With the onset of the Delta variant of COVID-19, local, state, and federal governments are once again speaking about possible lockdowns. We know the elderly population is extremely vulnerable to the virus and to keep them safe, many had been separated from their loved ones for close to a year and now, could such isolation return? Before that happens, both medical and adult care providers need to review some of the latest literature regarding the effects of separating seniors from their families. Doctors now see a trend, in some cases, that distance leads to death. Let’s look at the case of Cintia, an 83-year-old woman, who lives in a long-term care facility here in the Northeast who was separated from her daughter Julinha for nearly a year.
“My mother (Cintia) was a very active woman given her age and her diagnosis of dementia,” said Julinha. “She would walk around the facility several times a day with her walker, something that helped keep her legs working and joints feeling pretty good. She would visit other residents often sharing cookies or some other treat with them. Before the last lockdown, she was dancing at her birthday party, but after months of being confined, she has become a different person who refuses to even get out of bed and her cognitive decline was faster than any of us expected.”
Cintia’s health deteriorated drastically, and she is now in hospice care. “I know that given her age and health problems, this was going to happen, but I'm sure the isolation and lack of human contact played a huge role in this downward plunge,” said Julinha. “I think the only thing that has kept her going has been my family’s weekly visits. But if we go on another lockdown, like some are hinting at, I’m afraid we’ll never see my mom alive again.”
"Although there is a lot of anecdotal stories of how the lockdown affected the mental and physical health of seniors in long-term care facilities, the actual data is beginning to trickle in and it indicates that the lockdown has fueled a mental health crisis that has amplified the already horrific impact of the pandemic on the senior care industry," said certified elder law attorney RJ Connelly III. "We have also heard from our clients who are aging in place who were unable to attend senior centers, go shopping or even see loved ones and they tell us about their feelings of loneliness, abandonment, despair, and fear which are taking their toll on the physical and cognitive health."
Robyn Grant, the director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care, told AARP recently "we're hearing from a number of family members and [long-term care] ombudsmen that many residents are just losing the will to live”, noting that social isolation has been listed on some death certificates as a causative or contributing factor in a number of patient deaths during the pandemic in her home state of Minnesota. In other states, "Adult Failure to Thrive (AFTT)" has also been listed as a contributing factor in senior deaths.
What Is Failure To Thrive?
The term "failure to thrive" when referring to older adults is something that the majority of us do not readily associate with this age group. "I think most of us immediately think of infants when the condition of "failure to thrive" is discussed," says Attorney Connelly. "Just like in children, this condition can be a critical and deadly syndrome with warning signs that can be missed and attributed to age, something that does not occur in children."
Failure to thrive in both children and adults has several similarities but unlike the childhood disorder, adults have a much harder time recovering from it, if at all, and let's explore why.
Briefly, failure to thrive was first detected in the mid-20th Century during wartime. As parents were killed in the fighting, infants, especially those born prematurely, were often placed in orphanages. Medical professionals noted that even though the nutritional needs of the children were being met, they continued to fall behind other children in weight gain, neurological and mental development.
Research done at the time found that the cause of this was a lack of human touch, skin-to-skin contact that is imperative if a child is to develop normally. Because the orphanages at the time were so overwhelmed with children, they were unable to provide the necessary contact needed.
In humans, when emotional deprivation and lack of attachment to someone do not occur, physical and emotional growth slows down. In such cases, the body goes into survival mode, forcing normal physiological functions to be preserved at the expense of physical, mental, and social development. The longer the body is in survival mode, the more permanent and negative the effects will be, for both children and adults.
The Role of Masks in AFTT?
Another major discovery at the time was the impact that medical providers wearing face masks had on babies. Without seeing smiles, full faces, and other human expressions, children were unable to develop normally. It was soon determined that emotional deprivation as well as touch, something very common in institutional settings, contributed to "failure to thrive". It is not a stretch to think that those with cognitive issues and dementias have not been negatively affected by all those around them wearing facial coverings which could be a contributor to AFTT.
