Safer Holiday Plans for Older and Vulnerable People

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

It should come as no surprise that observing the holidays will be different this year.  Here we outline important considerations about holiday gatherings during COVID-19 times, with special consideration to the health of older and more vulnerable relatives and friends.

First, leaders from Johns Hopkins Medicine are urging caution this holiday season.  In a recent memo to faculty, staff, and fellows, they provided the following guidance:

“As you consider participation in various forms of holiday gatherings, please be thoughtful and exercise great care to protect yourself and your loved ones, especially those who are elderly, have underlying medical conditions, or are otherwise more vulnerable to severe consequences from the infection.”

As we approach the Thanksgiving holiday, COVID-19 cases and deaths continue to increase dramatically in the US, and throughout many places worldwide. With winter upon us, everyone is spending more time inside with poor ventilation and dry air—ripe conditions for viral community spread.  At the same time, many people find themselves suffering from Pandemic Fatigue (or COVID-19 Caution Fatigue), and yearning for connection with family and friends.  Though we long to return to normal holiday rituals, it is so important for the health and wellbeing of our older friends and family members that we redouble our resolve to keep ourselves and our loved-ones safe.   Indeed, the Centers for Disease Control (CDC) warns that “small household gatherings are an important contributor to the rise of COVID-19 cases.”  By finding alternative ways to celebrate and reconnect with those dearest to us, we may be able to have safer holiday plans for frail, older, and vulnerable populations.  Below are the CDC’s assessment of lower to higher risk holiday activities:   

Lower Risk: 

  • A small dinner with the people in your household
  • A virtual dinner with family and friends
  • Preparing food for family and neighbors (especially those at higher risk of severe illness from COVID-19 who are physically distancing), and delivering it to them without person-to-person contact
  • Shopping online rather than in person on Black Friday and Cyber Monday
  • Watching sports events, parades and movies at home

Moderate Risk Activities: 

  • A small outdoor dinner with family and friends who live in your community
  • Visiting pumpkin patches or orchards where people are taking COVID-19 safety precautions like using hand sanitizer, wearing masks and maintaining physical distance
  • Small outdoor sports events with safety precautions in place

Higher Risk Activities: 

  • Going shopping in crowded stores just before, on or after Thanksgiving
  • Participating or being a spectator at a crowded race
  • Attending crowded parades
  • Using alcohol or drugs
  • Attending large indoor gatherings with people from outside of your household

As difficult as it may be, there are some individuals whose health conditions should preclude them any gatherings. The CDC advises the following people should not host or attend in-person holiday gatherings outside of their household; including anyone who:

Please see CDC guidelines here to help celebrate Thanksgiving more safely.

Safer Alternative Holiday Planning:

The reality is that socializing during Thanksgiving is likely going to be very limited in real life and may only include those in your household, but the potential for virtual or telephone connection is abundant for almost everyone. This social connection is especially important for our frail and isolated relatives and friends. If you would like to get ideas for hosting a virtual Thanksgiving, you will be pleased to know that the AARP has put together excellent suggestions, which you can find here as well as a “how to” guide, which you can find here.  As noted in a recent NIH Director’s blog, breaking the traditional way we observe Thanksgiving allows the opportunity for something new to emerge and blend in with time-honored traditions.  Here are some ideas to consider:

  • Don’t like Turkey?  Make a dish you love instead! 
  • Love cooking?  Ask for signature dish recipes from you family and friends and share yours! (Here’s a pecan pie recipe my grandmother made every Thanksgiving.)
  • Have you put on your COVID 19lbs?  Mask up and take a Thanksgiving walk and be mindful of nature, and maybe stroll with your pod maintaining physical distance
  • Missing family and friends?  Call them over the weekend on the phone or a video chat service, or write them a note.
  • Need to be more thankful this Thanksgiving?  Start a gratitude journal—it is really good for your outlook and mental health.
  • Want to go somewhere?  Visit a place virtually.  Plenty of venues and museums offer virtual tours these days.  Some of them have programs for children, such as the Baltimore Museum of Art’s opportunity to meet Matisse’s dog, Raoudi, and learn about Matisse’s art.
  • Feeling nostalgic for Thanksgiving pass times?  Fortunately, some aspects of Thanksgiving were pretty much virtual all along.  Here’s the Thanksgiving NFL schedule.  The Macy’s Thanksgiving Day Parade is still happening—which you have probably already virtually attended in the past from the comfort of your own home! In my household, watching “It’s a Wonderful Life” was a given, as well as playing board games.

