PSYCHOSOCIAL CARE FOR THE ELDERLY IN SOCIAL ISOLATION/COVID-19

ABSTRACT. The COVID-19 pandemic drove a large population contingent in Brazil and worldwide into social isolation. As reported by the highest international health authorities, including the World Health Organization (WHO), the elderly people are part of the so-called ‘risk group’ for the disease. Thus, more rigor and care were required among elderly people, including social isolation. It is well known that, despite the undeniable importance of this action, elderly people in social isolation were more exposed to a series of illnesses, mainly related to psychic problems. The goal of this paper is to propose psychosocial care for the elderly in a situation of distress, or vulnerability due to social isolation. The ideas seek to induce memory, cognition and psychomotricity through narratives, artistic resources, Information, Communication Technologies and autobiographical objects, such as video calls, reading, listening to music, storytelling and recalling. In general, the proposed activities can be coordinated by professionals and family members and adapted according to the characteristics of each elderly person.

Keywords:
Elderly; social isolation; therapeutic activities

RESUMO.

A pandemia da Covid-19 levou ao isolamento social grande contingente populacional no Brasil e no mundo. Conforme as mais altas autoridades de saúde internacionais, entre elas a Organização Mundial da Saúde (OMS), os idosos fazem parte do denominado ‘grupo de risco’ para a doença. Portanto, foram exigidos mais rigor e cuidado entre as pessoas com idade mais avançada, incluindo o isolamento social. Apesar da indiscutível importância dessa medida, os idosos em situação de isolamento social ficaram mais vulneráveis a uma série de agravos, principalmente os de ordem psíquica. O objetivo do presente trabalho é apresentar propostas de atenção psicossocial ao idoso em situação de sofrimento ou vulnerabilidade decorrente do isolamento social. As propostas buscam estimular a memória, a cognição e a psicomotricidade por meio de narrativas, recursos artísticos, Tecnologias da Informação e Comunicação e objetos autobiográficos como, por exemplo, realizar videochamadas, ler, ouvir músicas, contar e relembrar histórias. Em geral, as atividades propostas podem ser coordenadas por profissionais e familiares e adaptadas conforme as características de cada idoso.

Palavras-chave:
Idoso; isolamento social; atividades terapêuticas

RESUMEN.

La pandemia de COVID-19 llevó a un gran número de personas en Brasil y en todo el mundo al aislamiento social. Según las principales autoridades sanitarias internacionales, entre ellas la Organización Mundial de la Salud (OMS), las personas mayores forman parte del denominado ‘grupo de riesgo’ de la enfermedad. De esta forma, se requería más rigor y cuidado entre las personas mayores, incluyendo el aislamiento social. Como es sabido, a pesar de la indiscutible importancia de esta acción, las personas mayores aisladas socialmente fueron más expuestas a una serie de enfermedades, principalmente relacionadas con problemas psíquicos. El objetivo de este trabajo es presentar las propuestas de atención psicosocial para los ancianos en situación de sufrimiento o discapacidad debido al aislamiento social. Las propuestas buscan estimular la memoria, la cognición y la psicomotricidad a través de narraciones, recursos artísticos, tecnologías de la información y comunicación y objetos autobiográficos, como videoconferencias, lectura, escucha de música, narración y recordación de historias. En general, las actividades propuestas pueden ser coordinadas por profesionales y miembros de la familia y adaptadas según las características de cada persona mayor.

Palabras clave:
Ancianos; aislamiento social; actividades terapéuticas

Introduction

In December 2019, the first cases of the disease caused by the new Coronavirus, known as Covid-19, were diagnosed. The most common symptoms, listed in the specialized literature, are fever above 37 degrees Celsius, cough, fatigue, shortness of breath, muscle, joint, throat pain, headache, nausea, and reduced sense of smell and taste, among others. In an advanced stage, it can lead the victim to severe pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and death (Nunes et al., 2020).

