May 26, 2020

Honor Thy Father and Thy Mother

By Kenneth Ring, Ph.D.

Normally, I am not the kind of guy who begins to blog by making reference to the Bible, much less to one of the ten commandments, so I have to tell you at the outset why this one starts with a title from Exodus. It's because I think I have to make some amends for an earlier blog.

I'll get to that in a moment, but first a little prologue is necessary.

In my last blog, I discussed some of the baneful effects of the pandemic on college-age or college-bound youths. In this one, I mean to consider some of the challenges faced by the elderly in coping with COVID. The young have had their future, at least in the short term, and possibly longer, blighted. But the old have no future save for the grave. Yet for far too many elderly people, COVID is only expediting their passage toward terrestrial oblivion. Some wags have even started to call COVID a boomer remover.

In traditional cultures, or even in former times in our own, elders were revered. However, nowadays in America, it's not exactly that they are reviled, but they are often disparaged, dismissed and neglected, which is in fact a type of elder abuse. It's not that the treatment of the old, especially the very old, constitutes a pandemic in its own right, of course, but it is rife, and seems to be becoming increasingly so. And now the tensions associated with COVID that health care workers have to endure on a daily basis may be making life for the elderly even more fraught and dangerous.

Consider: There was a time, and it wasn't even so very long ago, that the elderly continued to live in an extended family setting and when they became frail and infirm were cared for in the home until they died. In such homes, they were honored and sometimes even venerated. But with the decline of extended family homes in favor of isolated nuclear family arrangements, we typically no longer care for our own elderly loved ones ourselves. Instead, increasingly, they live alone; or when they get old enough or infirm or demented, we warehouse them until they die. That's the new American way of death for so many now because we have come to de-venerate the old. They are surplus people who no longer count for much. 

And these days, in the age of COVID, nursing and old age homes and other such facilities for the aged are among the worst places to live because COVID can be so easily transmitted there. Thus, the most vulnerable are also the most at risk because we already know that COVID is a disease that disproportionately targets the old. People like me. 

Now to return to my wish to make amends, let me remind you that in one of my earlier blogs, I jokingly made what I called my own "modest proposal" -- that it would be better if we could bump off people when they reached the age of three score and ten. I made the point that once you hit 70, you've joined the surplus generation; you mostly just take up valuable space and ultimately require vast sums, especially in the last years of your life, to sustain yourself until you die.

I still think a lot of needless suffering and medical expense could be eliminated if so many people didn't live so long, as more and more of us do these days, but of course I am not really proposing anything so monstrous as the institution of widespread mandated mercy killing. I am not a Nazi! On the contrary, the more I read and hear about what COVID is doing to the old, the more sorrow I feel. Life is hard enough when you get old; COVID is just making it orders of magnitude more difficult for them and many are dying once they get infected.

And at least some of their suffering can be traced to still another factor -- "elder abuse." You see, the old just don't matter as much as younger people or children. In a time of limited resources, the old get short shrift. As one geriatrician, Louise Aronson, recently observed in an article in The Atlantic:
"The problem is that when the impact of disease in a population is unknown, there's little incentive to develop treatments tailored to that group's needs. When the affected population is elders, the problem is especially bad: As we've already seen with the current crisis, many people say that elders are dying anyway and tend to blame old age itself for their deaths -- not a flawed system."
Aronson, who is also the author of a highly regarded book, Elderhood, about the problems of and discrimination against the old, goes on to delineate various ways in which the elderly are second-class citizens when it comes to medical treatment, a state of affairs that has just been exacerbated by the pandemic.

For example, protocols for the treatment of COVID have been developed for children and adults, but so far, not for the elderly, who constitute the most vulnerable demographic.

Furthermore, she points out this:

"Medical schools devote months to teaching students about child physiology and disease, and years to adults, but just weeks to elders; geriatrics doesn't even appear on the menu of required training. The National Institutes of Health mandated the inclusion of women and people of color in medical research in 1986, but it didn't issue a similar mandate for elders until 33 years later, in 2019. "The bias is so implicit, it goes unnoticed," one of my colleagues said of ageism in the American COVID-19 response and in medicine generally. But when you start to pay attention, you see it everywhere."