In a 2013 report on WebMD, their story stated, "people with Alzheimer's disease or early thinking and memory problems tend to mirror the emotions of those around them, researchers find. This transfer of emotions, known as emotional contagion, appears heightened in people with Alzheimer's and related mental decline, according to the University of California, San Francisco (UCSF) team. And it can be important in the management of these patients, they added. "Calm begets calm," said Dr. Sam Gandy, associate director of the Mount Sinai Alzheimer's Disease Research Center in New York City, who was not involved in the study."
The story continued, "an emotional contagion is a rudimentary form of empathy, enabling people to share and experience other people's emotions, said lead researcher Virginia Sturm, an assistant professor in the UCSF department of neurology. "It's a way by which emotions travel across people quickly and even without awareness," explained Sturm. This process can shape behaviors and cause changes in the brain, she added."
In another research study conducted by the Proceedings of the National Academy of Sciences, that involved 237 adults - 62 with mild memory and thinking problems, 64 with a diagnosis of Alzheimer's disease, and the remainder with no identified mental or cognitive issues, they took tests to identify depression and other mental health problems and also underwent MRI scans to identify changes in the brain related to emotional contagion.
WebMD reported on the results of this study: "the researchers found higher emotional contagion in those with mild mental impairment and Alzheimer's disease, compared with those who did not have these conditions. This growth of emotional contagion paralleled the increase in damage to the right temporal lobe of the brain, reflecting biological changes in the neural system".
Given these results, it is easy to see how everyone wearing masks during the pandemic, which limits the ability of individuals with early memory issues and Alzheimer's disease from reading emotional cues given off by facial expressions, has contributed to emotional deprivation in this group specifically and generally within our society.
Defining Failure to Thrive
According to The Institute of Medicine, failure to thrive is defined as, “Weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity.” Failure to thrive in older adults is not just one medical condition. It is a deep-seated disorder that can include physical and mental components. Very often it is accompanied by depression, dehydration, and low cholesterol.
The number of those affected with AFTT is shocking, with up to 35% of older adults in general, up to 40% of nursing home patients, and up to 60% of hospitalized veterans having this syndrome. This condition is not simply part of the aging process and can often lead to death. It is important to recognize the signs early, so AFTT does not advance in an elderly individual before meaningful treatment can begin.
Four conditions are prevalent and predictive of adverse outcomes in persons who may have failure to thrive:
impaired physical function
A comprehensive initial assessment should include information about physical and psychological health, functional ability, and socioenvironmental factors if these symptoms are present.
Failure To Thrive And Isolation
Professor of Clinical Psychiatry at Vanderbilt University, Dr. William Petrie, told a Tennessee news station that he believed older people were dying from isolation (AFTT) caused by COVID. “It has played a major role," said Petrie. “In my practice, I have had more than the normal number of deaths in the last three months. I have seen it personally.”
"Being isolated which leads to depression, whether it is caused by fear of getting sick or the subsequent lockdowns has become such a problem that elderly death certificates are now listing the cause of death as “isolation/failure to thrive related to COVID-19 restrictions”, said Petrie.
Death among seniors who are isolated is not a new phenomenon. “There are lots of studies that have been done,” Petrie told the news station, “Some of them have estimated that you’re fifty percent more likely to die if you’re in a socially isolated situation. And, that’s before COVID-19.”
Throughout the COVID-19 lockdown, senior care facilities and home care providers expressed their concerns about the effects of social isolation on seniors and pushed for reopening as soon as possible.
"During the height of the pandemic, nearly every senior care facility I spoke with wanted to reopen as soon as possible because they fully understood that a visit is not simply a social call for their residents," said Attorney Connelly. "Even with the excellent care the overwhelming majority of them provide, administrators are well-aware that most family members act as much as essential caregivers and care monitors as do their staff."
