Being an older adult with post-COVID-19 syndrome: a qualitative study

Abstract

Objective  to understand the meanings of the experience of Being an older adult with COVID-related complications.

Method  A qualitative, phenomenological study was conducted at the Post-COVID-19 Municipal Reference Center in the city of São Luís, Maranhão, Brazil, between May and July 2022. Interviews of 10 older adults were carried out. The theoretical-philosophical framework used was that of Martin Heidegger, and the Heideggerian hermeneutic circle supported the analysis and interpretation of the phenomenon.

Results  Six meaning units were identified. The impacts on physical and mental health, and on functioning , forced older individuals into a new context, a new Dasein (form of Being), being-in-the-world and being-with others. Resigned to the facticity of existence, a Dasein thrown into a world without choices, led the older adults to experience the body becoming ill due to COVID-19, facing the existential anguish caused by the pain and suffering of their clinical condition, insecurity and fear for the future and for the lives of their loved ones.

Conclusion  Older adults who experienced the circumstances of illness were permeated by negative feelings of insecurity, frustration, sadness, anguish and loneliness that deprived them of their well-being, resulting in impaired quality of life.

Keywords
Aged; Post-Acute COVID-19 Syndrome; Philosophy; Qualitative Research

Resumo

Objetivo  compreender os sentidos e significado de Ser-pessoa-idosa com síndrome pós-covid-19.

Método  estudo qualitativo, fenomenológico, desenvolvido no Centro Municipal de Referência pós-covid-19, do município de São Luís, Maranhão, Brasil, nos meses de maio a julho de 2022. Foram realizadas entrevistas com dez pessoas idosas. O referencial teórico-filosófico utilizado foi o de Martin Heidegger e o círculo hermenêutico heideggeriano subsidiou a análise e interpretação do fenômeno.

Resultados  As repercussões na saúde física, mental e na funcionalidade colocaram a pessoa idosa diante de uma nova condição, um novo Ser-aí consigo mesmo, com o mundo e com o outro. Resignado à facticidade do existir, o ser-aí lançado em um mundo sem escolhas, conduziu a pessoa idosa a vivência do adoecimento do corpo pela covid-19, deparando-se com a angústia existencial gerada pela dor e sofrimento da sua condição clínica, insegurança e medo em relação ao futuro e da vida daqueles que ama. Buscou-se em “si mesmo” possibilidades de lidar com a doença, revelando ser a portadora do seu próprio cuidado.

Conclusão  A pessoa idosa que vivenciou as circunstâncias do adoecimento foi permeada por sentimentos negativos de insegurança, frustração, tristeza, angústia e solidão que lhes sequestraram o bem-estar, resultando em uma qualidade de vida prejudicada.

Palavras-Chave:
Idoso; Síndrome de Covid-19 Pós-Aguda; Filosofia; Pesquisa Qualitativa

INTRODUCTION

Post-COVID-19 syndrome is characterized by the presence of persistent symptoms 4 weeks after infection by Sars-Cov 2, irrespective of the severity of the disease, with most prevalent complications including pulmonary (fatigue, cough and dyspnea), neurological (headaches, dizziness, olfactory and taste dysfunctions and cognitive deficit) and cardiac (myocardial lesion, interstitial fibrosis and hypoxia) symptoms¹.

This complex, poorly understood condition, negatively impacts quality of life (QoL) and represents a public health concern². The World Health Organization (WHO) estimates that 10-20% of Sars-COv 2-infected individuals subsequently present post-COVID-19 syndrome. In addition, over half of the patients that develop moderate-to-severe COVID-19 report at least one functional sequela associated with symptoms severity, preexisting comorbidities and older age³,⁴.

The post-pandemic scenario continues to be marked by increased susceptibility to unfavorable outcomes and by post-COVID-19 syndrome. A study in Israel reported that most (79.8%) individuals who developed post-COVID-19 syndrome were aged >60 years⁵. Another study found greater mortality among older adults, prolonged hospitalization, delayed clinical recovery, lung damage and rapid disease progression⁶. A large contingent of individuals with post-COVID-19 syndrome exhibit a decline in QoL, impaired performance and dependence for activities of daily living (ADLs)²-⁷.

