Beyond Uncertainty: The Long Haul of COVID-19 for Older Adults
Eva Kahana PhD, Editor-in-Chief
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It has been a long year since we originally posted a call for papers for the Journal of Elder Policy (JEP) related to the COVID-19 pandemic. As the papers accepted are now in print, the world is still shell shocked in the aftermath of losses and the future of uncertainty. Many of us lost family, friends, neighbors, and coworkers, and all of us lost our innocence about the predictability of our daily life and future. Older adults have been one of the most severely affected and threatened groups by the pandemic. Nevertheless, it notable that this age group does not consistently express greater worry about the pandemic than do their younger counterparts (Barber & Kim, 2021).
Large segments of the world’s older population remain unprotected from COVID-19 in countries where vaccines are hard to come by. Even in the U.S., where vaccines are readily available, there are vast differences among states in terms of vaccine hesitancy, resulting in many Southern states remaining unvaccinated. In the absence of a federal mandate, uneven vaccination rates are likely to persist along with an uneven application of protective measures (Sallam, 2021). As of September 2021, only one vaccine has received full approval from the United States Food and Drug Administration (FDA), thereby limiting more effective measures for persuading the hesitant.
This special issue of the Journal of Elder Policy on COVID-19 is being published about a year and a half after the onset of the global pandemic. Prior to this crisis, very few of us would have believed that a virus could upend the lives of the world’s population and persist for such a long period. The world experienced pandemics before: Ebola, swine flu, and SARS, but they were not the same magnitude as COVID-19.
COVID-19 has resulted in unprecedented policy challenges. Experts in public health have had a difficult time providing consistent and effective guidelines for coping with challenges faced. Even as vaccines have proved to be successful in diminishing rates of infection, hospitalization, and mortality, there has been considerable political controversy regarding the best and safest ways to return to more normal lifestyles.
The case of the COVID-19 pandemic provides an exemplar of the intertwining between public policy and public attitudes. Trust in government was undermined during the period of the pandemic (Han et al., 2020). This lack of trust also coincides with the lack of individuals trusting one another. This problem was exemplified in the reaction to the CDC recommendation, during the spring of 2021, for eliminating the mask mandates. The question arose: Can vaccinated individuals assume that all of those no longer wearing masks have indeed been vaccinated?
Both because of the severe impact of COVID-19 and the ambiguity regarding the best ways to fight it, public policy has become polarized and the subject of major political disagreements (Alcott et al., 2020). As we begin fall of 2021, we hope to be seeing the light at the end of the tunnel of this terrible pandemic, but uncertainties abound. Masks have become a symbol of caution on the one hand and of enforced limitations on the other. The CDC has made contradictory pronouncements, and the public finds it easy to blame absence of leadership for the lack of clarity regarding prudent actions to follow (Latkin et al., 2020).
In this editorial, I aim to discuss relevance and contributions of the featured articles and acknowledge methodological limitations of empirical studies due to the pandemic. Prior to focusing on the articles published in this issue, I will briefly share my own lived experience during this period that can help contextualize the personal impact of the pandemic on older people.
My Lived Experience Coping with the COVID-19 Pandemic
Being 80 years old, and now a widow, living alone, I can readily understand the dilemmas and insecurities of older adults in dealing with the pandemic. I noted in previous issues of JEP how my husband, Boaz, a recently retired psychology professor, and I “escaped” from our rented high-rise apartment in Florida in March of 2020 and took a risky flight home to Cleveland, Ohio. Living in a single-family home felt much safer than our prior elevator rides and proximity to neighbors. During the seven months between April and October 2020, Boaz and I did not leave our Cleveland home. We shifted to telehealth visits for our health care and ordered our groceries and medications delivered by Instacart.
Our work-related and long-distance family interactions were all on Zoom. Starting in August 2020, I was teaching a combined graduate and undergraduate class on stress and coping on Zoom, with considerable help from my graduate students and my tech-savvy adult children who live nearby. In order to protect us, their elderly parents, my son and his wife started homeschooling their two children, including an autistic son. They also engaged in and advocated strict social distancing.
In my last editorial I shared my difficult experiences related to the hospitalization of my husband, Boaz, and his death on November 6th while in a highly regarded hospital. During Boaz’s hospitalization, starting in mid-October, I left my home daily to be with him, as I was the designated relative and the only one allowed to visit due to COVID protocols. I stopped worrying about my own safety as I felt that I needed to be with my beloved husband of 59 years. He died unexpectedly due to aspirating a large pill he was given. Our two sons were allowed to visit and be with him in his final hours.
After Boaz passed away, my surreal COVID-19 era experience continued with a Zoom funeral. Colleagues were largely absent. Friends and relatives, participating by Zoom, added to an eerie unreality of the experience. My husband’s elderly sister and brother and our extended family who lived out of town could not attend Boaz’s funeral. Although Boaz did not pass from COVID-19, his death was shrouded in the tragedy of the pandemic. I did the best I could to find solace in the closeness of my children. They made a major sacrifice to protect me by keeping their children out of school for most of the school year.
The new year brought rays of hope with the vaccine on the horizon. I was vaccinated in February 2021 and felt great relief. I was able to think of visiting the dentist and the podiatrist. I had been cutting my own hair during the pandemic and got used to having gray hair. About a month after being fully vaccinated I returned to the beauty shop wearing a mask.
Early this summer my vaccinated adult children and I undertook a long-distance trip to visit my younger son and five grandchildren in Philadelphia. We remained cautious about indoor dining but appreciated the return of some normalcy in our lives. My grandchildren enjoyed day camp and greatly welcomed the company of other children. We visited museums and I felt comfortable enough to take a chance on flying between Cleveland and Philadelphia.