"Family involvement is vital for providing information as well as the emotional support that staff just cannot provide. Family members being present help monitor if their loved one is eating appropriately, that daily hygiene is being maintained, and that socialization is continuing. Family members are also usually the first to see the minor changes in a loved one's condition and share these concerns with staff," continued Connelly.
Symptoms of Adult Failure to Thrive
One of the issues that make adult failure to thrive difficult to diagnose is the fact that during the normal aging process, many of the symptoms associated with AFTT may be present from time to time. "What's important here is for family members to understand that AFTT is not a disease that manifests with one symptom, but a series of symptoms that when occurring together are cause for concern," said Attorney Connelly. Here is a brief look at the most common symptoms of AFTT.
Appetite Loss - For most, a gradual decrease in appetite is part of the aging process. This occurs as seniors have lower energy levels and engage in less activity meaning fewer calories are needed. However, a loss of appetite or refusing to eat is a major concern that must be addressed. Without essential nutrients, health will suffer and existing conditions may worsen.
No Interest in Activities - Again, seniors tend to slow down with aging, but a total loss of interest in things that once motivated them can be concerning. Such a loss of interest can indicate that depression may be setting in, which is a symptom of AFTT.
Dehydration - Spotting the signs of dehydration is difficult in any age group until it affects the body to a point that could be dangerous. Refusing to drink or take in adequate amounts of fluid can affect blood pressure, regulate body temperature through sweating and waste elimination. Severe dehydration can cause other problems such as urinary tract infections, confusion, and pneumonia.
Low Cholesterol Levels - Isn't low cholesterol a good thing? Not in this case. The liver produces 75% of the body's cholesterol, where good cholesterol (HDL) is also produced. AFTT can affect the amounts of HDL circulating within the body.
Weakened Immune System - As people age, the immune system begins to become less effective. AFTT weakens the immune system even further, increasing the risk of acquiring illnesses faster and affecting healing.
Depression - As stated earlier, depression can lead to or be a part of AFTT. This condition results in a decrease in normal day-to-day functioning. Some of the signs of depression include persistent sad or anxious mood, feeling hopeless, lack of energy, restlessness, and thoughts of death or suicide.
Weight Loss - Obviously, a poor appetite and depression will lead to weight loss, aggravating some pre-existing conditions. Some issues of aging (certain health issues or medications) can result in a loss of taste or smell further exacerbating the lack of appetite and weight loss.
Cognitive Impairments - As an aging body experiences changes, so too does the brain. Older adults often experience mild symptoms of cognitive decline including memory loss and an inability to concentrate. Such a decline in cognitive functioning can lead to depression, anxiety, mood, and personality changes. These changes can lead to irritability and aggressiveness.
There are multiple treatment options and plans available for AFTT patients. "One of the first things to do is contact a health care professional to rule out other possibles causes for what loved ones are seeing in the senior," said Attorney Connelly. "These causes could be just a normal function of aging, other underlying physical issues, drug interactions, or even substance abuse."
In almost all cases, nutrition and physical exercise will play a central role in a treatment plan for someone with AFTT. Medical providers usually prescribe nutritional supplements and exercises designed to increase the senior's strength, endurance, and flexibility. Also important to spend time outside with others since such activity tends to raise a person's spirits without the use of additional medications.
"The importance of exercise and resistance training cannot be under-estimated for seniors," said Connelly. "As their strength and endurance improve, their fall risks decrease adding to their sense of well-being and that leads to a feeling of independence. This all goes hand in hand in lifting depression in people."
Unfortunately, those patients who refuse to eat or exercise will need other interventions to help them and the treatment team needs to determine if the course of action being taken does not needlessly prolong a patient's life if he or she is suffering.
"Hospice professionals have educated me on the subject of medically aggressive, life-prolonging interventions in patients with a terminal illness or condition," said Connelly. "When an elderly patient exhibiting symptoms of AFTT refuses all interventions, the best that can be done is to make them comfortable. When all is said and done, it's really about respecting the wishes of the individual."