The rapid spread of the disease on a global scale led the World Health Organization (WHO) to declare a pandemic on March 11, 2020. Among the measures to prevent the spread of contagion, social isolation stood out, since infection with the new Coronavirus spreads mainly through the movement of people and social contact (Organização Mundial da Saúde [OMS], 2020). Among the groups most vulnerable to the harms of Covid-19, known as the risk group, were included those with chronic diseases such as diabetes, hypertension, those with cardiovascular and kidney diseases, cancer and the elderly, people aged 60 years or more (Liu, Chen, Lin, & Han, 2020). Age is the main and most worrying risk factor, which becomes even more serious when accompanied by other comorbidities such as chronic diseases and obesity (Mercês, Lima, & Vasconcellos Neto, 2020).

Although necessary during the pandemic, social isolation is a risk factor for older people’s physical and mental health (Costa, 2019; Rozendo & Justo, 2012). In this way, the elderly became doubly vulnerable during the quarantine, both because they are a risk group for Covid-19 - which required adherence to isolation measures - and because of the psychosocial vulnerability triggered by the very situation of remaining isolated.

Some elderly people live in isolation in Long-Term Care Institutions for the Elderly (LTC) who, depending on the institutional model, may suffer from restrictions on social interaction (Goffman, 2010; Rozendo & Justo, 2012). Such restrictions - arising from asylum models corresponding to the total institutions proclaimed by Goffman (2010) -, linked to the measures to limit the movement of people in these institutions during the pandemic, made the suffering more acute in the institutionalized elderly during this period (Nunes et al., 2020).

The latest survey on LTC for elderly people, in Brazil, carried out by the Institute of Applied Economic Research (Ipea), pointed out that there are 3,548 institutions in operation, housing about 0.8% of the elderly population in the country (Camararo & Barbosa, 2016). Estimates by the Brazilian Institute of Geography and Statistics (IBGE) indicate around 28 million elderly people in Brazil and applying the percentage of residents in LCT indicated by Ipea, the total number of institutionalized elderly people would exceed 220 thousand nowadays (Instituto Brasileiro de Geografia e Estatística [IBGE], 2019).

As highlighted by Nunes et al. (2020), isolation of elderly people can cause effects such as anxiety, depression, panic, changes in sleeping habits, frustration, annoyance, hopelessness, and compulsion to consume alcohol, medication, and food. In Brazil, a series of materials were produced by research groups, associations, and institutions linked to professional categories, with information and guidance on mental health in the context of the pandemic, including special attention to the elderly (Lima, 2020). In general, they suggest strategies aimed at promoting mental health and reducing stress and anxiety resulting from social isolation. For example, organizing the domestic space, listening to music, watching movies, seeing photographs, reading books, and learning to play an instrument, as well as games, handicrafts, online courses, and virtual connection with people outside the home are included among the recommended measures (Cachioni & Batistoni, 2020; Fundação Oswaldo Cruz, 2020; Khoury et al., 2020).

Among the institutionalized population, other even more serious effects can be observed, in addition to those already mentioned by Nunes et al. (2020), such as withdrawal from reality, regression, loss of autonomy, and incapacity to perform basic activities of daily living (Goffman, 2010; Rozendo & Justo, 2012).

Importantly, it is not intended to equate the situation of home isolation with that of institutional isolation, as there are vertiginous differences between the two - which can be discussed at another time (Goffman, 2010; Zimerman, 2000) -, nor to state that the situation of isolation will necessarily cause suffering, either at home or in LTC. For this reason, we deal here with possible interventions that can bring benefits to elderly people in a situation of home isolation and extend them to institutionalized elderly people, who represent a large number of Brazilian citizens, or even to elderly people in general, depending on their pertinence and interest.

The main objective of this article was to propose activities to preserve and/or rehabilitate cognitive and psychosocial skills such as autonomy, memory, sense of reality, ability to live together, affective bonds, and interaction with others that may be vulnerable or at-risk, due to isolation. The aim was to cognitively stimulate the elderly, including such activities as protective factors for delaying the onset and progression of dementia.

Method

The proposals for activities described here are based on some classic theories and everyday experiences. Roughly speaking, the Operative Group (Pichon-Rivière, 1983) and Psychodrama (Moreno, 1983) reveal the importance and role of the coordinator(s) in carrying out dynamics, as well as the therapeutic function of exchanging experiences and of subjective expression shared through tasks. Psychodynamics (Dejours, 1994), in turn, analyzes the subjective relationship of the subject with art, labor activities, material and immaterial tasks and with the respective significant contents, movements, objects involved, relationship with the other, and the creative process. In this sense, the choice of objects and activities appropriate to the characteristics of each subject can be a source of pleasure, mental health, and personal fulfillment and, therefore, have therapeutic properties.

