Our Ambivalent Relationship to the Aged

In the pandemic, protection of the frail elderly has not been a high priority

Posted Jun 22, 2020

Joseph E. Davis and Paul Scherz, editors of The Evening of Life: The Challenges of Aging and Dying Well (2020).

Martha Crawford spent her adult life surrounded by family. As she came to require skilled nursing care, she entered a facility near her two youngest children. Failing steadily, she was in her last days when the pandemic hit, and all visitation was suspended. She died two weeks later of a condition unrelated to the pandemic. Nonetheless, she died alone and was interred alone. Neither vigil nor funeral were permitted. 

Ms. Crawford’s experience is not unique. Thousands of others have quietly faced their greatest fear in this pandemic: not to die, according to reporting in The New York Times, but to die alone. 

This viral storm is exposing deep contradictions in our way of life. None is greater than our ambivalent relationship to the frail elderly.

COVID-19 disproportionately strikes the old. This very fact is one of the key reasons for the unprecedented stay-at-home orders and visitor bans at long-term care facilities (LTCF) across the country. These well-intentioned actions aimed at protecting the oldest and most vulnerable among us. Yet our response also betrays some of the worst tendencies of our society in confronting the distinct circumstances of the aged.

This group already suffers from isolation and loneliness. A February National Academies report showed that loneliness is widespread in the older population and contributes substantially to their health problems. A 2017 study found some 40 percent of nursing facility residents reporting depressive symptoms. Now, in the name of health, safety, or “flattening the curve,” draconian measures sever sources of resilience, and the care and connections that make life worth living. While the rest of society may be “opening up,” we are hearing proposals for prolonged isolation of the old.

The high percentage of COVID deaths occurring in LTCFs makes it obvious these measures are failing. Long before the current pandemic, we knew that people residing in such facilities were susceptible to infectious diseases with potentially devastating consequences. Their risk is elevated by their overall frailty, close living arrangements, shared caregivers, and, in many homes, poor infection control training and practice. Aside from extreme visitor restrictions, we know of no steps to provide alternative arrangements, as are made in facilities with similar risks, like prisons. In fact, the proposed California budget would cut funding for community-based health programs that allow people to age at home.

Stay-at-home orders do little to address this vulnerability since they do not apply to the millions of facility staff. The circumstances of these low-paid workers make them disproportionately vulnerable to the disease. Further, state policies focused on hospitals have made things worse. LTCFs have struggled to gain testing capacity and overcome severe shortages of personal protective equipment. The mandate by New York, now rescinded, requiring nursing homes to accept COVID-19 patients from hospitals is a glaring example of this neglect and one that almost certainly contributed to the very high LTCF death rate in that state. 

The protection of the frail elderly has simply not been a high priority. The daily body count of COVID reveals another blindspot: little research exists on the dynamics of these kinds of diseases in LTCFs. While COVID-19 is different from the flu, no one has bothered to count flu deaths among the elderly. We know anecdotally that they are common, but in a 2019 review of the published literature, researchers found only two small US studies of the burden of flu among LTCF residents, published in 1983 and 1986 respectively. Similarly, both the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services report that there are as many as 380,000 deaths from infectious pathogens in LTCFs each year. These agencies provide no source, but we traced this frequently cited estimate to a single paper published in 2000 based on small studies conducted in the prior two decades. Clearly, there has been little effort to create an evidence base for more effective clinical practice, policy, and prevention measures. 

In this and other ways, our response to COVID-19 reveals a deeply ambivalent attitude toward the frail elderly—isolate them for their safety but avoid the targeted steps that would secure it; prioritize their health but actualize their worst fears; spend billions on aging research but a tiny fraction on the most lethal killers.

It doesn’t have to be this way. The pandemic could teach us important truths we otherwise so often deny. It could show us that we are all dependent, vulnerable, and frail. It could illuminate the ways that our society, for old and young, is not properly structured to enable care. And it could help us recognize, with Ms. Crawford, that some things are more precious than life itself.