The tragedy of COVID-19 and the elderly

The most heartbreaking consequence of the COVID-19 pandemic is that involving our elderly and infirm.  The mean age of those who have died is 78, but those around this age and older who have not perished from the disease have had to endure a multitude of tragic sequelae.  The diagnosis of the virus prompts required isolation.  Among the physical sequelae of the virus are those that lead to prolonged weakness and loss of exercise tolerance.  And the acquired mild dementia that many experience with aging accelerates with the inflammation caused by the viral infection.

If you have a relative with COVID-19 that has required hospitalization or sequestration in an extended care facility, you already know that visiting your loved ones is highly restricted.  Many families have had to try to communicate through windows and doors, standing outside and speaking through screens or only on the phone.  Overburdened nurses, medical assistants, therapists, and doctors don't usually have the time or ability to fill the longing for company that the hospitalized need, and the communicability of the illness restricts visitation by practically anyone else.  Little is more sad than the lonely aged, unable to leave their rooms.

Isolation, especially in the elderly, frequently leads to depression.  When talking to the sequestered, a frequent complaint is that they have no loved ones or friends with whom to interact.  Watching television and playing solitaire entertain for only so long.  Added to the boredom may be the feeling of an overwhelming sense of being purposeless and worthless.  Not wanting to be a burden to others or feeling shame and guilt over their infirmities can dominate their thoughts.  This, combined with the physical problems associated with the illness (over which they have no control and which have their own timetable for resolution), may contribute to negative thinking.

In survivors of COVID-19, one of the consistent complaints is of a prolonged exercise intolerance.  Climbing stairs or doing routine chores around the house can be exhausting even after the other signs of the infection have resolved, lingering for weeks even in the previously fit.  In the old and infirm, this weakness may not easily go away.  Before they had the virus, they may have been able to ambulate on their own.  The infection may result in them ultimately requiring a walker because of weakness.  They could deteriorate to being able to ambulate only with assistance or even be so affected that they are not easily able to get out of bed.  Loss of strength may lead to more frequent falls, with the risk of a broken hip or subdural hematoma, both injuries linked to earlier morbidity and mortality.

The saddest upshot of viral inflammation in the elderly is accelerated dementia.  Before the onset of the viral illness, if mild forgetfulness and slowed intellectual function were noticeable, the risk of deterioration with COVID-19 is high.  Sadly, once the recovery from the life-threatening effects on the heart, lungs, circulatory system, and GI tract is on its way, unrecoverable brain damage manifesting as dementia may be evident.  Even in people who do not have obvious signs of cognitive deterioration, if they have any other chronic inflammatory illnesses such as arthritis, diabetes, and obesity, they are at increased risk of the virus causing dementia.

Isolation, depression, inactivity, weakness, and restricted capability of movement combined with the patient's own recognition that his "brain is gone" have grown into a plague in the elderly recovering from COVID-19.  Many who were previously able to care for themselves are now in need of assisted care with emphasis on "memory care."  Many in assisted care have deteriorated to needing skilled care.  Many in even skilled care are in desperate circumstances with regard to their end-stage dementia, existing as shadows of themselves, unable to die because their bodies are too strong, our medicines are too good, and our ability to "let them go" is not there.

If nothing else is learned from this plague as regards the elderly, maybe changing the way we isolate them and keep them stimulated could change first.  Our level of understanding dementia is improving, with new medications on the horizon, but pills don't fix everything.

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