How to care for the elderly in Pakistan during Covid-19

Introduction

Communicable diseases have always emerged as a grave public health concern for the global health of the masses; while viral and bacterial diseases have continued to escalate the epidemiological disease burden for ages. In the last two decades, the world has faced two forms of Corona Virus epidemics with Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) outbreak in 2002 to 2003, and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012. Currently, the world is in the midst of another Corona Virus (CoV), officially named as SARS-CoV-2 on February 11, 2020 by a task force of the World Health Organisation (WHO).

This contagious virus has affected more than 216 countries, including Pakistan, with the highest number of positive cases being reported in the United States (US) followed by Italy and Spain, making a total of 7,690,708 definite cases and 4,27,630 fatalities (as of June 14, 2020) (WHO, 2020). The aggressive nature of the virus has resulted in an upsurge in the death toll among the older population. This article focuses on the challenges confronted by older adults during this pandemic in Pakistan. It will also present specific contextually tailored solutions for the senior citizens of Pakistan and other low middle income countries (LMICs) to tackle this transmissible virus.

Background

The phenomenon of population ageing has been one of the most significant social transformational events of the 21^st century. According to United Nations World Population Ageing Report (2019), the number of people 60 years and older are expected to increase from 9% in 2019 to 16% by 2050. It is also estimated by the World Health Organisation (WHO) that LMICs will be recording approximately 80% of elderly people by 2050. The magnitude of the ageing of the population is much quicker in the lower middle income countries, with Asia being the largest continent recording the population in the age bracket of 60 years and above (Cassum, Cash, Qidwai, Vertejee, 2020).

Pakistan, being the world’s sixth most populous state, has more than 8 million older people, and this number is expected to reach 27 million by 2050 (Ahmad, Owais, Siddiqui, Mamun, Rao, Yousufzai, 2013; Sabzwari, Iqbal, Fatmi, Azam, 2019). Thus growing numbers of the elderly people worldwide are highly susceptible to get infected with this deadly virus.

The first case of Covid-19 in Pakistan was confirmed on February 26, 2020 in Karachi, Sindh by the Ministry of Health, Government of Pakistan (Waris, Atta, Ali, Asmat, Baset, 2020). Since then, the number of Covid-19 cases have been rising exponentially, however the number of older people infected across Pakistan has not been reported separately. Given these escalating figures of positive cases, mortality rates are expected to rise among older adults who are at a particular risk of developing severe forms and complications of Covid-19.

Challenges for older adults

In this unprecedented time there are several challenges which are experienced by this vulnerable section of people living in Pakistan and other LMICs. Some of them are discussed below and are a major concern to the health and wellbeing of the elderly during Covid-19.

Medical risk factors and SARS-CoV-2

Covid-19 has become a major concern, particularly for the physical and psychosocial wellbeing of the elderly in Pakistan. Various physiological changes are seen with ageing and the presence of underlying medical conditions predisposes them to catch the infection readily. WHO reports that in Europe, approximately 95% of the mortality has occurred in people 60 years and above (WHO Africa, 2020). In the global ranking of mortality rates Pakistan ranks at number 29, where more than 500 deaths are reported daily, whereas it occupies the eighth position among the Asian countries (Junaidi, 2020). Besides, 8 out of 10 fatalities are seen in patients having conditions such as hypertension, diabetes mellitus and cardiovascular disease (WHO, 2020).

A comprehensive report by the Chinese Center for Disease Control and Prevention suggested that adults older than 80 years, with multiple comorbid illnesses like diabetes, hypertension, cardiac disease, respiratory disease, chronic and terminal illness, are at the greatest risk of getting infected with Covid-19 and can succumb to the disease (Bedford, Enria, Giesecke, Heymann, Ihekweazu, Kobinger, Lane, Memish, Myoung-don Oh, Alpha Sall, Schuchat, Ungchusak, Wieler, 2020).

LMICs like Pakistan and India have a significant burden of non-communicable diseases (NCDs) among the elderly (Sabzwari, Iqbal, Fatmi, Azam, 2019; Sehgal, Garg, Anand, Singh Dhot, Singhal, 2016). Age specific morbidity and mortality linked to Covid-19 has not been clearly determined in Pakistan. Findings from a study in China suggest that older patients with comorbidities and SARS-CoV-2 have greater disease severity due to severe inflammatory response and lung injury. Some comorbidities like hypertension, diabetes mellitus, COPD, coronary heart disease and terminal illnesses frequently coexist with an increase in age and escalates the risk of poor clinical outcomes in older patients with COVID-19 (Wei-jie Guan et al, 2020; Naqvi, Shah, Ahmad, 2017; Murphy, McAvay, Allore, 2017).

