How older adults are weathering the COVID-19 pandemic

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Today. I'm speaking with Dr. Sharon Brangman, Upstate's chief of geriatrics, about the impact of the pandemic on senior citizens. Dr. Brangman is a distinguished service professor of geriatric medicine at Upstate. And she's the former president of the American Geriatric Society. Thank you for making time for this interview, Dr. Brangman.

Sharon Brangman, MD: Thanks for inviting me, Amber.

Host Amber Smith: I wanted to check in with you and see how older adults are fairing in general during the pandemic. At the start older adults were considered high risk because of their age, and they were the among the first to be offered vaccines a year ago. Are seniors who become infected, having a rougher time than younger people who are infected?

Sharon Brangman, MD: So in my patient population, I've seen the full spectrum of how the COVID virus impacts older adults. I've seen some that have very mild to no symptoms, maybe just having a cough and a runny nose. And I've seen some that have gotten sicker. So one of the things we've learned about this virus is that it impacts people in different ways. And I think it depends on your own personal risk factors. So we know in general that older adults tend to get a worse outcomes when they get sick with COVID. However, it doesn't mean that everyone is going to get the same response.

Sharon Brangman, MD: And most of my patients got their first round of vaccinations early on. And when I talked to patients, now, most of them have gotten their booster. And, you know, we're starting to think that this isn't really a booster. This is really just the third vaccine in a three-step vaccination process. So you're really considered fully vaccinated when you've had all three of either the Pfizer or the Moderna or two of the Johnson and Johnson.

Host Amber Smith: Is there a difference when it comes to your patients? Are you recommending one over the other?

Sharon Brangman, MD: No. I basically encourage my patients to get vaccinated with whichever vaccine they can obtain. The biggest issues that we have found is that not all older adults have access to technology, so they can't make appointments online. I have many patients who have landlines or maybe they have a flip phone. So when we make all of these public health rules, we tend to forget that not everybody has equal access to the internet and technology. Not everyone has a laptop and a smartphone. And we forget the people, usually the people who have income restrictions or older adults who may not have the technological skills. So our biggest, focus has been making sure that our patients can access the vaccine. They want it, but they may have mobility problems so that it's hard for them to go somewhere and stand in line, and they have difficulty making appointments.

Sharon Brangman, MD: The first round of vaccines, the nurses in our office were helping older adults work out the appointment process online because they may not have had someone to help them at home. So I think it's very important when we're working in a community with people of all different incomes and ages and technological skills that we have to remember a one-size-fits-all policy doesn't work well.

Host Amber Smith: What has been your advice to patients who develop symptoms and test positive?

Sharon Brangman, MD: So it depends on what their individual circumstance is. We really don't want people to go to the hospital right now, unless they're very sick. If you have mild symptoms, you should not go to the emergency room. You should not go to a hospital.

Sharon Brangman, MD: So if somebody has a cough, runny nose, maybe a fever but they're otherwise able to eat and drink, they are not short of breath, they don't have chest pain, I would encourage them to stay in touch with their physician and stay home. If they start to get very, very high fevers that they can't keep up with, or they get chest pain or have real significant problems breathing, then that might be a time to consider speaking with your doctor about going to the emergency room. But as you know, our emergency rooms right now are completely overloaded. And so anyone who has mild symptoms should not be in the emergency room.

Host Amber Smith: Are you concerned about older adults who've not been able to get into regular medical appointments during the pandemic?

Sharon Brangman, MD: So there has been a big concern about the disruption in basic health care because of the pandemic. So we know the people who have had COVID, that's a direct impact from the virus. But then there are indirect or unintended consequences of COVID, and that's the ones that I'm concerned about. So these are people who may not go for their normal checkups. They are still afraid of catching the virus, they don't want to go and maybe get a mammogram or sign up for a colonoscopy if they're in the right age group for that. A lot of elective surgeries have been put on hold because the hospitals are so overloaded and elective surgeries are not necessarily minor surgeries. When we hear the word elective, we think that must mean they're not very important. And so we've had people who have significant health problems who have put them on hold, because the hospital may not have the capacity to take care of them.

Host Amber Smith: It sounds like this makes preventive care almost impossible, because if you're not seeing these people to catch things early, you're not going to be able to catch the things early before they become a bigger problem.

Sharon Brangman, MD: This is a national concern, and I think that there have been calculations about how many preventive measures have not happened or have been postponed, and how many people may have lost the ability to get a handle on very serious diseases because they have not been able to get into see their physician or their healthcare provider on their usual schedule.