Besides pathophysiological aspects, psychosocial aspects should also be highlighted. Amid the need for social distancing, older adults found themselves in a situation of isolation, reduced interaction with family members and friends, exposure to news of deaths and collapses in the health system, giving rise to feelings of fear, anxiety and loneliness⁸. Although the use of technological tools had been widely recommended to help keep in touch with family and friends, the majority of the older population have low education and encounter difficulty using these resources⁹.

Halting of health treatments, and of leisure, physical, work, and spiritual activities, among others, together with the fear of becoming infected, adversely affected self-care practices, negatively impacting socialization and functioning⁷.

In this context, older adults with post-COVID-19 syndrome have experienced a worsening of their physical, mental, social and economic health, creating demand for care, health services² and the need to produce scientific knowledge on the long-term consequences of COVID-19 and its impact. The scenario of the COVID-19 pandemic posed the challenge of redefining the meaning of care for older adults to cater for the host of different circumstances of this population group. Assessing this condition from a Heidegger phenomenological perspective can make important contributions to the way things are regarded and done in the health area, delving into the meanings of the phenomenon and revealing how these manifest in their own right.

According to Martin Heidegger¹⁰, the phenomenon is that which reveals itself, which shows itself, and is whole (totality). In his work “Being and Time”, the philosopher states that phenomenology exposes the “Being” of the entity, its meanings and changes. The “entity” is that which is being, these are things that can be described and exist in this world. The “Being” refers to that which is accompanied by a conscience and able to think and reflect upon its own existence, i.e. human beings. And, to designate the “entity” or person that has this “Being”, he uses the term “Dasein”, the original German expression which permeates throughout his work. Dasein refers to a human being thrown into the world and endowed with the various possibilities of “Being”.

Thus, the intersection between phenomenology as a method of research and Gerontology converge toward care which valorizes the existential questions of Dasein, in all its different dimensions: physical, psychological, social and spiritual, enabling a care approach based on the notion that the older adult experiences their process of aging, ailing and existence in unique and singular way. This emphasizes that the body cannot be regarded as a reduction of the individual and that the interpretation of the world which arises intentionally to the consciousness, emphasizes the pure experience of the subject.

The present study was grounded in the theoretical-philosophical framework of Martin Heidegger´s phenomenology¹⁰ based on his work “Being and Time”, which expounds on the meaning of existentialism of “Being”. Drawing on this theory, the objective of the study was to understand the meanings of Being an older adult with COVID-19 complications.

METHOD

A qualitative phenomenological study based on the theoretical-philosophical framework of the work “Being and Time” by Martin Heidegger and employing hermeneutic analysis methodology was conducted¹⁰.

The study was carried out at the Post-COVID-19 Municipal Reference Center, of the Municipal Secretariat for Health (SEMUS) of the city of São Luís, Maranhão state, Brazil. Sample size was determined based on the data saturation criteria and the meeting of the study objectives. Data collection took place between May and July 2022. Study participants were older adults (age ≥60 years), users of the Center during the study period, seen by at least 2 professionals (one of whom a nurse), and having a score ≥1 on the Post-Covid-19 Functional Status (PCFS) scale recorded in the patient´s medical record.

The PCFS is a tool devised by a panel of international experts designed to identify functional impairment and graded on a scale of 0-4 points, with higher scores indicating greater impairment¹¹,¹². PCFS Grade 0 is defined when the person has no functional limitations in everyday life and no symptoms, pain, depression or anxiety related to the infection. Grade 1 indicates the person has negligible functional limitation in their everyday life, although has persistent symptoms, pain, depression or anxiety. For Grade 2, the person suffers from limitations in everyday life and needs to avoid or reduce activities or spread these over time due to symptoms, pain, depression or anxiety. In Grade 3, the person is not able to perform all usual activities, while in Grade 4, the subject has severe limitations in everyday life, is unable to take care of themselves and depends on another person due to symptoms, pain, depression or anxiety¹³. Individuals diagnosed with dementia or any other cognitive deficit were excluded from the study.

Participants were first contacted by telephone and the objectives of the study explained. Interviews were conducted by one of the researchers (nurse reading for a Master´s degree) at the Center, between Mondays and Fridays during morning and evening shifts, according to the availability of participants.