Healthcare system in Pakistan

Majority of the developing countries, including Pakistan, are also suffering due to weak healthcare infrastructure. In addition to this, factors like limited beneficiaries of post retirement pension and lack of health insurance coverage can further compromise the health and wellbeing of this cohort during the pandemic. The economic and political background of Pakistan further complicates this scenario as only Rs.13 billion, which is less than 1% of the Gross Domestic Product (GDP), was allocated for the health sector in the fiscal budget 2019 (Qasim, 2019).

There are approximately 1279 public and 700 private hospitals in Pakistan (Health care resource guide, 2019), where the majority seeking healthcare services spend out of their pockets, including retirees. Public hospitals provide care that is inexpensive but lacks quality. Therefore this cohort, already burdened with multi-morbidity and a weakened immune system, are at a very high risk during this pandemic.

Contextually relevant solutions

While various countries and health organisations have published guidance for care of older adults, no specific contextual guidance exists for Pakistan. We wanted to share advice for settings with similar social and economic backgrounds for healthcare providers to share with the patients and their families.

Impact of Covid-19 among older adults

• Limited medical access due to lockdown, public transport limitations, lack of access to tele-healthcare
• Social and psychological impact

Social considerations

The problems that have emerged during this pandemic need concerted efforts and creative solutions to ensure the well-being of those at risk and provide care for those already affected. Older adults in our part of the world thrive on family and social connections.

Using simple means to restoring those connections may have an impact. Family members could help their older parents/relatives engage safely with others by using mobile phones and, whenever possible, video calls. This could be incorporated into the daily or weekly schedule of older adults. While not providing the same level of contact, a smile, a wave, a conversation can create a much needed connection (n.d., 2020)

Establishing or maintaining connections via religious organisations or community sessions have also been found to be useful. A local community in Pakistan has started an online group for its older adults. It is run by a volunteer base and organises online sessions via Zoom where older individuals connect with friends and family once a week and get 30 minutes of basic healthcare advice. Similar programmes can be started by local neighborhood organisations or youth volunteer programmes.

Physical health and well-being

Families and healthcare workers should encourage older adults to maintain their daily routine. For those now confined indoors due to the lockdown, a daily exercise regimen within the home would be helpful to avoid deconditioning and muscle weakness. Families can help maintain daily routine and structure to promote mental and psychological health.

Emphasis on practicing safety measures for Covid-19 is imperative as older adults are at greater risk of morbidity and mortality if the virus is contracted. These measures must be followed even during lockdown when there is minimal contact with the outside world.

Many healthcare providers/organisations have started tele-health services during the lockdown to esnure ease of access. For older adults this access can be provided via a phone call or, when possible, via video programmes/applications. Identifying older adults who are most vulnerable during the lockdown and prioritising tele-services for them would help maintain co-morbid conditions and ensure opportunities to identify disease exacerbation.

Incorporating the help of family members (with consent) would be vital in such interactions, especially for those where tele-health may pose difficulty due to visual, auditory and cognitive impairment. Physicians should also advise patients to keep provision of a two week supply of all essential medicines to ensure continuity of use during the lockdown (WHO, 2020). Home delivery services for medications and nutrition may be utilised where they are available.

Mental health and well being

During the lockdown mental health and well-being deserves special attention in this age group. There is anecdotal evidence from clinical practice as well as cited literature on the psychological impact of social distancing in this age group. While regular physical activity and social engagement may reduce the risk of depression, those with multi-morbidity may still be at risk.

Healthcare providers in collaboration with family care-givers should be aware of this and must closely monitor for the signs of depression. In this age group symptoms may be vague. New onset weakness, loss of appetite, social withdrawal may be early signs that warrant detailed assessment. Older patients with poor social support may be particularly vulnerable to depression, loneliness and must be monitored periodically.

Older adults with cognitive impairment such as Dementia and Alzheimer’s are also at particular risk of being impacted psychologically by the disruption of routine during the lockdown or, in some cases, due to the sudden unavailability of formal care-givers. These impacts can range from agitation, aggression, depression and in some cases delirium as well (Wang, Li, Gauthier, et al, 2020).

The role of family care-givers here becomes even more important. Healthcare providers should educate family members to report any change in the baseline mental health of their family members for timely intervention or referral to a mental healthcare provider and facility. Recently, the Sindh government has also started a mental health hotline in collaboration with UNICEF and UNDP in response to the pandemic (Samaa, 2020). Such services could be utilised by older individuals and their families as a first step for combatting psychological distress. An important consideration during this unprecedented time is the physical and psychological well-being of family care-givers of the elderly. This holds particular relevance for LMICs where a large majority of caretakers are family members.

Conclusion

In developing countries with limited healthcare resources, utilising family units to help care for older adults is a valid option. Maintaining regular schedules and minimizing disruption caused by the lockdown is important for the health and well-being of older individuals. Social and health needs of older adults can be met safely by the use of mobile or internet based options during the lockdown. Upholding the physical, psychological and social wellbeing of older adults with co-morbidities during this time can help defend this age group from the development of serious illnesses and mortalities due to Covid-19.

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