I have been a college professor for the past 54 years and was looking forward to teaching in person this fall. I have truly missed interacting with my students, as Zoom just does not provide the same interaction as face-to-face conversations. As the summer progressed, we learned about the advance of the new Delta variant of the COVID-19 virus that can lead to breakthrough infections for vaccinated individuals. I became more concerned about in-person teaching even with the good news that all returning students must be vaccinated. Indeed, the latest University directives call for both students and professors to wear masks in class. Given that at age 80 I am hard of hearing, a further worry now relates to my ability to understand comments and questions of my students who will be wearing masks (Sheik-Ali et al., 2021). Due to these concerns, I requested to return to online teaching as a disability accommodation.
Although I do go out shopping and visit my children, I am still hesitant to have visitors and to eat out despite being vaccinated. As preparations for school intensify, we face further uncertainties of the new variants. This puts the fear of COVID-19 back at center stage. One of the major hardships for me is the inability to plan ahead. I had multiple abstracts that were accepted for presentation at the Gerontological Society of America (GSA) meetings in Phoenix, Arizona, in November, but I have been unsure about the safety of travel and face-to-face interactions. Recently GSA announced that the meeting would be switched to a virtual format. I realize that unpredictability is part of the reality of reaching old age. This may be a reason for the findings mentioned earlier that older people do not worry more than the young about the pandemic.
At the same time, the uncertainties of the pandemic still linger in my life. Last week, the UPS driver delivered the boxes that I had sent back from our trip to Philadelphia. When I noticed that the driver who was at my door was not wearing a mask, I quickly retreated to my hallway and experienced a fear I had been used to prior to vaccination.
Methodological Limitations of Studies Focused on COVID-19 and Older Adults
There have been numerous studies published over the past year, addressing the unique challenges of COVID-19 for older people. The present issue of JEP adds national and international contributions to better understand this important topic. In evaluating the quality of research on aging and COVID-19, we must acknowledge limitations of the current literature for offering a broad and deep understanding of the impact of the COVID-19 pandemic on lives of older adults, those of their families and caregivers and their health care providers. The problem lies in the many restrictions both researchers and their subjects have been living and operating under. Due to the ongoing threat of the pandemic, we cannot yet apply conventional methodological expectations to research on the impact of the pandemic.
Unlike traditional social science research that is based on representative samples and typically collects data through surveys or interviews administered in person, most of the current research available related to COVID-19 does not meet these standards. After the start of the pandemic, investigators lacked the usual opportunities to apply for peer reviewed funding. Nor did most investigators have the facilities and supports needed to craft first rate proposals. During lockdowns, older adults could not be interviewed in person. Pilot data was thus difficult to obtain by investigators working from home. Data from older adults could mostly be collected online or by phone.
Data for most of the COVID pandemic studies were collected during the first half of 2020. As mentioned above, in an effort to quickly collect relevant data, scholars relied on internet-based surveys (Barber & Kim, 2021). Such surveys include an overrepresentation of educated respondents who had access to computers and the Internet and who are technologically literate. Minorities were generally underrepresented in such samples. Furthermore, older adults living in long-term care facilities, who were among the first major victims of the Pandemic were seldom included in research on COVID-19. These older adults lived under strict lockdowns. Their families were not permitted to visit and thus could not offer firsthand, personal testimonials about the lived experiences of this highly vulnerable and victimized group. Those elders who contracted COVID-19 in institutional facilities suffered high mortality rates. Just 2.1 million people, accounting for 0.62% of the U.S. population, reside in a nursing home or assisted living facilities. Yet as of May 22, 2020, this population constituted 42% of all COVID-19 deaths (Girvan, 2020).
Before summarizing contributions of studies included in this issue of JEP, I want to offer a few insights from the larger literature related to older adults and COVID-19. The challenges experienced by older people during the initial months of the pandemic were explored by Heid and colleagues (2021). The most frequently noted problems among their sample (N=1272) related to constraints on social interactions during the pandemic. A study mixed methods study (N=825) by Whitehead and Torossian (2021) echoed this finding, noting that 42% of older respondents reported constrained social interactions and 30.9% reported activity restriction. Again, these authors found the most frequent stressors to be confinement and loneliness. However, sources of joy included family/friend relationships, digital social interactions, and hobbies. Predictors of poor psychological wellbeing during the pandemic included concern for the wellbeing of others, fears of an uncertain future, and fears of contracting the virus.
The larger literature on COVID-19 and aging also focuses on caregiving. The complex demands of caregiving to older adults during the pandemic have led to anxiety, depression, and other mental health problems among caregivers (Beach et al., 2021). The presence of multiple caregivers was often found to result in family conflict (Xu, Liu, & Beach, 2021). With regard to policy implications of COVID-19, one of the most important lessons involves the rise of ageism (Ehni & Wahl, 2020). The adverse impact of COVID-19 on the health and survival of elderly patients has underscored vulnerability and frailty in late life, and has resulted in ageism that devalues older individuals. Because older adults were at risk for adverse outcomes related to COVID-19, they were not always considered as high priority for interventions and in some environments, they were not deemed worthy of saving (Ehni &Wahl, 2020). Further reflecting on pervasive ageism, the United States has formally adopted the Ventilator Allocation Guidelines whereby “age may be considered as a tie-breaking criterion in limited circumstances” (Zucker, Adler, & Berens, 2015).
As a counterpoint to arguments about the negative impact of increased ageism during the COVID Pandemic, there is also some evidence of benefits derived by older adults from Federal and State based programs and entitlements that aid elders. Young and colleagues (2020) provide a list of new policies initiated in response to COVID-1919 that can improve health care and quality of life of older adults. Some of these programs are short-term but have the potential to be extended if they prove to yield evidence warranting their long-term implementation.
