Humanistic and Holistic Strategies for Combating Mental Health Sequelae in the Elderly During the Post-COVID Era

Abstract

Background

The elderly population is rapidly growing worldwide. By the year 2050, the elderly population will increase up to 2.1 billion. Among them, most of the elderly will be from low- to middle-income countries. India and China are the most populated countries in the world, and also they fall in the category of low- to middle-income countries. The elderly population in these two countries is also growing rapidly and creating an economic burden of geriatric care. On the other hand, the COVID-19 pandemic greatly affected the healthcare system. A higher mortality rate was documented among the elderly due to COVID-19; hence, it was a challenge for them to deal with a high load of the elderly population during the pandemic. These challenges never sublimate even during the post-COVID era. Mental health issues, such as stress, anxiety, and depression, are major drawbacks of COVID-19 among the elderly due to excessive fear of getting reinfection of COVID-19 and fear of social withdrawal. These factors are affecting healthy aging among the elderly. Even though WHO has taken few initiatives for healthy aging, proper interventional strategies are required to prevent mental illness and improve mental health among the elderly during the post-COVID era.

Summary

In this review, we have proposed a few mind-body strategies like Yoga, Exercise, Tai-Chi, and Qigong to improve mental health and holistic patient-centric implementation of those practices in the elderly during the post-COVID era.

Key message

Mind-body interventions can be used in a holistic patient-centric manner to prevent infectious diseases, and post-infection consequences. Further, it enhances immunomodulation along with mental health in the elderly.

Keywords

Post-COVID-19 elderly mental health humanistic strategies holistic strategies

Introduction

Global numbers of the elderly population are growing faster in comparison to the past. Around one billion people aged 60 years or more were living worldwide.¹ By the year 2050, the proportion of elderly people will be around 22% of the total population. The number of elderly population will increase up to 2.1 billion by 2050. Among them, most of the elderly will be from low- to middle-income countries. The World Health Organization (WHO) estimated that around 80% of elderly people will be living in low- and middle-income countries by 2050.² China and India are considered the most populated countries in the world, and they fall under the category of low- and middle-income countries. On the other hand, these two countries have higher numbers of elderly populations. China is facing challenges in the healthcare system due to the excessive and rapid growth of the elderly population, and it also increases the economic burden of geriatric care.^{3, 4} The study estimated that around 400 million people will be aged above 65 years, and around 150 million people will be aged above 80 years by 2050 in China.^{5, 6} Based on the census in 2011, India also has around 104 million population aged above 60 years which is 8.6% of the total population,⁷ and by 2050 it can be raised to 319 million (19.5%).⁸

The elderly population has many challenges such as molecular and cellular damage leading to the deterioration of physical and mental health, increasing the risk of multiple organ damage, disease, and finally death.² These challenges were triggered during the COVID-19 pandemic especially in low- and middle-income countries due to poor medical facilities, fewer medical professionals, and inadequate infrastructure in old-age homes.⁹ Till 6th September 2023, there were a total 770,437,327 confirmed cases of COVID-19, and 6,956,900 deaths due to COVID-19 have been detected worldwide. Of these, 44,997,326 confirmed cases and 532,023 deaths were reported from India; 99,306,563 confirmed cases and 121,679 deaths in China have been detected.¹⁰ The study reported that the prevalence of COVID-19 and mortality rate were higher in the aged population (5.3%) in comparison to the young- and middle-aged population (1.4%).¹¹ Most of them might die because of multiple organ failure, low immunity, poor physiological function, and comorbidities such as diabetes, hypertension, cardiovascular disease, and respiratory disorders.^11–13 A study done in Wuhan, China, reported that 21 patients with a mean age of 70.2 years died due to COVID-19 pneumonia, whereas 158 patients with a mean age of 56 years survived after COVID-19 infection.¹⁴ A very recent study conducted in Mumbai, India, showed 67.5% mortality among elderly above 60 years of age.¹⁵ On the other hand, developed countries like Italy have a higher elderly population. A higher mortality rate of around 83.7% was found due to COVID-19 in people with an age greater than 70 years in Italy.¹⁶ A total of 21% mortality rate has been seen in COVID-19 patients in New York City; among them, 15.9% were aged greater than 65 years, which was 75.77% of total death and most of the patients had hypertension, diabetes, obesity, and received oxygen supplemental, ventilation, and kidney replacement therapy.¹⁷ Also, the mental health condition of the elderly was greatly affected by the COVID-19 pandemic and continues in the post-COVID era.