Reports of experiences and strategies previously experienced by the author are presented from graduation in psychology to the present moment as a professor, extensionist, and researcher at a public university. During this period, work was carried out with groups of elderly people in LTC inside and outside Brazil, as well as with groups of third-age³ people from different cities and institutions, distributed among some Brazilian states. During these years, there was also the exercise of the presidency of the Municipal Council for the Elderly of a medium-sized municipality; as a member of the State Council for the Elderly in a large state in the country; as a member of the Municipal Council for the Elderly in a large city; and member of the International Association of Universities of the Third Age (IAUTA). On these occasions, it was possible to follow the work of specialists from different areas and schools of psychology, gerontology, and geriatrics from around the world and, consequently, get involved in discussions and exchanges of knowledge about activities with elderly people of different characteristics, regions, and nationalities.

Activities are aimed at elderly people in situations of vulnerability and/or suffering, especially as a result of social isolation, which can be further favored. They can also be performed with the elderly in general, with the potential to provide psychosocial, cognitive, behavioral, and physical benefits at any time in their lives. In case of refusal and persistent resistance to these initiatives, other strategies should be sought. Activities can be coordinated by family members, professionals from different areas, and formal or informal caregivers. They can be adapted to elderly people affected by dementia, or cognitive, physical, and even speech impairment, through body communication resources, gestures, and visual and facial expressions capable of expressing basic to complex emotions such as joy, surprise, sadness, satisfaction, fun, attention, and admiration (Corrêa et al., 2020).

General guidelines, description and discussion of activities

The coordinators should select, adapt and apply the activities according to the reality of the participants so that they are feasible and also pleasant for the elderly and for those who are coordinating. It is known, for example, that elderly males are more resistant to adhering to some of them, while females easily assimilate them (Debert, 1999). Periodicity is important and the activities should be part of a routine (daily, interspersed, weekly, etc.) established between those involved. There may be a rotation of coordination of activities among family members, but priority is given to maintaining the same coordinator(s) in the case of professionals, as the adherence of the elderly person may be associated with the bond established with this(these). Coordinators can be anyone who has access to and frequents the LTC, such as caregivers, assistants, managers, social workers, psychologists, volunteers, interns, etc.

There is no set duration for the activities, but recommendations indicate between 40 and 120 minutes. Beyond this limit, there may be dispersion, disengagement, demotivation, and, in the case of institutionalized elderly, problems with institutional schedules and routines. In general, priority should be given to those activities that employ a larger set of psychic abilities, such as creativity, imagination, expression of subjectivity, identification, idealization, and sublimation in relation to the tasks and objects involved (Dejours, 1994).

Depending on the degree of complexity of what is done, the organization can be based on classic models of group dynamics. Moreno’s proposal (1983), usually applied in therapeutic groups, can be adapted, even for activities with the participation of only one elderly person and a coordinator. According to Moreno (1983), the functions in a dynamic should be divided into protagonist (the target of the action, in this case, the elderly); coordinator (who elaborates and coordinates the action); observer (the public, the one who observes and contemplates the activity, who can participate by giving an opinion, for example); and assistant (who helps, who is in connection with the dynamics and supports the elderly when necessary) (Miranda, Vidal, & Castro, 2020).

In the case that only one person can coordinate the activity, they can assume all the other functions of the team (coordinator, observer, and assistant). The assistant’s interference should be punctual and restricted to some situation of impediment, blockage, or difficulty on the part of the participant (elderly) while performing the task. The final result is not as important as the execution process; the means is more important than the end, as therapeutic processes occur in the course of the task. Regardless of the context and the number of people involved, care should always be taken for the elderly to play a leading role in the activity, in the selection of topics and materials, and so on.

The subtlety in proposing the tasks is something very relevant in this type of activity, because, depending on how the invitation to participate is made, repressed and unconscious contents can be activated. Situations in which the elderly person feels challenged, tested, or intimidated can lead to impediments, apathy, and abstention. When approaching them, a more playful and informal approach should be taken into account, regardless of the method of application of the activity to be used by the coordinator. Next, an attempt was made to describe the possible activities, techniques, and materials to be used.

