January 2017 (Organization of American States 2015). The Inter-American Convention has encouraged the development of Elder Law in the region and has opened new possibilities for the protection of the Rights of the Older Persons.

National Executive Power 1. The National Government developed specific protocols to guarantee the rights of the elderly to health care by Covid-19 (and others), and the right to be assisted in long-term care institutions and mental health institutions for elders and people with disabilities. The Government have taken into account the recommendations of WHO, UN, the OAS, and the standards established in the Inter-American Convention on the Protection of Human Rights of Older Persons, in force at the Inter-American Human Rights and at the Argentine law. At the national level, the following protocols should be mentioned: (1) Recommendations for the prevention and approach of Covid-19 in Long-term care services, by the National Ministry of Health, March 2020. (2) Covid-19 virus. Protocol of action for Long-Term Care Residences of Older Adults, of the National Ministry of Social Development (National Secretariat of Childhood, Adolescence, and Family), March 2020. (3) Recommendations on Admission in monovalent Mental Health institutions in the context of the Covid-19 pandemic, from the National Review Body of the National Mental Health Law, April 2020. (4) Protocol for admission and re-entry in establishments and Services of Mental Health and Addictions, in the framework of the emergency of the National Ministry of Health, May 5, 2020. (5) Recommendations for the care and attention of the Health / Mental Health of Older Persons in the framework of the pandemic, of the National Ministry of Health, July 7, 2020. (6) Protocol of support and care systems for people with disabilities hospitalized by pandemic, of the National Ministry of Health and the National Agency for Disability, July 2, 2020. In addition, the Autonomous City of Buenos Aires and each of the 23 provinces of Argentina developed regionals protocols in accordance with the Argentine Federal legal system to deal with the pandemic of the Covid-19.

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National Parliament In the Argentine Congress, the National Senator Norma Durango presented a draft to regulate the “Protection and Care System for persons at Risk in Humanitarian Emergency Situations”. The system includes the protection and care of people in situations of vulnerability to threats, disasters, or emergencies “girls, boys and adolescents, people with disabilities and elders, whatever their gender, economic or cultural context”; and it covers the process of prevention, intervention, reconstruction and recovery measures that are adopted. The rules contained are of public order and integrate policies implemented. The system is founded on International Humanitarian Law and on the International Human Rights Treaties. Its principles are (a) Dignity. (b) Equality and non-discrimination. (c) Respect for gender and cultural diversity. (d) Good treatment and preferential and expedited protection. (e) Resilience, solidarity and institutional, family, and community cooperation. (f) Sustainability in the planning and development of humanitarian aid. (g) Transparency, proportionality between means and ends, coordination, effectiveness, and continuous coverage throughout the country. (h) Access to accurate information for the entire population. 1. Judiciary There have been judicial remedies for economic coverage detection tests for Covid-19 and the required adequate working clothing. In all cases, judges have ordered the payment to different types of health insurance systems, including private hospitals, as appropriate in each case. Legal actions that have been processed have been resolved fast enough, according to the urgent need for answers imposed by the pandemic. 2. Civil Society It is important to highlight the role of citizens, professionals, Directors of care and health facilities, Universities, and Argentine NGOs both in identifying problems and in finding solutions. So, they have formed numerous extensive networks that enabled spaces for reflection and awareness through the development of campaigns, seminars, participation in newspaper, radio, and television programs, and use of social networks, among others. This has had a positive impact on the media and the authorities responsible for carrying out the policies relating to the pandemic, providing an important social role of auditors of the effectiveness of public policies in this area. Dr. Isolina Dabove, Lawyer specialized in Older Persons Human Rights.