Mental Health of Elderly Population During the COVID-19 Pandemic

Mental health was greatly affected in the elderly population by COVID-19 and its associated fear and stress. A survey conducted in China reported that around 37.1% of elderly people experienced anxiety and depression during the COVID-19 pandemic.¹⁸ Lockdown, social isolation, and loneliness might have played an important role in increasing the risk of psychological distress in the elderly during COVID-19.¹⁹ Several studies evaluated the negative psychological effects such as anger, confusion, and post-traumatic symptoms during the quarantine period. It may be due to the long quarantine period, fear of infecting others like family and friends, stigma, lack of information, and lack of connection with the outer world, economic loss, frustration, etc.²⁰ Even though younger people are able to overcome these issues by online communication through smartphone and internet services, this option was not easy for most of the elderly people. Even guardians or family members were unable to visit the elderly or provide maintenance treatment due to the massive lockdown and quarantine.²¹ Fear of getting an infection is one of the most important factors for getting mental illness. Fear is essential for survival, which is associated with various biological changes in the body and works as a natural defense mechanism against any particular frightening situation. However chronic fear has an adverse effect on our body and generates various psychological illnesses.²² Fear increases stress and anxiety and can trigger preexisting mental health issues, especially during the COVID-19 pandemic.²³ During the severe acute respiratory syndrome outbreak at Hong Kong in 2003, the suicide rate was highly prevalent among the elderly due to fear of infection, fear of disconnection with society, stress, anxiety, and feeling like a burden to their families and friends.²⁴ This burden can multiply for the elderly with physical disabilities. A recent study showed higher depression, anxiety, loneliness, poor sleep quality, and poor quality of life among elderly with physical disabilities during the COVID-19 pandemic.²⁵

Fear and Ageism During COVID-19

According to WHO, “Ageism refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or oneself based on age.” In simple words, ageism is nothing but how you think, feel, and act toward yourself or others, and it also affects health and lifespan. In some cases, ageism can lead to several mental and physical health issues, slow down disease recovery rate, and promote bad habits, such as smoking and drinking, disturb the quality of life, and cause early death in the elderly. Around 6.3 million people suffer from depression due to ageism. On the other hand, ageism leads to the economic burden for the society. Around US$ 63 billion was spent in the United States due to ageism and its associated conditions.^{26, 27} Ageism intensified during COVID-19 due to the spread of fear, hatred, and discrimination against elderly patients.²⁸ Higher levels of fear, anxiety, and irritation were observed among the elderly diagnosed with COVID-19. Also, changes in interpersonal relationships, relationships with family, and higher ageism were observed among the elderly during lockdown.²⁹ On the other hand, several social media trends, such as “Boomer Remover” and “Ok Boomer,” increase the age-related biomedical risk of elders where today’s generation targets the elders and shows generosity toward the young.²⁸ The death rate was higher in the elderly during the COVID-19 pandemic. A study showed fear about the death of others was both negatively and positively linked with ageism.³⁰ A recent study showed that diverse negative attitudes toward the elderly can also be associated with dementia-related anxiety.³¹ Ageism during COVID-19 positively predicts loneliness and indirectly predicts mental health issues. Loneliness along with social isolation and fear of COVID-19 works as a predictor of mental health issues.³² More hostile ageism is associated with lower behavioral modification; more benevolent ageism is associated with lower behavioral modification and higher pandemic-related fear during the COVID-19 pandemic, but when fear was considered as a mediator, the direction of the result between benevolent ageism and behavioral modification was exchanged.³³ Not only fear of the pandemic but also attachment toward any objects or person was associated with ageism. Studies showed anxious attachment was positively associated with ageism by considering “fear of death” as a mediator, whereas avoidant attachment was negatively associated with ageism by considering “empathy” as a mediator.³⁴

Studies showed secure attachment may help to regulate ageism and can improve the quality of life in the elderly.³⁵ At present, scenarios around all countries are encouraging collaborative research on the aging population to combat ageism. WHO suggested three strategies to combat ageism, viz., implementation of policy and law to address discrimination, and inequality based on age and protect human rights for everyone; educational events to eradicate misconception about various age groups, improve empathy among the public and for authentic knowledge; intergenerational interventions to connect diverse generations together, which may reduce biasness among different age groups.26,27 To eradicate the negative perspective of aging, a nursing education program can be implemented by including a holistic perspective of a person’s life experience and understanding the diversity of aging. On the other hand, more elders can be included in social service and medical organizations.³⁶

