The COVID-19 pandemic requires society to provide more care for the elderly

Some 300,000 older people live alone in São Paulo City, and more than 8,000 say they have no one to turn to for help. A study supported by FAPESP describe their vulnerability in the ongoing public health crisis.

By Maria Fernanda Ziegler  |  Agência FAPESP – São Paulo City in Brazil has more than 1.8 million inhabitants aged 60 and over. Sixteen percent (290,771) live alone. Of these, 22,680 are 90 years old or older. Another concern is the number of completely solitary older people in the city: for different reasons, more than 8,000 have no one to ask for help in times of need and no active and efficient social support network.

Statistics on the vulnerability of the elderly in São Paulo have been compiled specifically for Agência FAPESP. They are part of the FAPESP-funded Survey on Health, Wellbeing and Aging, or SABE in the Portuguese-language acronym, investigating the living conditions and health of 1,236 older inhabitants of the city. This is considered a representative sample of the age group, so that the figures cited here can be extrapolated for the overall population.

“It’s important to draw attention to this situation, especially during the pandemic. We’re concerned about elderly people living in long-stay institutions [formerly called old age homes] because they’re very vulnerable and there’s a significant risk of mass contagion. Older people are a concern in general, especially the number living alone during the pandemic with no one to turn to for help. We should be aware of this problem and plan actions for the period,” said Yeda Duarte, a professor in the University of São Paulo’s Public Health School (FSP-USP) and co-principal investigator for the study with Jair Licio Ferreira Santos.

Health is a particular concern, as older people typically have diseases or disorders considered risk factors for COVID-19, Duarte added. Among those who live alone, 63.1% (183,477) have two or more chronic diseases concurrently. These conditions include high blood pressure (67.9% or 197,434), diabetes (25.4% or 73,856), heart disease (22.9% or 66,587) and chronic lung disease (9.3% or 27,042).

In addition to the high chronic disease rate, other factors worry the specialists: 12.9% (37,510) of the elderly age group are frail and 52.2% (151,782) are what is called “pre-frail”, meaning they feel unenergetic or weak, walk slowly and lose weight unintentionally, among other risk factors.

According to the SABE survey, 75.1% of the older people who live alone in São Paulo are becoming frail and are even more vulnerable at this time. Duarte noted, adding that elderly people with frailty syndrome should be prioritized by primary healthcare services as they are most susceptible to falls, hospitalization, incapacity, and early death.

For Duarte, the grave threat posed by the COVID-19 pandemic sheds light into the plight of the elderly in terms of lack of care and the need for public policy to support this portion of the population.

“The pandemic is a major problem, but it may help bring about much-needed changes in society and increase the visibility of these seniors, who have never been given the care they require,” she said. “It’s important to show that these elderly people exist. They continue to live alone and now need even more care from society and the state.”

Support measures are essential, she added, as many elderly people who cannot go out because of the pandemic do not have a cell phone or do not know how to use one to order food and other basic necessities, for example.

“More than 28% of these older people living alone, or more than 80,000, don’t have a cell phone or the ability to handle one, for example,” Duarte said. “So, they’re forced to go out in breach of the quarantine, not as an act of disobedience but because they can’t avoid it. These elderly people have always existed, but they’ve been left out by public policy. They’re being brought into view by the pandemic.”

Neighbors can help, among others. “The solidarity we’re seeing on the rise in São Paulo because of COVID-19 needs to increase even more. Anyone who hears of older people living alone in an apartment block or a nearby house could offer to help or be a link to the outside world,” Duarte said.

Among the 1.8 million people over 60 in São Paulo, in addition to the 16% who live alone, 48% live in households with other elderly people, who are often spouses or other relatives.

“This group also requires attention. In recent decades, social perceptions of older people have changed a great deal. They’re often seen as healthy and full of joie de vivre. Some are, of course, not all, and not even a majority. Society should consider all of them,” Duarte said.

A positive finding of the study was that 84% had been vaccinated against flu. However, only 39% had been vaccinated against pneumonia. “This shows that the policy should be to vaccinate all older people against pneumonia, rather than only those considered vulnerable, as has been the case hitherto,” she said.

Another important point, Duarte continued, is the need for more planning to help vulnerable elderly people during the pandemic. “There’s no such planning. Vulnerable seniors usually just cope, doing whatever they can, but that’s not very practical or even sufficient in this situation. Not to say older people are now a problem, because they aren’t,” she said.

According to the SABE survey, most elderly people live with offspring. Among those who do not live alone, only 9.6% do not live with offspring. Some 12% live with children under 11, and 10.3% live with adolescents (aged 12-18).

“The data underlines the importance of organizing social distancing with this group’s risk factors for the disease in mind,” Duarte said. “It’s pointless to let younger people go out to work and re-open schools if they’re going to get infected. Many will be asymptomatic and may infect others, including the older people in their own homes.”

The survey findings also show that approximately a quarter of the older people in São Paulo face difficulties in performing basic day-to-day activities such as bathing, getting dressed or feeding themselves. They therefore need home caregivers. “This highlights the need for careful planning before hardline measures such as lockdown are introduced,” she said.

Lockdown planning must take into account the existence of these elderly people and draw up a list of those who need help, Duarte stressed. “Advance initiatives are required to make sure older people who need care can be monitored by phone in the event of a lockdown,” she said.

Protective genes

SABE is a multiple-cohort longitudinal study of the health and living conditions of people aged 60 and older in seven cities of Latin America and the Caribbean, including São Paulo. It began as an initiative of the Pan American Health Organization (PAHO) in 1999-2000, with follow-up surveys in São Paulo supported by FAPESP in 2006, 2010 and 2015.

According to Duarte, a new edition has been scheduled for 2020. Because of the pandemic, however, the researchers will start by calling the participants to determine how they are coping with quarantine and try to identify their main needs and vulnerabilities.

Any participants who contract COVID-19 will also be monitored by members of the Human Genome and Stem Cell Research Center (HUG-CELL), a Research, Innovation and Dissemination Center (RIDC) supported by FAPESP and hosted by the University of São Paulo (USP). HUG-CELL’s principal investigator is Mayana Zatz, a professor in USP’s Bioscience Institute.

“We’ll observe the outcomes for those who are infected by SARS-CoV-2. Older people who fend off the virus certainly have protective genes in their DNA, and we want to investigate this,” Zatz said.

Some years ago, HUG-CELL sequenced the genomes of the SABE participants as part of Project 80+, a study of the DNA of healthy individuals over 80 years of age, to investigate the genetic and environmental factors that enable them to live longer and better.