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Older Adults Regarding Gender-Based Violence in Quarantine The Ministry of Social Integration for the Elderly, under the Ministry of Habitat and Human Development of the Government of the City of Buenos Aires, has among its missions and functions to design and implement policies for comprehensive assistance, protection of rights, social inclusion, and access to new technologies for older people in the Autonomous City of Buenos Aires. The General Direction for Protection and Sustainable Development, which is in charge of the Operational Management Protection of Rights, works within its sphere and under its orbit, the PROTEGER PROGRAM, created in 1998. Throughout its years of existence has assisted elderly victims of abuse, mistreatment, and violence in its various forms, offering psychosocial assistance, emotional support, access to judicial protection, and in those cases in which the safety or life of the victim was at risk favoured the referral to the Accommodation Device Protected (DAP) also called “Shelter”. The main objectives are to promote the prevention of violence against older people through actions aimed at all risk factors of the problem. The approach to cases that enter the Protect Program is carried out by an interdisciplinary team made up of: Psychologists, Social Workers, and Lawyers. There is a Prevention and Training area that consists of awareness-raising, dissemination, and training activities within the Program and with external Judicial, Security, Health, and Social Organizations. During the last seven years, training has been also carried out for the police personnel of the City of Buenos Aires, both officers and Heads, and professionals who work in the area of gender in order to provide tools for taking complaints in cases of violence against older people. Of the cases that have been treated during the quarantine in the Protect Program, 80% are women and 20% are men. Older people in general, and women in particular, by the mere fact of being women and older adults, experience situations of violence (physical, psychological, sexual; economic and patrimonial, abandonment) in their homes, in institutions, in care centers, and in society in general. In the context of violence against older women, it is observed that the main perpetrators are their own children, a greater proportion of middle-aged men, unemployed, with a history of violence, and living with the older adult. In statistical terms, the second place in relation to the percentage of perpetrators is occupied by the spouse or partner. In these situations it is observed, 78% of cases that the violence suffered is long-standing, in some cases for 30 or 40 years, which is why it is more naturalized and invisible, representing an obstacle for older women to support the complaint and request protection measures such as exclusion from the home and/or perimeter restriction.15 During the quarantine, the income of cases due to violence increased with 378 new cases admitted, higher than the same period during the year 2019. Also, there was an increase in the age group of 80 years and over. It must be considered that dependency in the older adult population is accentuated in the age range

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of 80 years of age and over, which also increases risk and vulnerability situations in older women. Among the offenders, we found that 71% were males and 29% were females. The situation of compulsory social isolation has led to an increase in cases of violence perpetrated against older women and a decrease in the resources available to request assistance in the context of the health emergency. Let’s think that one of the strategies used by the perpetrators to perpetuate their power is to isolate the victim, which is considered one of the main risk factors for the increase in violence. That is why the physical proximity to the perpetrator by remaining confined in the home during the quarantine, hinders the possibility of access to resources to get out of the situation of violence. Older people center and civil society organizations often form part of community networks where older people participate and are the first places they turn to for support in the face of this problem, which is now affected by the quarantine situation.

Violence: The Refuge The Secretary of the Third Age of the Buenos Aires city offers a secret refuge for elders who denounce their relatives for mistreatment, physical violence, or abandonment, and who needs, by judicial order, to live in a protected and anonymous way until their situation is resolved. They are not only verbally abused, insulted, and even beaten, but also prevented from using their own money or disposing of their own property. Since the refuge was created in 2014, more than one hundred people have passed. The photos in the files show how they were when they got there. They arrive in a pretty bad state. However, when you enter the refuge, which has a location unknown even to the Head of Government, you might hear them start laughing, singing, and talking to each other. There are mandalas on the walls. After a few months in this house, most seem to be someone else. With the necessary care, the correct medical assistance, and in an environment without the harassers nearby, they appear several decades younger. They regained dignity and begin to feel alive. The cases go to the Office of Domestic Violence, the court is given participation, and the judge considers that they should be protected. In the refuge they receive medical attention and care, food, participate in workshops, and are involved in all house activities. The most extreme cases that are reported come to this refuge, in which the family must be prevented from finding the person to guarantee their life. Really in most cases, there is also a situation of financial abuse. However, this legal figure is not so well known and perceived in the first instance by those who denounce it as a situation of abuse.

