The government announced on 10 March 2020 that it was suspending activities for seniors for 14 days, affecting some 290,000 participants. Current projections suggest that our fight against COVID-19 will be a long one, and suspensions like these form part of the measures necessary to slow and contain the spread of COVID-19.
Although necessary, suspending communal activities presents our seniors with unique challenges, especially to their mental health. While a 14-day suspension may not result in the mental health issues brought about by isolation or loneliness, without knowing when our fight against the virus ends, we must be able to talk frankly about the impacts of our measures on our seniors.
The immediate impact of a suspension of activities on seniors is the fear of isolation or loneliness. Isolation or loneliness is a subjective concept and immensely personal in nature; seniors may view the temporary suspension of communal activities or the occasional loneliness as a form of isolation, even though they may in fact continue to have access to their family and friends. No matter the reality, their subjective reality is enough to trigger the detrimental effects of isolation.
There is a strong link between isolation and morbidity.
Morbidity is a term used by mental and other health professionals to describe illness or disease. In fact, isolation is used as one of the risk factors in predicting the development of morbidity. The detrimental effects of isolation are even more pronounced in seniors, where the protective factors of employment, access to technology, and strong social support networks, do not generally exist. By contrast, seniors are often associated with risk factors such as frailty and neurodegenerative disorders, or the lack of strong social support networks.
Sustained isolation brings about increased levels of stress and emotional distress, which in turn puts physical and mental strains on the body. Specific examples of illnesses and diseases that are associated with isolation include depression, Alzheimer’s disease, heart disease, including high blood pressure, and a general decline in cognitive functioning. One longitudinal study in Singapore found that isolation was associated with a greater risk of death in Singapore and was more predictive of mortality than even living arrangements or social networks. With more than 41,000 seniors above the age of 65 living alone in Singapore in 2015, we must take care that we do not mitigate an immediate crisis by substituting it for a longer term one. The number of seniors above the age of 65 living alone is projected to increase to 83,000 by 2030.
However, our seniors do not merely face the feelings of isolation or loneliness. As much remains unknown about COVID-19, there is also a general anxiety among the population, including seniors, about its prognosis and mortality rates. In the face of escalating case numbers and fatalities amidst the widespread media coverage on COVID-19 especially among the vulnerable and the elderly, given that much remains unknown about the novel coronavirus, it is inevitable that fears of dying and death are stoked. And when combined with the effects of isolation or loneliness and being unable to externalise their anxieties, the anxieties and isolation become more pronounced.
To cope with their anxiety and low mood, our seniors may develop unhealthy coping behaviours such as excessive smoking or drinking, maintain a poor diet, or experience a decline in exercise or physical activity.
These behaviours are unhelpful and contribute to other long-term health issues, and they tend to persist even after the period of isolation is over. We must therefore continue to keep an eye out for our seniors, given especially that no one can accurately predict how COVID-19 will continue to impact us.
However, it is not easy to design alternative activities to allow our seniors to continue to feel engaged outside of their usual social settings. Seniors hold on very dearly to their sense of independence and freedom, to the extent that some seniors may choose to live by themselves or away from their families. These seniors tend to form strong external social networks, and the communities that they participate in become an integral part of their identity and serves as a powerful protective factor against the detrimental effects of isolation.
It is important to remember that many seniors take part in community activities as a way to cope with their unique set of circumstances in the first place. In recognition of the role that strong social networks play in combating depression and isolation, many of these activities were specifically designed to promote “gotong royong” or a sense of community.
It is commendable that extensive efforts have been made to extend these activities to all our seniors, given that strong social networks have been found to be effective in reducing symptoms of depression. Seniors who were engaged in social activities were associated with positive health outcomes were more likely to be happier, live longer, and experience fulfilment. Furthermore, social activity also slows cognitive and physical decline. Like muscles in our body, our cognitive functions gradually weaken if it is not put to regular use. Retirees who had more social interaction and engagement through some form of work involvement or volunteering reported better cognitive performance, fewer depressive symptoms and overall better mental health and life satisfaction compared to those who did not.Other studies have also found that socialisation was associated with a delay in memory loss, cognitive impairment and reduced the risk of dementia.
Returning to the impact of the suspension of activities for seniors, the potential loneliness or isolation experienced from the suspension of a single routine activity cannot be considered “in isolation”. A change in a single key activity is a significant deviation that might impact on all their other activities for the day. For example, seniors typically structure their entire day around these activities that take place at the same place or activity centre, involving the usual suspects (i.e. their friends). While some seniors might be able to adapt or find substitutes for their routine activities, there will be many who find it difficult to give up routines that were honed through years of practice. Without a routine activity to “anchor” their day, seniors may not be able to plan or follow through on activities for the rest of their day,even if those activities have nothing to do with the routine activity.
One strategy is to give our seniors a sense of purpose;
that they are very much an important tool in Singapore’s fight against COVID-19. Providing seniors with accessible and regular updates on our fight against COVID-19 and empowering each senior with an individual action plan are useful measures that can help mitigate their sense of loss from the suspension of activities. For example, seniors could be appointed as COVID-19 ambassadors responsible for disseminating information on COVID-19 to their social networks, and to check-in regularly with other seniors to address or escalate any health or other concerns to the authorities. These informal social network models tap on existing social media and chat platforms and are already effectively employed in our armed forces to boost camaraderie and reduce AWOL numbers. Seniors can continue to engage one another in small coffeeshop groups,alleviating some of the impact from the suspensions. This approach is preferable to the usual prescriptive approaches of encouraging seniors to “look on the bright side”, as emotional regulation is a finite resource that is scarce in the battle against COVID-19 without an end date in sight.
Seniors should also be encouraged to maintain the non-affected portions of their daily routine. The gap created by the suspension of activities should be positively reframed as an opportunity to try new activities or crafts such as baking, gardening, mah-jong, reading or other individual activities that the person has always wanted to try. There are plenty of options available if seniors can be persuaded to perceive the gap as a welcomed development.
There is also a role for family and friends to play. Seniors who were previously very independent and mobile may develop feelings of isolation or loneliness now that they are unable to engage in their usual social activities. They must recognise the enhanced impact that COVID-19 has on seniors, and wherever possible increase the number of engagements with their senior family members or friend. Engagement may take the form of phone or video calls, visits, or small-group activities to keep our seniors socially active. This form of social interaction will go a long way in assuring our seniors that they are still cared for, and they can reach out for emotional or other support during their time of need. This will help to prevent and reduce negative feelings and thoughts that might arise from loneliness or isolation.If the feelings of isolation or loneliness persist, it is advisable to seek help from a mental health professional.
Lastly, we should remind our seniors that it is normal to feel distressed or isolated during this period. We should also ostensibly acknowledge that our seniors are making an important sacrifice and contribution to Singapore’s fight against COVID-19. Their sacrifice, together with our front-line workers and healthcare professionals, will keep us and our loved ones safe.