As of May 2021, over 32 million individuals have been diagnosed with COVID-19 in the US.1 Of those, at least 3.5 million are 65 years and older.1 Those 65 years and older are 5 to 13 times more likely to be hospitalized and 90 to 630 times more likely to die from COVID-19 than 18- to 29-year-olds.2 The CDC reports that 8 out of 10 deaths attributed to COVID-19 occurred in adults age 65 years and older.2,3
In response to the pandemic, the CDC recommended protective measures to reduce the risk of severe illness from COVID-19, including social distancing, mandates on mask wearing, restrictions on gatherings, and closing of recreational facilities, parks, and religious services. These recommendations have important implications for the geriatric population and can lead to social isolation.4 The older adult population understands their increased risk for COVID-19, which has heightened their vigilance in adhering to CDC recommendations.4
However, social distancing may have unintended consequences, as social isolation has been linked with the development of depression and anxiety.5,7,9 Because CDC recommendations for protection during the pandemic have the potential to impact older adults in multiple areas and to a higher degree than other age categories, it is vital for NPs to understand their implications. Being well versed in evidence-based recommendations on how best to adapt care for this patient population can potentially reduce the impact of social isolation, including its detrimental effect to overall health and wellness in geriatric populations.
COVID-19 and psychosocial impacts on the older adult
As we age, our social groups normally become smaller, but stronger and more supportive.6 The smaller, stronger social network that is typical of many older adults can be greatly impacted by social distancing and can lead to feelings of having “lost touch” with close family and friends.
Over the course of the pandemic, many regularly scheduled and celebratory gatherings have been cancelled or put on “hold” for months, leading to further isolation. Additionally, hospitalized individuals and residents of long-term-care facilities have been sheltered from outside visitors in order to prevent the potential spread of COVID-19 within facilities.4
While social isolation is a different phenomenon from loneliness, loneliness can result from social isolation and has been demonstrated to have physical and mental consequences of its own.7 Social isolation is not always coupled with loneliness, but when it is, increased risks exist for such physical and mental health issues as high BP, heart disease, obesity, weakened immunity, anxiety, depression, cognitive decline, dementia, and even death.8 Social isolation also creates a heightened risk for the development of depression and anxiety among the geriatric population.9
It is important for NPs to understand the potential impacts of social isolation on the older adult population. Including depression and anxiety screens during scheduled visits with older adults, as well as being aware of indicators that are often linked to mood changes (for example, sleep changes, unintended weight changes, new-onset fatigue, and so on) can support providers in detecting psychologic consequences of social isolation. During times of imposed social isolation, providers should regularly incorporate the UCLA 3-Item Loneliness Scale, including an evaluation of coping activities being utilized (social support, hobbies, exercise, self-care, and so on). Educating and encouraging older adults to engage in regular self-care and remain socially active can help them mitigate the potential negative sequelae of social isolation. Remembering that social distancing requirements are time-limited can also help reduce stress. Even though we may not know when social distancing will no longer be recommended, understanding that the situation is not permanent, and supporting individuals to reframe the situation can downregulate emotional and stress responses.10 Offering suggestions on activities like sharing favorite recipes, writing letters to friends and family, volunteering remotely, improving online networking skills using interface modalities such as Facebook and Zoom, and engaging in online physical activities, or taking an online course of interest can lend new ways to diffuse the impact of isolation.11
Spirituality, COVID-19, and the older adult
Public expressions of spirituality, such as attendance at religious services, have sharply declined due to the COVID-19 pandemic. Churches and other places of worship closed in many areas when the pandemic was at its peak, but even as many reopened, older adults have been reluctant to resume attendance at religious gatherings due to fear of contracting COVID-19. While the impact of COVID-19 on spirituality in the geriatric population has not specifically been addressed in the literature, we can project that for those older adults active in their religious communities, COVID-19 and social distancing parameters have significantly reduced participation, and that such individuals have experienced some level of a sense of loss due to this decline of activity and connection within their community of faith.
Over the life course, there is often a shift in later years from a focus on career to spending increased time with family, friends, and within social networks, including routines that meet spiritual needs and support faith-based religious practices.6,12 Older populations participate in religious behaviors and are practicing believers at higher rates than other age groups.13 The practice of spirituality and attending faith-based gatherings provide a sense of well-being and connectedness while also encouraging social and personal relationships.12 This connectedness outside of oneself, such as faith-based support, provides the ability to cope in difficult situations like a pandemic.13 Without the ability to attend their religious and worship services, many older adults feel a sense of hopelessness and a disconnect from their spirituality.14
Encouraging older adults to get connected via online “streaming,” or real-time religious services can support them to reconnect with their religious community. Many churches and other religious communities are also offering distance connect options for regularly scheduled meetings, such as prayer groups, grief support groups, survivors support groups, and community outreach, to name a few. Taking the time to develop a list of distance community activities that might be of interest for older adults, including those offered by local faith communities, would serve as a useful resource for NPs and providers they work with. Offering a list of local faith communities with distance meeting capacity to older adults whose churches or religious communities may not offer these options can provide the impetus and encouragement they may need to reach out and engage in a new faith community during this period of social distancing. Dialoging with our older adult patients about ideas and options for meeting their spiritual needs is demonstrative of the holistic nature of NP care.
