An unprecedented level of societal anxiety around the unfolding Covid-19 pandemic has gripped many of us as we eagerly consume and anticipate the next morsel of scientific detail or grim statistic about the global impact of the virus. 

Doctors are not immune to media distortion or political spin about many health topics, yet in their professional roles, they are trusted allies of many older members of our community and they preciously guard the most prized and personal asset of this cohort – their health and wellbeing. We are at the forefront of the current global Covid-19 outbreak and have frequently been asked to dispense advice to older patients, including the guidance to self-isolate to minimise the risk of contracting this virus and its associated illness and complications. 

Strictly speaking ‘quarantine’ is the separation and restriction of movement of people who have been potentially exposed to a contagious disease to ascertain if they become unwell and thereby reducing the risk of them infecting others.¹ The term ‘isolation’, however, refers to the separation of people who are diagnosed with a contagious condition from persons who are not sick, yet the two terms are frequently used interchangeably. 

Recently, asymptomatic older people have been advised to isolate themselves from other members of the community (particularly younger people who might be carriers of Covid-19) as due to their advanced age and greater preponderance of underlying medical conditions, they appear to be more vulnerable to develop severe illness associated with this virus.² We can instinctively speculate that quarantine is an unpleasant experience for those who undergo it owing to the effects of separation from loved ones, loss of freedom, uncertainty over disease status, never mind the inevitable boredom. 

With this in mind, what advice and psychological support can doctors and family members provide our senior citizens to mitigate these negative effects of lengthy periods of movement restriction and self-isolation?

Benefits and costs

Chronological age is only one aspect of objectively describing the health risks and health outcomes of an older person and, as medical professionals, we need to reassure our patients that many of them are healthier and more resilient than they think they are. Many older people are highly functional and physically active and such positive lifestyle factors can help fight off disease of any kind. 

Above all, we need to put out the message that older people are just as worthy as anyone else of intensive medical care, including access to a highly-coveted ICU ventilator, should it be needed. On the other hand, many older people will want to play their part by sheltering during the present crisis and not risk burdening or putting undue strain on healthcare resources. 

The potential benefits of quarantine measures, although compelling in the context of a surge in infection rate, nonetheless need to be weighed carefully against the possible psychological costs. Many quarantine studies surveying the effects on those quarantined reported a high prevalence of symptoms of psychological distress and disorder.³

There appears to be an escalation of general psychological symptoms such as emotional disturbance including anger and exhaustion, depression, irritability, insomnia and post-traumatic symptoms. Healthcare workers themselves, in direct contact with quarantined patients, reported significantly greater levels of exhaustion, detachment from others, insomnia, anxiety when dealing with febrile patients, and reluctance to work or consideration of resignation. There is nothing to suggest from quarantine studies that advanced age is a negative factor in relation to adverse psychological effects of periods of quarantine, in fact younger age (16 to 24) seems to be correlated with negative psychological impacts, according to a recently published review by Brooks et al.³

Informed decision

Mitigating the psychological effects of quarantine is an essential priority for all health practitioners, irrespective of subspecialty, especially if periods of self-isolation are likely to be prolonged. Evidence exists for the persistence of these negative effects months or years after the quarantine event.⁴ Quarantine duration of greater than 10 days, fears of infection and of having inadequate basic supplies and a dearth of accurate information from public health authorities were deemed to be significant causes of anxiety and distress. 

Brooks el al also highlighted longer term mediators of stress in those exposed to quarantine measures, especially financial concerns and stigma.³ They suggest that those with a pre-existing history of mental health difficulties require extra support by any possible means during a period of quarantine. They specifically suggest that periods of enforced quarantine be kept as short as possible to avoid cumulative frustration and demoralisation. An adequate flow of information to ensure that those in quarantine have a good understanding of the disease in question and the reasons for the isolation measures is also a priority. 

Provision of basic supplies and reassurance about the future viability of food chains and services is likely to ameliorate anxiety, when other aspects of the self-quarantine period such as its duration remain subject to uncertainty. Brooks et al argue that appealing to people’s higher motives is more likely to ensure voluntary compliance with isolation measures and even better mental health outcomes, therefore altruism is clearly favoured over compulsory restriction of liberty, but buy-in is more likely be maintained if people are provided with adequate information and reasons for the measures. 

Self-care first

Boredom and isolation predictably cause distress for human beings who are inherently programmed to be socially connected. Medical professionals are as well placed as any to provide practical advice about staving off boredom, as well as coping, wellness and stress management strategies. Taking self-care seriously in the context of a transmissible community infection is as important as airline safety. 

In such a scenario, we are metaphorically compelled to fit our own oxygen mask first, before being able to take care of others. Basic self-care such as maintenance of a good routine and sleep hygiene and minimising alcohol and other over-indulgences is not selfish, but may be a useful way to maintain a healthy immune system. 

Stepping up the management of any chronic condition such as chronic obstructive pulmonary disorder (COPD) or depression may be especially prudent to avoid a cascade of insult to mind and body from poorly managed illness of any kind. Now is the time to take inhalers correctly or improve diabetes control. 