The interview was guided by the following questions: What was being infected by COVID-19 like for you? What health problems emerged after COVID-19? Do these health problems affect your everyday life? In what ways? Are there any changes in your everyday life that you attribute to COVID-19? Talk about your lived experiences and feelings of Being an Older Adult with COVID-19 complications.

Interviews lasted approximately 1 hour and, with the consent of participants, a digital voice recorder was used to register the information, where the researcher was attentive to different forms of discourse, including gestures, pauses and moments of hesitance, silence and facial expressions. A field diary was used to note down these perceptions, along with complementary data the interviewer deemed pertinent. Interviews were not repeated.

Full transcriptions of the recordings were performed. Subsequently, 3 nurses (2 PhD holders and 1 reading for Masters) with experience in qualitative studies derived the meaning units. The first step entailed naïve reading followed by more detailed examination, mediated by emerging hypotheses, test excerpts, content selection. Based on consensus of the researchers, the meaning units were identified and checked against the theoretical-philosophical framework and pertinent literature.

The analysis and interpretation of the phenomenon was grounded in the Heideggerian hermeneutic circle and comprised 3 stages: pre-understanding, understanding and interpretation. In pre-understanding, structural or (pre-) conceived positions are abandoned, suppressing judgments. Understanding is evidenced by the express vague phenomenon in the ontic structure of the facts. In the interpretation stage, the ontological (hermeneutic) nature of the phenomenon is taken beyond the ontic form toward the perspective of being¹¹,¹².

In order to protect the anonymity of participants, the older adults are represented using a code “OA” (Older Adult), together with their identifying number in the study. In compliance with National Board of Health Resolution no. 466/12¹³, the project was submitted to the Research Ethics Committee of the University Hospital of the Federal University of Maranhão and approved under permit no. 5.241.776 of the 14^th February 2022.

RESULTS

Of the 45 older adults who completed the PCFS, 22 attained a score of ≥1, and 10 took part in the interview. Participants were predominantly male (6), aged 62-77 years, married (7), and half (5) had an income ≤ 1 minimum salary. Six meaning units were identified: the ill Being with post-COVID-19 syndrome; the physical Being with post-COVID-19 syndrome; the psychological Being with post-COVID-19; the dependent Being with post-COVID-19 syndrome; the Being with post-COVID-19 syndrome; and the Spiritual Being with post-COVID-19 syndrome.

Ill Being with post-COVID-19 syndrome .

The experiences shared revealed that, after the acute stage of the disease, and as the older adult recognized the presence and persistence of the post-COVID syndrome, there was a change in the relationship with their body and the world in which it is part, an experience which changed the being-in-the-world, which was previously familiar:

“I wasn´t well. I had complications, pretty severe, tiredness, listlessness, fever, chills, feeling sick, headache (..) I still haven´t fully recovered from the complications I have (OA 1);

“I got overly tired, I can´t even walk without feeling tired. This problem is really bad, I´m still dealing with it today, I never got better. I have seen the doctor, but I didn´t get better, I also have a painful arm, I had an injection, medication, did physiotherapy. But I can´t raise my arm much” (OA 3).

Physical Being with post-COVID-19 syndrome

Their being-in-the-world was weakened and activities of daily living were transformed into real challenges, requiring from the older adult possibilities and attempts at overcoming them:

“I´m not the way I was before. I would start doing my things in the morning and just stopped at 5 in the afternoon, I kept on going and now I can´t do that anymore. I get tired, dispirited.. I tell you, I ended up with so many problems, God help me” (OA 3);

“Smell, I can´t anymore.. it´s not right, I even underwent treatment with a speech-hearing therapist, my sense of taste is also poor. I can taste things, but I can taste some things better than others. And smell, when I can smell it..” (OA 5).

The Physical Being with post-COVID-19 syndrome feels bothered by the new clinical condition of the disease, which promotes changes in everyday life and disturbing feelings, which take away the feeling of peace and fills daily life with uncertainty over the future, resulting in impaired quality of life.

Psychological Being with post-COVID-19 syndrome

This manifests as an anguishing process and fear for the lives of people held dear, requiring adequate support:

“I feel very lonely living on my own and with the pandemic it got worse. I became isolated because there is nobody to stay with me. When I was sick, my son was too scared to come close. That upset me a lot” (OA 2);

“I got really angry, irritated, I am at war with everything at home (laughs), I fly of the handle easily, no patience. I´m in tears easily, sometimes for no reason. I never used to be like that” (OA 3);.

