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'Cocooning by voluntary informed consent or enforced expectation? Time to rethink our treatment of over 70s'

Consultant geriatrician Rónán Collins understands the reasons for cocooning but says enough is enough.

Professor Rónán Collins Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital

Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light…

Dylan Thomas

THE LIGHT IS dying, not because of actual death but rather the life being removed from older people by state paternalism.

Paternalism is usually well-meant but often misguided and harmful to those that it purports to protect. It is not lost on me that none of our current senior government ministers dealing with this crisis is older, which is a relatively new departure in politics.   

At the outset let me state that there is as much medical scientific evidence that cocooning the over 70s will end this pandemic any sooner, as lying in the sun will cure you of Covid-19. Cocooning is in place for two reasons, to protect older people and prevent our medical system from being overwhelmed.

I understand the need for this, but like many geriatricians, I am concerned as many recent patient interactions have made me question the ‘enforced’ cocooning of older people. We have reached the objective in the short-term. Our ICUs have not been overwhelmed and our system is still coping. It’s time to give older people a break.

Imagine an older, healthy and active relative or friend, one of the ones who ‘never sit down’. Their generation learned to be busy from a young age. There are many older people like this in Ireland. That person is missing out right now on the most basic of physical activity, all because of their age, and nothing else.

Too much to ask

Let me be clear here – I am fully behind the public health policy and the results achieved thus far have been remarkable with exceptional co-operation, but this mandatory cocooning expectation on one sector of society is a step too far in my opinion.

I have been disappointed that many a conversation on what should re-open first focused on the likes of golf and tennis ahead of the more immediate plight and needs of older people. 

In the Spanish flu pandemic of 1918-1919, the fatality rate was greatest amongst young adults. This was an era before antibiotics and many people died from secondary bacterial infection. No one at that time suggested we cocoon younger people. That’s despite many older people doing better in that pandemic, maybe as they had survived many a previous bacterial infection. 

medicine-flu-epidemic-pandemic-influenza-science 1918 Spanish influenza outbreak. USA Source: SIPA USA/PA Images

There are many over 70s in Ireland who have lived through polio epidemics, tuberculosis, a world war, deep recurrent recessions, institutional abuse and bereavement. Many have held the responsible positions that have delivered the state that we all now live in. I think they can be trusted with the facts and take on board the personal risk to themselves.

Let’s be clear, it is not primarily older people spreading this disease. Cocooning is advice, yes, for the wellbeing of older people. Any disproving looks from younger neighbours should be quenched quickly by the deserving respect and empathy due to this generation.

They lived through very tough times and for a lot longer than you and I, reared us, educated us, healed us, financed us and are still working, helping with childminding, caring for family members and net contributors to society.

I think they can be trusted to act responsibly with the facts, weigh up the personal risks and follow public health messages, and probably more so than the 20 somethings on the radio telling us about how they find on-line dating great as they ‘really got to know someone‘!

Inequality

An older friend recently tearfully told me of their frustration at wanting to follow the public health advice and feeling absolutely obliged to do so as a responsible citizen while a slightly younger friend could take a walk or cycle or call around to other people’s front gardens.

Contrast this with groups of younger people gathering for drinks parties in the nearby parks. This person ran a large educational organisation. Are we seriously suggesting an older person must absolutely and indefinitely cocoon for their own benefit?  They can’t decide for themselves?

002 Gardai Rathcoole gardai providing a meals on wheels service for those cocooning. Source: @gardainfo

What about older people living with spouses with dementia who don’t understand or remember there is a pandemic?  Many older people are ‘voting with their feet’ by going for a walk. Providing they understand the facts and risks involved, that is something we should support as an age-respectful society, just as much as we are a race-respectful society, or respecting the right-to-choice society.

I love the tales I’m hearing in my work, of friends on the phone to older relatives being abruptly cut off as they dive into a ditch to avoid being seen, or conversely ensuring they are seen outside once a day to show the neighbour they aren’t that age.

Our older people don’t need to be taught wellness and how to cope by younger people who, quite often seem to not really have lived much themselves. They need to be allowed to exercise informed freedom of choice.

Most older people have learned wellness through experience, hard-won and self-taught resilience and a deeper understanding of themselves that innately advises them what is likely to work for them to improve a situation when challenged.

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I always ask my father’s advice; he’s seen more and experienced more situations than me and maybe a starting point in wellness for everyone is to seek the advice of someone older you trust if you feel in trouble. 

It is important to remember, as has been stated many times and shown in evidence, that the majority of older people will not die if they contract this illness and the illness will be mild.

It’s true that mortality is greater if you are older especially if you have heart disease, but it’s also greater if you are younger and overweight with high blood pressure. The fact that many older people are dying in nursing homes is a sad reality and the variables for outbreaks such as poor infrastructural design, inadequate health governance structures to residential care in Ireland, as elsewhere, and health-worker transmission has been well articulated already.

What is not as well articulated is that many older people in residential care are very frail with naturally very limited life expectancy. This is not permission to ignore and accept, but rather a recognition of gerontological reality. 

We must also recognise that older people, like younger people,  are not a homogenous group in any setting and care must always be appropriate and not dictated by age. Surely this also applies to public health advice and older people can be trusted as much as younger people to interpret the advice responsibly.    

Professor Rónán Collins MD FRCP (Lond) FRCPI FESO is a Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital. Follow him @ronancollins7. 

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About the author:

Professor Rónán Collins  / Consultant Physician in Geriatric and Stroke Medicine at Tallaght Hospital

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