Vitamin D supplements may be important to discuss with your primary care doctor for those who are staying indoors for prolonged periods, and exercise is important to avoid complications associated with immobilisation. A regular exercise regime is vital for everyone and may be easy to implement even within the confines of one’s dwelling through seated exercises, exercise equipment or walking circuits of one’s garden or corridors. Outdoor exercise in public places, while maintaining social distance, may also be possible during different phases of the quarantine but is likely to be at the discretion and advice of public health authorities.   

Minding the mind

Flattening the spike of psychological distress associated with Covid-19 may be easier for older adults, as opposed to younger people, as our seniors anecdotally have perhaps greater reserves of self-sufficiency and memories to contextualise the present crisis. 

Reframing the experience as a therapeutic hibernation, allowing quiet reflection and meditation, can be useful but undoubtedly the closure and temporary unavailability of community services will be challenging for many. 

Filling the time productively and focusing on tasks that bring a sense of achievement, pleasure and closeness to others can instil a sense of satisfaction and prevent an accumulation of guilt. It could be the time to undertake an online course or learning programme, to learn a new language or to rediscover the joys of reading. Having background music to fill the void associated with too much silence can inhibit brooding and rumination which otherwise can excavate and reactivate excessive regret and negativity. 

Equally, simple tasks that we have postponed such as decluttering or cleaning can finally be tackled, if we are otherwise fit and healthy during the quarantine, to help us reassure ourselves that we have made the most of the enforced isolation. 

Journalling about our feelings during isolation, as well as our hopes when the quarantine is over can be very therapeutic. We may have special insights about our own circumstances that can only emerge in times of relative solitude, and committing these feelings to paper or hard drive can help us articulate and formulate new aspirations and strategies to get the most out of our remaining years.     

Embracing technology

Doctors should encourage their patients to have a working mobile phone, which should be seen as a necessity and not a luxury. It may be the only way to communicate with essential services such as your local medical practice or pharmacy. Personal security is also enhanced by technological devices and innovative products and vulnerable older people need to be perpetually wary of scammers and cold callers calling to the doorstep offering ‘help’. 

With these considerations in mind, family members may make yet another attempt to encourage older family members to embrace technology, not least to activate a remotely accessible social network which is vital to maintain for long-term as well as short-term mental wellbeing. Tablet devices may be less intimidating for older people to learn basic computing skills on and easier to operate, and the availability of messaging services and social media to keep in touch with, and be reassured by, loved ones may be an incentive to finally learn to use the plethora of devices that are in circulation. Having WiFi networks that are robust and reliable can be seen as an essential service to communicate directly with loved ones and reduce feelings of isolation and panic. 

Telephone support and other services such as community psychiatric teams and public health can also be a means of supporting people experiencing quarantine, by providing regular monitoring and official updates about quarantine practices and advice. 

Reality versus stereotypes

Despite the public discussion of older people and those with pre-existing medical conditions in general constituting an ‘at-risk group’, the stereotype of frailty and infirmity being inevitably associated with old age may rear its head during this crisis but should not stick, considering the recruitment campaign aimed at retired healthcare workers in many countries. 

Older, experienced clinicians are being targeted in droves and enticed to return to the frontline, with little reference to personal risk or chronological age. The reality of the situation is that in time of national crisis, older workers are a considerable asset bringing experience, perspective, wisdom and skills to bear in solving virtually any calamity they find themselves immersed in. This should be fully appreciated by society, however, without the need for older people to keep having to prove themselves by repeatedly emerging from the shadows of retirement. 

If older healthcare workers could be retained in ‘the system’ in even part-time teaching or mentoring roles and appropriate late career structures, incentives and modes of upskilling developed, we may be better prepared to face future global health threats. Extending medical careers by also reducing factors associated with burnout and promoting mid-career development should be urgent, present and future considerations for health planners.  

When the reasons for imposing quarantine finally recede in terms of the passing of a contagious infection or disease, the psychological sequelae for individuals are likely to persist, and sometimes for a long period of time. Older people are an extremely heterogenous group with some being more vulnerable and frail than others, yet as an age cohort, are all likely to be the subject of increasingly vocal advice and compulsory measures to restrict their movements in public, to prevent their contracting Covid-19. 

The potential benefits of mass quarantine, an age-old measure to contain infectious disease, are undoubted, yet need to be weighed against their psychological costs. Older people, as well as needing protection from the virus, may yet be called upon to step forward from the shelter and sanctuary of self-isolation to support younger people financially and emotionally as the full implications of Covid-19 unfold.

References 

1. Centers for Disease Control and Prevention. Quarantine and isolation. 2017. https://www.cdc.gov/quarantine/index.html (accessed Mar 21, 2020)
2. Zunyon W, McGoogan J. Characteristics of and important lessons from the coronavirus disease 2019 (Covid-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA, 2020, Feb 24 (published online). doi:10.1001/jama.2020.2648 
3. Brooks S, Webster R, Smith L et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet, 2020 (Feb 26 (published) https://doi.org/10.1016/S0140-6736 (20) 30460-8
4. Jeong H, Yim H W, Song Y-J et al. Mental health status of people isolated due to Middle East respiratory syndrome. Epidemiol Health 2016; 38 e2016048