|PERSPECTIVE/VIEWPOINT - SPECIAL POPULATIONS
|Year : 2020 | Volume
| Issue : 2 | Page : 152-155
The Elderly: “Age in the Time and Aftermath of Corona.” Some Personal Reflections and a Plea
Department of Clinical Social Work, University for Applied Sciences, Coburg, Germany; Division of Rehabilitation Research, Karolinska Institutet, Stockholm, Sweden
|Date of Submission||17-May-2020|
|Date of Decision||02-Jun-2020|
|Date of Acceptance||02-Jun-2020|
|Date of Web Publication||14-Aug-2020|
Prof. Wolfgang Rutz
Department of Clinical Sciences, Danderyd Hospital, Unit for Stressrehabilitation Research, Karolinska Institutet, Stockholm
Source of Support: None, Conflict of Interest: None
The situation and societal positioning of the elderly are specifically affected during the ongoing Covid-19 pandemic situation related to down regulations of social contact within societies, families, and next of kin. This is related to the elderly's specific demand to social contact and respect for their identity but also their specific sensitivity to matters of helplessness, self-determination as well as identity and dignity. In addition, people of higher age are often getting increasingly diverse in personality traits, interests, and functional capacity, demanding individual person-centered respects to their needs. In Europe, different attitudes are brought forward when it comes to treating and respecting elderly people, from gerontocracy attitudes of high appreciation to tendencies to see the elderly as a burden in the society. These differences are often illustrated by, for example, reported figures of completed suicides in this risk population. According to this, even the structural societal responses to, for example, health problems and existential needs of the elderly might decisively be influenced by these attitudes. Sweden had one of the highest Covid-19-related morbidity and mortality figures in the older population. In the article, this unacceptable situation is elaborated on, as well as the needs of paying person-centered attribute to the elderly's specific needs and capacities in analysis, resilience, and sustainable long-term approaches. In general, this seems decisive to formulate a plea to cope with the risk for future societal and global challenges lying ahead of us – future viral and digital pandemics, migration waves, and climatic as well as social “tsunamis”. Here, the elderly persons need to be given a significant role to contribute to the necessary solutions.
Keywords: Covid-19, Elderly, Pandemic, person-centred approaches, psychogeriatric
|How to cite this article:|
Rutz W. The Elderly: “Age in the Time and Aftermath of Corona.” Some Personal Reflections and a Plea. World Soc Psychiatry 2020;2:152-5
| Aging in a Historical and Societal Perspective|| |
The Covid-19 “Corona” pandemic is a public health problem of dramatic influence on the world's populations. Mostly, due to a higher degree of multimorbidity, the elderly are at a particular risk for adverse health consequences when being infected. Different strategies have been taken in affected countries to protect this population. While the diminution of death tolls due to COVID-19 to the lowest possible levels has naturally been the focus of most national intervention and scientific endeavors, reporting of the possible adverse mental health consequences of the pandemic is increasingly raised. Apart from the medical perspective and the increased mortality rates due to Covid-19 in the elderly, many different dimensions should be considered with regard to the consequences for this vulnerable population group.
Reflecting the status of the elderly in the development of different cultures and societies seen from a historical perspective, we find prominent characteristics in the ways how they are treated, culturally valued, and societally positioned in different cultures throughout the history of humankind. Hugh differences can be seen. In some countries, a type of “gerontocracy” can be found, including an appreciation and sometimes adoration of the highly valued elder generation. In these cultures, the elderly's wisdom and advice have been given influence in councils and steering committees, clearly demonstrating their high status in the society. This is, for example, reflected in the old testaments' ten commandments, gerontocracy principles in ancient Greece, and in habits of veneration of the elderly and former generations in Eastern religions.
