BACKGROUND
Older adults over 60 are at a higher risk of getting severely sick and
dying from Coronavirus disease 2019 (COVID–19).1,2Sri Lanka has one of the fastest aging populations in South and
South–East Asia.3 In 2015 the population over 60
years was 13% of the total population.4 According to
World Bank 10.47% of the Sri Lankan population was 65 years and above
in 2018, which is approximately 2.27 million people.5In addition to having a rapidly aging population, Sri Lanka is a
developing country with limited resources to accommodate the older
population that can be significantly affected by COVID–19. As of May
28, 2020, Sri Lanka has 1,469 COVID–19 cases and 10 deaths since the
first confirmed case on January 27, 2020, where half of the deaths
(50%) have been above the age of 60.6 Statistics up
to date shows that older adults are at a much higher risk of dying from
COVID–19. Older adults being at a much higher risk of contracting and
dying from COVID–19 has important implications for the way in which
public health and clinical responses should be
developed.2 These implications have been largely
overlooked in both high and low and middle–income countries (LMICs)
when providing guidance and implementing regulations, which can have a
greater impact in LMICs.2 This commentary addresses
concerns and points to keep in mind that are specific to Sri Lanka when
developing public health and clinical responses to protect older adults
from COVID–19.
The first concern is the preparedness of healthcare systems in Sri Lanka
to respond to a pandemic. Long–term care homes (LTCs) or similar
facilities that care for older adults in Sri Lanka are not as
well–regulated and at an equal standard when compared with high–income
countries. Most of the LTCs lack necessary multidisciplinary staff
and/or financial resources that are needed to take care of older adults
who need continuous care.7 Some LTCs in Sri Lanka lack
basic requirements that would allow adults to keep a distance within the
home such as individual rooms. In some long–term care homes, all older
adults sleep in the same hall in separate beds, not separated by a wall.
Therefore, LTCs in Sri Lanka do not have advanced facilities as those of
high–income countries to immediately react to a COVID–19 surge and
different approaches should be taken to meet the needs of each
long–term care home.2 In high–income countries,
there is already evidence of COVID–19 widely compromising nursing home
residents.2 The risk of COVID–19 spreading fast in
under–developed LTCs in Sri Lanka could be significant if appropriate
measures are not taken in time. Some of the measures that LTCs in Sri
Lanka can adopt as examples from the rest of world are discussed next.
Some countries have been taking measures to restrict visits to LTCs and
similar facilities to only “essential” visits, where “essential”
visits mean allowing family visits in end of life or critically ill
situations.8 While this is a difficult arrangement for
family members and residents, at this time, limiting visits can
contribute to saving the lives of older adults in LTCs. However, it is
important to remember to maintain the quality of lives of older adults
while they are distanced from their families through means such as using
available technologies to help them stay in touch with their family
members. In addition to restricting visits, it is essential to actively
screen long–term care home staff and residents, which includes checking
for symptoms and gathering information about travel history and
contacts.9 It is also crucial to instruct all staff to
self–screen at home and not to come to work if any symptoms are present
and report their symptoms.9 All staff would need to be
educated of early signs and symptoms of COVID–19 in order to prevent
unnecessary exposure and spread among the most vulnerable older adults.
In addition to educating staff, it is important to also educate the
residents as well to strictly follow precautionary measures.
Similarly, hospitals and intensive care units can face greater
challenges due to the increased demand for healthcare services due to
COVID–19. Complications from COVID–19 require respiratory support and
a large number of patients who require respiratory support are likely to
be older adults.2 Some hospitals in Sri Lanka face
ventilator and capacity shortages on just regular days and are unable to
meet the demand. Therefore, hospitals could be facing difficulties in
meeting even higher demands during a pandemic.7 The
government and policy makers would need to take into account the
limitations of the current healthcare system and prepare for potential
difficulties that the healthcare system could face when planning and
evaluating regulations and policies that are being implemented to
contain COVID–19. Above all, it is imperative that Sri Lanka takes
immediate preventative measures discussed here as well as additional
measures to prevent a potential unbearable burden that
COVID–19 could bring to the healthcare system.