Connecting to Our Current COVID-19 Issue of JEP
The articles published in this issue of JEP are largely responses to our call for papers. However, we also included two invited articles by physicians, Dr. Heidi Gullet and Dr. Nathan Stall and colleagues, who each provided important accounts of health care providers’ perspectives on the pandemic in the U.S. and in Canada, respectively. We also include cross-national perspectives from Romania in the paper contributed by Drs. Ivan and Cutler. Our papers reflect interdisciplinary perspectives and include medical, legal, nutrition, sociological, and historical approaches.
1. Equity for Older Adults and Those in Congregate Sites: Lessons from the First Year of a Local Public Health COVID-19 Response, by Heidi Gullett, MD, MPH, offers a medical and public health focus and walks the reader through her firsthand experience of serving as the Commander of the Cuyahoga County, Ohio Board of Health (CCBH) COVID-19 response team. Gullet presents details of what worked well, and lessons she and her multi-discipline team learned through this pandemic. She places particular emphasis on the impact of the pandemic on the vulnerable (e.g., older adults, the disabled, those in congregate settings, racial minorities, and individuals facing socioeconomic disadvantage) and describes how the response team attempted to mitigate COVID-19 outbreaks among these groups. Some of the efforts included a physician hotline for those without a physician, testing, support systems and vaccination efforts for marginalized groups, and building trust within the community. Lastly, Gullet provides policy recommendations which focus on strengthening public health infrastructure to prevent and/or lesson future health crises.
2. COVID-19 and Ontario’s Long-Term Care Homes, by Nathan Stall, MD & Collaborators, undertakes an extensive examination of risk factors that contributed to high incidence of COVID-19 infections in long term care facilities in Ontario, Canada. Indeed, as of July 2021, 43% of Ontario’s COVID-19 deaths were comprised of LTC residents. Analyses revealed that the risk of COVID-19 outbreaks in LTC homes was strongly associated with the rate of infection in the communities surrounding them, profit status of LTC home, and crowding. The authors also examine whether public health interventions had any impact on mitigating this risk and suggested other measures that may be effective moving forward. These measures include improving working conditions for staff, restricting employees to only working in one LTC type setting within a 14-day period, further reducing crowding, prioritizing testing, guaranteeing paid sick time for employees, improving infection prevention, improving strategies for vaccine acceptance, and continuing the rapid collection and access to data on COVID-19 and LTC homes.
3. Racial Differences in Self-Appraisal, Religious Coping, and Psychological Well-being in later Life during the COVID-19 Pandemic by Timothy Goler, PhD, Tirth Bhatta, PhD, Nirmala Lekhak, PhD, and Neema Langa, MA, moves the conversation from mitigation efforts to a survey of coping resources and strategies of older persons that impacted mental health. Using a stress and coping framework, they examined racial differences in well-being of older adults during the COVID-19 pandemic. Their online survey (N=1764) specifically looked at how religious coping, subjective religiosity, emotional support, and self-appraisal of the pandemic shaped racial differences in anxiety and depression. Their findings revealed that Black study participants showed greater concerns about the pandemic than their white counterparts, but had fewer depressive symptoms and anxiety. Further analysis indicated that subjective religiosity, religious coping, and emotional support appeared to buffer stress for black participants. The study suggested that emotional support (for both blacks and whites) independently influences psychological well-being of the participants.
4. Older Adults and the Digital Divide in Romania: Implications for the Covid-19 Pandemic represents a collaboration between a Romanian communication scholar, Loredana Ivan, PhD, and a U.S.-based Sociologist, Stephen J. Cutler PhD. They explored the role of the digital divide among older adults and its implication for the COVID-19 pandemic in Romania. Since many in-person activities were moved to online platforms during the pandemic, older adults who did not have access to the Internet or who were not savvy users risked vulnerabilities. Factors that contribute to the digital divide include the cost of computers and Internet. In Eastern Europe, many younger persons leave to work abroad, and their aging relatives are left in the villages with no means of communication with their children. These older adults are motivated to learn technology but do not have the resources to purchase the needed devices. Although the data for this study was collected prior to the pandemic, Ivan and Cutler raise important points about Internet use among older adults relevant to the pandemic. Those older adults with access and skills likely found opportunities to learn new digital skills, while non-users may have faced social exclusion. They continued relying on phone calls to friends and families and meeting someone in person when facing illnesses.
5. Differential Treatment of Older Workers Due to COVID-19 Accommodations: Potential Issues of Ageism and Age Discrimination by psychologist Lisa Hollis-Sawyer, PhD, focuses on the challenges faced by older workers during the pandemic. The author notes that the COVID-19 pandemic shifted the environment for workers in the United States. Many were laid off or had to adapt to online platforms. Prior to the pandemic, workplace discrimination and ageism were already significant problems for older workers. Hollis-Sawyer examines the strain that older workers faced in relation to the pandemic by studying 2020 employment trends. Her work reveals negative impacts and wear and tear effects on older workers including involuntary early retirement, workplace discrimination based on stereotypes of technology use and perceived health vulnerability, and intergenerational tensions. Hollis-Sawyer concludes her article by suggesting ways that employers can create age-friendly work environments. Suggested strategies are: 1) reducing ageism, 2) training staff to avoid stereotyping, 3) judge workers case-by-case, and 4) training staff on aging issues.
6. The Return of Typhoid Mary? Immigrant Workers in Nursing Homes by professors of Law, Shefali Milczarek-Desai, JD, MA and Tara Sklar, JD, MPH, focuses on problems in staffing in nursing homes. Thousands of COVID-19 infections in long-term care facilities could be traced back to the nursing aides who cared for residents. The authors explore the underlying cause of high COVID transmission rates by looking at the relationship between historical epidemics in the U.S. and low-wage immigrant workers. They do this by presenting the story of “Typhoid Mary,” who was a poor, Irish-immigrant worker labeled the most dangerous woman in America a century ago for spreading typhoid fever. The authors present the poor workplace conditions of aides that contributes to them working in several nursing homes and not having the ability to take paid sick time. The precarious nature of their job often led aides to choose between loss of income or contributing to the spread of the virus. The authors conclude their article by suggesting concrete policy recommendations, specifically enforcement of paid sick leave for low-wage immigrant workers.