Perhaps the one thing we can all be grateful for this Thanksgiving is how swiftly coronavirus vaccine research has been progressing, and the hope that this may be the only COVID-19 Thanksgiving we must endure.  We must be grateful for our good health.  And protect it, and the health of those most vulnerable.  Know that we are in solidarity with each other this holiday season in this regard, and that we are in good company in that sense; click here for a message from Dr. Anthony Fauci, world-renowned infections disease expert:  “My Thanksgiving is going to look very different this year.”

Double Jeopardy for Older Adults of Color: An Urgent Call to Address Frailty Disparities in the United States

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Karen Bandeen Roche, PhD
Karen Bandeen Roche, PhD

Frank Hurley and Catharine Dorrier Chair of Biostatistics
Johns Hopkins Bloomberg School of Public Health
Co-Director, Johns Hopkins Older Americans Independence Center

Sarah Szanton, PhD, MSN, RN
Sarah Szanton, PhD, MSN, RN

FAAN, ANP
Professor
Endowed Professor for Health Equity and Social Justice
Director, Center for Innovative Care in Aging

Roland Thorpe, Jr., PhD
Roland Thorpe, Jr., PhD

Co-Director DrPH Concentration in Health, Equity, and Social Justice
Professor

Racial inequality that has been embedded in US structures and institutions has been exposed by twin catastrophes of 2020. In the height of the early novel coronavirus pandemic, Black, Latinx, and Native Americans were roughly 5 times as likely to be hospitalized for COVID-19 than their white peers, and Black Americans were twice as likely to die as whites (CDC COVID-19 Hospitalization by Race/Ethnicity, accessed 11/18/20). The killing of George Floyd, Ahmaud Arbery, Breonna Taylor, and others highlight the fact that people of color in the US continue to disproportionately experience police and vigilante violence along with other forms of inequality, including substandard housing, under-resourced schools, and restricted access to living-wage employment.

As one observes that highly publicized disparities in health and safety disproportionately affect young and middle-aged individuals, it can be tempting to predict that inequities lessen or even out in old age. Some have argued this (Meich, 2009). Motivated by studies we have performed as well as others’, we fear that such an approach—whether arising from complacency or misunderstanding—will leave older people of color in America with considerably diminished quality of life and heightened risk of other adverse outcomes. Frailty is a case in point. In a study to evaluate national racial/ethnic prevalence disparities, we found that the odds of frailty among non-Hispanic Black and Hispanic older adults were inflated approximately 1.5 times compared to non-Hispanic White older adults, after adjusting for age, sex, income, BMI, and comorbidity (Usher et al., 2020). Relative to a non-Hispanic white sociodemographic group with 15% prevalence—likely a quite typical group, given an estimated overall national prevalence of 15.3% (Bandeen-Roche et al., 2015)–this translates into prevalence of roughly 21% for non-Hispanic Blacks and Hispanics.  We further found that, for Black older adults, relative Black versus white disparities were comparable across income quartiles (and the estimated percentage inflation in frailty odds actually was greatest in the highest income quartile). This means that intersectionality looms large; added risks appear to aggregate when under-represented race/ethnicity and economic disadvantage are taken together.

Disparities in frailty experience may provide a particularly telling case because of implications for other risks as well as for mechanisms leading to the disparity in older age.  The studies described above employed physical frailty phenotype (PFP) ascertainment of frailty. Under the PFP paradigm, frailty is hypothesized as a clinically recognizable syndrome arising from critical dysregulation in physiological systems governing energy production and use as well as stress response, resulting in vulnerability to adverse outcomes following stressors (Fried et al., 2001; Bandeen-Roche et al., 2020). With heightened frailty prevalence, older Americans of color or minority ethnicity may disproportionately frequently experience amplified physiological vulnerability together potentially with impaired access to resources by which to compensate, leading to a vulnerability “double-hit” putting them at particularly amplified risk for adverse outcomes. Considering frailty as an outcome of unraveling stress response regulation, moreover, may provide insight into mechanisms leading to such a large race disparity in frailty in late life; stress response stands to be impaired with chronically elevated stress over the life course, and this is exactly what one might hypothesize to follow from the persistent experience of socioeconomic inequities, social injustice, and structural racism. It is the inextricably intertwined historical context and life experiences that many older Black Americans have endured that position their bodies for poor outcomes, such as frailty. 

