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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 101-106

Study on the effect of COVID-19 lockdown on health care and psychosocial aspects of elderly in Kerala State


1 Department of Internal Medicine, Government T. D. Medical College, Alappuzha, Kerala, India
2 Department of Community Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
3 Department of Psychiatry, Dr. S.M.C.S.I Medical College, Thiruvananthapuram, Kerala, India
4 Department of Internal Medicine, Government Medical College, Alappuzha, Kerala, India

Date of Submission24-Aug-2020
Date of Decision24-Aug-2020
Date of Acceptance20-Sep-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Padmakumar Balasundaram
Department of Internal Medicine, Government T. D. Medical College, Alappuzha, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_3_20

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  Abstract 


Objective: The objective of the study was to determine the effect of COVID-19 lockdown on the health care and psychosocial aspects of the elderly in Kerala. Methodology: The study was a community-based cross-sectional study designed as an online survey, and the study setting was the entire state of Kerala. Target participants (more than 60 years old) were selected with nongovernment organizations working in geriatric welfare. The tool used for the survey was a semi-structured online questionnaire. To assess the magnitude of psychological distress, Geriatric Anxiety Scale-? Version 2.0 was used. Results: Five hundred and thirty-six elderly people were included in the study, of which 273 (50.9%) were males and 263 (49.1%) were females. Four hundred and forty-two people (82.5%) were on regular medications before the lockdown, of which 28 (6.3%) missed the same during lockdown. Routine laboratory testing went down from 404 (75.4%) to 294 (54.9%) and medical follow-up from 348 (64.9%) to 180 (33.6%) during the lockdown period. Two hundred and three elderly (37.9%) in the study population showed significant anxiety symptoms. Conclusions: Lockdown has adversely affected the health care and non-COVID medical services of the elderly. Fear of COVID infection and the presence of possible COVID infection symptoms were associated with psychological distress and anxiety. Proper psychosocial interventions are necessary to mitigate the effects of lockdown on health care and psychosocial aspects of the elderly.

Keywords: COVID-19, elderly, geriatric anxiety scale, healthcare, lockdown, psycho-social


How to cite this article:
Balasundaram P, Libu G K, George C, Chandy AJ. Study on the effect of COVID-19 lockdown on health care and psychosocial aspects of elderly in Kerala State. J Indian Acad Geriatr 2020;16:101-6

How to cite this URL:
Balasundaram P, Libu G K, George C, Chandy AJ. Study on the effect of COVID-19 lockdown on health care and psychosocial aspects of elderly in Kerala State. J Indian Acad Geriatr [serial online] 2020 [cited 2022 Sep 29];16:101-6. Available from: http://www.jiag.com/text.asp?2020/16/3/101/309987




  Introduction Top


The world is experiencing pandemic COVID-19 caused by severe acute respiratory syndrome coronavirus 2 on an unprecedented scale. The virus causes worse outcomes and a higher mortality rate in elderly and those with comorbidities such as diabetes, hypertension, coronary heart disease, chronic obstructive pulmonary disease, and chronic kidney disease.[1] The joint World Health Organization-China fact-finding mission found that patients older than 60 years and those with comorbidities had the highest risk for complications and death.[2]

One of the major strategies that were adopted by governments all over the world to contain the pandemic was nationwide lockdown. Although this was intended to stop the virus's spread, sudden enforcement of lockdown might have disadvantaged the already vulnerable elderly population. Due to the disruption of non-COVID medical services during lockdown, there is a possibility that the elderly are denied adequate health care and treatment of their chronic illnesses such as diabetes, hypertension, and coronary heart disease. Further, reverse quarantine, which was implemented to protect the elderly from contracting the infection from the rest of the household members and community might also have challenged the mental health of the elderly.

While there has been much discussion about the symptomatology, morbidity, and mortality pattern of COVID-19 in the elderly, there has not been much research in the literature about the effect of lockdown on the well-being of the elderly. Hence, we have conducted a study on the impact of lockdown on the health care and psychosocial aspects of the elderly in Kerala, which has the highest proportion of the elderly population (12.6%) in India.[3]


  Methodology Top


The study was a community-based cross-sectional study, and the study setting was the entire state of Kerala. As it was not possible to conduct an in-person interview during the lockdown period due to mobility and transport restrictions, the study was designed as an online survey. The study's inclusion criteria were people aged more than 60 years who could access the online questionnaire through smartphone, tablet, or computer and were willing to participate in the study. People who were seriously ill, bedridden, or not willing to participate in the study were excluded from the study. The study duration was 1 month from May 10, 2020, to June 10, 2020. Sample size estimated was 345, and the calculation was based on a study on the prevalence of anxiety among aged in relation to COVID-19 lockdown, which was found to be 22.6%.[4]

Target participants were selected with the help of nongovernment organizations working in the field of geriatric welfare such as Kerala Senior Citizens forum and pensioner's organizations. The tool used for the survey was a semi-structured online questionnaire that included consent and questions regarding sociodemographic aspects, comorbidities, and effect of lockdown on health care and psychosocial aspects. The questionnaire questions were direct, simple, precise, and given in both regional languages Malayalam and English.

