Letter to the Editor: COVID-19 and the Impact on Caregivers.

Dear editor,

I read with interest the recent article by Canevelli et al (1). In the article, higher levels of frailty, measured by the frailty index, were found in caregivers of patients affected by dementia compared to controls. The authors suggest that the chronic emotional strain derived from caregiving could contribute to frailty. Chronic emotional strain in caregivers, also known as “caregiver burden”, has been associated with many negative outcomes (2) but its association with frailty has never been assessed. The study has important potential clinical implications, as establishing a tailored intervention on chronic psychological stress in caregivers could prevent or slow the onset of frailty.

Evaluating caregiver burden is extremely relevant and even more so at this particular time. Caregivers represent an essential part of geriatric every-day practice: as geriatricians, we are used to liaise with caregivers, to rely on their contribution for the delivery of care and to assess their well-being. Consequently, we have witnessed first-hand the dramatic impact that the Covid-19 pandemic has had on this category. A recent survey from Eurocarers (3) seems to confirm what is under our eyes: since the Covid-19 outbreak, caregivers have significantly increased both the amount (+ 17% in the average number of weekly hours of care) and the type (i.e., emotional support + 60.3%, practical help in person + 43.9%) of care provided. Increases affected not only on caregiving intensity, but also caregiving burden: after the pandemic, most carers (61.7%) feel overwhelmed and just about half of them (51.5%) feels able to look after their own health and wellbeing. The survey reflects what a growing body of literature is confirming: caregivers are facing higher levels of anxiety, depression and exhaustion compared to before the pandemic (4, 5).

Furthermore, the number of informal caregivers has increased because of Covid-19: 10% of the survey respondents started to provide care during or after the pandemic. These “new” caregivers add up to the already impressing number of existing ones, which accounted for over 2.8 million of people in Italy in 2018 (6).

Among the many factors that may have contributed to this result, the forced absence and/or the restriction of traditional caregivers’ support services (i.e. respite care, training programmes), is definitely one worth mentioning. Inevitably, the pandemic shed the light on the importance of community services without whom many caregivers experimented a vicious circle of social isolation and lack of professional help (7).

Now, after the acute stage of the pandemic, a crucial discussion is arising on the need to reshape healthcare systems and move from an hospital-centred to a community-centred model (8). The need to adapt the system to a person-centred model of care is the core concept of the Integrated Care for Older People (ICOPE) guidelines (9) promoted by the World Health Organization (WHO). In the guidelines (9), caregivers’ support through psychological intervention and training is recommended to prevent and/or manage declines in intrinsic capacity in the community.

In order to strengthen primary care and to reorganize long-term care, the caregivers’ role and the available caregiver support strategies should be part of the discussion. “Traditional” support strategies (i.e respite care, caregiver training and education) need to be furtherly implemented as well as better integrated within the spectrum of care. However, not everything done during the pandemic has to go to waste: although existing strategies were severely hit, “new” strategies flourished during Covid (10, 11). Since the outbreak, technology-based interventions (i.e., tele-health, counselling/information via helplines, virtual respite) have forcedly replaced other forms of support. In the near future, these innovations could work not as surrogates, but as valuable integrations of other services. However, the effectiveness and feasibility of these interventions need to be furtherly evaluated. Research could play a key role both in identifying effective models of caregiver support and, as shown by Canevelli et al (1), in identifying risk factors for the health and well-being of caregivers.

The pandemic has exacerbated existing problems for informal caregivers and imposed a whole new set of challenges. Looking ahead, it is essential that caregiving support strategies, both old and new, are adequately implemented.