The next concern is around protecting community–dwelling older adults.
It should be noted that there are common family dynamics unique to Sri
Lanka. One of them is grandparents taking care of grandchildren, which
provides an added risk of exposure for older adults as caregiving
lifestyles make it impossible for them to self–quarantine or keep a
distance from possibly exposed individuals.2 Providing
parents of these families options for alternative child care methods, or
providing flexibility and relief around work hours can be helpful in
reducing the risk of exposure to older adults in this kind of a family
dynamic. Another family dynamic that is common in Sri Lanka is informal
care that older adults receive, where older adults are looked after by
their adult children in the same household rather than sending them to
LTCs or similar facilities unless long–term care home admission is
absolutely necessary. A majority of older adults live in the community
with or close to their children and receive informal care from their
children. Informal caregivers should be prepared to plan for alternative
care in case the primary caregiver falls ill or gets exposed to the
virus.2 Informal caregivers should also be educated
and made aware of preventive measures that they need to follow in order
to reduce the risk of exposure (i.e., frequently washing hands, wearing
masks, disinfecting surfaces and groceries after buying groceries for
the older parents and keeping a distance between adults/children and
older adults in the same household). Because of these widely interactive
family dynamics, the risk of exposure to community–dwelling older
adults is much higher and therefore preventive measures are crucial to
lessen the risk of exposure among community–dwelling older adults.
When responding to the pandemic, it is important that governments pay
special attention to community–dwelling older adults who are living
alone and are in remote areas. Any response developed to limit the
spread of COVID–19, must be extended and adjusted to meet the needs of
these most vulnerable older adults living in the
community.2 For example, if one of the responses by
the government is regional lockdown, the government has to consider how
lockdown could be affecting community–dwelling older adults who are
living alone or dependent on others for care and support and extend the
responses to accommodate them. These older adults may be at risk of
having limited access to food and other essential supplies if the
country decides to take longer and extensive quarantine
measures.2 In remote areas of the country, older
adults are likely to go to the stores by themselves, potentially
increasing their risk of exposure, especially in high risk areas.
Appropriate actions such as delivering essential supplies to their
households can help these older adults immensely. The government can
also assist these vulnerable older adults through the use of emergency
relief and public assistance programs in collaboration with the Ministry
of Social Services and Ministry of Health, and by further working with
non–governmental organizations (NGOs) such as HelpAge Sri Lanka, who
are key stakeholders in assisting the aging population in Sri Lanka.
In addition, policymakers must remember that a large number of older
people may be uninformed and may not have access to adequate information
on prevention and precautionary methods (i.e., how to use a face mask,
physical distancing and wash hands or use hand
sanitizer).2 These older adults must be given special
attention and provided with adequate information with the involvement of
volunteers or health educators. Moreover, it is important to educate all
citizens to look out for older adults who may be living alone while
keeping in mind to keep a distance with older adults if individuals are
sick themselves.
While the entire world is acting fast to fight COVID–19, it is
important to pay special attention to vulnerable populations around the
world. While protecting older adults from COVID–19 is getting a
significant amount of attention around the world, taking actions to
lower the risk of exposure to older adults can be difficult in different
environments such as in developing countries due to lack of resources.
Sri Lanka is one example of developing countries with a rapidly aging
population, where if preventive measures are not taken in time,
community–dwelling older adults as well as older adults in healthcare
facilities can be significantly affected by COVID–19. For a developing
country with a large population of older adults, the weight of a heavy
demand due to a COVID–19 surge can be unbearable. Therefore, it is
imperative that policymakers, governments and healthcare workers pay
attention to the shortcomings and challenges within the country, so that
effective measures that are most applicable to the environment can be
implemented.