Geriatric Anxiety Scale (GAS) version 2.0 was used to assess the magnitude of psychological distress and was included in the questionnaire. GAS is a 30-item self-report screening and assessment tool specifically designed for older adults.[5] Of the thirty items, the first 25 were scored to assess experienced symptoms of anxiety. The remaining five items were to investigate the specific content areas of anxiety, often reported to be of concern for older adults (e.g.,: health and financial concerns, fear of dying, etc.). Individuals were asked to indicate how often they have experienced symptoms in the past week, including that day. Respondents answer using a 4 point Likert scale ranging from 0 (not at all) to 3 (all the time) with higher scores indicating higher anxiety levels.

KoBo Toolbox, a free, open-source tool for mobile data collection, was used in the survey. Those giving consent could finish the online survey and submit to the principal investigator's account on a real-time basis. The gathered data were exported from the database to? IBM SPSS v. 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.) and analyzed.

Means and its standard deviation, proportions, and 95% confidence interval (CI) were used to summarize the findings. Chi-square test, correlation, Mann–Whitney U–test, Kruskal–Wallis test, and binary logistic regression were also done. Prescribed statistical methods were used to analyze the findings of? GAS-Version 2.0.

The Institutional Ethics committee approved the study protocol of T. D. Medical College, Alappuzha (EC: 41/2020 Date: May 05, 2020).


  Results Top


Five hundred and thirty-six elderly people were included in the study, and the mean age of the study population was 68.86 years (standard deviation 7.3 years). There were 350 (65.3%) people in the ≥70 years age group, 147 (27.4%) in the 71–80 years, and 39 (7.3%) in the ≥81-year age group. Of the people studied, 273 (50.9%) were males and 263 (49.1%) were females. Three hundred and ninety-eight persons (74.3%) were employed, and the most common occupation was government employment (30%). Even though 145 (27.1%) were either widowers/widows, only 16 (3%) reported staying alone. Others had support at home from either spouses (290 [54.1%]), sons/daughters (205 [38.2%]), grandchildren (16 [3%]), or relatives/other helpers (7 [1.3%]).

Prevalence of comorbidities

Only 476 participants responded to the question regarding comorbidities. Hypertension was the most common medical condition present (219 [46%]), followed by diabetes (212 [44.5%]) then cardiac disease (101 [21.2%]), arthritis 35 (7.4%), stroke 14 (2.9%), cancer 13 (2.7%), and other diseases 167 (35%).

Regular medications and blood tests during lockdown

A total of 442 people (82.5%) were on regular medications before the lockdown, of which 28 (6.3%) missed the same during lockdown. As far as the blood tests were concerned, 404 (75.4%) of the study population used to do regular blood tests before the lockdown, and this went down to 294 (54.9%) during the lockdown period.

Effect of lockdown on exercise

A total of 354 people (66.1%) used to do regular exercise before the lockdown. However, this came down to 263 (49.1%) during lockdown.

Effect of lockdown on medical follow-up

A total of 348 people (64.9%) used to do regular medical follow-up before the lockdown. This came down to 180 (33.6%) during the lockdown period.

Effect of lockdown on use of addictive substances

Two hundred and seventeen (40.5%) in the study population had the habit of using addictive substances before lockdown. However, this came down to 29 (5.4%) during lockdown.

Use of telemedicine

Ninety-seven people (18.1%) used telemedicine consultation during the lockdown, while 133 (24.8%) had no knowledge about it.

As far as the source of information regarding COVID-19 was concerned, television (90%) followed by the newspaper (62.1%) were the most important information sources. Other sources of information are as illustrated in [Figure 1].
Figure 1: Source of health-related information (n = 536)

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COVID-related symptoms in elderly

Only 74 people responded to the questions related to COVID symptoms. As far as the primary symptoms related to COVID-19 were concerned, the most common symptom in the study population was cough (27 [5%]), followed by sore throat (24 [4.5%]), breathing difficulty (21 [3.9%]), and fever (6 [1.1%]). Among the additional symptoms, tiredness is the leading one (35 [6.5%]), followed by body aches (24 [4.5%]), rhinitis (18 [3.4%]), and diarrhea (6 [1.1%]).