There are other, sometimes less obvious, problems that the old are more likely to have to deal with than younger people. For instance, although many older people have learned to use computers and other technological devices of our time, they, and especially the very old, often fall on the wrong side of the digital divide, making it harder for them to arrange for video visits with their doctors.

And doctors are beginning to see that older people often don't have the typical symptoms of COVID, but quite different ones that make it more difficult to diagnose and treat them. For younger people, the usual symptoms indicative of COVID are fever, an insistent cough and shortness of breath. But older adults may have none of these. Instead, they may just be sleeping longer or not eating. They may become apathetic, confused or disoriented -- or get dizzy and fall. In extreme cases, they can stop speaking and collapse. And when they come to the hospital and are tested, they have COVID. Older bodies just don't respond to illness and infection the same way younger people do, and drugs don't work the same way for older adults either. All this means that older people, the most susceptible to COVID, may be misdiagnosed and more at risk to die on that account.

And let's not forget what I already alluded to above -- the perilous situation many elders face who live in nursing homes or other facilities that are designed to care for the aged. Dr. Kathleen Unroe, a geriatrician at Indiana University, has observed that seniors living in such settings are going to get weaker because of greater immobility and may become confused on account of changes in routine. Plus, of course, living in close proximity to vulnerable others just increases the risk of uncontrolled COVID outbreaks, as we have seen.

All these factors just make the lives of older people more onerous and the likelihood of successful diagnosis and treatment much less than for younger adults. The result is that more older people die than would have been the case if modern medicine was not structured so as to de-value the elderly.

And even though the death rate from COVID is, relatively speaking, quite low, older people -- those 65 or older -- seem to account for about 80% of all COVID-related deaths, according to the figures I've seen. They may not be entirely accurate, but at any rate it is already clear that the great preponderance of deaths from COVID is taking place among the old.

Let's delve into this further by drawing on some more specific statistics. I'll begin with the area where I live, Marin County in California.

Our COVID cases are continuing to rise quite steadily and by the time you read this, they will exceed 400. We old timers make up about 20% of the population here, which is slightly higher than the national average of 15%. And so far my age group represents our fair share of COVID cases, also about 20%. But once you move to the number of hospitalizations, nearly half are old folks and when you come to death, old people comprise all of them -- 100%. Everyone else so far has survived; only the old have died here.

And the news is even worse if old people become so sick that they have to be put on ventilators. I don't want to numb you into insensibility by deluging you with more statistics, so let me just quote a one more set -- the mortality rate for older adults who have had to be put on ventilators. In one study, 70% of those over 70 died; in another study, 80% of those over 80 died. The death rate for younger people on ventilators is very much lower.

In sum, COVID is no friend to the old; it is often literally their mortal enemy.

Of course, statistics are bland fare. But when we are talking about death by COVID we are often talking about your grandfather or perhaps your aunt or even your mother. Or the dear relative of someone you know. As I write this, close to a hundred thousand people -- most of them old -- have died of COVID-related infections in the United States. And more will die in the future, and many more throughout the world have already died. Cynics might claim with some justification that they were due to die soon anyway. But still, many who died should not have had to die -- and why not? Because in medicine, as in life, we do not honor our fathers and mothers. Instead, we often abandon them or simply do not want to take the time to give the attention to them that we devote to younger people. So many old people these days die alone with no one to hold their hand, no one to ease their way into death, no one to weep at their bedside. All we can do is to take a moment to feel pity for those who have had to perish under the worst of circumstances -- and to remember them.

And maybe to resolve to make some changes in how medicine deals with the old. Louise Aronson has some hope for this, so to end this lachrymose blog on a positive note, let me conclude with some of her suggestions for how things may be made better for our elders:

"Everyone can help create a less ageist culture and improve individual institutions. Aging experts like myself are (for now, digitally) collaborating to devise elder-specific protocols for managing COVID-19. These protocols include essential information, such as the fact that body temperature runs lower in many elders, so a thermometer reading of just 99 degrees Fahrenheit in an 80- or 90-year-old might signal fever. In hospitals, these guidelines would include other, less obvious recommendations, such as also allowing patients with dementia or delirium -- whether or not they have COVID-19 -- to have a loved one by their side to limit terror, agitation, and the need for drugs proven to increase the time they will take up a much-needed bed. Such steps can boost early COVID-19 diagnosis and decrease suffering and complications in elders, thus benefiting all Americans by reducing the strain on our health-care system."

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