Information and Communication Technologies (ICTs)

The use of tools associated with ICTs, such as personal computers, smartphones, apps, the internet, digital social networks, and others, is internationally recognized as a form of inclusion and social participation of the elderly, especially in the context of social isolation as in the Covid-19 pandemic (Seifert, Cotton, & Xie, 2020). In Brazil, this has become routine for part of the elderly population, reaching 85% of the elderly with higher education, compared to 71% of the general population (Fernández-Ardèvol, 2019).

In recent years there has been great enticement, propagated by the media, which has sought to dissipate and naturalize ICTs among elderly people. Television advertisements, mainly from financial institutions, have been specifically targeting this clientele, daily encouraging the performance of various banking operations through smartphone or computer applications (Santos et al., 2019). Similarly, care actions for the elderly - such as groups for the elderly at universities and in basic health and social assistance - also seek to promote ICTs as a strategy for updating, integrating, or social reintegration in the most different contexts (Rozendo, 2015). These and other managements have brought the elderly population closer to digital social networks, enabling virtual connections with affective references and the world, even in a situation of isolation (Costa, 2019; Fernández-Ardèvol, 2019).

In the same sense, it is possible to reflect on videoconferences. The various free platforms - some of which are easy to access and use - can be used with elderly people for whom ICTs are available. Calls and videoconferences can be carried out at the invitation of the coordinator and even be used to coordinate the other activities (listed below), in case it is impossible to follow them in person. Elderly people with limitations in speech and cognition can benefit from ICTs with the help of third parties, establishing body, gesture, and facial communication in video calls, in addition to creating profiles on digital social networks so that relatives and distant acquaintances can resume contact. Added to this is the use of image, music, and video search tools on the internet to stimulate memories or awaken new interests, regardless of the condition of the elderly person. Browsing the internet, digital social networks, or videoconferences (or even phone calls), the use of these tools has been recommended to reduce the effects of social isolation (Cachioni & Batistoni, 2020; Fundação Oswaldo Cruz, 2020; Khoury et al., 2020; Seifert et al., 2020).

Psychomotor, artistic and playful activities

These activities help occupy free time, exercise memory, express subjectivities and use psychic abilities that enable a sense of personal fulfillment and psychosocial well-being. The active participation of the elderly in the process of choosing the task and in the selection of materials must be ensured, to guarantee their involvement with the content and meaning of the activity (Dejours, 1994). In domestic or institutional environments, most of the materials needed for such proposals are usually part of the routine, such as image and sound devices, basic tools, ink, paper, scissors, screwdriver, thread, needle, ink, glue, etc.

Handicrafts, knitting, embroidery, sewing, painting, music, cinema, and reading are examples of activities widely used in third-age groups and that can be used with elderly people in isolation (Cunha, 2015). Each of them responds to one or more preferred ways of discharge and psychic realization of the participants (Dejours, 1994) and can be alternated at each meeting to avoid the loss of interest of the elderly person.

Manual activities such as knitting, embroidery, sewing, and painting contemplate the pathways of psychic and motor discharges, giving use to a larger set of work abilities in the execution of the task. Nevertheless, those that require repetitive movements must be preceded by a period of reflection and planning on the part of the elderly person, to enable the idealization and object investment in what will be produced (Rodrigues, Faiad, & Facas, 2020). In this way, the use of creativity, imagination, and the affective investment of the elderly on the object is sought, as a strategy to promote psychosocial well-being, as proclaimed by the psychodynamics of Dejours (1994). These manual activities must be used sparingly, as they can trigger or enhance psychic suffering if they become something repetitive, monotonous, and meaningless (Dejous, 1994).

In long-term institutions or at the home of the elderly, one can think of building a physical and symbolic space, such as an atelier or workshop, creating a setting for artistic elaboration and creation. Self-employed elderly women, for example, adapt well to handicraft production in general. New challenges in the production of these materials can be launched and internet tutorials can help coordinators and seniors to assimilate new techniques, materials, and productions. Elderly men, on the other hand, may be interested in something more objective and pragmatic, but something that adjusts to the artistic becoming, such as restoration, repair, and maintenance of antique objects, furniture, cars, motorcycles, machines, and utensils in general; in these cases, it is also possible to rely on the help of tutorials on the internet.

