Dr. Yoram Maaravi, Head of Rehabilitation and Geriatric Rehabilitation at Hasdassah Medical Center in Jerusalem is concerned that the elderly will find themselves discriminated against in the battle against Covid-19. He says that people over 65 are not one monolithic group and that age is not a suitable criterion for defining who is at risk from the virus. "The question begins with how we define old and that's a complicated matter. The basic principle says that the ageing process is very individual."
He continues, "If we took a high school class reunion of 40 year olds and looked deeply into their capabilities, we would see certain but not extreme differences. But take them when they are 90, and the differences in those who had survived would be dramatic. You cannot relate to people above 65 as one population."
Maaravi cites the latest report by the US Centers for Disease Control and Prevention (CDC), which has analyzed hospitalization for Covid-19 in the US according to age and preexisting conditions. The report found that as of March 28, 7,162 (5.8%) of the 122,653 Americans who had tested positive for coronavirus had underlying conditions.
According to the report, 18%-20% of these patients aged 19-64 with Covid-19 and underlying conditions were hospitalized while 6% had no underlying conditions. Of people aged over 65 with underlying conditions 42%-44% were hospitalized while 17%-18% had no underrlying conditions.
"Despite these figures," remarks Maaravi, "I don't see that they are only restricting populations with underlying conditions. I expect them to protect the elderly with high risk as is proper but shouldn't those who are younger with high risk also stay at home. When we shut up older healthy people, we are making two mistakes at the same time. Firstly, we are not protecting those who are really at risk - and we see this with the high mortality in assisted living facilities for the elderly because they are not checking everybody and doing what they are supposed to be doing. The second mistake is that you are taking all the elderly and shutting them up. People don't know what the price of the lockdown will be and are speaking in code but the risk in numbers from the outcome of the lockdown is bigger than the risk from the virus."
The indirect damage of isolation
The outcome that Maaravi presents are dramatic. According to an analysis published in 2015 for the Association of Psychological Science there were three indicators for social isolation. Isolation and living alone led to a 30% rise on average in mortality rates. Isolation also aggravates heart disease, especially for women.
Another outcome of the lockdown is a fall in functioning, which can be dramatic for older people. This fall can be measured in walking speed, and self-belief which drops when the elderly become less active and move around less as happens in self-isolation. "A fall in functionality is one of the risk predictors of mortality in old age, more than heart disease, more than cholesterol," says Maaravi.
In 2017 by BMC Health Services Research investigated the impact of mobility on mortality among the elderly, using the objective measurement of Time Up Go (TUG) to represent the level of functioning and how it fell as a person aged and became less mobile. The research investigated the link between TUG results and mortality and found that the rate of mortality rose 79% with the fall in functioning.
Maaravi said, "among the elderly it is more difficult to maintain motivation for physical activities. Just leaving the home and going up and down stairs, and walking along the street are frequent activities for everybody but especially the elderly. Walking at the moment doesn't exist. Many people are lo0sing their strength and functionality - diabetes worsens, people get fatter and the risk for the elderly rises further. If we are talking about one million elderly people then who'll be up to the burden of getting them functioning again."
Another possible outcome is dementia, which Maaravi terms one of the biggest viruses of old age. Dementia is one of the biggest predictors of mortality. Research by the American Heart Association and by the American Stroke Association found that for every five points lost on the MMSE cognitive scale, leads to a 35% rise in overall mortality and a 56% rise in death from heart disease.
Maaravi stresses, "Isolation, fall in functioning, dementia - this price is higher than the danger of the coronavirus and certainly for the elderly, but to a lesser extent there are risks even for the 'young elderly.' If I add all these things together and put them on the scales against the risk of being infected with the coronavirus, then the numbers from the risk of isolation, and the fall in cognitive functioning are higher than the risk of the coronavirus."
How do you decide who is at risk?
He says, "There are four underlying conditions that put a patient at risk: heart diseases, diabetes, cancer and lung diseases. In addition, there is an index of frailty - a physiological-biological syndrome effecting some of the elderly, which is at the junction between health and illness. The data base for everybody over 65 is held by the health funds and the government could easily take this data and create a list of people at risk. The ones suffering from underlying diseases are the ones who should be staying at home." Maaravi says, "At a crude estimate 20% of those over 65 are in danger according to the frailty index and of course there is in addition those with underlying diseases and they must be protected. My argument is that if you take out from the elderly population those with fairly, underlying conditions, those being nursed and with dementia, the rest are in higher risk. There is no point in just glancing quickly at the statistics, they must present the data for mortality risk according to age and functioning."
You're saying that about 20% of the elderly should be released from lockdown. Doesn't that seem like a risk?
"All conduct at the moment is based on estimates and every action is checked out. Even this week with the start of the easing of the lockdown, they will monitor if there is a rise in morbidity and mortality and it's possible that they will bring back some of the prohibitions. It's the same with the 'young elderly' who I claim are in bigger danger today from isolation than from the coronavirus."
There is a moral as well as a health issue
Maaravi stresses, "For the elderly like everyone there are basic rights. We are shoving the elderly indoors who with all their experience can teach the young that they deserve respect."
Published by Globes, Israel business news - www.globes-online.com - on April 21, 2020
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