On the other hand, in other civilizations, one finds more “utilitaristic” traditions sometimes again embedded in religious fashions and rituals, examples are situations where the elderly have been seen as a molesting burden, no longer of any use, which, for example, is shown in roman cultural and Scandinavian traditions, and even in Japanese traditions of climbing up to and disappearing on the holy mountains. Still today, the view experiencing age and the aged as a burden influences parts of the “end of life time” discussions in Western European countries.
Hereby, a focus is often directed on the rights and possibilities to human and assisted death where even materialistic judgments have are made and the “value of the lives” of the elderly is compared to one of the younger populations. Such discourses are going on in the Benelux countries, Switzerland, Canada, United States, Germany and Sweden. Perceptions on aging might therefore also today influence the degree of social inclusion of elderly people in the society, which, in turn, might reflect on their health – particularly mental health – status, and on societal strategies to take care of their health problems.
| Determinants of Mental Health in Older Age|| |
Mental health in older age can be discussed from different perspectives. In general, in a biopsychosocial and even existential view, we can postulate four domains to be decisive for people's capacity and willingness to keep healthy, not to become mentally ill, and to consider life being worth living:
- Meaning, and the feeling of an “over-individual” cohesion, even in an existential and spiritual context
- Identity and respect, to be treated as a person by one's own, with a personal identity, not to feel humiliated, to be respected with dignity and status,
- The experience of love, to be cared for, but even being able to help others, to feel socially and societally significant and experience family cohesion,
- Self-directedness, being in charge of one's own life, having possibilities to influencing one's live conditions, not to be helpless.
These domains are crucially important in the life of elderly people and should receive the most attention at present, in times of a pandemic crisis and in the aftermath of national regulations following the Covid-19 outbreak. These regulations target “social distancing” or – a more appropriate term – “physical distancing” and have increased the risk of loneliness and social isolation in elderlies as a most vulnerable group. There even might be gender differences. Elderly women seem particularly susceptible to these regulations as they might react with a feeling of losing their social significance and of a sense of “uselessness,” which they feel that hard to cope with men – on the other hand – might be more often suffering from an experienced loss of social status in the society and as a responsible provider in the family, resulting in a feeling of lacking respect and dignity in an increasing isolation.
Regardless of gender specificities, both genders risk to suffer heavily by the limited access to other people, friends and family members, the difficulties of communication, and the lack of possibilities to analog and direct contact “in real life” with children and grandchildren. The “digital divide” found today where still big parts of the elderly population are not at all used to the “social media” and quite illiterate in virtual digital communication is here an aggravating factor.
| Some Examples|| |
Thus, the different national regulations which have been put in place to tackle the emerging pandemic crisis are naturally given in accordance to national infrastructures and sociocultural traditions and influence the design of health-care systems and elderly care. To describe the challenges of national governments to protect the elderly in an ongoing pandemic in Europe, Sweden is here an illustrative example. One reason is that the author as an even internationally working Swedish psychiatrist is familiar with the society and another that Sweden has decided to tackle the public health threat of the corona crisis with a different approach than other countries.
Looking at the diversity in Europe, one gets a feeling about different degrees of mental well-being in the elderly population throughout the continent. Suicide figures can in Europe often be considered as a main and measurable indicator of the mental health status in a population, for example, the elderly. There is hardly a condition of mental state in which persons are more mentally suffering than in a situation where the only way of coping with one's social and existential situation seems to be to suicide. Completed suicides are throughout Europe quite accurately and continuously registered – even if underreporting and uncertainties exist as in any epidemiological situation. Thus, suicide figures in higher age, reflecting the mental state of a population, differ widely in different parts of the European region. There are very low figures or no prevalence at all in some regions, for example, the Caucasus, Central Asia, and even Southern Europe where elderly people by tradition are met with high respect and given important roles in the community, both officially and informally. High and increasing figures, however, are found in some of the Western, Central, and Northern European countries. These figures may reflect a different social, psychological, and even existential situation – from unrealistic focuses on the youth, glorifying juvenile attitudes to an acceptance of the dissolution of traditional family cohesion and even secularized religious traditions. Furthermore, generational contracts and – in society – the presence of structural employment regulations and policies adverse for the elderly lead to sometimes nearly “ageistic” discrimination practices, by neglecting, down talking, minimizing, and sometimes ridiculing the cultural and societal importance of older persons. In some countries, the result is a significant absence of existential support, felt and reported in the elder generation.