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The reality of gerontologists who work in the Public Health System in the face of the Covid-19 pandemic in Argentina For the reason that the population served by gerontological and geriatric services were considered as a risk group for Covid-19 disease, both patients and professionals over 60 years of age were part of the preventive and mandatory social distancing. This is why these were the first to re-functionalize and restructure and perform a double task. On the one hand, all groups of older people who attended the workshops at the Hospital (movement, memory, chikung, health promoters), became virtual (whatsapp/ZOOM); as well as faceto-face consultations, they became telephone calls. Participation in courses for specialists, caregivers, and other academic activities became virtual with the work involved in restructuring classes and in some cases, certain courses had to be suspended due to the impossibility of modifying them in a timely manner, and the increase in hospital work. At the level of hospitalization, in some Hospitals, the Geriatric places became a “Covid ward”, with all that this implies and serving all ages and others were created in order to be a “non-covid” medical clinic (for all ages), directed by geriatricians and with the support of medical surgery residents. Overcoming all these difficulties, most geriatricians felt exhausted; since they have the double task of maintaining the health care of the population that had been attending pre-pandemic plus all the new activity during the pandemic and with personnel not trained for special tasks. All this for a very long period of time (from mid-March, until September) and with large periods with fewer staff since as some of them were infected, while the non-infected were overloaded with work. Feelings and symptoms that were experienced with this kind of situation were multiple and varied: anguish, fatigue, concern for the older people whom they could only attend to by phone, living daily with death and dying, and making all this compatible with taking care of their own health and of their families; the responsibility to take care of themselves to continue caring and “the feeling of guilt, so as not to fail the people”, who needed their care more than ever. In addition to this, have the uncertainty of when this atypical way of working will end, who are the people who will remain, and how they will return to the “new normal”. Maya Sinjovich MD

The Media The Covid-19 pandemic exposed to the public the National Health System, lack of social care and assistance, inequalities, but also AGEISM. That older adults were one of the risk groups caused and increased prejudice with the spread of a virus. During the last years, misconceptions about ageing and old age were tried to be overthrown, but they were still latent in society, and as the media were no strangers this became present daily.

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We frequently observe how on television, radio, and newspapers the stigmatization and massification of the most heterogeneous population group falls. They are called “grandparents”, “granny”, depersonalizing and reducing their entire life and experience to an exclusively family bond. They are also shown as fragile and dependent, and become infantilized when they are even questioned on their capacity for self-care and caring for others. As a result of the media treatment that was being carried out during the pandemic, different NGOs, Universities, gerontologists, geriatricians, and journalists dealing with old age issues noticed the situation and issued Statements and Recommendations of good practices to communicate about and to older people. The National Institute against Discrimination, Xenophobia and Racism (INADI) noted that “words can serve to discriminate, to label but also to raise awareness, open new horizons and fight discrimination” and recalled the “Manual of Inclusive Communication for Communicators -Seniors”. The Public Defender’s Office released “Ten recommendations for those who communicate about older people.” The Direction of Communication and Senior Citizens of the Faculty of Journalism and Social Communication of the National University of La Plata (UNLP) also presented a series of recommendations. The Career of Communication Sciences of the Faculty of Social Sciences, University of Buenos Aires (UBA) and “Colectivo de Ideas” launched the Campaign #Seamos Responsables con la Comunicación on social networks (Let us be responsible). Another one was “Let’s make a deal: Grandfather, NO, Older person, YES”, from the master’s degree in Old Age, Faculty of Law, National University of Córdoba (UNC) among others. There was neither consultation nor participation in decision-making process during the pandemic by the National Government or the City of Buenos Aires Government. Hopefully and due to the influence of several International and National NGOs and Civil Society Campaigns, older people have the opportunity of expressing their thoughts, feelings, and desires for the near future and ways to recover from Covid-19 to make it a more inclusive and age friendly society. Acknowledgements We are grateful to the Executive members of ILC Argentina, Argentinean Society of Gerontology and Geriatrics (SAGG-IAGG) Professionals of the Government of the City of Buenos Aires, Secretary of Social Integration, the University of Law (UBA), CONICET and the University ISALUD.

Notes 1. 2.

Ministerio de Salud de la Nación http://www.msal.gob.ar/index.php?option=com_bes_conten idos. https://www.buenosaires.gob.ar/coronavirus/protocolos-coronavirus-covid-19. The National Institute of Statistics and Censuses (INDEC) http://www.indec.gob.ar/ https://www.argentina.gob.ar/trabajo Ministerio de Trabajo de la Nación. https://www.indec.gob.ar/indec/web/Nivel4-Tema-4-31-58%20Indicadores%20al%2023/06/ 2020.

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4. 5.

6.

7. 8.

9. 10.

11. 12.