The frequency of daily handwashing among the elderly during the period of lockdown was studied, it was found that 224 (41.8%) study participants practiced it all the time, followed by 231 (43%) most of the time, 68 (13%) some times, and 10 (2%) not at all.

Effect of lockdown on mental health

The mean score on the GAS total was 9.11 (9.81), and the subscores were 3.95 (3.79), 2.45 (3.35), and 2.71 (3.31) on the somatic, cognitive, and affective subscales of anxiety. About 203 people (37.9%) in the study population showed significant anxiety symptoms while using GAS cutoff at 8/9, while a higher cutoff score of 16 revealed anxiety in 121 (22.6%) respondents.

There was no significant association in Mann–Whitney U–test between age ≥74 and ≥75 (P = 0.054) or gender (P = 0.41) with the total GAS score.

There was a statistically significant minimal negative correlation observed between GAS Total score and age of the participants, as shown in [Figure 2] (Spearman's correlation coefficient -0.03 and P = 0.031).
Figure 2: Association between age and Geriatric Anxiety Scale score

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On bivariate analysis employing the Chi-square tests for variables compared to the presence of anxiety, it was found that age, gender and widow/widower status were not associated with significant anxiety. In contrast, education and socioeconomic status showed statistically significant association as shown in [Table 1].
Table 1: Association of demographic variables with Geriatric Anxiety Scale score in the elderly study population

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Among the preexisting illnesses, only the presence of arthritis (P = 0.01) was significantly associated with anxiety, as shown in [Table 2]. Lack of exercise after the onset of the pandemic (P = 0.042) was also significantly associated with anxiety as was the presence of primary symptoms (P = 0.01) and additional symptoms (P = 0.01) related to possible COVID-19 infection [Table 3].
Table 2: Association of comorbidities with Geriatric Anxiety Scale score in the study population

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Table 3: Association of possible COVID-19 symptoms with Geriatric Anxiety Scale score in the study population

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The content items across GAS score category at 9 were also significant statistically (Chi-square test P = 0.001) as shown in [Figure 3].
Figure 3: Stacked area graph showing distribution of Geriatric Anxiety Scale score category at nine against content items of Geriatric Anxiety Scale

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Content items 26–30 of the GAS scale were statistically associated with GAS total score (Kruskal–Wallis test P = 0.001 for all items).

On multivariate analysis using binary logistic regression, only items in GAS related to “Finance,” “Health,” and “Death” and presence of any of the COVID-related symptoms showed statistical significance.


  Discussion Top


Among the 535 older adults who participated in the study, it was interesting to note that only 3% reported being alone. The rest had some support either from the spouse (54.1%), children (38.2%), or grandchildren (3%). This shows traditional family home care in the state, which is the best mode of geriatric care.[6] This is also evident in other data in our study showing that 48.3% of the study population would depend on their relatives in case of a health emergency.

As far as the prevalence of comorbidities among the elderly was concerned, the most common condition was hypertension (41.2%), followed by diabetes (39.6%) and cardiac diseases (18.8%). This was consistent with various population studies in India, demonstrating that hypertension was the most common lifestyle disease in the elderly, followed by diabetes.[7] Studies from Kerala also show the same distribution pattern of noncommunicable diseases (NCDs) among the elderly population.[8]

Among those on regular medications (82.7%), only 6.5% missed the same during lockdown even though there were restrictions for movement and travel. This was probably due to the NCD control program started in the state in 2008–2009 which provides NCD services through public health facilities such as primary health centers, community health centers, and district hospitals.[9] Apart from NCDs' treatment, the service also includes distributing medicines for chronic diseases for 1 month. Of those who missed regular medications, the most common reason cited was financial trouble. Understandably, these medications would have been quite expensive and not freely available through NCD services.

In contrast, 27.1% of those who used to do regular blood tests missed the same during the lockdown period. This was probably due to the fact that most of the private laboratories were closed during the lockdown period and elderly people would have been reluctant to visit hospitals because of fear of acquisition of COVID.[10] Moreover, there were stringent restrictions for travel of elderly and reverse quarantine imposed on them also restricted their access to laboratory services. A practical solution to overcome this problem in future would be to promote house call programs and home care laboratory services. Health authorities should take the initiative to provide glucometers and electronic BP apparatus to the elderly and educate them for self-monitoring of blood sugars and blood pressure.

A similar picture was evident among people who missed regular exercise (25.5%) during this period, possibly due to the same reasons listed above. Indoor exercises such as treadmill and stationary bicycle have to be promoted among older adults so that, when restrictions such as lockdown are implemented, their routine exercise would not be affected. A significant proportion of the study population (33.2%) reported as not having had the habit of doing exercises. Hence, proper health education activities that highlight the importance of regular exercises in controlling NCDs in the elderly have to be introduced through community health workers.