7. A Stage Set for Disaster: For-Profit Nursing Homes, Federal Law, and COVID-19 by legal historian David Papke, JD, PhD, also shines a spotlight on the high rates of COVID-19 infection and deaths among nursing home residents. To explore why this disaster occurred within these settings, he takes an upstream approach, presenting historical information about the rise of for-profit nursing homes. Papke argues that the for-profit model does not provide safe and conscientious care for residents. For profit nursing homes often try to maximize profits by skimping on infection control measures and staffing. Papke points out that federal regulations often do little to punish nursing homes that are non-compliant, and regulations promoting infection control actually decreased leading up to the pandemic. The paper skillfully lays out the ways that these nursing homes valued profit over patient care, particularly during the Pandemic (e.g., accepting COVID-positive patients). Papke concludes with regulatory policy recommendations.
8. Nutrition-Related Policy Fundamentals for Supporting Older Adults in the Community during a Pandemic: Lessons from COVID-19 by nutrition and law scholars Meredith Whitmire, JD, Mary Beth Arensberg, PhD, RDN, Alexandra Ashbrook, JD, LL.M, and Robert Blancato, MPA, highlights the important role that nutrition plays in supporting a strong immune system. Unfortunately, many older adults are malnourished or face food insecurity, which places them at an increased risk for chronic conditions. Poorly nourished elders are at risk for contracting COVID-19 and suffering its complications. While malnutrition and food insecurity are known problem among older adults, they are often not screened during care visits. This article provides an overview of community-based, federally funded nutrition services for adults which became extremely important for seniors during the pandemic. Policy recommendations are laid out at the end of the article to ensure that older adults can access adequate nutrition, even post-pandemic. These recommendations focus on how to increase funding for community services which have been proven to help address this need.
Conclusion
The current issue of JEP is capturing an important glimpse into the ongoing COVID -19 pandemic. Each article offers unique and creative perspectives on older adults and the pandemic. Yet due to the rapidly changing nature of the threat, and the selective perspectives of authors, we only gain a partial overview of the impact of the pandemic and future needs of older adults.
At this point, it is clear that the pandemic will have lasting adverse effects on physical and mental health of older adults (Morrow-Howell, 2020). In particular, social isolation and loneliness are proving to cause major adverse mental health problems for older adults (Van Tilburg et al., 2020; Wu, 2020). However, both formal and informal programs have been found to be helpful in counteracting social isolation (Kahlon et al., 2021). There have also been some positive developments for elders based on increased technological skills, increased self-care, and proactivity in reducing social isolation (Morrow-Howell, 2020).
In early fall of 2021, at the time of our publication, we are learning to live with the realization that we are in the midst of a new surge, based on the highly contagious Delta variant affecting mostly unvaccinated individuals, but also causing breakthrough infections of the vaccinated. Although the FDA has now approved vaccines, there is still vaccine hesitancy by some. Older adults, who suffered disproportionally during the early waves, fortunately have a relatively high vaccination rates in the U.S. and are spared from the most severe outcomes, should they experience breakthrough infections (Teran et al., 2021). Yet it is increasingly clear that the pandemic is not yet behind us. Furthermore, we must live with the recognition that the COVID pandemic is a global, rather than a local problem. We must be cautious and yet we must also remain optimistic that the next chapter of this battle will bring some new “breakthrough.” There are many challenges for policy makers to which innovative ideas can be of great value.
References
Abrams, H. R., Loomer, L., Gandhi, A., & Grabowski, D. C. (2020). Characteristics of US nursing homes with COVID‐19 cases. Journal of the American Geriatrics Society, 68(8), 1653-1656.
Allcott, H., Boxell, L., Conway, J., Gentzkow, M., Thaler, M., & Yang, D. (2020). Polarization and public health: Partisan differences in social distancing during the coronavirus pandemic. Journal of Public Economics, 191, 104-254.
Barber, S. J., & Kim, H. (2021). COVID-19 worries and behavior changes in older and younger men and women. The Journals of Gerontology: Series B, 76(2), e17-e23.
Beach, S. R., Schulz, R., Donovan, H., & Rosland, A. M. (2021). Family caregiving during the COVID-19 Pandemic. The Gerontologist, 61(5), 650-660.
Ehni, H. J., & Wahl, H. W. (2020). Six propositions against ageism in the COVID-19 pandemic. Journal of Aging & Social Policy, 32(4-5), 515-525.
Girvan, G. (2020). Nursing homes & assisted living facilities account for 38% of COVID-19 deaths. Retrieved from https://freopp.org/the-covid-19-nursing-home-crisis-by-the-numbers-3a47433c3f70
Han, Q., Zheng, B., Cristea, M., Agostini, M., Belanger, J. J., Gützkow, B., & Leander, P.
(2020). Trust in government and its associations with health behaviour and prosocial behaviour during the COVID-19 pandemic. PsyArXiv Preprints.
Heid, A. R., Cartwright, F., Wilson-Genderson, M., & Pruchno, R. (2021). Challenges experienced by older people during the initial months of the COVID-19 pandemic. The Gerontologist, 61(1), 48-58.
Kahlon, M. K., Aksan, N., Aubrey, R., Clark, N., Cowley-Morillo, M., Jacobs, E. A., ... & Tomlinson, S. (2021). Effect of layperson-delivered, empathy-focused program of telephone calls on loneliness, depression, and anxiety among adults during the COVID-19 pandemic: A randomized clinical trial. JAMA Psychiatry, 78(6), 616-622.
