By: Dr Brian Beach 

For those of us who work on issues related to the social experiences of later life, the COVID-19 pandemic has raised a number of questions, challenges, and dilemmas. Governments across the world have implemented lockdown measures to contain and manage the spread of the virus, while those considered at greater risk – for example, those aged 70+ in the UK – have been compelled to practice shielding to further reduce their risk of contracting SARS-CoV-2.

Question: Should age be used as a criterion for lockdown?

There is ongoing debate about whether selecting an age cut-off is the most appropriate approach to helping the public manage the risks related to COVID-19. On one hand, there is clear evidence that age is correlated with mortality risk, so older people are more susceptible to dying from the virus. On the other hand, some argue that simply using age as the criterion for stricter or extended lockdown rules is ageist, especially as it does not account for other associated risk factors like morbidity or underlying health conditions. Moreover, the age structure of a given population appears to interact with age-specific mortality, so that countries with older populations will experience a higher burden of mortality, which has important implications for implementing transmission-mitigating measures.

Still, chronological age does provide an uncomplicated signpost for helping the public understand the public health messages around COVID-19. Let’s put aside the recent controversy around UK government advisors diluting the clarity of lockdown messages for now…

Even if we accept that age can be useful in mitigating risk from COVID-19, everyone in the community has a role to play in reducing the spread of the virus, as previously noted by the WHO Regional Director for Europe. This point is of paramount importance as countries move to loosen their lockdown measures. It also raises the reality that, even during a lockdown, we are embedded in and need social structures, with the social connections and beneficial feelings of belonging this often brings.

Challenge: Social isolation and loneliness contribute to poorer health outcomes

We are all linked to each other in society and the communities in which we live – after all, real people are still working to keep food arriving in stores and homes, to stabilise the digital infrastructure we use to connect to the internet, to provide care, etc. As many of us restrict our movements due to lockdown measures, we must consider the consequences of our “normal” links to each other being strongly curtailed or even severed.

This links to the topics of social isolation and loneliness, which have received notable research interest in recent years, including with respect to older people and later life. Loneliness in particular has received significant attention outside academic circles, featuring in news articles and policy (with three Ministers for Loneliness in the past two years).

Much of this interest stems from the fact that social isolation and loneliness have been linked to a range of poorer health outcomes, which in turn are linked to higher mortality (see here for an overview). These two concepts are also interrelated, with loneliness generally considered a reflection of the consequences of isolation. However, despite an arguably greater emphasis on loneliness in policy and media, some research has suggested that isolation is a stronger determinant of mortality, independent of loneliness.

Social isolation and loneliness are also associated with age, with risk increasing as people move through later life. However, evidence also demonstrates that younger people experience relatively high levels of loneliness, with one poll suggesting loneliness affects 31% of 18-24 year-olds compared to 17% of those aged 55+. If we accept that younger people are more likely to be digitally connected, this suggests that digital technologies, e.g. social media, have a limited role in reducing the feelings related to loneliness.

The challenge for all of us hoping to make a difference through our work – from researchers to practitioners – therefore lies in trying to ensure that the isolation experienced by many due to lockdown does not manifest in the same way as other forms of isolation/loneliness that negatively influence health. One can only wonder at this point, given limitations in available data, how the relationship between isolation and poorer health outcomes will affect mortality through an indirect effect from the pandemic. Perhaps this explains the stark difference between official UK death figures from COVID-19 and excess mortality during this period – 37,460 compared to 59,537 as of 27 May 2020. After all, a recent study using Italian data found that, contrary to expectations, higher infection rates among older people were associated with higher levels of social isolation (rather than e.g. greater intergenerational connectedness).

Dilemma: Residential settings can protect but entrench isolation

Those following the statistical trends related to COVID-19 mortality will be aware of the issues surrounding the extent to which reported figures include suspected (rather than confirmed) cases and those that occur outside of hospitals (i.e. in care homes). The UK Government has claimed that a “protective ring” was put around care homes to protect them from the virus, but the pattern of infections in care homes suggests otherwise. Indeed, with respect to mortality from COVID-19, the available data suggest that care homes residents in many European countries have accounted for anywhere between a quarter to over half of all COVID-19 deaths.

Had systems and governments been better prepared and equipped, the residential nature of care homes, coupled with the (unfortunate) reality that many care home residents do not leave the home, could have certainly been used to protect residents. However, even where there are opportunities to protect people in communal residential settings, the dilemma is the extent to which such vulnerable people will simply have their experiences of isolation and loneliness more deeply entrenched.

In our sector, we have worked extensively to foster social connections among people at different stages of later life, including those in residential settings. While actions over the next few months will need to be taken carefully to protect vulnerable people, we must prepare for ways to generate social connections for those who are more isolated. There are some lessons on this from the housing-with-care[1] sector, and I have co-authored a blog for providers with colleagues from the University of Bristol as part of the DICE project (available here).

What happens next

One day, we will be able to move back to living our lives in a way somewhat close to normal. Many of us will be able to freely join our families, friends, and colleagues to re-engage in the kinds of socialisation to which we all used to be accustomed. Yet we must not forget those who won’t have the same kind of access to social activities and connections that most of us have.

We can also use the shared experience of lockdown as a reflective learning tool. Many people have been frustrated or inconvenienced by living in lockdown, but these experiences of isolation will end as the restrictions are lifted. For many older people already at higher risk of isolation, lifting lockdown could change very little. In the shift back to a new normal, we must ensure that the kind of isolation we have all experienced does not become a permanent feature for those more vulnerable to social exclusion, isolation, and loneliness.

For more information on ILC’s work with the University of Bristol and Housing LIN on the DICE project (Diversity in Care Environments), please visit the project website.

[1] Housing-with-care refers to housing schemes that provide independent living to older people with care and support available as needs develop. Such schemes are also variously called extra care housing, sheltered housing, or supported living.