Mental Health and COVID-19 Complication in the Post-COVID Era

Even though the effect of the COVID-19 pandemic has been sublimated in the current scenario, and people started coming back to their normal life, but the negative effect of the pandemic is still hazardous and threatening to society. The people who fought with COVID-19 and survived anyway are still having several complications such as difficulty in breathing, cognitive decline, and fatigue along with many psychological factors such as lack of concentration, anxiety, and depression even after four weeks of infection.^{37, 38} Fatigue and cognitive decline are very common symptoms of any infectious disorders along with several physical and mental abnormalities and can present at least for six months.³⁹ Also, COVID-19 infection showed similar symptoms. The study showed that around 30% of the elderly aged from 50 to 72 years have symptoms of impaired cognition, and 37% of them have fatigue even after two months of discharge from the hospital. Around 6.7% of COVID-19 survivors have died, 15.1% were rehospitalized, and 31.2% were either emotionally affected or have mental health issues two months after discharge from the hospital.⁴⁰ In some cases, symptoms continued till six or twelve months, and more than 50% patients reported at least one symptom. Symptoms include anxiety, depression and PTSD.⁴¹ Another study showed that stress and anxiety persist among the elderly with a mean age of 65.9 years even after six months from the day of discharge.⁴²

Fear of Reoccurrence of COVID-19

Different initiatives have been taken by different countries and organizations to stop the spread of new variants of COVID-19. India has taken five steps: “mandatory risk profiling of each individual, institutional quarantine should be a must, genome sequencing of samples, aggressive contact tracing of suspects and strict observation of appropriate COVID appropriate behavior to stop spreading COVID-19.”⁴³ WHO has given five tips to stop COVID-19: “wash your hand often, cough into your elbow, don’t touch your face, stay more than 3 feet apart and feel sick? Stay home.”⁴⁴ But the new variant of COVID-19 often emerges due to mutation of the virus, and the same patient is infecting several times. Also, it has a very high risk of infection.⁴⁵ Respiratory hygiene, including wearing a mask, is the most common strategy popularized by the governments of many countries to curb the spread of COVID-19. Social media platforms like Twitter and Facebook are used to serve this purpose. However, the observed outcomes are different from the expected outcomes in some cases. A survey on mask-wearing tweets by Hopfer et al. suggested that people perceive the tweets differently, and the information regarding mask-wearing on Twitter amplifies the COVID risk perception, and these platforms complicate information regarding wearing masks.⁴⁶ A survey conducted during the delta variant showed higher fear of re-outbreak, anxiety, and depression, especially in women.⁴⁷ A new variant like Omicron has been found even in COVID-19–vaccinated patients.⁴⁸ Even though most people have taken the COVID-19 vaccination worldwide, the fear of reinfection is still torturing people.

Initiatives Taken for the Elderly

To improve the health status of the elderly population, WHO has taken the initiative called “UN Decade of Healthy Ageing (2021–2030)” in global collaboration with different government and nongovernment organizations to improve the lives of the aging population.¹ The person must live a long and healthy life. According to WHO, “Healthy aging is a continuous process of optimizing opportunities to maintain and improve physical and mental health, independence, and quality of life throughout the life course.”⁴⁹ Also, a person must have functional ability during their lifetime. Functional ability comprises the physical and mental ability of a person to perform any activity, pertinent environmental characteristics, and the interaction between them. These factors also depend on other associated factors such as age-related changes and the existence of the disease. Functional ability also includes the “ability to meet their basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society.”⁵⁰

Mind–Body Medicine on Mental Health

Mind–body interventions, such as Yoga, exercise, Tai chi, and Qigong, are popular practices and may improve mental health and help in psycho-immune homeostasis during and after the COVID-19 pandemic.^{51, 52}

Yoga

Yoga is an acceptable, easily accessible, and cost-effective intervention and is gaining popularity worldwide⁵³ and can be used as an effective intervention for the prevention of COVID-19 infection, immunomodulation, and mental health.^{54, 55} Yoga is helpful for developing cognitive and mental health in the elderly.⁵⁶ Also, Yoga can be a beneficial intervention for reducing stress and anxiety and promoting mental well-being in the social distancing era.⁵⁷ A survey showed higher times and days of yoga practice are associated with better mental health during the COVID-19 pandemic.⁵¹ Meditation is a part of eightfold yoga and can reduce anxiety and perceived stress during COVID-19.⁵⁸ A very recent study on COVID-19 patients showed a significant reduction of D-dimer and improvement in exercise capacity after 15 days of breathing intervention.⁵⁹ Also, several study protocols are being implemented to check the efficacy of yoga for healthy aging in the elderly.^{60, 61}

