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Commentary: Here's how our elderly can better protect themselves against COVID-19

To ward off viruses, it is vital for the elderly to keep moving even when indoors, says Changi General Hospital's Dr Samuel Chew.

Commentary: Here's how our elderly can better protect themselves against COVID-19

An elderly man gets a morning workout at a fitness corner in Toa Payoh on Jun 19, 2020, the first day of Phase 2 of Singapore's reopening. (Photo: Jeremy Long)

SINGAPORE: After nearly two months in circuit breaker mode, Singapore is gradually re-opening.

At the same time, we all need to continue to make concessions and limit our movement until the fight against COVID-19 is truly over. Central to this is the need to look out for our seniors.

In March, government figures showed one in four people infected with COVID-19 in Singapore was aged 60 and above.

The elderly are more vulnerable to COVID-19 as their immune systems are at higher risk of being overwhelmed by infections due to their advanced age.

In some cases, elderly COVID-19 patients may have undiagnosed undernutrition and poor muscle health, as well as pre-existing chronic conditions such as diabetes and hypertension, which are known to increase the risk of poor outcomes and death.

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The elderly are all too aware of this. As a geriatrician, I have observed a higher level of anxiety in the elderly.

Many worry about the risk of infection, especially those admitted to the hospital. With the support of their families, these patients often ask to be discharged as soon as possible.

Yet these patients can only be discharged if they have enough physiological reserves, which is demonstrated by good nutrition, lean muscle mass and physical strength to ensure a faster recovery. Otherwise, their recovery at home may be compromised by a pre-mature discharge.

So as we all try to stay healthy, what more can seniors do to protect themselves, beyond limiting their social interactions and taking extra care with personal hygiene and safe distancing?

Members of the public visit a durian stall at Toa Payoh Central on Jun 19. (Photo: Jeremy Long)


Staying active is crucial as it can boost the immune system to help defeat invading viruses. Since our immune systems weaken with age, it is vital for the elderly to keep moving – even when indoors.

For patients at high risk of complications from COVID-19, the European Society for Clinical Nutrition and Metabolism recommends traditional exercises such as Tai Ji Quan, Qigong and yoga as home-based exercises for the older persons.

In addition, physically and mentally able seniors are also encouraged to do resistance training such as lifting light weights or exercises, using their own body weight to improve muscle, bone and overall physical health.

This is something I advocate on a daily basis in my practice, particularly in my outpatient clinics. One of my octogenarian patients performs 30 squats at home every day, in spite of his advanced age and having multiple medical conditions.

Seniors who are reluctant to do so can turn to simple household chores such as cooking, carrying groceries, or watering the garden to maintain muscle strength. Online public exercise programmes by the Health Promotion Board (HPB) can also help them keep fit.

At the same time, the elderly should not over exert themselves since this can erase the benefits of exercising and put them at risk of injury, according to research by the Human Performance Laboratory and the Department of Nutrition and Health Care Management at the Appalachian State University.

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Regular exercise helps to protect against diseases, and is central to improving cardiovascular health, lowering blood pressure, controlling body weight and maintaining muscle strength.

In particular, strong muscles are associated with immune system regulation, and play an integral role in our ability to maintain good health.

For the elderly and those caring for them, we need to be mindful that age-related muscle loss can affect those who may otherwise seem healthy, according to the Strengthening Health In Elderly Through Nutrition (SHIELD) study.

The study by Changi General Hospital, SingHealth Polyclinics and Abbott revealed that one in five participants aged 65 and older has low muscle mass despite normal nutritional status. The clinical study also showed that the loss of muscle mass increases each year after the age of 65, with women more at risk than men.

A man pushes an elderly man on a wheelchair, both wearing masks, at Orchard Road, Singapore on Feb 3. (Photo: Gaya Chandramohan)

A subsequent study involving over 800 independently-living, community-dwelling older adults at risk of undernutrition in Singapore found four in five participants had low muscle mass, compared with the findings in the previous group of participants with normal nutritional status.

Due to the natural ageing process, adults on average lose 8 per cent of their muscle mass every decade starting at age 40, according to Dr Low Yen Ling, co-author of the SHIELD study and Abbott’s nutrition divisional vice president, scientific and medical affairs.

Some of the signs of muscle loss include less energy, slower walking speed, decreased strength, fatigue and general weakness.

“One of the simplest ways to assess muscle strength in older adults is to look at their handgrip. If they struggle to open a jar lid, it is an indication that their hands may be getting weaker and can be a warning sign of a progressive loss of muscle strength,” Dr Low said during the study.

After the age of 70, the rate of muscle loss can double, especially if they are not exercising regularly and ensuring all their nutritional needs are met.

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Exercising needs to be coupled with good nutrition to maintain good muscle health. In fact, good nutrition, regular physical activity, muscle health and a healthy immune system are inextricably linked. 

Amino acids, the building blocks of muscles, are essential for the immune system to function properly.

While amino acids can be derived from good nutrition and a diet with adequate protein, our muscles form a natural reservoir of these amino acids, providing a continuous supply to fight infections and rebuild damaged tissues.

(Photo: Unsplash)

Physical exercises not only help to maintain and build this reservoir, research shows they directly influence the immune system by priming it.

This is because muscles are also a reservoir for immune cells and contain almost as many immune cells as that circulate in the blood. 

Studies have shown that the amount and activity of immune cells in the blood system increase after moderate exercise, and this is true for the older population too.

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Getting enough protein isn’t always easy, especially since our protein needs increase with age.

Some seniors experience a decreased appetite, or encounter problems chewing meat which can hinder their protein intake, so taking steps to ensure they consume enough protein is important.

Normal sources of protein in daily diet are soybean, nuts, eggs, meat, fish and dairy products. Oral nutritional supplements can also be used if diet alone is insufficient to meet the daily requirements for older persons.

In addition, there is one key micronutrient which can help preserve muscle mass – beta-hydroxy-beta-methylbutyrate (HMB). It is an active metabolite of the amino acid leucine that occurs naturally in the body and is found in small amounts in foods like avocadoes, citrus fruits, cauliflower and catfish.

Research has shown that as we get older, we produce less HMB but prolonged supplementation of the metabolite can improve muscle mass and strengthen the quality of muscles in older adults.

The presence of sufficient amounts of amino acids can stimulate muscle protein synthesis and inhibit muscle breakdown. Resistance-based exercise further enhances these effects.

Dr Tan Ngiap Chuan, Senior Consultant and Family Physician at SingHealth Polyclinics, reiterates that muscle loss begins from adulthood if an individual leads a sedentary life with a diet lacking in proteins.

Besides maintaining a protein-rich diet, seniors should therefore engage in doses of exercises for active and graceful ageing. Receiving the routine vaccination will also help build immunity and keep you safe from other infectious diseases, which is especially crucial during this time.

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READ: How to protect yourself against age-related muscle loss


In these unprecedented times, the best way of reducing the risk of contracting any infection, and ensuring the greatest chances of recovery if one is infected, is to have a strong immune system.

We cannot underestimate the value of good nutrition and regular exercise to help seniors maintain good health, boost their immune system and reduce the risk of acquiring infectious diseases.

As we look to resuming our regular lives, the elderly and those caring for them should aim to build up their immunity to ensure they can stay safe, both now and for years to come.

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Adjunct Assistant Professor Samuel Chew is Senior Consultant of Geriatric Medicine at the Changi General Hospital, and principal investigator for the Strengthening Health in Elderly Through Nutrition (SHIELD) Study.

Source: CNA/el