Latkin, C. A., Dayton, L., Strickland, J. C., Colon, B., Rimal, R., & Boodram, B. (2020). An assessment of the rapid decline of trust in US sources of public information about COVID-19. Journal of Health Communication, 25(10), 764-773.
Morrow-Howell, N., Galucia, N., & Swinford, E. (2020). Recovering from the COVID-19 pandemic: A focus on older adults. Journal of Aging & Social Policy, 32(4-5), 526-535.
Sallam, M. (2021). COVID-19 vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates. Vaccines, 9(160), 1-14.
Sheik-Ali, S., Sheik-Ali, S., & Sheik-Ali, A. (2021). Hearing impairment and introduction of mandatory face masks. Editorial. Ear, Nose, & Throat Journal, 1-2.
Vahia, I. V., Jeste, D. V., & Reynolds, C. F. (2020). Older adults and the mental health effects of COVID-19. JAMA, 324(22), 2253-2254.
Teran, R. A., Walblay, K. A., Shane, E. L., Xydis, S., Gretsch, S., Gagner, A., & Black, S. R. (2021). Postvaccination SARS‐CoV‐2 infections among skilled nursing facility residents and staff members—Chicago, Illinois, December 2020–March 2021. American Journal of Transplantation, 21(6), 2290-2297.
Van Tilburg, T. G., Steinmetz, S., Stolte, E., van der Roest, H., & de Vries, D. H. (2020). Loneliness and mental health during the COVID-19 pandemic: A study among Dutch older adults. The Journals of Gerontology: Series B, 76(7), e249–e255.
Whitehead, B. R., & Torossian, E. (2021). Older adults’ experience of the COVID-19 pandemic: A mixed-methods analysis of stresses and joys. The Gerontologist, 61(1), 36-47.
Wu, B. (2020). Social isolation and loneliness among older adults in the context of COVID-19: A global challenge. Global health research and policy, 5(1), 1-3.
Xu, J., Liu, P. J., & Beach, S. (2021). Multiple caregivers, many minds: Family discord and caregiver outcomes. The Gerontologist, 61(5), 661-669.
Young, H. M., Quinn, W., Brassard, A., Gualtieri, C., & Reinhard, S. (2020). COVID-19 pandemic spurs policy changes benefiting older adults. Journal of Gerontological Nursing, 46(6), 19-23.
Zucker, H., Adler, K., Berens, D., Bleich, R. J. D., Brynner, R., & Butler, K. A. (2015). Ventilator allocation guidelines. Albany: New York State Department of Health Task Force on Life and the Law.
Large segments of the world’s older population remain unprotected from COVID-19 in countries where vaccines are hard to come by. Even in the U.S., where vaccines are readily available, there are vast differences among states in terms of vaccine hesitancy, resulting in many Southern states remaining unvaccinated. In the absence of a federal mandate, uneven vaccination rates are likely to persist along with an uneven application of protective measures (Sallam, 2021). As of September 2021, only one vaccine has received full approval from the United States Food and Drug Administration (FDA), thereby limiting more effective measures for persuading the hesitant.
This special issue of the Journal of Elder Policy on COVID-19 is being published about a year and a half after the onset of the global pandemic. Prior to this crisis, very few of us would have believed that a virus could upend the lives of the world’s population and persist for such a long period. The world experienced pandemics before: Ebola, swine flu, and SARS, but they were not the same magnitude as COVID-19.
COVID-19 has resulted in unprecedented policy challenges. Experts in public health have had a difficult time providing consistent and effective guidelines for coping with challenges faced. Even as vaccines have proved to be successful in diminishing rates of infection, hospitalization, and mortality, there has been considerable political controversy regarding the best and safest ways to return to more normal lifestyles.
The case of the COVID-19 pandemic provides an exemplar of the intertwining between public policy and public attitudes. Trust in government was undermined during the period of the pandemic (Han et al., 2020). This lack of trust also coincides with the lack of individuals trusting one another. This problem was exemplified in the reaction to the CDC recommendation, during the spring of 2021, for eliminating the mask mandates. The question arose: Can vaccinated individuals assume that all of those no longer wearing masks have indeed been vaccinated?
Both because of the severe impact of COVID-19 and the ambiguity regarding the best ways to fight it, public policy has become polarized and the subject of major political disagreements (Alcott et al., 2020). As we begin fall of 2021, we hope to be seeing the light at the end of the tunnel of this terrible pandemic, but uncertainties abound. Masks have become a symbol of caution on the one hand and of enforced limitations on the other. The CDC has made contradictory pronouncements, and the public finds it easy to blame absence of leadership for the lack of clarity regarding prudent actions to follow (Latkin et al., 2020).
In this editorial, I aim to discuss relevance and contributions of the featured articles and acknowledge methodological limitations of empirical studies due to the pandemic. Prior to focusing on the articles published in this issue, I will briefly share my own lived experience during this period that can help contextualize the personal impact of the pandemic on older people.
My Lived Experience Coping with the COVID-19 Pandemic
Being 80 years old, and now a widow, living alone, I can readily understand the dilemmas and insecurities of older adults in dealing with the pandemic. I noted in previous issues of JEP how my husband, Boaz, a recently retired psychology professor, and I “escaped” from our rented high-rise apartment in Florida in March of 2020 and took a risky flight home to Cleveland, Ohio. Living in a single-family home felt much safer than our prior elevator rides and proximity to neighbors. During the seven months between April and October 2020, Boaz and I did not leave our Cleveland home. We shifted to telehealth visits for our health care and ordered our groceries and medications delivered by Instacart.