Exercise

Several review studies suggested physical exercise is recommended for improving immunity and mental health in the elderly during the COVID-19 pandemic.^{62, 63} Exercise can increase immune biomarkers such as leucocytes, lymphocytes, and immunoglobulin A in COVID-19–infected patients.⁶⁴ A recent randomized control trial (RCT) during the COVID-19 pandemic showed improvement in mental health among the elderly with cognitive decline.⁶⁵

Tai Chi

Tai Chi is a most popular mind–body technique especially famous in China. A recent study showed that Tai chi can reduce perceived stress and depression and improve cognition and learning in the elderly during the COVID-19 pandemic.⁶⁶ A meta-analysis showed that Tai Chi is a safe and effective practice for elderly COVID-19–infected patients during the recovery phase.⁶⁷ A very recent pilot study on the elderly showed that virtual reality Tai Chi can be beneficial for enjoyment during the COVID-19 pandemic.⁶⁸

Qigong

Qigong is another Chinese mind–body technique that can be beneficial for stress reduction, emotional regulation, and improved immune function in the elderly with COVID-19 infection. Hence, it can be used for the prevention, treatment and rehabilitation of COVID-19 patients.⁶⁹ A pilot RCT on the hidden elderly (disconnected from society) showed improvement in loneliness, confidence interval, satisfaction, and social support by using the elderly neighborhood volunteer approach.⁷⁰ A study showed that Qigong improves mental health–related QoL in stroke patients,⁷¹ reduces perceived stress and depression in women survivors of intimate partner violence,⁷² and improves night-time sleep quality in cognitively declined elderly patients.⁷³ A study on the elderly showed that Qigong is beneficial for improving cognitive function via the interleukin-6–hippocampus pathway.⁷⁴ Also, a meta-analysis showed that Qigong practice is beneficial for reducing depression and anxiety and promotes healthy aging, but there are very less RCTs that include the elderly population.^75–77 Recently, several study protocols have been designed to evaluate the effect of Qigong on lung function and QoL in COVID-19–recovered patients and also those who are in the recovery phase.^78–81

Need for Cost-effective, Humanistic, and Holistic Strategies

The bankrupt economic condition of different countries, especially of low- to middle-income countries, is a hindrance to the fight against the COVID-19 pandemic. Countries such as India and China with huge loads of elderly populations must be prepared enough to fight against the upcoming COVID-19 variants or any other infectious diseases. On the other hand, fear of COVID-19 infection leads them to mental health abnormalities. Hence, we must think about therapeutic preventive and cost-effective remedies, such as mind–body interventions, psychotherapy, and community-based collaborative PROACTIVE strategies for the elderly that include primary care teams, mental health specialists, lay counselors, cross-sector providers, and family and caregivers.^{82, 83}

Psychosocial factors play an important role in the mental health of the elderly during the post-COVID era due to fear of social withdrawal and hopelessness.⁸⁴ Fear of reinfection restricted the outside movement of the elderly, and they are getting afraid to attain any form of physical activity in the post-COVID era.⁸⁵ Hence, the implementation of physical intervention is very difficult for them. Also, elderly people are not very aware of digital activity. In this condition, the implementation of any digital intervention is not an easy task. Therefore, proper training programs should be implemented as a strategy for the elderly to improve digital awareness, and mental health issues which have been born due to fear of social withdrawal during the post-COVID era.^{86, 87} Also, different integrative strategies can be digitally implemented to improve the mental health of the elderly and elderly with physical disabilities.^{25, 88}

Even though very few studies started digital mental health interventions, such as online courses, computer classes, physical activity, cognitive intervention, and rehabilitation programs, to reduce mental illnesses like anxiety and depression in the elderly,⁸⁹ in the present scenario, lower participation of elderly was seen in most of the COVID-19–related RCTs. Hence, the government must make a policy for the enhancement of COVID-19–related research on the elderly and implement internet-based strategies for healthy aging.⁹⁰

Even though several treatment modalities are available to improve mental health in the elderly, there is a need to give more priority to the patient by implementing patient-friendly humanistic and holistic strategies to improve the mental health of the elderly during the post-COVID era,⁹¹ where the patients can choose the line of treatment based on their comfort. It should be a patient-centric rather than a treatment-centric approach.

Footnotes

Acknowledgements

The authors would like to thank all members of the Neuroscience Research Laboratory, Department of Neurology, PGIMER, Chandigarh, and S-VYASA University, Bengaluru for their encouragement and guidance.

Authors’ Contribution

KM and SJ have written the manuscript. PL, PB, UKT, GS, VM, SP, and JA have edited the manuscript. AA Conceptualized the manuscript. All authors read and approved the final manuscript.

Statement of Ethics

Not Applicable

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Parul Bali

Akshay Anand

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