When Older Relatives Shrug at Coronavirus Restrictions

Although the virus poses a heightened threat to older people, some of their middle-aged children feel they aren’t taking it seriously enough.

Lorenzo Gritti

By Julie Fingersh

I went hoarse shouting at my mother last week.

“You really got into your building elevator with someone else?”

She blamed the other person for standing in the middle of the elevator; I blamed her for getting in, putting herself at risk of catching the coronavirus.

By the time my 88-year-old father got to the phone, I remembered the researcher Brené Brown’s theory that vulnerability opens all doors. I would move my father by sharing my deepest fear.

I told him I loved him. I said the thought of losing him was devastating. I asked him, “Dad, are you afraid?”

He laughed. “What’s to be afraid of? If I get it, Sayonara!”

Despite the virus’s heightened risk to older people, my parents seem inexplicably casual about it.

And I’m not alone. From every corner of our new virtual community, in Zoom cocktail hours, Google hangouts and private message boards, I’ve been hearing from fellow members of the sandwich generation fighting to persuade older loved ones to protect themselves from a potential death sentence from Covid-19.

“My mother’s still going to the market and post office, even though she has an aide,’” said Claire Muirhead, a writer from Los Angeles who recently recovered from Covid-19. “She’s 90. She knows how sick I was, and still, there’s no stopping her. I’m beside myself.”

We have good reason to worry. According to the Centers for Disease Control and Prevention, eight out of 10 deaths reported in the United States have been in adults 65 years old and older.

“We can’t pretend this is not life or death,” said Tara Brach, a psychologist and author of “Radical Acceptance.” “This is the real thing. These are beings we love, and we’re scared we’re going to lose them.”

For some adult children, this means grappling with the anguish of not being able to see parents quarantined in nursing homes.

For those whose parents live independently, it is often a challenge to get our older loved ones to take the risks as seriously as we do. I caught my father-in-law, a radiologist, on his way out to play cards with friends in Boca Raton, Fla., one day before Florida issued its stay-at-home order.

“Just because they’re friends doesn’t mean they don’t have the virus,” I told him. He laughed and said, “We appreciate your concern.” And then he left for his game.

It turns out, according to experts, my approach was doomed to fail.

“If you go in with anxiety and with the very innocent and loving intention to control, every human being on earth will push back against that,” said the sociologist Martha Beck. “There’s something about being self-determined that is fundamental to being human.”

Also at play is a high-stakes role reversal in the parent-child relationship. “Earlier in your life, you were on the other side of this fighting-for-autonomy battle,” said David Fish, a therapist specializing in dialectical behavioral therapy. “Now aging parents are the ones struggling with limitations to their freedom and with others telling them what to do.”

The Age Positivity Effect

Part of the problem, according to Claudia Haase, a psychologist and the director of the Life-Span Development Lab at Northwestern University, is that older adults may not experience the same level of threat as younger people do.

“A massive body of scientific work has documented age-related shifts in the service of making negative emotions smaller and positive emotions bigger,” Dr. Haase says. “Older adults are often masters in turning their attention away from information that is threatening, upsetting and negative.”

The priority of older adults, Dr. Haase explains, is to make the most of their limited time on earth, and their highest value is social connection. “For them, being home alone with just their thoughts and nowhere to go can be a frightening place.”

And then there’s the fact that older adults may not see themselves as, well, old. “Older adults may not think of themselves as being at heightened risk for Covid-19 because old age carries a lot of stigma. There’s a huge reluctance to view oneself in those terms.”

How to Be Heard

So how do you explain your concerns to older relatives?

Dr. Brach believes it begins with self-understanding. “When you talk to them, ask yourself, what’s going on for you? Once you start to name what’s going on underneath under all the agitation, you get to your anticipatory grief: You don’t want to lose them.”

Dr. Beck recommends a simple, practical approach for coping, and managing anxiety, when older relatives don’t see the risks the way you do. “The idea is, you want to invert that — you have to manage your own anxiety first.”

