By Liz Seegert

While some older adults are coping well during the coronavirus pandemic, many others are struggling with mental health issues.

We know the elderly are the most vulnerable to becoming ill and dying from COVID-19, but don’t yet fully understand the emotional toll of the virus on this population. It’s prompted The American Journal of Geriatric Psychiatry to call for more research into the mental health effects of the pandemic.

Retrospective studies of the 2003 SARS epidemic found that rates of suicide among older adults spiked during that time. It’s urgent to study the mental health effects of COVID-19 on older adults in real time so any adverse impact can be anticipated and minimized, according to geriatric experts.

Some of the stressors include behaviors that may lead to contact/infection (including contact with caregivers), consequences from social distancing and isolation measures instituted by federal, state, or local governments, and the neurobiological consequences of the resulting stress and inflammation that may increase vulnerability to mental health issues.

Mental health symptoms in older adults vary and may not always be recognized as distinct problems. These symptoms generally fall into three categories:

• Emotional changes
  • anxiety
  • depression
  • guilt
  • anger
  • sadness
  • feeling overwhelmed
  • non-caring
  • insomnia
  • feeling scared or unsafe
  • worry
  • loss of control and consistency
  • reduced opportunities for meaning and pleasure in life

• Behavioral changes
  • blaming
  • difficulty communicating
  • inability to feel pleasure or fun
  • increased use of alcohol, tobacco or illegal drugs
  • Lower quantity or quality of sleep,
  •  dietary changes,
  •  lower physical activity and other lifestyle changes
• Thinking changes
  • Loss of memory
  • confusion
  • poor concentration

Medical professionals report that forced isolation during the COVID-19 pandemic will increase the risk of depression and anxiety even among those who do not normally struggle with these conditions. Depression can lead to impairments in physical, mental, and social functioning, including isolating oneself from social gatherings (even at a distance).

Worries about physical health, increased isolation from social distancing and stay-at-home orders, and financial struggles impact mental health. When these factors are considered together, it makes sense that older adults may feel increasingly anxious or depressed.

Seniors may experience more intense symptoms of both mental and physical illnesses. They may have a harder time remembering to eat, take their medications, or sleep. Older adults are generally more likely to have chronic health problems, lower income levels, and isolated living situations. This combination increases the risk of poor cognitive function, dementia, heart disease, and stroke, according to MedicareAdvantage.com. Even for healthy adults, loneliness is as dangerous to health as smoking 15 cigarettes per day, according to a study published in 2018. Another study, published in 2013, found that older men and women who were lonely or isolated had a significantly higher risk of dying.

Community-dwelling older adults

In the U.S., about 28% of older adults (about 13.8 million people) live alone. Prior to the COVID-19 crisis, 20% of older adults in the community may already have been experiencing mental health problems, primarily depression, , according to Patrick Hendry, vice president of Peer Advocacy, Supports and Services at Mental Health America.

Individuals who already live with anxiety and/or depression may experience a worsening of their mental health, and those who haven’t experienced it previously are at an increased and substantial risk, Hendry said.

A 2017 report from the Administration on Aging found that living alone was not necessarily a direct cause of loneliness, but it can contribute to a sense of isolation. Some older adults report feeling alone or isolated even when surrounded by friends or family.

Any regular interaction with family, neighbors, clubs, faith communities, and social services (such as meal delivery or home care personnel) can serve as important points of contact. These can be a lifeline for social connection. When losses occur in combination with other stressors, mental health deterioration can occur. The COVID outbreak can feel like a threat that could bring about even more potential loss adding to the older adults’ baseline experiences.

As someone isolates due to loneliness, various health risks increase, according to the National Institute on Aging. These include:

• High blood pressure
• Heart disease
• Obesity
• Weakened immunity
• Anxiety and depression
• Cognitive decline
• Dementia or Alzheimer’s disease

Further exacerbating the effects of isolation and loneliness are the loss of access to senior day programs, religious services, fitness classes and other activities that help older people gather and interact. Many community-dwelling seniors are afraid to even venture to the store, let alone get together with a friend or family member for a meal. Grandparents who had played an active, vital role in their families’ lives, may now find themselves fearful of a grandchild’s hug or reluctant to participate in milestone events like birthdays. While these practices are vital for keeping the person physically safe, an individual’s mental and emotional health can suffer greatly.

Since social distancing is a way of life because of the coronavirus, seniors have to manage the effects of isolation. Mitigating the associated loneliness is important, as it may reduce some of the negative health impacts.