The impact of COVID-19 on health and functional ability in older adults
Social isolation has been shown to have detrimental effects on functional status and overall health and contribute to comorbid states in the geriatric population.5,15 For adults age 65 years and older, the U.S. Department of Health and Human Services recommends at least 150 minutes per week of moderate activity (for example, brisk walking) with at least 2 days per week of activities for muscle strengthening.16 Improving balance should also be considered in the activity plan, with physical activity levels within range of personal ability.16 Sedentary lifestyle is the fourth leading cause of mortality globally, so maintaining an active lifestyle is vital to health.17,18
Unfortunately, while staying at home can lessen the spread of COVID-19, it has been linked to negative outcomes.18 Sheltering in place can reduce physical activity in a myriad of ways. Decreased outings among the geriatric population to shop, eat, visit friends and family, or exercise reduces overall daily physical activity. Utilizing home delivery services to acquire prepared foods and household and grocery items has become the “new normal,” for many and has decreased physical activity even further. Routine visits to see NPs in their offices have been reduced or transformed to virtual video visits or phone calls, which further reduces physical activity. Taken together, these changes in normal day-to-day activity amount to significant reductions in overall daily activity levels for older adults.
Lack of physical activity is well known to be linked with the development of chronic diseases such as diabetes, osteoporosis, and cardiovascular disease, falls, and death.18-20 Additionally, social isolation has been shown to lead to a decrease in functional ability in older adults.21 The combination of reduced physical activity and social isolation has been linked to mental health consequences such as depression and anxiety.19
Prepandemic, 31% of individuals 15 of years of age or older were reporting physical inactivity, and physical inactivity alone was reported to cause 3.2 million deaths per year.17,22 Furthermore, each hour over 6.1 hours in a day spent sitting is estimated to increase healthcare costs by $126.17 Many normative ways of being physically active have been suspended during the pandemic.23
Older adult patients can increase their physical activity through programs such as those organized by local hospitals and community centers, which have not only been shown to improve health but also have the potential to increase self-reported perceptions of health and to lessen levels of social isolation and loneliness, such as programs designed like SilverSneakers.24 Many of these programs are now employing COVID-19 precautions, making them viable options for older adults. Engaging in virtual exercise activities is also an option for those who do not have access to in-person programs, or for those living in areas where social activity is still more restricted.
Changes related to morbidity and inaccessibility to routine healthcare
As clinics navigated how to adhere to CDC guidelines for social distancing and other public health measures in busy waiting rooms, access to patient visits became increasingly limited. Many healthcare practices have taken steps to limit in-person appointments for vulnerable populations with the goal of reducing exposure. Reduced healthcare visit frequency can make it difficult for older adults to stay on schedule with routine services and/or medications.25 What NPs and administrators alike did not anticipate was the increase in morbidities resulting from cuts in health maintenance appointments and elective procedures due to fear of contracting COVID-19.26 Because this fear can also lead to refusing or deferring care for emergent situations, the older adult patient should be educated about the extraordinary precautions being taken by healthcare organizations to protect against infection.26
To avoid losing patients to follow-up, providers should set up a system to track patient follow-up and have office staff call patients to remind them to schedule a visit with their provider. In addition to visit reminders, making older adult patients aware that during the COVID-19 national public health emergency they can opt for a virtual video visit if they do not feel comfortable coming into the office or a virtual visit by phone if they do not have access to a device that supports video interface can reduce healthcare visit hesitancy. It is vitally important that we assess patients' needs and barriers to care during times where social distancing and other public health measures are in effect in order to ensure we are delivering timely, safe, and quality care.