It follows that the need for research to discover the etiology of late life frailty, and then to intervene on or buffer it, is particularly urgent for reducing racial/ethnic disparities in the health and well-being of older Americans. Meanwhile, efforts to buffer the implications of frailty for older Americans need not wait. Interventions with proven effectiveness for reducing stressors in the home environment already exist;  CAPABLE, an evidence-based program which provides tailored occupational therapy, nursing, and handy worker services to enhance function of older adults aging at home and prevent costly institutional care, is a strong example of these. Programs and policies to reduce disparities in opportunity to maintain good health also could have high impact. These are needed to address health facilitators that are unavailable to many older adults of color, including ready transportation by which to access health care, high-quality nutrition, and neighborhood environments in which to safely engage in physical activity—all essential to staving off frailty and reducing its impact. If feasibility mandates, these interventions could be targeted—for example, using methods to assess pre-frailty pioneered by our Older Americans Independence Center as well as other groups. Screening to identify pre-frail and frail older Americans of color could not be more timely in the face of the COVID-19 pandemic. We suspect that the etiology underlying frailty intersects considerably with the etiology of susceptibility to the novel coronavirus, and conversely infection may contribute to future frailty. Finally, whether to bolster robustness and resilience in the short term or for protection against future health threats, addressing frailty among older Americans of color is a matter of the highest import for researchers, clinicians, and policymakers alike.

Overcoming the stress of selecting a frailty assessment instrument: guidance and considerations.

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Brian Buta, MHS

Brian Buta, MHS

Project Administrator, Geriatric Medicine
Johns Hopkins University School of Medicine

Research on frailty has exploded over the past two decades. A quick PubMed search of the term shows an exponential increase in the number of frailty-related publications since the early 2000s. 

NIH Library of Medicine Search on Frailty

But the concept of frailty can be diverse in its underlying theory and measurement.

Different frailty measures can identify different groups of people as frail (Cigolle et al., 2009 ; Xue et al., 2019). And different user scenarios may require different types of measures (Buta et al., 2016; Martin & Brighton, 2008). So how do we move past these challenges?

  • One option: focus on screening for frailty in order to capture vulnerability early, regardless of the measure.
  • Another option: focus on comparing measures to illuminate discrepancies in measurement, and to better inform similarities and differences between measures.
  • Or: prioritize the instrument’s ability to predict poor outcomes… or its construct validity relative to geriatric experience and theory… or its strength as a lever to elucidate and address underlying etiology….

Indeed, these approaches are all important. We need to be able to screen for frailty using existing instruments.  We also need to hone in on what information these different measures – which all fall under a blanket term of “frailty” – are actually telling us about the health of older and vulnerable persons. And for certain studies, we need to know how well frailty will predict adverse health events, while also recognizing the importance of other types of validity (Bandeen-Roche et al., 2020).

In an effort to guide researchers and clinicians who plan to assess frailty, we have posted a new section to FrailtyScience.org: “Frailty Assessment Instruments: Guidance on Selecting a Frailty Instrument.”  We aim to stress the importance of selecting an instrument that best fits the purpose of the research or clinical need.  As noted in this section, “certain measures may be better suited for different purposes.”  For example, a frailty assessment may be utilized as a quick screening instrument (e.g., the FRAIL Scale), or as a method to measure frailty in an electronic medical records system (e.g., the Deficit Accumulation Index), or as an instrument to study physical frailty as distinct from multi-morbidity or disability (e.g., the Physical Frailty Phenotype).

The field continues to lack a consensus operational definition of frailty. But if we can account for the distinct features and uses of different instruments, and if we can use language that better clarifies how frailty is assessed (e.g., physical frailty, deficit accumulation frailty, etc.; Walston et al., 2019), we may be able to improve our ability to prevent and manage health risks for vulnerable older adults across a variety of settings.

Please know that we welcome your thoughts and feedback. You can reach me with comments at bbuta@jhu.edu.

Brian Buta is a project administrator and researcher in the Division of Geriatric Medicine and Gerontology at Johns Hopkins University.  He offers his great thanks to Drs. Karen Bandeen-Roche and Qian-Li Xue for their review and feedback during the writing of this post.