Host Amber Smith: Have you seen racial or ethnic inequities among older adults with COVID or seeking COVID care?

Sharon Brangman, MD: Well, I think that's been very clearly delineated and discussed. Again, this has to do with so many different factors, but it's usually a one-size-fits-all policy does not fit all. And so when we have groups of people who have been marginalized from the health care system and may not have complete trust or may not be able to get complete information, these are people who may not know enough about the vaccine or have concerns about it, then we do see some inequities. And this is primarily an African-American and Latino communities. I have found, though, that information coming from a trusted and reliable source, combined with making access to the vaccines very easy goes a long way to making sure people get vaccinated. So, again, we talked earlier about people who may not have the technological skills or internet service to go online. But if we bring the vaccine to convenient locations and neighborhoods that people can readily access, we see a huge increase in people getting vaccinated. When people have the chance to speak with trusted community leaders about the virus and about the vaccine and have their questions answered, we see an increase in people getting vaccinated. And the same thing stands for boosters, or for that third dose, if you're getting either the Pfizer or the Moderna.

Sharon Brangman, MD: So we have to make sure that trusted leaders in the community are speaking to people. And that we make the vaccine easy to get. You shouldn't have to jump through many, many hoops to get something this important.

Host Amber Smith: I read about some studies that link COVID infections to cognitive impairment months later. And I wonder if your practice has patients who survived COVID and then months later are experiencing cognitive declines or accelerated Alzheimer's disease symptoms. Are you seeing anything like that?

Sharon Brangman, MD: So I have seen very interesting events related to COVID and cognition. First, we see people who have been spending more time with each other than they ever have, who suddenly start to notice their partner or their loved one has some memory problems. And this may not have been evident if they hadn't been spending so much time together. So we see that as one piece.

Sharon Brangman, MD: Another piece is that people who are socially isolated often have an increase in their dementia progression. So social connection is so important for all of us, and it's especially true as we get older. And it's even more true when we have any kind of dementia or memory problem. So people who have been isolated and haven't had regular interaction with the world and their family, we have seen a decline in not only their brain function, but their physical function. So we have people who haven't been getting out to walk or move and they're getting weaker, and they're more likely to fall and get hurt. So that is another unintended consequence of COVID for people who may not have even had COVID.

Sharon Brangman, MD: Then for people who have had COVID, we typically think of COVID as affecting their lungs or the respiratory system. But we know that COVID, especially the delta variant, can affect all parts of the body. And one of the things it can cause is a brain fog where people feel, after they've recovered from COVID, that their brain is just not working as sharply as it had in the past. One person described it as they felt like they were sleepy and groggy. And we're starting to understand that in some people, the COVID virus may be causing some inflammation of the nerves in the brain. And this may give them this foggy feeling. What we don't know yet is what the long-term effects are. And this is what we're learning. So, we are understanding that there are long-term effects of COVID. We've heard of long COVID syndrome where people feel tired and may have a chronic cough or other problems, including brain fog. So we're learning as we go, because this is all very new.

Host Amber Smith: Are there any treatments, or what's being experimented with to treat people with brain fog?

Sharon Brangman, MD: Well, we have to try to figure out if this is permanent or not, and we're following people over time. We're encouraging them to get good rest, good nutrition to exercise -- all of the things that you would normally do to stay healthy, maybe limit alcohol, because we know alcohol isn't good for the brain in general, and certainly if you have brain fog, you may not want to add to that with alcoholic beverages. But this is going to be a matter of waiting and seeing what happens. This is all new territory.

Host Amber Smith: You're listening to Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Sharon Brangman, the chief of geriatrics at Upstate.

Host Amber Smith: Now, you mentioned a little bit about loneliness, and I know that can be a concern for older adults anytime, let alone during the pandemic. I wonder, has it become more of an issue? Have you seen in the patients in your practice, and how are you dealing with it?

Sharon Brangman, MD: So this is a significant issue because people often live far away now, and they may not have the technological skills to reach out and talk to people. Or if people are in their neighborhood and nearby, there's been great concern about catching the virus. And so people have put distance between themselves and others. Their normal routines have changed. So people may not be going to church or out to senior centers or doing some of the other social activities they used to do. I've also had patients who have been avoiding seeing their grandchildren, especially if they're younger children who are not yet eligible for the vaccine. So there are concerns about younger children who might pass the virus on to grandparents and just so many different issues.