She suggested being direct, providing solid reasoning and being clear about the consequences. “You tell them why you’re worried, and why you want them to do this thing,” she said. “It has to be rational. It can’t just be because ‘I know better and I say so.’”

And you may have to acknowledge the worst-case scenario. “So it might be like, ‘Mom, you’re living in Florida, and you’re going to the beach. I cannot stop you. But if you get sick, I can’t come see you. And if you die, you may die alone, and I won’t be there.’ This may sound harsh, but it’s true. Let them sit with the real possibility of what may happen.”

Radical Acceptance

When all else fails, Dr. Brach espouses the art and power of radical acceptance, both for our loved ones and ourselves.

“There has to be a letting go, because ultimately, you cannot control them,” she said. “They’re responsible for their living and dying.”

Once we understand that, Dr. Brach said, “You say to yourself, ‘I am afraid. I am helpless. I am feeling the grief of what could happen.’ And this is where the real pain is. You put your hand on your heart and offer compassion to the place in yourself that is helpless and fears the loss.”

The act of physically putting your hand on your heart is vital, Dr. Brach said, to coming to peace. “There’s a network of neurons in the heart area. When there’s warmth and pressure on it, it actually calms the sympathetic nervous system and reduces the fear centers in the brain.”

And what about those anxious, racing thoughts?

“We need to remember that just because this feels like it’s a catastrophe doesn’t necessarily mean that it is,” Mr. Fish said. “What you’re upset about right now is your imagination. It’s not what’s actually happening. Our minds are really good at anticipating consequences and making them very present for us, which is useful, except when it’s not.”

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When Older Relatives Shrug at Coronavirus Restrictions

Older Americans Are Awash in Antibiotics

The drugs are not just overprescribed. They often pose special risks to older patients, including tendon problems, nerve damage and mental health issues.

Last month, Caryn Isaacs went to see her primary care doctor for her annual Medicare wellness visit. A patient advocate who lives in Manhattan, Ms. Isaacs, 68, felt perfectly fine and expected a clean bill of health.

But her doctor, who’d ordered a variety of blood and urine tests, said she had a urinary tract infection and prescribed an antibiotic.

“The nurse said, ‘Can you take Cipro?’” Ms. Isaacs recalled. “I didn’t have any reason not to, so I said yes.”

There are actually plenty of reasons for older people to avoid Cipro and other antibiotics known as fluoroquinolones, which have prompted warnings from the Food and Drug Administration about their risks of serious side effects.

And there are good reasons to avoid any antibiotic when bacteria are detected in a urine culture in a patient who has no other signs of infection. So-called asymptomatic bacteriuria increases with age, but these women are not sick and don’t need drugs, so medical guidelines recommend against routine screening or treatment.

Yet Ms. Isaac’s prescription was hardly unusual. Despite ongoing campaigns by the Centers for Disease Control and Prevention and other public health groups, older Americans still take too many antibiotics.

Patients over age 65 have the highest rate of outpatient prescribing of any age group. A new C.D.C. study, published in the Journal of the American Geriatrics Society, points out that doctors write enough antibiotic prescriptions annually — nearly 52 million in 2014 — for every older person to get at least one.

Because the researchers used a national pharmacy database that tracked only outpatients, the study likely underestimates the problem. “The volume would be higher if you included hospitals and nursing homes and other long-term care settings,” said Katherine Fleming-Dutra, deputy director of the C.D.C.’s Office of Antibiotic Stewardship.

Glass-half-full types might be pleased to see that after climbing 30 percent from 2000 to 2010, antibiotic prescriptions for older adults leveled off between 2011 and 2014. “That’s potentially good news,” said Dr. Sarah Kabbani, an infectious disease specialist at the C.D.C. and lead author of the study.

But what public health advocates want to see is a decline, as has happened with young children, once the group most likely to use antibiotics.

“It’s hard to feel heartened about a plateau when overuse remains so prevalent,” said Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “It’s as perennial as the grass.”

Antibiotic overuse contributes to a serious public health threat by creating drug resistance, as infectious bacteria adapt to the medications. Drugs then lose their effectiveness, forcing doctors to resort to more toxic, less potent, often costlier options. Two million Americans get antibiotic-resistant infections annually, the C.D.C. has reported, and 23,000 die from them. 