Our work-related and long-distance family interactions were all on Zoom. Starting in August 2020, I was teaching a combined graduate and undergraduate class on stress and coping on Zoom, with considerable help from my graduate students and my tech-savvy adult children who live nearby. In order to protect us, their elderly parents, my son and his wife started homeschooling their two children, including an autistic son. They also engaged in and advocated strict social distancing.
In my last editorial I shared my difficult experiences related to the hospitalization of my husband, Boaz, and his death on November 6th while in a highly regarded hospital. During Boaz’s hospitalization, starting in mid-October, I left my home daily to be with him, as I was the designated relative and the only one allowed to visit due to COVID protocols. I stopped worrying about my own safety as I felt that I needed to be with my beloved husband of 59 years. He died unexpectedly due to aspirating a large pill he was given. Our two sons were allowed to visit and be with him in his final hours.
After Boaz passed away, my surreal COVID-19 era experience continued with a Zoom funeral. Colleagues were largely absent. Friends and relatives, participating by Zoom, added to an eerie unreality of the experience. My husband’s elderly sister and brother and our extended family who lived out of town could not attend Boaz’s funeral. Although Boaz did not pass from COVID-19, his death was shrouded in the tragedy of the pandemic. I did the best I could to find solace in the closeness of my children. They made a major sacrifice to protect me by keeping their children out of school for most of the school year.
The new year brought rays of hope with the vaccine on the horizon. I was vaccinated in February 2021 and felt great relief. I was able to think of visiting the dentist and the podiatrist. I had been cutting my own hair during the pandemic and got used to having gray hair. About a month after being fully vaccinated I returned to the beauty shop wearing a mask.
Early this summer my vaccinated adult children and I undertook a long-distance trip to visit my younger son and five grandchildren in Philadelphia. We remained cautious about indoor dining but appreciated the return of some normalcy in our lives. My grandchildren enjoyed day camp and greatly welcomed the company of other children. We visited museums and I felt comfortable enough to take a chance on flying between Cleveland and Philadelphia.
I have been a college professor for the past 54 years and was looking forward to teaching in person this fall. I have truly missed interacting with my students, as Zoom just does not provide the same interaction as face-to-face conversations. As the summer progressed, we learned about the advance of the new Delta variant of the COVID-19 virus that can lead to breakthrough infections for vaccinated individuals. I became more concerned about in-person teaching even with the good news that all returning students must be vaccinated. Indeed, the latest University directives call for both students and professors to wear masks in class. Given that at age 80 I am hard of hearing, a further worry now relates to my ability to understand comments and questions of my students who will be wearing masks (Sheik-Ali et al., 2021). Due to these concerns, I requested to return to online teaching as a disability accommodation.
Although I do go out shopping and visit my children, I am still hesitant to have visitors and to eat out despite being vaccinated. As preparations for school intensify, we face further uncertainties of the new variants. This puts the fear of COVID-19 back at center stage. One of the major hardships for me is the inability to plan ahead. I had multiple abstracts that were accepted for presentation at the Gerontological Society of America (GSA) meetings in Phoenix, Arizona, in November, but I have been unsure about the safety of travel and face-to-face interactions. Recently GSA announced that the meeting would be switched to a virtual format. I realize that unpredictability is part of the reality of reaching old age. This may be a reason for the findings mentioned earlier that older people do not worry more than the young about the pandemic.
At the same time, the uncertainties of the pandemic still linger in my life. Last week, the UPS driver delivered the boxes that I had sent back from our trip to Philadelphia. When I noticed that the driver who was at my door was not wearing a mask, I quickly retreated to my hallway and experienced a fear I had been used to prior to vaccination.
Methodological Limitations of Studies Focused on COVID-19 and Older Adults
There have been numerous studies published over the past year, addressing the unique challenges of COVID-19 for older people. The present issue of JEP adds national and international contributions to better understand this important topic. In evaluating the quality of research on aging and COVID-19, we must acknowledge limitations of the current literature for offering a broad and deep understanding of the impact of the COVID-19 pandemic on lives of older adults, those of their families and caregivers and their health care providers. The problem lies in the many restrictions both researchers and their subjects have been living and operating under. Due to the ongoing threat of the pandemic, we cannot yet apply conventional methodological expectations to research on the impact of the pandemic.
Unlike traditional social science research that is based on representative samples and typically collects data through surveys or interviews administered in person, most of the current research available related to COVID-19 does not meet these standards. After the start of the pandemic, investigators lacked the usual opportunities to apply for peer reviewed funding. Nor did most investigators have the facilities and supports needed to craft first rate proposals. During lockdowns, older adults could not be interviewed in person. Pilot data was thus difficult to obtain by investigators working from home. Data from older adults could mostly be collected online or by phone.
Data for most of the COVID pandemic studies were collected during the first half of 2020. As mentioned above, in an effort to quickly collect relevant data, scholars relied on internet-based surveys (Barber & Kim, 2021). Such surveys include an overrepresentation of educated respondents who had access to computers and the Internet and who are technologically literate. Minorities were generally underrepresented in such samples. Furthermore, older adults living in long-term care facilities, who were among the first major victims of the Pandemic were seldom included in research on COVID-19. These older adults lived under strict lockdowns. Their families were not permitted to visit and thus could not offer firsthand, personal testimonials about the lived experiences of this highly vulnerable and victimized group. Those elders who contracted COVID-19 in institutional facilities suffered high mortality rates. Just 2.1 million people, accounting for 0.62% of the U.S. population, reside in a nursing home or assisted living facilities. Yet as of May 22, 2020, this population constituted 42% of all COVID-19 deaths (Girvan, 2020).
