Elder Care during COVID-19 : Reflections from Shanghai

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On January 23, 2020, Wuhan, a Chinese city with over 10 million people, was locked down due to COVID-19. Subsequently, all cities in China instituted the highest level emergency response. The response mandated home isolation, reduced unessential hospital visits, restricted social activities, and the use of personal protection equipment (e.g., face masks) outdoors. We summarized the challenges brought by the COVID-19 to community-dwelling older Chinese, and reflected on Shanghai’s strategic efforts against COVID-19.

In Shanghai, 14.3% of its 24.2 million population were aged 65 or above in 2017,  higher than national average of 10.3%.1 Older adults tend to have pre-existing health conditions, making them susceptible to COVID-19.2 Data from the Chinese Center for Disease Control (CCDC) show that the mortality rate of older patients due to COVID-19 is 5.1% versus 0.6% among young people, and that the rate among patients with comorbidities (e.g., 10.5% for patients with cardiovascular diseases, 7.3% for diabetes, 6.3% for chronic respiratory diseases) is much higher than the average rate of 1.4%.3

Elders are sensitive to abrupt changes in their daily routine.4 Before the pandemic, many elderly people used to exercise at community parks, dance in public squares, and socialised regularly with families. However, these daily routine activities were interrupted after the COVID-19 outbreak, including more serious disruption of health care access routine. Older Chinese are used to visiting large hospitals for better services and more comprehensive specialties covered. Unlike neighborhood clinics or community hospitals, large hospitals are more distant from where patients live. During the pandemic of COVID-19, older adults who needed regular treatment for chronic health conditions had to forego visits, for fear of being infected during travel.

The disruption in medical treatment posed a threat to physical health, while home isolation and social restrictions may have contributed to poor mental health (e.g., anxiety and loneliness). For elders with depression or dementia4, the dramatic changes of their daily routine can trigger psychiatric or behavioral problems. For example, elders at the early stages of dementia who struggle to grabble with the situation (i.e., not understanding social distancing order) are at higher risk for panic and anxiety. Those at the late stages of dementia may lose needed care if their quarantined family members cannot visit them. Elders with low socioeconomic status may have limited means to access Internet, an essential source of information and social connection during city lockdown, and feel further alienated.

Strategies used in Shanghai

In response to COVID-19 challenges, Shanghai government mobilized and orchestrated medical resources to treat all affected. Additionally, it formed a collaborative crisis prevention system across multi sectors (e.g., health care, social care, local government, and community) and involves professionals from various disciplines (e.g., medicine, nursing, social work, public health) and community stakeholders 6. As about 90% of older Chinese live in the community, screening and monitoring COVID-19 infection in the community was stressed for prevention control.

  • Strict screening in hospitals and communities using professionals and informal community leaders. As of January 3, 2020, CCDC Shanghai Branch began to recruit and train 80 public health workers to perform screening for the “unknown pneumonia” in all local hospitals. Later, screening of elders extended in communities of 16 districts of Shanghai. A team including public health workers, community physicians, neighborhood committee members, local police, and informal leaders of residential buildings was formed to ensure a screening of all community residents. Informal leaders of residential buildings served as a bridge between older residents and service professionals. As they knew about older residents in every household, their appearance helped ease resident anxiety and smoothen the process of screening. They assisted in tracking residents’ travel history, explaining the need for screening, and monitoring quarantine violations. This approach is effective for older Chinese that tend to trust their acquaintance.
  • Health information and preventive strategies advertised on public media accessible and acceptable to older Chinese, including TV and social media. Many older people were ignorant of the situation at first and rarely took precautionary steps to prevent infection. This was mainly because they didn’t have full access to information unlike their younger counterparts.7 However, due to the gradual and constant exposure to updated information, they started to follow stay-at-home orders and wear face masks.
  • Innovative ways used to assist the health care needs of vulnerable elders. Online appointments and help from social workers were utilized to solve the problem of obtaining medical treatment for elders with pre-existing conditions. Elders with severe mental health disorders were arranged to visit inpatient psychiatric hospitals by community public health workers, police, and family members. The inpatient units have been redesigned to provide isolated wards and treatment for 14 days in response to the epidemic. After admission, family members could not accompany or visit. To solve this problem, the geriatric department of the Shanghai Mental Health Center set up virtual ‘visits’ for elders and their families to chat . This allowed videoconferencing, and enhanced feelings of security in older patients. Doctors and nurses used WeChat videos to conduct case reviews, updated family members, and involved them in patient care.
  • Continual monitoring was maintained even after elders were discharged . Those with severe mental illness or behavioral problem, received follow-up psychological interventions and remote counseling by mental health professionals. Community public health workers and volunteers also assisted the elderly with basic needs to protect them from exposure to COVID-19 . Groceries were delivered to the door to reduce the need for older adults to go out shopping.