The effect of lockdown on the mobility of the elderly population was even more evident among those who missed regular medical follow-ups and consultations (48.3%). Scarcity of public transport shut down of outpatient departments in many private hospitals, and the conversion of many government hospitals into COVID hospitals would have been the reasons for this scenario.[11] Use of telemedicine consultation would be a useful way to overcome many of the health-care challenges the elderly face during lockdown.[12] In our study, only 18.1% utilized this novel mode of medical consultation, and 24.6% had not even heard of telemedicine consultation. Lack of technical skill, availability, and cost might be the major hindrances for the widespread use of teleconsultation by the elderly. To familiarize them with this technology, proper education programs, including technical skill development activities, have to be provided by the health workers.

As far as the source of all the information regarding COVID-19 was concerned, television (90%) followed by the newspaper (62.1%) were the most important ones. This shows the importance of more health education activities explicitly focusing on geriatric health care in the visual media. Although a significant proportion of the study population (40.7%) reported using addictive substances before the lockdown started, only a small fraction (5.5%) continued to use them during the lockdown period. This was probably due to the shutdown of liquor shops and other outlets that sell tobacco products such as cigarettes during this period. This may be taken as an opportunity to promote education, counseling, and deaddiction activities among the elderly against substance abuse.

Frequent handwashing was one of the essential practices promoted in the state as a part of “break the chain” movement in Kerala against COVID. It was well received among the elderly population as only 1.8% reported as not having done it. This was a fair indicator of the acceptance and practice of preventive measures by the elderly during the lockdown period.

The mean score on the GAS total was 9.11 (9.81) and was lower than that reported in a previous study in the United States,[5] where the mean total score was 13.35 (9.7), particularly on the somatic subscale. This may be explained by the fact that most of the elderly in the study were living with one of their close relatives, as demonstrated by the results. This, in turn, could be explained by the strong family ties that exist in Asian culture that play a protective role.[13] In our study, the prevalence of anxiety was nearly 40% in the elderly, while Indian studies using screening instruments for anxiety have detected higher levels at almost 50%.[14] However, these studies employed shorter screening instruments such as GAD 7, while our study had used a 30-item questionnaire. A study in China in the pandemic's initial stages showed a 31.6% (95% CI: 31.2%–32.0%) for anxiety. The lower levels in China could be explained by the study being done in the early stages of the pandemic, perhaps without its full implications being evident to the population and differing methodologies.

Although 48.9% of the population were females, gender was not associated with anxiety, unlike other studies.[15] Besides, living alone, spouse not being alive or having a comorbid NCD were not associated with anxiety. In a study conducted in Turkey during the COVID-19 pandemic, anxiety was associated with being a woman, individuals living in urban areas, and those with an accompanying chronic disease.[16] This was not replicated in the current study. It may reflect the decreased focus on these long-term health issues in view of the current health emergency. Arthritis was associated with anxiety, probably because both pain and disability naturally increased anxiety.[17]

Interestingly, the presence of primary and associated symptoms of a possible COVID infection cross-sectionally was associated with anxiety, bringing to the fore the natural preoccupation and fear of COVID infection. It may also be due to the constant reminders received through various media outlets. This also implied that the elderly in the study were possibly hypervigilant about these symptoms. Paradoxically, some anxiety related to the possibility of COVID-19 infection might be adaptive in promoting social distancing, which is paramount to disease control.

There have been several psychosocial interventions in the state such as community kitchen, online/telephonic supportive services, particularly for individuals under quarantine, to reduce individuals' psychological burden. Various programs such as the district mental health programs have been instrumental in addressing the population's psychosocial needs. “Ottakallaoppamundu” (We are with you) program for providing psychosocial support are in place, and 1143 mental health professionals are involved in mainly supporting people in quarantine.[18] The government has adopted an inclusive approach and addressed the unique needs of elderly people living alone too.

Although our study had identified a few effects of lockdown on the health care and psychosocial aspects of elderly, it had some limitations. The duration of our study was only 30 days. A significant proportion of the participants in our study was from good socioeconomic status. Hence, the observations might not represent the real issues of the general geriatric population in the state.


  Conclusions Top


Lockdown has adversely affected the health care and non-COVID medical services of the elderly. Fear of COVID infection was associated with psychological distress and anxiety. Proper psychosocial interventions are necessary to mitigate the effects of lockdown on health care and psychosocial aspects of the elderly. Long-term studies are necessary for the future to detect the impact of lockdown on the health care and well-being of the elderly population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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