| Elderly in Sweden during the Covid-19 Outbreak|| |
The government in Sweden has put several “recommendations” in place to prevent infections with severe acute respiratory syndrome-CoV-2 in the elderly, particularly trying to inhibit the population not to visit their elderly family members. After reports of infections in elderly homes, the government decided to stop physical visits. Despite these strategies, there has been a dramatic increase of age-group-related morbidity and mortality due to Covid-19 in people above the age of 70 years.
Morbidity in corona-infected people in Sweden and measured in percentage of the population is dramatically higher in Sweden than in neighboring Scandinavian countries, with more than 80% of corona-related death in the age of 70 years and above. A consecutive shortage of resources for intensive care has led to selective “triage” recommendations given by the authorities. These recommendations are – in spite of vivid discussions – expected by the authorities to be generally obeyed to and build on a judgment of life expectation outgoing from the biological and chronological age combined with prognostic considerations regarding the treatability of comorbid disorders. There are recommended as a basis to decide which patients should be given access to lifesaving intensive care with respiratory assistance in view of the presupposed shortage of resources.
A public statement given by an earlier minister of finance some years ago has been actualized in the actual public debate. The description he gave of the elderly part of the Swedish population profile was the picture of a “meat mountain”, leading to problematic economic consequences. Nurses, doctors, elder parliamentarians, and recently a highly respected author earlier belonging to the Swedish academy – she related to the ministers statement quoted above – have protested to actual recommendations and a polarized discussion is going on. The social isolation is felt both by the elderly and relatives and increasingly publically discussed. Even a recent Worldwide Value Survey that showed Sweden to be one of the countries that gave the least respect to the importance of elderly citizens in the society was actualized in the discussion. Also, the contacts of elderly people to one of the available suicide preventive helplines increased about tenfold during the last month.
A society – as it has been said by a Swedish social psychiatrist – has like a symphony orchestra to respect different harmonies and contain different groups of players with a diversity of voices to be heard. In Sweden – but not only in our country – many of the regulations and binding recommendations in context with the tackling of the pandemic crisis use “templates” and general recommendations. They try to draw persons and “cases” into a “Procrustean bed” of conformist and equality-driven ideologies that do not respect the diversity among elderly people who have a tendency to become in older age more individualized than in younger years. “One size fits it all” – strategies are the least suitable ones with regard to a higher age. Personality traits become more and more unequally prominent in their characteristics, leading to evident and sometimes dramatic needs of senior people to be seen and treated in a person-centered and respectful way as a person by one's own.
As been said, Sweden has until now one of the higher morbidity figures in Europe, especially in the elderly, especially in men, manifold higher than in neighboring countries, for example, Finland. The reasons are discussed but seem mainly to be found in administrative changes and the introduction of a sometimes harsh shareholder value-oriented market economy in the care of the elderly. This has considerably lead to economic restrictions and a partly neglect of personalized services, followed by a decrease of their ability to quantitatively prolong elderly's life time, but also their possibilities to improve elderly's life quality, in spite of sometimes strong efforts by a motivated staff.
Psychological, medical, and existential shortcomings and deficiencies are at time being quite dramatically experienced in the country by parts of the elderly population. These are in contrast to an earlier quite common feeling of a harmonious social protection in the former Swedish solidary society, where safety especially for the weak, sick, and elderly existed and which was built up by todays' elderly generation. They felt their social protection to be “carved in stone” and secured for a future.