Activities such as music, cinema, reading, and writing, on the other hand, have the psychic pathway as their preferred discharge, but, when associated with movements, they also contemplate the motor pathway (Dejours, 1994). The simple fact of listening to pleasant music may be related to the improvement of basic health and well-being conditions in elderly people in isolation (Rocha, 2020). Brazilian popular music, for example, has great potential for evoking and representing life stories, emotions, and feelings in elderly people, and can provide satisfaction, memories, and joy in living (Corrêa et al., 2020). Music and singing enable social interaction, well-being, and memory development, in addition to awakening emotions (Souza et al., 2020). The elderly are expected to actively participate in musical activities, if possible with the aid of an instrument, performing movements that expand the possibilities of benefits from the activity (Dejours, 1994; Mello, Haddad, & Dellaroza, 2011). Such activities can also be proposed as an organized workshop, permeated by a task such as, for example, working on memory by asking the elderly to say the name of a certain song or musical genre or asking them to continue a song paused by the coordinator.

In the same sense, reading and writing have significant results in maintaining or rehabilitating the cognitive performance of elderly people in isolation (Mello et al., 2011). A novel, for example, makes it possible to break down an activity into several meetings focused on the reading and discussion of each chapter. Similarly, the writing of memories by chapters, stages, or phases of life can engage the elderly in multiple encounters.

The adoption of film sessions, in the care of the elderly, was associated with psychic processes such as identification with the characters and motivation for everyday practices inspired by the characters and plots (Carmo, 2020). In the same way, memory and mood can be activated by films. Films have an impact on the behavior of elderly people by presenting images, sounds, and events that can lead to reflection on unusual topics, thus contributing to new experiences, even in a situation of isolation (Carmo, 2020).

Memory

Memory is perhaps the most required skill for all of the aforementioned activities. From this point on, we intend to discuss strategies that work directly and deeply. It is understood as a mechanism for adapting the subject to suffering, such as that eventually triggered by the situation of isolation (Bosi, 1979). It can be modified, recreated, and adapted by the subject in search of fulfillment and psychic comfort, even if unintentionally, in addition to enabling the evocation of affective and reference bonds, even if physically absent (Bosi, 1979).

In this way, memory is a sine qua non-cognitive function for relieving tension, suffering and for establishing the subject in reality. This is because the defense mechanisms that distance them from it are also quite common in situations of psychic suffering triggered by social isolation, loss of psychosocial functions, and fear of death (Rozendo & Justo, 2012).

In the case of the elderly, the primordial set of elements to work directly and deeply on memory can be close at hand, in their own home, among their objects of affective investment. According to Zimerman (2000), a home is a place where the elderly person feels safe and emotionally supported by memories - in some cases, of a lifetime. Each elderly person keeps a set of material and immaterial elements that form a large case of memories and identity that can be explored in situations of isolation. Even among those who live in LTC and who, eventually, are deprived of their object and identity case (Goffman, 2010), it is possible to work on memory by evoking personal memories and stories.

Objects of the elderly: box of memories

Elderly people tend to keep objects of great symbolic meaning, considered self-evocative, which can help stimulate memory (Zimerman, 2000). There is a variety of autobiographical objects full of stories that bring back memories and can easily lead to narratives, depending on the predisposition of each elderly person. Photos (and, less frequently, videos), usually present in their homes, keep the memory of facts and events. Photography is a great companion and ally in the trajectory of life and helps in re-elaborating the past and planning the future (Justo & Justo, 2012). Considering that until a few decades ago, image records were not so accessible and that photographs were only used on special occasions, for some elderly people, such images always deal with a special moment to be evoked, narrated and, if necessary, resignified. It is enough to open a photo album, and, without the need for intermediation, the narratives and the exercise of memory begin (Justo & Justo, 2012).