“What really arose after COV|ID was the mood thing. Irritability, I´m too impatient, I become irritated, upset, unhappy” (OA 7).

The symptoms accompanying post-COVID-19 syndrome can have severe physical impact on the individual, negatively impacting their ability to work and, consequently, their economic health. The inability to go back to work and the loss of family income experienced was a reality during the pandemic which exacerbated social and health inequalities, causing a deep sense of sadness and affecting hopes of a healthy life.

"It was a very difficult time, I lost my job, my daughter lost her job, my son-in-law as well as and I was also mugged with a gun to the head.. and when this on top of the normal everyday problems, it mounts up with the disease and creates a burden and this burden starts to crush you” (OA 8).

Under these circumstances, the fear of death reared its ugly head. The perception of finitude and insecurity regarding clinical outcome gave rise to feelings of fear and desperation, culminating in anguish:

“I was afraid of dying, a really strong fear because we saw people dying all the time, we thought it might also be our turn, right?” (OA 5);

“There were still deaths, our next-of-kin that died, a nephew, neighbors.. this messes with our mind. This COVID destroyed us” (OA 3).

Dependent Being with post-COVID-19 syndrome

The functional capacity of older adults is also affected by post-COVID-19 syndrome, in as far as it impairs the performing of activities of daily living, previously carried out with ease, posing a further challenge for this age group:

“Now I´m living with a lot of pain hampering everything I do. My legs are as if they were paralyzed all the time. In the mornings, when I get up it´s unbearable, it´s almost impossible to put my feet on the floor, even making walking hard” (OA 5);

“I´ve lost the strength to carry and feel a lot of back pain due to the problems I have. And, if I were to tell you something now, 2 hours later I wouldn´t even know what I had said. This forgetfulness also developed after COVID” (OA 6).

The impact of post-COVID-19 on the functioning of the older adult Being attains a level which calls for a process of returning to oneself, of reassigning meanings, with the setting of new priorities based around the clinical condition. The post-COVID-19 syndrome significantly impairs everyday life, creating difficulties involving the new condition:

“After catching the corona virus, I had this sequela of not being able to be the same person, of not being able to do the same things I used to do” (OA 1);

“I forget everything. If I leave my bedroom to get some medication, I get as far as the kitchen, literally over the way, and then I don´t know what I meant to do. Then I have to go back to my bedroom, I don´t remember what I was doing again. This has been going on since I got this COVID” (OA 6);

“And now I have extreme difficulties to do my activities because of my mobility which was impaired after COVID” (OA 7).

The dependent Being with post-COVID-19 syndrome faces a reality of insecurity and frailty, having had their world shaken by the impacts on functional capacity and, hence, needing to find new ways of coexisting. With the frailty stemming from change in their way of being-in-the-world, the situation reaches a high level of anguish with the need to assign new meaning to the forms of being-in-the-world and being-with others. What was hitherto normal, part of everyday routine, takes on a dimension of uncertainty, insecurity and anguish when analyzing the possibilities of loss the virus presents.

Being-with with COVID-19 syndrome

The family and social support network showed the Being-with (others) to be a measure of support at this challenging time. Even amid the pandemic, in which guidance from health bodies was to maintain lockdown as a means of prevention, the family structures which the older individual was a part represented an asset:

I still have a number of COVID complications to this day: itching, burning, and because I already had injuries to my left ankle and knee they just got worse, right.. I was always active, I wasn´t one to be idle.. I want to get things done, but I get tired and this is annoying” (OA 7);

“A calmer situation that creates a major problem because I live alone, thank God I have this friend who was watching over me, he´s really concerned about me and maybe this is giving me a boost” (OA 1);

“She (daughter) really cares about me. Every day I thank God for the family I have. Thank God they always helped me a lot. If it weren´t for them I´d be lost today” (OA 6).

Support of family and friends is important in overcoming the adversities caused by the pandemic, particularly for older individuals.

This meaning unit shows the Being with complications of COVID-19 as an opportunity to transcend oneself and the world and as a manifestation of the self as a possibility of reassigning meaning in the post-COVID-19 scenario, showing that the dimension of being-with others constitutes an essential aspect of existence of humans in coping with situations of adversities and anguish.