Technology challenges for the older adult
In 2020, the Centers for Medicare and Medicaid Services (CMS) recognized that delivering healthcare virtually can improve access to care, eliminate travel, and be cost-effective.27,28 CMS reimburses telehealth visits at the same rate as face-to-face visits, at the time of writing.27 Unfortunately, 38% of older adults living in the US are unprepared for video telehealth visits due to lack of experience with technology.27 While telehealth visits via phone may reach more older adults, barriers such as hearing impairment, physical deficits, and cognitive issues exist.27,29
While 42% of people age 65 and older report that they own a smartphone and 67% report using the internet, 34% of older adults lack confidence in using technology and almost 50% need assistance to set up and use any new electronic device.30 Older adults have also indicated increased anxiety regarding lack of knowledge in computer use.31 Seniors who report having a physical disability indicate that they would be less likely to utilize technology.30 Aside from physical difficulty manipulating devices, other factors that affect the use of electronic devices in the geriatric population include psychosocial, moral, and economic issues.32 Internet safety while using technology can pose concerns for older adults unaware of cybercrime and other associated risks.33 Equipment costs can create economic burden for those on fixed incomes.32 Despite the above challenges, once obstacles are overcome, technology is often readily adopted by older adults.30
Many options are available for those who may need special assistance to engage with technology. Mobile applications that facilitate health have proven to be valuable tools for the geriatric population to stay connected with family, friends, and medical providers as well as for encouraging steps toward good physical and psychiatric health.34 Showing older adults how to use the selected office telehealth app when patients are in the office can support them to have a better understanding of how to use such apps at home. If an older adult patient has a family member or friend who usually accompanies them to the office during visits and that person has technology capacity, they may be able to work with the older adult to engage in a telehealth visit if the latter is comfortable with that and does not want to come in for an in-office visit and when a phone visit is not a feasible option.
Recommendations and future implications
Many factors should be considered regarding quality of life and making recommendations for the geriatric population during the pandemic. The psychosocial impacts of restrictions due to the pandemic can cause older adults to feel disconnected from their loved ones.
Distance education courses and remote community involvement activities can assist older adults with remaining connected to the world outside their home. Pets can also ease the gap in missing human interactions, as can tele- and video-conferencing.35 The National Academies of Sciences, Engineering, and Medicine advocates the importance of educating patients experiencing social isolation and their caregivers on the adverse health conditions that occur due to isolation and loneliness, such as increased risk of early death, dementia, cardiac disease, and stroke.36 Strengthening alliances between social services and NPs to facilitate a team-based approach to care can tailor services to address social isolation. Connecting the patient with social services can decrease barriers and reduce social isolation and loneliness.36
To embrace spirituality during a time of isolation, older adults can engage in services livestreamed over the internet. Many faith-based communities have adopted live streaming of services along with holding outdoor or socially distanced indoor services to allow safe participation in a variety of ways. Many church and religious community members are also maintaining regular church group meetings via phone or other distance modalities to support a sense of normalcy and belonging. For those older adults who do not choose to engage in a religious community, practices such as prayer or meditation can be vital to supporting personal inner peace and well-being. Finding a serene location in nature to meditate, be thankful, and reflect upon the positive during such tumultuous times can also support spiritual and overall health.37
It is common knowledge that we require physical activity to remain healthy. NPs should inquire older patients about their daily activity levels and support them in finding suitable ways to safely meet their daily activity goals. Tufts University, with support from the CDC, developed a detailed and useful handbook that NPs can reference when making activity recommendations to their older adult patients.38 There are also many available apps that help with exercise plans, as well as prerecorded exercise videos and television programs, which can be leveraged by older adults within their homes.39 For those unable to get outdoors to walk, reaching out to local community centers/YMCAs about socially distanced indoor exercise classes may present a solution.40
NPs should address and alleviate technologic stressors as much as possible when using telehealth with older adult patients, as telehealth will likely become a standard healthcare delivery modality.41 Requesting clinic staff to call ahead and offer patients instruction on utilizing the telehealth platform for their upcoming healthcare visits can be very helpful. For those patients who may encounter difficulties with button-type tasks, reviewing the verbal command function on a phone or tablet, such as voice assistants like “Siri,” can be invaluable.
Older adults are at special risk for negative ramifications of social distancing. Discussing with patients their concerns, how they are coping with the CDC recommendations, and working with them on ways to participate safely in enjoyable activities that promote wellness while following guidelines are important considerations for practitioners while developing care plans. Additionally, providers can educate patients about the COVID-19 vaccines and provide them with information related to scheduling/locating vaccination sites within their communities.42 Vaccination can help prevent COVID-19, as well as mitigate illness severity should the disease be contracted. These reductions in risk can support the geriatric population in resuming appropriate social activities and assist them in moving back toward normalizing their lifestyles.43 Research is needed to explore connections among older adults in the community during times of social distancing and other public health measures. This has the potential to provide information on how to support the health of vulnerable populations during situations such as the COVID-19 pandemic.
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36. National Academies of Sciences, Engineering, and Medicine (NASEM); Division of Behavioral and Social Sciences and Education; Health and Medicine Division; Board on Behavioral, Cognitive, and Sensory Sciences; Board on Health Sciences Policy; Committee on the Health and Medical Dimensions of Social Isolation and Loneliness in Older Adults. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. National Academies Press (US); 2020 Feb 27. Summary. www.ncbi.nlm.nih.gov/books/NBK557972/
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42. Centers for Disease Control and Prevention. COVID-19. What older adults need to know about COVID-19 vaccines. 2021. www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/older-adults.html
43. Centers for Disease Control and Prevention. When you've been fully vaccinated. www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated.html