Moreover, antibiotics interact badly with many of the other drugs older adults take, including such widely used medications as statins, blood thinners, kidney and heart medications. “The number of potential drug-drug interactions with antibiotics are vast,” Dr. Alexander cautioned.

Some antibiotics also have dismaying, even alarming, side effects in themselves. In 2013, the F.D.A. issued a warning about azithromycin, which in rare cases leads to dangerous heart arrhythmias. 

But for more than a decade, the agency’s most frequent target has been fluoroquinolones.

It has warned that this class of antibiotics (including Cipro and Levaquin) increases the risk of tendinitis and tendon rupture, particularly in older adults; that it can cause the nerve damage called peripheral neuropathy; and that it can lead to hypoglycemia (low blood sugar).

“One of the most common problems for older adults are changes in mental status — getting anxious, getting loopy,” said Dr. Sara Cosgrove, medical director of the Johns Hopkins Hospital’s Adult Antimicrobial Stewardship Program. “These drugs get into the brain.” The F.D.A. also warned of the problem in July. 

In fact, the agency advised in 2016 that fluoroquinolones’ potential side effects outweighed their benefits for several common infections. Last year, it added still another warning about ruptures or tears in the aorta, a rare but serious condition for which older people are at greater risk.

Fluoroquinolones are also most implicated in the rampant, difficult-to-cure infection called C. difficile, along with an earlier antibiotic, clindamycin. C. difficile, too, occurs more frequently in older people. 

Yet what class of antibiotics did the C.D.C. team determine was most commonly prescribed for older adults? Fluoroquinolones. (The most used single drug was azithromycin, marketed as Zithromax, which isn’t a quinolone.)

More troublingly, doctors often prescribe these medications unnecessarily, studies repeatedly show. Upper respiratory infections — colds, sinus infections, bronchitis — trigger most prescriptions, but those infections are typically viral, not bacterial, and thus impervious to antibiotics.

Nonetheless, a large 2017 study of older adults in Ontario found that almost half were prescribed antibiotics for nonbacterial upper respiratory infections that likely would have cleared up in a few days without them. “Patients usually get better in spite of the drugs, not because of them,” Dr. Alexander said.

As Dr. Kabbani pointed out, “when antibiotics are needed, they are lifesaving drugs.” But because they are so widely misused, with resistance such a menace, the C.D.C. has pushed for more prudent practices for consumers and for hospitals. The Centers for Medicare and Medicaid Services, similarly, is phasing in policies for wiser antibiotic use in nursing homes.

“We want patients to get antibiotics when they need them — the right drug at the right time and the right dose — and not when they don’t,” said Dr. Fleming-Dutra. Even when antibiotics prove necessary, she noted, patients may get the wrong ones or take them for too long. 

(Fluoroquinolones, for instance, can be useful for hospitalized patients but aren’t first- or even second-line treatments for uncomplicated urinary tract infections; older antibiotics like Bactrim, Septra and Macrobid are.)

Getting this right will mean breaking longstanding habits among providers, including dentists (who may unnecessarily tell patients to take antibiotics before appointments if they’ve had certain surgeries).

Sometimes, though, patients are the ones demanding a pill to end a cold’s miseries, even when there is no such pill.

“We encourage patients not to pressure their physicians to prescribe antibiotics,” Dr. Kabbani advised. And when doctors do prescribe them, “Have a conversation about why. Do I really need it? What else can I do to feel better? What do I watch out for in terms of side effects?”

Caryn Isaacs didn’t do well on Cipro. She suffered severe chest pain — “I thought I was having a heart attack” — and felt anxious and irritable. 

She finished the weeklong course of the drug anyway and her personality changes have receded, she said. But occasional twinges of chest pain persist, along with a sense of weakness.

She does worry about urinary tract infections; she has seen the delirium they sometimes cause in her older clients. But she may approach the issue differently next time.

“I probably would take something,” she said. “But I won’t take Cipro.”

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Older Americans Are Awash in Antibiotics