Prolonged social isolation of the elderly during COVID-19: Between benefit and damage.

Dear editor,

In response to the increasing spread of SARSCoV-2, several states have gradually suppressed social interaction between people. As an ultima ratio and with regard to the fact, that the death rate is highest in elderly people (CRF 70-79 yrs.: 24,4%; 80–89 yrs.: 30,3%; CRF ≥ 90 yrs.: 25,1%; 20.04.2020, Italy (Infografica, 2020), residential and nursing homes in Italy and other states were isolated, as visitors were first reduced and then banned altogether. Nevertheless, due to a lack of resources and strategies to prevent nosocomial infections, 3859 residents of nursing homes in Italy officially died in connection with COVID-19 between 01.02.2020 and 06.04.2020 despite isolation, although a higher number of unreported cases must be assumed (Survey, 2020).

During the acute and severe threat coming from SARS-CoV-2, social distancing may be our best hope to slow the silent spread of SARS-CoV-2 since this strategy seemingly worked in China (Sun, Chen, & Viboud, 2020). However, as measures continue to be imposed and are gradually prolonged, medium and long-term secondary damage caused through isolation must be considered in the risk assessment. Most states discuss the ongoing implementation of shielding measures for high-risk groups such as the elderly even after the end of the current regulations. In this context, we face a particular challenge, since elderly people do not only belong to the SARS-CoV-2 risk group, but also to those who suffer increased morbidity and mortality as a result of the withdrawal of social interaction and mental stimulation. It is, of course, major priority to identify and protect from immediate and acute threats - but as the COVID-19 situation progresses, additional attention should be paid to the secondary damage resulting from the measures.

Social isolation and loneliness have been associated with an increased prevalence of vascular and neurological diseases and premature mortality (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015). Additionally, it is well known that social exclusion is significantly associated with higher risks of cognitive impairment, which, in turn, increases the risk of Alzheimer’s disease and accelerates disease progression of existing conditions (Friedler, Crapser, & McCullough, 2015). Emotional distress, which is likely to be provoked by the current situation, is another risk factor for premature death, since anxiety is known to predict all-cause death and is especially detrimental in persons aged 75 and older (Ostir & Goodwin, 2006; Van Hout et al., 2004). Besides the psychological burden of isolation, the reduced opportunities for physical activity represent an additional health-damaging burden in the long run. This, of course, applies not only to home residents, but also to elderly people living alone. Eventually, the impoverished environment and lack of regular social, cognitive and sensorimotor stimulation of isolated people may therefore lead to severe conditions and premature death in the elderly. The sad climax of isolation is the lonely dying and the impossibility of an accompanied, palliative situation - a human as well as medical-ethical debacle.

The implementation of social isolation – in itself harmful to health – as a preventive measure must therefore, if the acute situation persists, be weighed up to a reasonable extent, considering both the immediate and the medium-term consequences. In addition, and without entering into the depths of an ethical-philosophical debate, the autonomy and individual understanding of quality of life must be taken into account. It must be assumed that for many of those affected, an isolated and lonely existence in the last phase of life is not a desirable condition. It should therefore be ensured that, with continuing isolation and increasingly better available testing resources and protective equipment, regular monitoring of the infection status allows individual adjustment of the isolation: Healthy residents should have the opportunity to be visited by their (healthy) relatives in compliance with hygiene regulations and precautionary measures. They should be allowed to leave their room, for example to go for a walk in the garden. In order to be able to retain hygienic standards, the flow of visitors must certainly be reduced and “visit plans” may be introduced. Coordination and scheduling should be the responsibility of the nursing homes. Special attention should be paid to the dying: People in institutions have the right to a dignified death and palliative care, even in isolation. With adequate hygienic measures taken, healthy relatives should be admitted to the dying as they should be enabled to accompany the dying process.

Using a setting that is known to be harmful to health as a preventive measure can therefore only be a suitable measure during acute emergencies and within limited periods of time, as it must always be questioned and weighed up in terms of maintaining the ethical and health-promoting aspects of each individual. Desperate times require desperate measures - but prolonged desperate times require step by step a wholistic approach including risk-management of both acute and chronic threats and the maintenance of dignity at the end of life.