13. 14. 15.

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https://www.uia.org.ar/centro-de-estudios/%20Informes%20de%20la%20Uni%C3%B3n% 20Industrial%20Argentina. Ministerio de Desarrollo Social de la Nación https://www.argentina.gob.ar/desarrollosocial/ ninezyadolescencia/materialescovid19/protocolos https://www.argentina.gob.ar/desarrollosocial/hogaresparaadultos. Gobierno de la Ciudad de Buenos Aires https://portal.coronavirus.gba.gob.ar/docs/instituci ones/Protocolo%20para%20la%20prevenci%C3%B3n%20y%20control%20de%20COVID. https://portal.coronavirus.gba.gob.ar/docs/instituciones/Protocolo%20para%20la%20prev enci%C3%B3n%20y%20control%20de%20COVID Hogares de residencia permanente | Buenos Aires Ciudad …www.buenosaires.gob.ar. Comprehensive Medical Assistance Program (PAMI) https://www.pami.org.ar/pdf/reside ncias_y_centros_de_dia.pdf https://www.pami.org.ar/saberesprevenir. National Social Security Administration (ANSES) http://anses.gob.ar. Gobierno de la Ciudad de Buenos Aires. https://www.buenosaires.gob.ar/experienciasencasa https://www.buenosaires.gob.ar/coronavirus/mayorescuidados/delivery-para-personas-may ores-de-70. http://www.lanacion.com.ar/2023597-violencia-el-refugio-que-protege-a-las-personas-may ores. Buenos Aires Ciudad - Gobierno de la Ciudad …https://www.google.com/search?q=www. buenosaires.gob.ar-el-nuevo-147&rlz=1C1GCEU_enIN958IN958&oq=www.buenosaires. gob.ar-el-nuevo-147&aqs=chrome..69i57.398j0j4&sourceid=chrome&ie=UTF-8. Corte Suprema de Justicia de la Nación Oficina de Violencia Domestica. http://www.ovd.gov.ar/ovd/. https://www.diarioelargentino.com.ar/noticias/206098/pami-alerta-por-estafas-con-la-tar jeta-alimentaria http://diariotortuga.com/2020/04/23/desde-pami-y-anses-alertan-por-posibles-intentos-deestafa/ Sanchís Crespo, Carolina; Velasco Núñez, Eloy; Delincuencia informática. "Tipos delictivos e investigación con jurisprudencia tras la reforma procesal y penal, editorial-tirant-lo-blanch, 2015. https://youtu.be/8ILZiMaTS7A. La casa del encuentro. http://www.lacasadelencuentro.org/femicidios.html. Ministerio de Justicia y Derechos Humanos https://www.argentina.gob.ar/justicia/derechofa cil/leysimple/-19-aislamiento-y-distanciamiento-social Ministerio de Justicia y Derechos Humanos https://www.argentina.gob.ar/justicia/derechofa cil/leysimple/covid-19-aislamiento-y-distanciamiento-social Ministerio de Justicia y Derechos Humanos - SAIJ - http://www.saij.gob.ar/buscador/jurisp rudencia-nacional DABOVE, María Isolina, Derecho de la vejez. Fundamentos y alcance, Buenos Aires, Astrea, 2018. DABOVE, María Isolina; Derechos humanos de las personas mayores. Acceso a la justicia y protección internacional, 2a ed., Bs. As., Astrea, 2017.

Chapter 25

Encounter of Older People in Sub-Saharan Africa with COVID19: A Review of Literature Dolline Busolo

