Older people and COVID‐19: Isolation, risk and ageism

Internationally, health authorities and governments are warning older people that they are at a higher risk of more serious and possible fatal illness associated with COVID-19. Mortality data from Oxford COVID-19 Evidence Service (25/3/20) indicate a risk of mortality of 3.6% for people in their 60s, which increases to 8.0% and 14.8% for people in their 70s and over 80s. Therefore, the global recommendation for older populations includes social isolation, which involves staying at home and avoiding contact with other people, possibly for an extended period of time, currently estimated to be between three and four months. Older populations in this current context refers to people over 70 years and 50 years in some particularly vulnerable Indigenous populations. Social isolation includes avoiding social contact with family members and friends, organising the delivery of essential items, such as groceries and medications, where social contact is also to be avoided by maintaining a distance of two metres from the person delivering goods. Over the course of the pandemic, we have seen evidence of openly ageist discourses, which we argue, complicates the experiences of living through COVID-19 for older people. There have been distressing reports of older people abandoned in care homes (Keeley, 2020) and concerns about the representation and positioning of older people in the social media discourses around COVID-19. Ageism evident through phrases such as #BoomerRemover has emerged in relation to COVID-19. The hashtag #BoomerRemover has even been trending on social media platforms; often accompanied with ageist disparaging and devaluing memes (Sparks, 2020), as well as considerable media coverage and online discussions and commentary about potential for rationing of care with older people being potentially disadvantaged and positioned as more expendable than persons in other age groups. Some of the coverage seems to suggest that the death of older people somehow is not as important as loss of life of younger people (Haffower, 2020). These ageist discourses and the subtext of negativity and devaluing of older people can and will very likely contribute to feelings of worthlessness in older people, a sense of being burdensome and having no value. These factors when considered in relation to current social restrictions make older people particularly vulnerable to a range of negative health and social outcomes, particularly social isolation and loneliness. We know that loneliness is a real risk factor to the health and well-being of all people, and even in the best of times, older people can be more vulnerable to being lonely. Social circles can decline with ageing, due to factors such as the development of long-term conditions and deteriorating health, death of partners and friends, so older people may have fewer closer relationships and may be more likely to live alone (Victor & Bowling, 2012). Environmental barriers also impact on social isolation and loneliness of older people, such as the feeling of being unsafe in their neighbourhoods and there can be a lack of resources to support socialising or attending activities, leading to both boredom and inactivity (Cohen-Mansfield, Hazan, Lerman, & Shalom, 2016). Social isolation and loneliness are related but distinct concepts. Social isolation refers to a lack of contact with or physical separation from family, friends, or broader social networks and the lack of involvement in social activities (Valtorta & Hanratty, 2012) and is due to environmental restrictions, rather than an individual's ability to create or maintain social relationships (Tanskanen & Anttila, 2016). Loneliness is a complex, subjective emotion, experienced as a feeling of anxiety and dissatisfaction associated with a lack of connectedness or communality with others, and a deficit between the actual and desired quality and quantity of social engagement (Victor, Scambler, Bowling, & Bond, 2005). Social isolation and loneliness are correlated, albeit weakly (Steptoe, Shankar, Demakakos, & Wardle, 2013); however, these terms are often used interchangeably. The acknowledgement of social isolation and loneliness of older people is essential and paramount due to the detrimental impact on their physical and mental health, which has been recognised for over two decades. Social isolation and loneliness increases older people's risk of anxiety, depression, cognitive disfunction, heart disease and mortality (Barth, Schneider, & Kanel, 2010; Holt-Lunstad, Smith, & Layton, 2010; Santini et al., 2020; Shankar, McMunn, Demakakos, Hamer, & Steptoe, 2017). Prior to COVID-19, this was acknowledged in health and social care policies and campaigns. In the UK, the Campaign to End Loneliness (2011) created a network of national, regional and local organisations to work together to ensure that loneliness of older people remains a public health priority. Similarly, the government in New Zealand committed to a vision of positive ageing principles to promote community participation and prevent social isolation (Ministry of Social Development, 2001). There is also a need to recognise that older people who previously had not reported being socially isolated and lonely