Sharon Brangman, MD: You remember in the beginning of the pandemic, people who are in nursing homes or assisted living facilities couldn't get visitors. And we decided as a society that it was better for older adults not to have visitors than to have visitors and risk getting the infection. And I've talked to patients who said "you took away my right to decide what was important for me." And I don't think there's any other age group where we as a society come in and tell you what is better for you without your input. So I think that's a whole issue about how we treat older adults, but in any case, visitation is now allowed in most nursing homes, as long as the visitors can show proof of vaccination and a negative COVID test. But isolation is a significant problem for older adults in this age of COVID.

Host Amber Smith: And loneliness isn't just an emotional thing, right? It can have a physical impact on people?

Sharon Brangman, MD: Loneliness is something that can affect the way your body functions. It can affect the way your brain functions, as well as the rest of your body. And we don't understand all the mechanisms yet, but it may create stress hormones and other things that then make it hard for your brain to work as it normally would, as well as the rest of your body. So we are social beings. We don't really relate well through electronical screens. We do better with face-to-face contact. So even though being able to reach out electronically is probably better than nothing, it's not the same as having face-to-face contact with people. And that's exactly what has been risky, or considered risky, during this pandemic.

Host Amber Smith: You mentioned the electronics, and I wanted to ask about telemedicine. Are your patients adapting to telemedicine? Are you able to offer that to them as a way to, to, you know, take the place of a physical in-person visit?

Sharon Brangman, MD: So we offer telemedicine, but it often isn't ideal. There are some people who do very well with it. Again, this is not a one-size-fits-all. Our office serves a 15-county area, and there are some people up in the North Country who really appreciate telemedicine because coming to see us used to be an all-day event. But I also have patients who have memory problems who don't really relate to a voice coming to them out of a screen. And I have other patients who do not have the equipment to even do a visit, and we're talking on the telephone, which is less than ideal. I have had situations where, I've had patients who are home with a home health aid who has a smartphone, but doesn't have a very good data plan. So in order for that home health aide to use their cell phone, it would have been a very expensive visit, which really isn't fair to the home health aide. So we need to figure out a way to reach people and to make sure that everyone has access to high speed internet. We have people in the North Country who still don't have high-speed internet. So this pandemic has really highlighted our digital divide about who has access to the internet, who can afford it and who can afford all the equipment that's needed.

Host Amber Smith: Well, I'm interested in what the health care system will learn from this pandemic, and that's one good example. If we could rewind to late 2019, what could we have done differently that would have reduced the impact of this pandemic, specifically on older adults?

Sharon Brangman, MD: Wow. There's a big question. First of all, recognizing it as an important and contagious virus and not something that would go away immediately. A lot of the infrastructure that's needed to address our digital inequities takes long-term planning, and I think that for telemedicine, for example, that that was something that was discussed for years and years, and within a matter of weeks, we were up and doing it. So there are some things that we do not do as a society until there is an emergency and a reaction. And that is part of human nature, but it's also part of our bureaucratic process, is that we're reactionary, and we don't like to be strategic and plan ahead.

Sharon Brangman, MD: And I think it's time for us to be strategic and to plan ahead.

Host Amber Smith: Are there policy issues that have been raised by the pandemic? Broadband access is one, but are there others that groups like the American Geriatric Society are working on?

Sharon Brangman, MD: So, yes. Certainly access to care has always been a big issue. Healthcare workforce issues have been very significant during the pandemic. Having input from a specialist in older adults, I think is very important when we're making decisions about people in nursing homes. And in many instances, decisions about medical care and nursing homes were not being made by the experts in geriatrics. I think that we should be looking at the role of caregivers and how important they are to taking care of older adults.

Sharon Brangman, MD: We understand how important caregivers are to children, but they are very significant and taking care of older adults. And considering how we excluded so many caregivers from assisted living and nursing homes, to the detriment of patients, is something that we should look at. So I think when my kids were little, I wanted to put them in bubble wrap and protect them, but that wasn't necessarily for their best interest. And I think the same is true for older adults. To cut them off from everyone around them to protect them is not in their best interest. And so we need to look at how we make decisions as a society, as they pertain to older adults. They should not lose their voice in these kinds of decisions.

Host Amber Smith: Well, thank you so much for your time and your expertise on this subject.

Host Amber Smith: My guest has been Dr. Sharon Brangman, the chief of geriatrics at Upstate. The Informed Patient is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, thanking you for listening.