By now, we all know the drill: Maintain physical distance. Wear a mask. Wash your hands. Avoid people who are sick and stay away from others if you are sick. While these measures may seem simple enough, they are not easy to keep up month after month. Yet they are likely to be with us for a while.
But what about those who cannot comply? Certain conditions can make the standard measures to stay safe during the pandemic seem impossible. At the same time, some of those likely to have the most trouble following the guidelines — such as older people with dementia — are at higher risk for illness and death if they do become ill. And the risk for spreading infection to others by not wearing face coverings, washing hands regularly, and observing physical distancing remains very real.
Mitigation efforts are harder for some than others
People who may have the most trouble complying with pandemic-related restrictions include those with
- Dementia. Without constant supervision and reminders, people with cognitive problems may take off their masks or wear them incorrectly, and fail to maintain distance from others.
- Breathing problems. Although for healthy people there is no evidence that commonly worn cloth masks lower your oxygen levels or raise your carbon dioxide levels, those who have lung disease (such as asthma, emphysema, or cystic fibrosis) may find it particularly uncomfortable trying to breathe through a mask.
- Claustrophobia. Wearing a mask may make people with claustrophobia feel panicky or smothered. And this not a rare problem: claustrophobia is the most common phobia, affecting 5% to 10% of the population.
- Depression and anxiety. For people who struggle with mood or excessive worry, concerns about one's health and the health of loved ones, and the limitations placed on social interactions, may make these conditions worse. According to recent National Center for Health Statistics data, symptoms of anxiety or depression have more than tripled since this time last year.
- Autism spectrum disorder. Difficulties with social skills, a need for routine, and a reliance on support services such as behavior or speech therapy are everyday challenges for many people with autism spectrum disorder. The pandemic has made these challenges even greater. A heightened sensitivity to touch and difficulty with nonverbal communication can make wearing a mask especially problematic.
Even the experts urging us all to wear face coverings to lower rates of illness and deaths recognize that some cannot comply. Still, there are steps that folks in these situations can take to reduce the risk of becoming infected with the virus that causes COVID-19 and spreading it to others.
What can be done?
There are no easy answers here. I know of at least one memory care center that has largely given up on requiring mask wearing for some of its residents (though staff are still required to wear them). While not ideal, it's the most practical option. And other measures are still followed: every resident is surveyed about symptoms and has temperature checks daily, chairs and activities are set up to encourage physical distancing, and the number of people in a room is limited. Gentle and frequent reminders and redirection to prevent crowding, increase handwashing, and encourage mask wearing (if possible) are now part of the routine in most nursing homes and long-term care facilities.
The Alzheimer's Association also recommends extra reminders to wear a mask and wash hands for people living at home with dementia. Visual cues around the home can help. Try tacking up images of people in masks — including their favorite actors or even superheroes — and written reminders in several spots explaining the rationale for all the handwashing and face masks. If possible, try to increase social support (while maintaining physical distance) for those with dementia living at home. For example, if someone living in a memory care center usually talks to family members on the phone once or twice a week, perhaps three or four times a week would be a good idea while social distancing restrictions are in place.
Those with breathing problems may be able to tolerate wearing a mask for short periods. If a particular mask seems too uncomfortable or restrictive, try another type. There are masks of many shapes, sizes, and fabrics out there, and it's worth trying more than one type of mask before giving up on them. If wearing a mask still seems impossible, conscientious physical distancing and frequent handwashing may make face coverings less necessary. For anyone whose respiratory condition is so severe that wearing a mask is impossible, experts suggest that the safest course of action is to avoid public places rather than relying on "mask exemptions."
People with depression or anxiety may need to consult more often with their mental health providers during the pandemic. Adjustments in behavioral therapies or medications may help. Claustrophobic people may find that wearing a mask at home for short periods, and gradually increasing the amount of time, may make it easier to consistently wear one in public.
Experts working with people who have autism spectrum disorder recommend a number of ways to help with mask wearing, including education about the rationale for wearing them, demonstrating the use of a mask on a favorite object or person, allowing the person to choose among different types of masks, and wearing the mask for only short periods of time to start. Transparent face masks that make the mouth or face of the speaker visible may be a good option.
The bottom line
While we should not have an expectation that people with certain medical or psychological conditions will be able to follow the guidelines perfectly, that's one more reason we should maintain high expectations for everyone else.
For more information about coronavirus and COVID-19, see the Harvard Health Coronavirus Resource Center.
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