may be disproportionately affected by the requirements of social isolation due to COVID-19, because of the removal of social contacts, which may have occurred during grocery shopping, attending community groups and places of worship and other day-to-day activities. As well, older people may be adversely affected by the ageist discourses that may seem to imply that the loss of older life is not as important as loss of life of other age groups. Alongside, the recognition of the continued impact on older people who do not have friends or family members and rely on social care, who may feel further isolated, especially when services become disrupted. A further population of older people who are at risk of becoming more socially isolated are those residing in residential care homes, as their friends and family members are not currently permitted to visit. Therefore, there is an urgent need to support older people to mitigate the negative impacts on their physical and mental health from social isolation and ageist discourses around COVID-19. We must support older people to have and retain their connectedness and communality with others to better enable a sense of belonging. One immediate element that needs to be highlighted is the possibility of previously vigorous older people becoming increasingly frail due to reducing their activities, especially walking, and leading an (enforced) more sedentary lifestyle, which will likely impact on their mobility and well-being over time (Hartmann-Boyce, Davies, Frost, Bussey, & Park, 2020). Along with social isolation, social distancing has been recommended when older people leave their homes for essential items and exercise. The terms social isolation, self-isolation and social distancing have often been applied interchangeably potentially causing confusion. Self-isolation refers to remaining at home when someone has symptoms of COVID-19, been in contact with someone with symptoms, or on return from overseas; usually recommended for 14 days, rather than for an extended or continued time period. The advice for older people is to maintain social isolation for an extended period, with all the attendant risks that entails. One response from Public Health England on 29 March 2020 included the publication of guidance on maintaining mental health and well-being during COVID-19 social restrictions (Public Health England, 2020). The guidance for older people included the importance of staying connected and getting practical help, alongside the provision of an Age UK helpline phone number, but no advice on how to achieve staying connected, or how this could be achieved nationwide for every older person. There has been a media campaign to recruit volunteers to support older people who might otherwise have fallen through the cracks, but is this a robust and inclusive approach to ensure no older person is left isolated, or sustainable over an extended period of time? Other responses to socially support older people have included the development of social networks through online technologies, such as Facebook, Twitter, WhatsApp and other similar platforms. In the UK, one example is the development of social networks through WhatsApp, supported through the national Neighbourhood Watch scheme, encouraging people to get online and talk. Other initiatives wider than the UK include the Nextdoor App, a platform for neighbours and communities, which again encourages conversations and connections between people. These apps could create a sense of belonging for those who are able to engage with these technologies. Beyond this, online therapies such as cognitive behaviour therapy have been identified as potentially decreasing loneliness (Käll et al., 2020). Creative ways of supporting not only older people, but the general population, have also emerged, although the majority are delivered through online platforms, such as performances of symphony orchestras in virtual concert halls, or becoming a member of a virtual choir, playing board games online, and joining online masses and religious services. Indeed, the majority of advice is to connect with older people virtually which leaves those most disadvantaged vulnerable and at risk. However, although many older people are highly IT literate, there will remain disparities in access and abilities, and so alternative ways of supporting older people are imperative. Whilst mail deliveries continue, cards, letters and parcels provide other avenues to ensure older people feel connected with the outside world. A further way to support older people during the current health crisis could involve regular meaningful telephone conversations, to ensure meeting mental, social and physical health needs, and that older people know how to ask for and access help if required. Family members, friends, local charities, voluntary organisations and community nurses could develop comprehensive networks to ensure each older person has some meaningful social contact to support them. Through an organised and comprehensive approach, charities, organisations and healthcare providers could work together to support older people through this period of social isolation and to minimise and mitigate the negative impact of negative ageism, social isolation and loneliness.