Before summarizing contributions of studies included in this issue of JEP, I want to offer a few insights from the larger literature related to older adults and COVID-19. The challenges experienced by older people during the initial months of the pandemic were explored by Heid and colleagues (2021). The most frequently noted problems among their sample (N=1272) related to constraints on social interactions during the pandemic. A study mixed methods study (N=825) by Whitehead and Torossian (2021) echoed this finding, noting that 42% of older respondents reported constrained social interactions and 30.9% reported activity restriction. Again, these authors found the most frequent stressors to be confinement and loneliness. However, sources of joy included family/friend relationships, digital social interactions, and hobbies. Predictors of poor psychological wellbeing during the pandemic included concern for the wellbeing of others, fears of an uncertain future, and fears of contracting the virus.
The larger literature on COVID-19 and aging also focuses on caregiving. The complex demands of caregiving to older adults during the pandemic have led to anxiety, depression, and other mental health problems among caregivers (Beach et al., 2021). The presence of multiple caregivers was often found to result in family conflict (Xu, Liu, & Beach, 2021). With regard to policy implications of COVID-19, one of the most important lessons involves the rise of ageism (Ehni & Wahl, 2020). The adverse impact of COVID-19 on the health and survival of elderly patients has underscored vulnerability and frailty in late life, and has resulted in ageism that devalues older individuals. Because older adults were at risk for adverse outcomes related to COVID-19, they were not always considered as high priority for interventions and in some environments, they were not deemed worthy of saving (Ehni &Wahl, 2020). Further reflecting on pervasive ageism, the United States has formally adopted the Ventilator Allocation Guidelines whereby “age may be considered as a tie-breaking criterion in limited circumstances” (Zucker, Adler, & Berens, 2015).
As a counterpoint to arguments about the negative impact of increased ageism during the COVID Pandemic, there is also some evidence of benefits derived by older adults from Federal and State based programs and entitlements that aid elders. Young and colleagues (2020) provide a list of new policies initiated in response to COVID-1919 that can improve health care and quality of life of older adults. Some of these programs are short-term but have the potential to be extended if they prove to yield evidence warranting their long-term implementation.
Connecting to Our Current COVID-19 Issue of JEP
The articles published in this issue of JEP are largely responses to our call for papers. However, we also included two invited articles by physicians, Dr. Heidi Gullet and Dr. Nathan Stall and colleagues, who each provided important accounts of health care providers’ perspectives on the pandemic in the U.S. and in Canada, respectively. We also include cross-national perspectives from Romania in the paper contributed by Drs. Ivan and Cutler. Our papers reflect interdisciplinary perspectives and include medical, legal, nutrition, sociological, and historical approaches.
1. Equity for Older Adults and Those in Congregate Sites: Lessons from the First Year of a Local Public Health COVID-19 Response, by Heidi Gullett, MD, MPH, offers a medical and public health focus and walks the reader through her firsthand experience of serving as the Commander of the Cuyahoga County, Ohio Board of Health (CCBH) COVID-19 response team. Gullet presents details of what worked well, and lessons she and her multi-discipline team learned through this pandemic. She places particular emphasis on the impact of the pandemic on the vulnerable (e.g., older adults, the disabled, those in congregate settings, racial minorities, and individuals facing socioeconomic disadvantage) and describes how the response team attempted to mitigate COVID-19 outbreaks among these groups. Some of the efforts included a physician hotline for those without a physician, testing, support systems and vaccination efforts for marginalized groups, and building trust within the community. Lastly, Gullet provides policy recommendations which focus on strengthening public health infrastructure to prevent and/or lesson future health crises.
2. COVID-19 and Ontario’s Long-Term Care Homes, by Nathan Stall, MD & Collaborators, undertakes an extensive examination of risk factors that contributed to high incidence of COVID-19 infections in long term care facilities in Ontario, Canada. Indeed, as of July 2021, 43% of Ontario’s COVID-19 deaths were comprised of LTC residents. Analyses revealed that the risk of COVID-19 outbreaks in LTC homes was strongly associated with the rate of infection in the communities surrounding them, profit status of LTC home, and crowding. The authors also examine whether public health interventions had any impact on mitigating this risk and suggested other measures that may be effective moving forward. These measures include improving working conditions for staff, restricting employees to only working in one LTC type setting within a 14-day period, further reducing crowding, prioritizing testing, guaranteeing paid sick time for employees, improving infection prevention, improving strategies for vaccine acceptance, and continuing the rapid collection and access to data on COVID-19 and LTC homes.
3. Racial Differences in Self-Appraisal, Religious Coping, and Psychological Well-being in later Life during the COVID-19 Pandemic by Timothy Goler, PhD, Tirth Bhatta, PhD, Nirmala Lekhak, PhD, and Neema Langa, MA, moves the conversation from mitigation efforts to a survey of coping resources and strategies of older persons that impacted mental health. Using a stress and coping framework, they examined racial differences in well-being of older adults during the COVID-19 pandemic. Their online survey (N=1764) specifically looked at how religious coping, subjective religiosity, emotional support, and self-appraisal of the pandemic shaped racial differences in anxiety and depression. Their findings revealed that Black study participants showed greater concerns about the pandemic than their white counterparts, but had fewer depressive symptoms and anxiety. Further analysis indicated that subjective religiosity, religious coping, and emotional support appeared to buffer stress for black participants. The study suggested that emotional support (for both blacks and whites) independently influences psychological well-being of the participants.
4. Older Adults and the Digital Divide in Romania: Implications for the Covid-19 Pandemic represents a collaboration between a Romanian communication scholar, Loredana Ivan, PhD, and a U.S.-based Sociologist, Stephen J. Cutler PhD. They explored the role of the digital divide among older adults and its implication for the COVID-19 pandemic in Romania. Since many in-person activities were moved to online platforms during the pandemic, older adults who did not have access to the Internet or who were not savvy users risked vulnerabilities. Factors that contribute to the digital divide include the cost of computers and Internet. In Eastern Europe, many younger persons leave to work abroad, and their aging relatives are left in the villages with no means of communication with their children. These older adults are motivated to learn technology but do not have the resources to purchase the needed devices. Although the data for this study was collected prior to the pandemic, Ivan and Cutler raise important points about Internet use among older adults relevant to the pandemic. Those older adults with access and skills likely found opportunities to learn new digital skills, while non-users may have faced social exclusion. They continued relying on phone calls to friends and families and meeting someone in person when facing illnesses.