Spiritual Being with post-COVID-19 syndrome

One way of coping with the new reality was by engaging in spirituality, which involves highly important practices in that they offer support, acceptance and the means to overcome, especially at times of stress. This is exemplified in the narratives below:

“There are days I´m scared to go out.. then I take a deep breath and start thinking about my life, calling on God for strength, breathing, get my prayer beads, starting praying, ask God to relieve me of this” (OA 2);

“I am a person with a lot of faith. I like praying, I appreciate the word of God (…) Now, looking back at my experience, God picked me up from the floor, because I really felt doomed and was brought into the light” (OA 4).

The pandemic led to a decline in function, losses and challenges for older individuals, such as the development of diseases, obliging them to adopt coping mechanisms to adapt to the changes and new life scenarios. Spirituality is cited by the respondents as an important resource used to overcome the clinical condition. The spiritual being with post-COVID-19 syndrome provides older adults with the opportunity to assign new meaning to negative perceptions of new possibilities of being and transcending.

DISCUSSION

The situation experienced shows that Being an older adult with post-COVID19 syndrome is characterized by negative impacts on functional capacities, physical and psychological well-being and quality of life¹⁴. Pain, sadness, inconveniences, changes in way of life and loss of the meaning of existence¹⁵, which reveal facets of ways of being in anguish, insecure about the future, centering around isolation, exposing the facticity of Dasein thrown into the world. The older individuals report being hampered by the new condition, which promotes changes in everyday life and leads to disturbing feelings, abolishing peace and introducing uncertainties into daily life.

The “pain of being” refers to existential anguish. Anguish is a manifestation of a being thrown into a fundamentally strange, disturbing, concerning and even offensive world. In this context, the Dasein feels foreign, an intruder and becomes affected by feelings of distrust, vulnerability, uneasiness and stress which conflict with their being¹⁵,¹⁶.

The anguish experiences pervade in the discourse of almost all the meaning units, proving an apparent significant burden of suffering. This is evidenced in the reports of pain, desperation, worry, insecurity, loneliness and uncertainty.

The post-COVID-19 scenario includes fear of the unknown, fears of death, stress, depressive symptoms, anxiety, insomnia which together contribute to an increased risk of suicide¹⁷. The Psychological Being with post-COVID-19 syndrome reveals itself as a broken Being, impacted by lockdown, mood swings, fear of death and berievement¹⁸.

During the COVID-19 pandemic, older individuals presented depressive symptoms associated with different factors, which induced fears of death, of losing a friend or loved one, and which promoted feelings of desperation in some individuals to the point where they lost the will to live¹⁹. End-of-life appears to be a real prospect and becomes suffocating, although it is in actual loss where the deepest pain lies.

The pandemic worsened social and family isolation. Close strong relationships and support network constitute one of the main predictors of satisfaction in life and of longevity, contributing to physical, mental and social wellbeing²⁰. Social and family relationships serve as resources in coping with tribulations, aiding acceptance and adaptation to the new situation, which confer feelings of protection and well-being. These tools help forge important bonds for older adults, in strengthening relationships and instilling feelings of belonging and emotional support, as well as contributing to improved mental health²¹.

According to the philosopher¹⁰, we are thrown into the world since the moment of our birth. This means we are always like Daseins thrust in one direction and disposed in different ways. We are also heading toward our death. In as far as we exist, we are always beings-towards-death. We are a finite project given we may die at any time, and this is a certain uncontestable truth²².

Therefore, this opens us up to the possibility of transcendence beyond ourselves and the world which belongs to the ontological constitution of Dasein. According to Heideggerian thinking, transcendence is recognized as overcoming anguish, it is the most immediate condition of the possibility of understanding of the self from the ontological perspective.

Dealing with a process of illness with a host of negative repercussions in life, intensifies insecurities, sadness, fears and anxiety. Moreover, aging is accompanied by physiological changes as part of a natural progressive process experienced by all beings, which lead to changes in the organism. It is singular and subjective, involving constant changes in common aspects in life, such as relationships with others, biopsychosocial and cultural factors²⁴.