Abstract This chapter presents the results of a literature review of 34 studies on the effect of COVID-19 on older people in Sub-Saharan Africa. The review shows that persons aged 60 years and above constituted over 50% of the deaths in the African region associated with COVID-19. The studies reveal that the risk factors for COVID-related deaths and infections were being male and advanced in age as well as those with existing comorbidities, delayed access to critical care service, reduced income, and social support. The studies highlight the situation of older people in long-term care facilities that showed a higher case fatality among those advanced in age and lack of transport to access the location of the care facility. The studies highlight how measures such as physical distancing and the overall challenges and conditions surrounding COVID-19 resulted in fear and anxiety among older people in these facilities. The studies show that though comorbidities were a risk factor for COVID-19 for all demographic groups, they elevated the risk for older people. Hypertension and diabetes were identified as common comorbidities that elevated COVID-19 deaths and infection among older people in Africa. The social, health, and economic effects of COVID19 on older people examined by the studies included loss of jobs, loss of businesses, contracting Covid 19 virus, hospitalization, fear that the impact of the containment measures could kill the older adults faster than the virus itself, a feeling of neglect and underestimation of healthcare needs of older adults, seeking for an alternative positive health-seeking behaviour among the older adults, and the concern about the absence of functional policy and plan to address the welfare of older adults. The studies revealed that social protection and universal pensions were key interventions for addressing the impact of COVID-19 on older people. These interventions became necessary because, during the Covid 19 lockdown, older people experienced reduced access to income, limiting the purchase of medicines and access to health care services. One study shows that older people who received old age grants utilized it to support their adult children and grandchildren. Keywords COVID-19 · Encounter · Older people · Effects · Sub-Saharan Africa · Mortality · Comorbidities · Mitigation · Social protection D. Busolo (B) Karen Ridge Road, Box 51884, Nairobi 00200, Kenya e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 M. K. Shankardass (ed.), Handbook on COVID-19 Pandemic and Older Persons, https://doi.org/10.1007/978-981-99-1467-8_25

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Introduction Research on the effects of COVID19 on older people in Sub-Saharan Africa is relatively new and no comprehensive literature review has been conducted on this constantly expanding body of knowledge. There is substantial synthesis of research findings on nutrition, HIV/AIDS, and human rights of older people in Sub-Saharan Africa (Nachega et al., 2021). But minimal if any synthesis on elder people and COVID19 in Sub-Saharan Africa. However, the expanding studies on COVID19 and older people in Africa remain scattered in different publications and organizations and one must look hard for this information to make a decision on further research and policy action. This chapter addresses this gap in knowledge by presenting and discussing a synthesis of emerging research of 34 studies on the encounter of older people with COVID19 in Sub-Saharan Africa. The literature review question addressed is: How has COVID19 affected the physical, socio-economic, psychological, and mental health well-being and relational boundaries of older people in SSA.

Methods An extensive search for studies was conducted to gather information for this chapter. As is the practice in literature review (Mullen & Ramırez, 2006). The search started off with determining the key words to enable an effective search of databases. The following keywords were identified: COVID19, older people, Sub-Saharan Africa, mortality, COVID-19 infection, comorbidities, older people specific interventions, effect, impact, factors, ‘predictors’, ‘mortality’, ‘fatality’, ‘death’, ‘elderly’, ‘older people’, ‘COVID-19’, ‘coronavirus disease, ‘geriatric’, ‘SARS-CoV-2 cases. In line with the principles of literature review (Moher, Alessandro, Tetzlaff, Altman, and the PRISMA Group. Preferred Reporting Items for (SR) and MetaAnalyses: The PRISMA Statement. Ann Intern Med (2009), inclusion criteria were established for studies to be considered. Four criteria were identified- Studies should have: • been conducted from 2020 when COVID19 started affecting and being reported in the African continent. • examined the social, health, economic, and environmental effects of COVID19 on older people as well as mitigation strategies • been based on surveys, case studies, retrospective approaches, clinical studies, and other methods. • focused on Sub-Saharan Africa. Search words identified earlier were used singly and in combination during the search for literature. Science, PubMed, and Google Scholar were the main databases searched. The search and assembly of the potential studies for consideration were

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Identification

done from 5th March 2020 to 30 April 2022. In addition, more studies were identified from citation tracking. The database search identified 501 studies. Another 49 studies were identified from other sources and added for screening. A total of 240 potentially relevant studies were screened after the removal of 310 duplicates. Based on title screening, 163 articles were excluded. Seventy-seven articles were screened. Against the eligibility criteria, 34 articles met the inclusion criteria literature review. Figure 25.1 shows the process of selecting studies for review. Each of the selected studies was examined and information extracted based on the focus of the study, geographical setting, methods, and results (Each item extracted was examined to identify patterns and themes into which to organize and present the findings). Several rounds of pattern and theme identification were undertaken,

Records identified through databases (n = 501)

Records identified through other sources (n = 49)

Records identified through databases and other sources (n= 550)

Screening

Records screened (n = 240)

Included

Studies assessed for eligibility (n = 77)

Fig. 25.1 Selection of studies for review

Studies included in review (n = 34)

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leading to the grouping and regrouping of themes by each item presented in the next section.

