Isolation and the elderly

Well, I might not know much about epidemiology. But it seems to me we have entered a new age. We have been successful in maintaining the physical well-being of our patients. So much so, they have reached an age when they are (a) old (b) suffering degenerative diseases (c) alone at home. I make a telemedicine call to Jenny Pierce, 82 years old, who has atrial fibrillation, mitral regurgitation, and controlled heart failure. She suffered a stroke two years ago, maybe due to poor anticoagulation, or her chronic hypertension. We go over her symptoms, her drugs and her lab results—trying to keep explanations simple and reassuring. I ask about her COVID vaccination status, and then her social situation. She lives with Mike, who has severe COPD and mild-to-moderate dementia. She is his caregiver. Jenny isn’t a trained nurse, a home-care assistant or a geriatrician. She is a wife. “Oh, I do OK,” she tells me. “I get the groceries delivered, and our daughter Martha visits once or twice a month. Of course, she is busy, what with Frank’s business taking him away, and it’s a long drive for her to come here.” I ask her about her homecare visits. “Oh yes, we had them, but then COVID came along, and they don’t visit anymore. They helped with baths, and some cleaning, but there’s all that fear out there.” What would happen if you fell down and broke your hip? I ask. “Oh, Mike would have to go into a home, for sure. He can’t cope without me.” And what arrangements have you made for this possibility? “Martha says she’ll take him in until a nursing home place turns up, I think.” And if Mike dies of pneumonia? “Eh, I’ll be on my own, but don’t worry, I’ll be OK.” Do you have a will, a power of attorney, and an advance directive? By now she is becoming concerned with my line of questioning, reading between the lines that her last echo was worse than before. “Well, Martha is power of attorney, for sure. Advance directive, does that mean intensive care?” I tell her this is just a declaration of personal treatment preference, in the event of a catastrophic illness. She seems reassured. What do you do these days? “Nothing much, I just look after Mike. Many of my friends and family are gone. I don’t drive. I haven’t been out of the house for weeks. I don’t want to go into a home: They might not let the grandkids visit from Calgary, what with COVID precautions and all. . . ”. At least Jenny has Mike. They are uniquely co-dependent, propping one another up, waiting for a minor destabilizing event to bring chaos into the forefront of their family circle. I remember the day when “leaving home” meant a daughter moved across town, or into the big city. Now our kids are can be spread across Canada, or working in a village in Spain. Hardly conducive to “taking mum home.” If it wasn’t for the internet, Skype and WhatsApp, how would we keep those relationships alive? What should we focus on, when quantity has been assured? Quality. What is quality for you and me, and mum and dad, and grandma? We need to answer that question, if only for ourselves. Starting with safety, and moving on to the things that bring us joy. Health, family, memories, love, hobbies and daily activities—to name a few. It strikes me that this “epidemic” of aged isolation must be the focus of a substantial volume of geriatric research, and I spend the evening surfing scholarly articles. Freedman and Nicole (1) tell us 17% of Canada’s population is over 65 years old, and growing rapidly. The authors point out that social isolation and loneliness are associated with considerable morbidity and mortality. This is on top of functional losses (reduced mobility, deafness, visual impairment, memory impairment). Hence it is not surprising that almost half of all seniors living in long-term care have been diagnosed with depression. Several “interventions” are quoted (from leisure and skill development to animal therapy, exercise and social facilitation) but evaluations are limited. Maybe, like the U.K. and Australia, we should have “Campaigns to End Loneliness.” I get the feeling everyone is different, and an individual approach is needed. In a country of immigrants, language and cultural challenges may layer on further complexity. And how should we, as physician caregivers, respond to this dynamic? I told Jenny I would call back in six months . . . eh, no, two months . . . to check on her clinical status. Six months for her might be a quarter of the rest of her life. The billing schedule is six months and a day, but surely we need to think outside this box—for our elders’ sake. Maybe our perspective would change if we did more home visits. On a personal note, I hope to live long and happily ever after. But I learn a third of my age group is destined to experience loneliness (2). How can I prepare for this? Can you call me sometime? Further reading: Social isolation and loneliness: the new geriatric giants. Freedman et al. CFP March 2020, 66(3), p176-182. https://www.cfp.ca/content/66/3/176. Loneliness and social isolation interventions for older adults. Olujoke et al BMC Public Health 20, 14Feb2020. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-8251-6 Read Dr Baillie on Age, frailty and loneliness

Casebook of a Community Internist

Isolation and the elderly

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Hector Baillie

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