Today, several of these safety mechanisms have weakened up. There is also a risk that the pandemic regulations lead to a continued social isolation of the elderly, and – if they really succeed in protecting the elderly from the corona-disease – result in the fact that an often apostrophized “crowd immunity” will reach the surviving elderly at last, with the consequence that the elderly have to stay longest in isolation and social distance. This has already been predicted in the societal discussion. In such a case, a still increasing, isolation, anxiety, and depression will be generated, consequently leading to problems to get a helping hand from friends and relatives.
However, Sweden is internationally not alone in the described situation and the problems emanating from it. Furthermore, supportive projects to assist the elderly have been put in place by the government. There are even lots of positive examples showing a renaissance of spontaneous altruistic and inter-generational activities, where people help each other, sometimes not only engage in risky health-care activities but also take responsibilities in assisting their neighbors and next of kin.
| So – What to Do?|| |
To communicate, to coordinate, and to develop our supportive and therapeutic efforts to the elderly population, we have to respect the fact that there are huge obstacles for them emanating from the “digital divide” -to understand and get use of digital solutions. Therefore, it seems important to integrate the expertise and advice of elderly persons as user expertise. Moreover, elderly people must be seen again and in a new way as the resource they really are. We need them to be involved in both the development of individualized services in the establishment of strategies of assistance and help as well as in evaluation research and implementation.
In the Swedish discussion, such an involvement has been iteratively postulated but is not realized sufficiently yet. Thus, the provision of services to the elderly has to be individually and culturally adapted and based all humans equal value, for example with respect to immigrant populations. The individual cultural specificities of groups and individuals of all ages and their suffering caused by isolation have to be taken into account – both regarding the afflicted elderly and their next of kin. Support has to be given in interdisciplinary, holistic and multidimensional, multi-sectorial approaches in multiprofessional teamwork and with sensitivity for transculturally and individual values. Hereby, a constant focus must be given on the four determinants of health and mental health as earlier described.
| But–how to Reach Meaning, Self-Determination, Social Significance, and Personal Dignity?|| |
It seems important to avoid solely digital interventions and supportive therapies. When meeting and supporting the elderly, a personal contact is decisive. Elderly are often not reached by digital information and even in established contacts, one has to respect that life events, resilience, crisis management, and psychological, social, and existential help have to be promoted differently to elderly people.
The elderly are an often overseen resource. Elderly have often better, but in any case different coping strategies, different perspectives, a different sensitivity for humiliation and identity loss and often different ways of developing resilience and compliance. Therapeutic and strategic alliances are crucial and presuppose the engagement of therapists, contact persons, and decision-makers with own experience of life events and crises and close to the culture of the people they meet.
Moreover, elderly people seem often more altruistic, more resilient, and less controlling. Their social competence is often significant. This makes the involvement of users, relatives, and people with the lived experience necessary to get to their amending corrections and to involve them in research and the implementation and evaluation of strategies.
| Finally|| |
How the elderly and weak are treated in a population is the strongest indicator of the degree of humanity and tolerance in a society.
We live in a special time. New and old challenges appear and exacerbate. Endemics, epidemics, and global migration have to be tackled and can – in the worst case – create a prerevolutionary situation. In the best case, a global, more tolerant, and transparent democracy will grow. Paradigms will change. An atmosphere of “fin de siècle” appears. Something new and different will come.
In these times of changes, the more holistic and over grasping intelligence, experience, wisdom, and perspectives of older people will be a decisive resource that gives human mankind a greater chance. To realize this, new paradigms in our ways of taking care of the elderly are crucial-person centered, with solidarity, pluralism, and tolerance, following strategies based on respect, humanism, and professionalism.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al
. Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. Lancet Psychiatry 2020;7:547-60.
Rutz W. A need to rethink social psychiatry. Int J Publ Health 2007;52:137-9.
Health for All. Database. WHO European Office Copenhagen, Available at: www.euro.who.int [Last accessed on 2020 Mar 08].
Rutz W. Person-centred public health promotion; an overview and a plea. Int J Pers Cent Med 2012;2:306-9.