Reflections and Implications

In Shanghai and other Chinese cities, leaders of residential buildings and members of neighborhood committees served as case managers. Case managers coordinated care between elderly and health care professionals. This model of elder care can bridge geriatric care in community and health care settings. Here are lessons that may apply to other countries where are now facing an upsurge in the COVID19 cases.

In Australia, the U.S.A., and other western countries,unlike in China, there is a tendency for the generations to live apart or for older people to live awar from the community. Older people live independently, in their homes in the community, often with home-care assistance or in retirement villages where there is greater access to medical and domestic support. The level of community surveillance and support, as exemplified by the Shanghai experience, is comparatively lacking. Very few older people live with their relatives in the same household, and cases of neglect can happen with increased isolation.7

The most apparent change for older people is increased isolation and alienation for two reasons. Firstly, the enforceable ‘stay-at-home’ regulations make older people living in the community experience declined visits by their relatives. Secondly, although the level of in-home care has remained at the same level with some modifications, personal contact with community workers have mostly decreased as they changed to leave meals or laundry outside for the older residents to collect.

However, with the support of community workers, relatives were encouraged to make contact via smartphones or iPads. The positive sides include that older people with help can learn how to use modern communication devices. With time, their level of communication and virtual visitation may increase., including more regular contact with health workers and case managers. Regular visits improve positive mood and functioning, and technology-facilitated social connection has positive health benefits.9

In China we saw that online appointments, family visits via videoconferencing, remote care coordination conferences, and consultations increased during the outbreak. The basic implementation of these technologies has demonstrates its potential convenience and benefits. In sum, the use of a coordinated surveillance multidisciplinary team involving informal community leaders, along with the adoption of technologies, can be useful tools to elder care provision during this crisis.

About the authors

Fei Sun (Ph.D., MSW) is an associate professor at the School of Social Work at Michigan State Univesity in the U.S.A.

Ross Colquhoun (Ph.D.) is affiliated with Dementia Australia and the Chinese Culture Translation and Studies Support Network of Beijing University.

Xia Li (M.D., Ph.D.) is a geriatrician at Shanghai Mental Health Center and a professor at the College of Medicine with Shanghai Jiaotong University.

Competing Interests :

None declared

References

  1. Shanghai Civil Affairs Bureau. One-third Shanghai residents aged 60 or over. Retrieved from Shanghai Municipal Committee on Aging and Shanghai Bureau of Statistics’ report. 2018. http://www.xinhuanet.com/english/2018-03/29/c_137074836.htm
  2. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L, Wei Y, Li H, Wu X, Xu J, Tu S, Zhang Y, Chen H, Cao B. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet. 2020 Mar 28;395(10229):1054-1062. doi: 10.1016/S0140-6736(20)30566-3.
  3. Chinese Center for Disease Control and Prevention. The epidemiological characteristics of COVID-19. 2020 Feb 19.
  4. http://kpzg.people.com.cn/GB/n1/2020/0219/c404214-31594469.html
  5. Mroczek DK, Almeida DM. The effect of daily stress, personality, and age on daily negative affect. Journal of personality. 2004 Apr;72(2):355-78.
  6. Wang H, Li T, Barbarino P, Gauthier S, Brodaty H, Molinuevo JL, Xie H, Sun Y, Yu E, Tang Y, Weidner W. Dementia care during COVID-19. The Lancet. 2020 Mar 30.
  7. Jiang X, Deng L, Zhu Y, Ji H, Tao L, Liu L, Yang D, Ji W. Psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in Shanghai. Psychiatry Research. 2020 Feb 28:112903.
  8. Inter-agency Standing Committee. Interim briefing note addressing mental health and psychosocial aspects of COVID-19 outbreak. 2020 Feb. https://interagencystandingcommittee.org/system/files/2020-03/IASC%20Interim%20Briefing%20Note%20on%20COVID-19%20Outbreak%20Readiness%20and%20Response%20Operations%20-%20MHPSS_0.pdf
  9. Dieker N. How to help elderly relatives and friends during the Coronavirus Outbreak. 2020 March 14. https://www.lifehacker.com.au/2020/03/how-to-help-elderly-relatives-and-friends-during-the-coronavirus-outbreak/
  10. Anderson G.O, Thayer C Loneliness and social connections: A national survey of adults 45 and older. AARP Research. 2018 Sep https://www.aarp.org/research/topics/life/info-2018/loneliness-social-connections.html
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