5. Differential Treatment of Older Workers Due to COVID-19 Accommodations: Potential Issues of Ageism and Age Discrimination by psychologist Lisa Hollis-Sawyer, PhD, focuses on the challenges faced by older workers during the pandemic. The author notes that the COVID-19 pandemic shifted the environment for workers in the United States. Many were laid off or had to adapt to online platforms. Prior to the pandemic, workplace discrimination and ageism were already significant problems for older workers. Hollis-Sawyer examines the strain that older workers faced in relation to the pandemic by studying 2020 employment trends. Her work reveals negative impacts and wear and tear effects on older workers including involuntary early retirement, workplace discrimination based on stereotypes of technology use and perceived health vulnerability, and intergenerational tensions. Hollis-Sawyer concludes her article by suggesting ways that employers can create age-friendly work environments. Suggested strategies are: 1) reducing ageism, 2) training staff to avoid stereotyping, 3) judge workers case-by-case, and 4) training staff on aging issues.
6. The Return of Typhoid Mary? Immigrant Workers in Nursing Homes by professors of Law, Shefali Milczarek-Desai, JD, MA and Tara Sklar, JD, MPH, focuses on problems in staffing in nursing homes. Thousands of COVID-19 infections in long-term care facilities could be traced back to the nursing aides who cared for residents. The authors explore the underlying cause of high COVID transmission rates by looking at the relationship between historical epidemics in the U.S. and low-wage immigrant workers. They do this by presenting the story of “Typhoid Mary,” who was a poor, Irish-immigrant worker labeled the most dangerous woman in America a century ago for spreading typhoid fever. The authors present the poor workplace conditions of aides that contributes to them working in several nursing homes and not having the ability to take paid sick time. The precarious nature of their job often led aides to choose between loss of income or contributing to the spread of the virus. The authors conclude their article by suggesting concrete policy recommendations, specifically enforcement of paid sick leave for low-wage immigrant workers.
7. A Stage Set for Disaster: For-Profit Nursing Homes, Federal Law, and COVID-19 by legal historian David Papke, JD, PhD, also shines a spotlight on the high rates of COVID-19 infection and deaths among nursing home residents. To explore why this disaster occurred within these settings, he takes an upstream approach, presenting historical information about the rise of for-profit nursing homes. Papke argues that the for-profit model does not provide safe and conscientious care for residents. For profit nursing homes often try to maximize profits by skimping on infection control measures and staffing. Papke points out that federal regulations often do little to punish nursing homes that are non-compliant, and regulations promoting infection control actually decreased leading up to the pandemic. The paper skillfully lays out the ways that these nursing homes valued profit over patient care, particularly during the Pandemic (e.g., accepting COVID-positive patients). Papke concludes with regulatory policy recommendations.
8. Nutrition-Related Policy Fundamentals for Supporting Older Adults in the Community during a Pandemic: Lessons from COVID-19 by nutrition and law scholars Meredith Whitmire, JD, Mary Beth Arensberg, PhD, RDN, Alexandra Ashbrook, JD, LL.M, and Robert Blancato, MPA, highlights the important role that nutrition plays in supporting a strong immune system. Unfortunately, many older adults are malnourished or face food insecurity, which places them at an increased risk for chronic conditions. Poorly nourished elders are at risk for contracting COVID-19 and suffering its complications. While malnutrition and food insecurity are known problem among older adults, they are often not screened during care visits. This article provides an overview of community-based, federally funded nutrition services for adults which became extremely important for seniors during the pandemic. Policy recommendations are laid out at the end of the article to ensure that older adults can access adequate nutrition, even post-pandemic. These recommendations focus on how to increase funding for community services which have been proven to help address this need.
Conclusion
The current issue of JEP is capturing an important glimpse into the ongoing COVID -19 pandemic. Each article offers unique and creative perspectives on older adults and the pandemic. Yet due to the rapidly changing nature of the threat, and the selective perspectives of authors, we only gain a partial overview of the impact of the pandemic and future needs of older adults.
At this point, it is clear that the pandemic will have lasting adverse effects on physical and mental health of older adults (Morrow-Howell, 2020). In particular, social isolation and loneliness are proving to cause major adverse mental health problems for older adults (Van Tilburg et al., 2020; Wu, 2020). However, both formal and informal programs have been found to be helpful in counteracting social isolation (Kahlon et al., 2021). There have also been some positive developments for elders based on increased technological skills, increased self-care, and proactivity in reducing social isolation (Morrow-Howell, 2020).
In early fall of 2021, at the time of our publication, we are learning to live with the realization that we are in the midst of a new surge, based on the highly contagious Delta variant affecting mostly unvaccinated individuals, but also causing breakthrough infections of the vaccinated. Although the FDA has now approved vaccines, there is still vaccine hesitancy by some. Older adults, who suffered disproportionally during the early waves, fortunately have a relatively high vaccination rates in the U.S. and are spared from the most severe outcomes, should they experience breakthrough infections (Teran et al., 2021). Yet it is increasingly clear that the pandemic is not yet behind us. Furthermore, we must live with the recognition that the COVID pandemic is a global, rather than a local problem. We must be cautious and yet we must also remain optimistic that the next chapter of this battle will bring some new “breakthrough.” There are many challenges for policy makers to which innovative ideas can be of great value.
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