Spirituality is associated with understanding essence, meaning and finitude, with a universal question about the sacred and divine, which may or may not lead to a religious practice. This can serve “as an individual´s inner resource which can be triggered by contact with nature, the arts, with experience of giving oneself or with engagement in causes aimed at contributing to the public good”²¹.

Spirituality represents an important coping strategy which contributes to and brings about beneficial effects for physical, mental and social health, and in the wellbeing of older individuals. It also plays a role in coping with the aging process, illnesses or stressor events, such as the COVID-19 pandemic scenario experienced by the global population²⁵. We may only live in our own time, accepting its gifts while combatting its threats²⁶.

In the scenario experienced, the meaning of existing is, in an abrupt ongoing fashion, “adjusted” to each new lived experience. This transformation of existence driven by the pandemic, unknown and causing long-term complications, ties in with the philosophy referred to as “facticity”, defined as the designation for the ontological nature of Dasein at each occasion, i.e. it is the aspect of human existence defined by situations in which we find ourselves, the “fact” we are forced to face. Facticity is regarded as a basic constituent of Dasein, which emerges on the time horizon and presents us with new possibilities of being-in-the-world ¹⁰.

In terms of the unpredictable circumstance experienced, post-COVID syndrome emerges as a Dasein bound to facticity. Consequently, Dasein experiences anguish over the pain of being, and all of us, at some point, can feel the pain of being. The feeling is that of being a foreigner in our own lives, with the invasion of a void and loss of meaning for existence²⁶,²⁷.

During this process, all older adults dove into the essence of their experiences, approaching the conscience allowing access to the phenomenon. In this context, it is clear that the care given should be individualized, making these experiences central as singular processes. Therefore, applying phenomenology to science, with respect to caring for older adults post-COVID-19, is to shed light on their experience and the disease process, acknowledging their singularities, while taking a broader view that embraces a multidimensional approach.

Care provision to older adults requires devising a new paradigm of health practices, calling for a broader view that looks beyond the prevailing disease-cure centered model²⁸. There is a clear need to redefine the meaning of care actions for older individuals to encompass the diversity of aging and of the experience of phenomena, elucidating other realities.

CONCLUSION

The meaning of being an older adult in post-COVID-19 syndrome appears to be one of resignation to the facticity of existence. In an ontic entity, facticity of the Dasein thrown into a world without choices, leads the older person to experiencing ailing of the body due to COVID-19, facing existential anguish, uncertainties with regard to clinical outcome, and fear of their own death and of that of their loved ones.

After the acute phase of the disease, the older adult with post-COVID-19 syndrome found themselves compromised by this new reality. The negative impacts on physical and mental health and on functional capacity thrust the entity older adult into new circumstances, a new way of Dasein, of being-in-the-world and being-with others. Observing limitations in body and mind, older adults found themselves amid transformations in their everyday life, giving rise to unsettling feelings such as insecurity, frustration, sadness, aguish and loneliness, which deprived them of wellbeing, resulting in impaired quality of life.

Having to face challenges while frail were risk factors for the onset of depression, anxiety, insomnia, cognitive impairment and impact on functional capacity, leading them to significant change in their world. Spirituality and family and social support networks proved important tools in coping with adversities, aiding acceptance and adaptation to the new situation, allowing for reassigning of meaning of experiences, the forging of valuable ties, promoting resilience, improved wellbeing and QoL.

Post-COVID-19 syndrome posed a challenge for health service professionals in reestablishing the capacities of older individuals and in providing integrated care from the perspective of plenitude of human existence.

The present study can help raise awareness of the need to establish new care strategies for the older population and pave the way for further investigations.

• Funding: PROGRAMA NACIONAL DE COOPERAÇÃO ACADÊMICA NA AMAZÔNIA-Edital Nº 21/2018- Procad Amazônia (processo Nº 88881.200531/2018-01)
• DATA AVAILABILITY
  The complete dataset underpinning the results of the present study is available upon request from the corresponding author.

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Edited by

• Edited by: Isac Davidson S. F. Pimenta

Data availability

The complete dataset underpinning the results of the present study is available upon request from the corresponding author.

Publication Dates

• Publication in this collection
  27 Jan 2025
• Date of issue
  2025

History

• Received
  19 Mar 2024
• Accepted
  03 Oct 2024