Results and Discussion A summary of the results of the literature review is presented below, highlighting area of focus, methods, and empirical findings of the 34 studies synthesized.

Focus of Studies The 34 studies reviewed for this chapter focused on the following themes: (a) access to basic needs and services specifically food, health, income, humanitarian assistance, water, and sanitation, (b) mortality and risk factors for mortality for older people including those in Long-Term Care facilities (LTCFs) (c) socio-economic and wellbeing and role of social workers, (d) basic needs and (e) the role of social protection and social assistance in mitigating the impact of Covid 19. While some studies focused on one theme, others examined more than one theme. The theme on social, economic, and health impacts attracted a substantial number of the 34 studies. As it can be noted, these themes have been of interest in studies on older people and the main difference here is that they are analyzed in the context of COVID19. To a large extent, these studies are a continuity of the research on older people with COVID19 providing a specific challenging context in which to examine its effects on this sub-population in Africa. The findings on these themes are fully discussed in a later section on empirical results.

Geographical Setting Five of the studies were global with mentions of specific countries in SSA; one was Africa-wide, 5 sub-regional, five districts, and 8 nationwide. Moreover, 8 were in localized camp/humanitarian settings in different countries, one was in a village/local council setting while two analyzed data from a hospital setting. From the study by Mashige et al. (2021), East and Southern African respondents reported the highest impacts of COVID-19 (about one-third of the respondents) followed by Central, and the least impact was found among West African respondents. This was also confirmed by the multivariable analysis which revealed similar results. More studies were undertaken in South Africa than elsewhere as demonstrated by several references compared to other countries in SSA. These studies are a reflection of the diversity within the continent and also to some extent the socio-economic status and population of older people in Africa. South Africa has the highest segment of the

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population of older people in Africa. These studies informed other studies in the sub-regional and Africa-wide reviews. This is further discussed in the results and discussions section.

Methods Eighteen of the 34 studies were based on surveys, 7 were retrospective descriptive studies analyzing hospital based data on mortality in hospitals and LTCFs, 3 used mixed methods particularly semi-structured and key informant interviews and case studies in addition to surveys to validate findings, 5 used semi-structured interviews and key informant interviews, while 3 were based on literature review. The sample size of studies varied from 11 people in a focus group discussion to 219 265 mortality data from hospital statistics. Most of the studies varied between 30 and 100. Because of the small sample size and localized rather than national studies, the information may not be generalized to represent the national status.

Empirical Findings A synthesis of the findings in the 34 studies generated five themes: prevalence and risk factors for mortality of COVID19, economic, social, and health impacts of COVID19; access to basic needs and LCT facilities services and social protections as a response mechanism. Details about these themes are presented and discussed in the sections below.

Prevalence of COVID19 Infections and Risk Factors for Mortality Among Older People The following sub-themes emerged under this major theme: prevalence, characteristics of the disease mortality, comorbidities, and long-term care facilities. The WHO Africa regional office study (2021) on COVID19 and older people in Africa, revealed that overall, persons 60 years and above represent a significant proportion of lives lost in the global pandemic and over 50% of the deaths in the African region. The study which aimed to gather and analyze health, social and economic data available on COVID-19 in older people in African countries, revealed that even though mortality rates had been lower in the region than elsewhere, the region had the highest mortality rate (48.2%) among critically ill patients globally (31.5%). This was attributed to the delayed access to critical care and to the presence of non-communicable diseases prevalent among older people advanced in age.

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Regarding the prevalence of COVID 19 among older people, Gyasi (2020), revealed that as of 2020, the case fatality ratio by disaggregated age stood at 14.8% for those aged above 80 years, 8.0% for 70–79 year olds, and 3.6% for 60–69 year olds compared to 0.2–0.3% for those less than 45 years of age in the SSA region. The high fatality rate was associated with advanced ageing. The study also observed that the high fatality rate affected the mental health of older people and needed further investigation. Lark et al. observed that, globally, the people infected by Covid 19, needing hospitalization ranged from