Other objects assume specific importance, according to the gender of the elderly person. Men tend to evoke and narrate memories based on objects and old memories linked to work and exploits of past times, such as tools, axes, sickles, machetes, uniforms, work identification cards, etc. (Debert, 1999). There is also a predilection for themes that may be materialized in objects associated with politics and the economy, such as old campaign posters, newspaper clippings, old banknotes, and coins, among other possible collections (Debert, 1999). Some programs aimed at the third-age group, which tend to have few male participants in Brazil (Debert, 1999), noted the particular interest of elderly men in topics associated with technologies and means of transport such as cars, trucks, and planes (Schoene, 2014).

Elderly women, on the other hand, tend to be more interested in objects related to their family, children, grandchildren, etc. Therefore, a simple toolbox, old baby clothes, or even old toys, books, and many other materials, can be valuable memory boxes, with the potential to bring comfort in times of isolation (Zimerman, 2000).

Although, usually, such objects are self-evocative and naturally encourage memory and the establishment of narratives, in some cases more direct stimuli through questions may be necessary. For example, in front of a photo album, you can ask the elderly person: “What era is this photo from?”, “Where was it taken?”, “Who are these people in the photo?”. Or, still, in front of a toolbox, one can ask: “What is this object?”, “What period is it from?”, “What is it for?”. In the case of LTC, where personal objects may be absent, the coordination of the activity can select a series of old materials, newspaper clippings, and photos of personalities from the past and use the same dynamic: “What is this?”, “ What is it for?”, “Does anyone know who this person is?”, “What did this person do?”.

In addition to photographs, videos, and autobiographical objects, stories are infinite records of memory (Bosi, 1979). Personal stories, biblical stories, legends, and so on can be largely explored in simple informal conversations, face-to-face, or through ICTs. By the way, the role of the storyteller, by the older members of a society, is an age-old tradition of attributing a social role to the elderly (Beauvoir, 2018). The stories are mnemonic, immaterial records, but which can be rescued and/or stimulated through common materials in homes and institutions for the elderly - such as bibles, books, photographs, old newspapers and magazines, music albums, etc. - or even by evocations directed by the coordinator, who can draw scripts based on life story narratives. For example: “How and where was your childhood?”, “What was your profession?”, “Where did you travel?” and so on.

Final considerations

The present work presented reflections and proposals in psychosocial care that do not end the universe of possible activities to be carried out with elderly people in a situation of home or institutional isolation. So many others can be thought of as therapeutic instruments in similar situations, such as taking care of plants, gardens, animals, etc. There is also a vast field of activities in areas more focused on the physical health of the elderly, equally relevant to the situation of isolation, such as physical activities and exercises aimed at health, strengthening, and muscle rehabilitation, which were not discussed because they are outside the scope of this proposal.

The discussion sought, above all, to trigger reflections in professionals and family members regarding care for elderly people in isolation and support for those who are suffering from the negative effects of institutionalization. Because it is not intended that the proposed activities be applied ipsis litteris, they were not described in detail as in examples of manuals and booklets; they must be rethought, adapted, and recreated during the intervention. This process can be replaced by the daily life of the elderly, at the end of the isolation situation, and the return to the usual psychosocial functions.

Although Dejour’s psychodynamics (1994) is more commonly associated with work contexts under the analysis of work psychology, it is believed to propose reflections and benefits for possible interventions with elderly people outside the universe of work. Following the same reasoning, methods, techniques, and dynamics designed for groups with more than one coordinator can be adapted for activities with a coordinator and a participant, in person or remotely.

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• 3
  Third age is a term commonly used by common sense and the media to designate elderly people in general. However, academically, it designates elderly people who are inserted in an active and healthy aging process, and it is adopted internationally by several schools of gerontology. Commonly, elderly people who fit this profile participate in programs, services, and other coordinated actions, mainly by the state and guided by gerontology and geriatrics. As, for example, mention is made of the so-called third age groups, which are widespread in Brazil in the basic health care and social assistance network, but also in the Commerce Social Service, public and private universities, churches, private associations, and others. Therefore, the term third age is used to refer to this specific portion of the elderly population that adheres to this lifestyle. The term elderly is used as a reference to the elderly in general, regardless of their lifestyle and experiences in the aging process. On this, see Debert (1999).

Publication Dates

• Publication in this collection
  10 Nov 2023
• Date of issue
  2023

History

• Received
  06 June 2020
• Accepted
  02 Feb 2021