The Wisdom I Gained From Older Patients in COVID-19
This Influencer in Aging, a geriatrician, made a list of facts, impressions and contradictions
When Next Avenue asked me to write about what I learned about older patients during this last remarkably different and difficult pandemic year, I thought, what a great idea! This will be fun. Easy. Interesting.
It should have been.
When COVID-19 struck the United States in 2020, I had been a trained geriatrician for 22 years and had finally arrived at what felt like a good balance of humility and confidence in caring for patients. Humility because it's impossible to know enough about medicine or the diversity of individual human lives and experiences. Confidence because I've developed diagnostic and communication skills that sometimes lead to better patient care — as well as the insight that comes from decades of listening to older adults and reading about aging.
The Pandemic Changed So Much for My Patients and Me
But, to be honest, the pandemic changed so much for my patients and me. I'd never used Zoom for patient care until the spring of 2020; now telehealth is commonplace for my medical center's virtual patient visits of the mostly sheltering-in-place older patients in my geriatrics clinic.
Physically, many of my patients declined — or so they tell me.
Yet when COVID-19 started in the U.S., all I could think about was how little seemed new or different with my patients, even as their lives and mine became unrecognizable. Instead, it often felt like a case study of the "more so" phenomenon: Month after month, all the well-documented vulnerabilities and strengths of old people and all the ageist and racist idiocies of our society and health care system were magnified and spotlighted by the virus and our country's responses to it.
Now that a year has passed, I've made a list of facts, impressions and contradictions of my experiences with older patients. These don't feel like wisdom as much as reasons to scream, cry, smile or indulge newfound hope for the future of old age:
While I spent time discussing with my patients COVID-19 fears, ways to stay safe and vaccination options, most of our time has been devoted to what it has always been: their health and medical conditions. This is important, since we know a large number of the "excess deaths" (the difference between the observed number of deaths associated with COVID-19 and the expected number) took place because people were given only virus, not person-focused, warnings.
Too often, public health messages told older adults to stay home; they didn't add the caveat that if they were sick, the best place to be was in a clinic or hospital.
Physically, many of my patients declined — or so they tell me. On Zoom, it's hard to assess walking or balance.
While many of my patients are taking walks or doing online exercise classes, they still note losses that seem unexpected. I assume this is because of sharp declines in their non-exercise physical activity. After all, if you go out of your home, you are more likely to move around than if you are confined to your personal space. This is particularly hard on people who live in single rooms or small apartments and in neighborhoods where going for a walk might be dangerous.
There's a structural inequality, too. Due to a lack of equal access to educational or employment opportunities, the pandemic has accelerated age-associated physical decline among minority communities and exacerbated gender and race-based inequities of old age.
Many more of my patients complained of memory loss than ever before. They said their brains "weren't right" or "weren't reliable." I began thinking of this as "COVID brain," akin to "chemo brain" (when some people feel foggy after chemotherapy). But since the coronavirus affects the brain and these people were not infected by COVID-19, a more accurate term is "pandemic brain."
Most of my patients showed greater resilience in the face of this year's challenges than younger people.
This might be described as a threshold effect. Since short-term memory is less reliable with age, older people's memories — even absent cognitive impairment — are closer to the "ok/not ok" line, so the same downward nudge in cognitive function from pandemic reductions, interactions and activities has pushed more older than younger people closer to, or over, the line of dysfunction.
Who Gained Weight the Most
None of my patients gained as much weight as I did. Was that because they didn't spend 10 to 14 hours a day on Zoom, WebEx, Skype or Teams and take on public health roles in addition to their full-time job as I did? Or because they were better able to prioritize their health, exert sensible will power and steer clear of the food-as-stress-reliever and food-as-sole-available-safe-form-of-entertainment responses I indulged in?
Research has shown that judgment increases with age for most people; this may be an example of it.
Most of my patients showed greater resilience in the face of this year's challenges than younger people, even though the patients with depression, anxiety and social isolation were the most adversely impacted by lockdown restrictions. Their resilience is a trend that pandemic research studies have borne out, too.
Many of my patients stopped working or volunteering and learned how important those activities were to them and their communities. Others missed months or, eventually, more than a year of supportive community programs, retirement activities, travel or opportunities to get a job. The ones who felt this the most were older, low-paid essential workers who risked their lives.
Although I initially spent time staring at my patients' ceilings or chests on Zoom because the technology was new to them, eventually my patients and many other older people learned to use tech in new ways, from medical visits to ordering supplies and socializing. But those who couldn't access or use technology had an array of potentially preventable social disadvantages that can also lead to poorer health and shorter lifespans. They were more likely to be people of color, people with low incomes, the "older old" (over 80 from a digital standpoint), ones with cognitive impairment and people less likely to have family or friends helping out.
The Wisdom I Gained
In the end, it seems the wisdom I gained from my patients in the pandemic may have been this: We already know what the greatest benefits and challenges of old age are, but we don't do nearly enough to take advantage of the former or to combat the latter.
A win-win next step would be for vaccinated older people to take the lead in shaping a less ageist and racist society and to help us all prepare better for a post-pandemic world.