Are older people with disabilities neglected in the COVID-19 pandemic?

Older people have been a central focus during the COVID-19 pandemic, as more than 90% of deaths in the UK have been among people aged 60 years or older. Messages around social distancing and high vulnerability will resonate strongly with this age group. Less often considered is that many older people have disabilities—almost half (46%) of people aged 66 years and older in the UK.  Having disabilities not only increases the risk of dying from COVID-19, but potentially also increases the adverse consequences of pandemic control, yet data on these dangers are scarce. In The Lancet Public Health, Andrew Steptoe and Giorgio Di Gessa have addressed this gap using data from the English Longitudinal Study of Ageing (ELSA) to compare the emotional and social effects on older people with and without physical disabilities during the early months of the COVID-19 pandemic. Their findings are stark. Older people with physical disabilities had significantly greater odds of having anxiety (odds ratio 2·23 [95% CI 1·72–2·89]; p<0·0001) and depression (1·78 [1·44–2·19]; p<0·0001) than their peers without physical disabilities, even after taking into account pre-pandemic differences. People with disabilities were also significantly more likely to report loneliness and poor sleep during the COVID-19 pandemic than people without physical disabilities. The adjusted proportion of people with disabilities who had symptoms of mental health conditions were high: 28·9% (95% CI 26·5–31·3) of disabled people had clinically significant depressive symptoms, 15·8% (13·9–17·6) had clinically significant anxiety, 39·6% (36·8–42·3) had clinically significant loneliness, and 45·9% (43·0–48·9) had poor sleep quality. This is a big public health problem.

The added value of Steptoe and Di Gessa’s study is that the researchers collected data in 2018–19, as well as during the early months of the COVID-19 pandemic in 2020. The observed differences in emotional health were already apparent between people with and without disabilities in 2018–19, and widened further during the pandemic. The study suggests that people with disabilities have a narrower margin of health, and are more susceptible to shocks than people without disabilities. The relevant question is therefore not why were the mental health impacts of the pandemic greater for people with disabilities, but rather, why did existing mental health gaps grow further during the pandemic? We do not yet have firm answers, but we can put forward a number of hypotheses. People with physical disabilities are likely to have an underlying condition, such as rheumatoid arthritis or stroke. Many of these are conditions that put people at higher risk from COVID-19.  Health messaging in the UK clearly stated that most people who died from COVID-19 had pre-existing conditions. This messaging could translate into anxiety. In the ELSA study, people with physical disabilities were more likely to have received instructions to shield during the pandemic, and even without official instruction, might have decided to be cautious, realising that they faced increased risk. As a result, social contacts will have been reduced more among people with disabilities than among people without disabilities, as Steptoe and Di Gessa show, and shielding did in part explain the effects on loneliness among people with disabilities. Health and rehabilitation access might also have decreased, partly because non-urgent appointments were postponed or went online, and partly because people became too fearful to go to the doctor.  Across Europe, an estimated 1·3–2·2 million people were not receiving the rehabilitation care that they needed each day because of reductions in services in the early months of the pandemic.  The consequences will be more pronounced for people with disabilities, who are more likely to need regular health care. Poor health-care access might exacerbate health and functioning decline and thereby contribute to worse mental health. Another likely scenario is that mental health and social care services, which were already eroded by years of austerity, were further restricted during the pandemic.  Indeed, the Coronavirus Act specifically over-rode the Care Act in the UK. Most local authorities did not abandon their care obligations; however, qualitative evidence shows that many people with disabilities in the UK had problems with social care during the pandemic. What is striking, as Steptoe and Di Gessa note, is the scarcity of research focusing on people with physical disabilities in the pandemic, also highlighted in a recent systematic review.  There has been little consideration of the social and emotional impact of the COVID-19 pandemic for people with disabilities, and little assessment of COVID-19 risks themselves. The ELSA study showed that people with mobility impairments were more than 5 times more likely to be admitted to hospital for COVID-19, although the absolute number of people in the study admitted to hospital was small. Few other data are available on the risk of COVID-19 adverse outcomes among people with physical disabilities.  What we don’t value as a society, we don’t count, and so these effects remain concealed. People with disabilities continue to be an afterthought, both in the pandemic response, but also in measuring its effect. COVID-19 is exacerbating a neglect that was already in place. The exclusions of people with disabilities are social choices, not inevitable consequences of a health condition, and they are not new. Steptoe and Di Gessa’s study makes a welcome addition to the literature by showing how these issues were affected by the COVID-19 pandemic. HK and TS are supported by the Foreign Commonwealth and Development Office as part of the PENDA programme of impact evaluations of disability projects in low-income and middle-income countries, outside the submitted work. TS is principal investigator of a UK Research and Innovation programme on disabled people in Britain and COVID-19, outside the submitted work.