Protecting older adults of Sri Lanka amid COVID-19

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COVID-19, novel coronavirus, 2019-nCoV, developing countries, low and middle-income countries, Sri Lanka, South East Asia, older adults 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. 4According 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. 2These 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.Longterm 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. 7Some 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. 2The 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. 8While 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. 9It is also crucial to instruct all staff to selfscreen at home and not to come to work if any symptoms are present and report their symptoms. 9All 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. 7The 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. 2Providing 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 communitydwelling 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. 2For 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. 2In 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.

Conclusion
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.There are few 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.Preparedness of the healthcare systems to respond to the pandemic with a lack of facilities, resources (i.e., ventilators) and staff in the healthcare system, specifically in hospitals, intensive care units and long-term care homes is a concern that should be taken into consideration when clinical responses are developed.Challenges around protecting community-dwelling older adults who are caregivers to grandchildren, receiving informal care from children in the same household, living in living in remote areas, or living alone or dependent on others need to be taken into consideration in public health responses.The use of emergency relief and public assistance programs in collaboration with the Ministry of Social Services and Ministry of Health, and working with NGOs such as HelpAge Sri Lanka, who are key stakeholders in assisting the aging population in Sri Lanka can help the country keep its older adults safe from COVID-19.

LIST OF ABBREVIATIONS
COVID-19: Coronavirus Disease 2019 LTCs: Long-term care homes LMICs: Low and middle-income countries NCDs: Non-communicable diseases NGOs: non-governmental organizations DECLARATIONS Ethics approval and consent to participate: N/A Consent for publication: N/A