Early reports indicate that similar to other medical illnesses, COVID-19 may present atypically in older adults. “Altered mental status can be an initial presenting symptom even in the absence of respiratory symptoms or fever. Presenting features may include worsening confusion (especially among those with dementia), agitation, disorientation, refusing care, and apathy. These are initial findings with significant clinical implications and bear replication, but suggest that among older adults a new-onset change in mental status be treated as a potential initial sign of COVID-19 and managed accordingly,” writes Ipsit V. Vahia, M.D.a geriatric psychiatrist and assistant professor of psychiatry, Harvard Medical School, in the July 28 issue of the American Journal of Geriatric Psychiatry.

Long-term care facilities

Eight out of 10 deaths from COVID-19 are in the 65-and-older age group, according to the CDC. Nursing homes account for some 40% of deaths from COVID-19, including both residents and staff.

As aging care facilities were forced to restrict visitation from friends and family, plus the care-critical need to follow social distancing practices, many older adults are battling new complications: feelings of isolation and depression, according to a ECRI, an independent, evidence-based health care quality and safety organization and Leading Age Pennsylvania.

Suicide is a real risk

According to 2018 data from the Centers for Disease Control and Prevention and reported by the American Foundation for Suicide Prevention, adults in the 75-84 and 85 age groups are among those with the highest rates of suicide.

AFSP says mental health conditions can have their first onset in later adulthood. Depression and severe anxiety are not a normal part of aging, and can be addressed with clinical treatment and social support. The stress of COVID-19, the uncertainty it creates, and the potential for older adults to be more susceptible to the virus, can exacerbate any underlying risk for depression or anxiety.

Potential solutions

For many older adults, strategies such as regular physical exercise, calling loved ones and friends, maintaining a routine, engaging in pleasurable or meaningful activities, and practicing mindfulness or relaxation strategies can be quite helpful. However, given the impact of the pandemic on day-to-day life, seeking support from a trained therapist or other mental health professional can help greatly with coping and improving quality of life.

Recent changes in Medicare and most private insurance coverage during the COVID-19 pandemic provide older adults with greater access to a variety of mental health services, including from their home, including:

• Psychotherapy: Talk therapy includes approaches that help with adjusting to life changes and health conditions, as well as treating issues such as depression, anxiety, sleep difficulties, chronic pain and substance use. Many psychotherapy approaches teach proven skills for reducing stress and dealing with uncertainty and change.
• Medication: Although many people do not require medication, it can be helpful in some cases for treating specific mental health conditions. In these instances, medication and psychotherapy together are often most effective.

Although mental health services are effective, older adults are much less likely than younger adults to seek mental health care. This is due to several factors, including limited awareness of services and how to seek help, affordability and transportation barriers. Many of these barriers have been removed or reduced during the pandemic.

Virtual visits using technology can help ease some of the isolation, but for those older adults who may be technologically challenged, have vision or hearing problems, this could actually lead to increased frustration. For those living in the community, online shopping or grocery delivery may be impossible without assistance; some seniors may opt to go hungry rather than brave the supermarket.

Getting help

• Some organizations provide tele-peer support.
  • Mental Health America (MHA )affiliates can help find local peer support .
  • Support Groups Central is one hub that can connect people with a variety of groups
• SAMHSA’s Disaster Distress Helpline 1-800-985-5990, provides 24/7, 365-day-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories.
• National Suicide Prevention Lifeline 1-800-273-8255
• Meals on Wheels and Feeding America can provide options for food delivery in a specific ZIP code.
• BenefitsCheckUp.org, helps find local options to help with utility bill payments, prescription drug costs, and more.
• Many states and communities offer services like Maryland’s, Senior Call Check Program, a daily call to support the well-being of residents 65 and older. Or this initiative in Aspen, Colo., where mental health agencies formed a coalition to support the community through COVID, including specific strategies for older adults. In Tallahassee Fla., WCTV looked at how senior advocacy groups address mental health impacts of COVID-19.
• Friendship Line: at 888-670-1360 for 24/7 support for those 60 years or older, or an adult living with disabilities.
• California Aging and Adult Information Line: 800-510-2020 for help finding local assistance.

Experts

Linda Fried
Geriatrician and dean of the Columbia University Mailman School of Public Health and professor of public health practice, professor of epidemiology and medicine. lpfried@columbia.edu

Bei Wu
Co-director, Aging Incubator, New York University, and professor in global health and director of global health and aging research at  NYU Rory Meyers College of Nursing. She also is the director of research at the Hartford Institute for Geriatric Nursing at NYU. bei.wu@nyu.edu

Benedict L. Gierl, M.D.
Assistant professor, Rush University Medical Center, Chicago, specializing in older adults’ mental health, including depression. 708-660-2077 or email Nancy DiFiore, Rush Media Relations, nancy_difiore@rush.edu

Dilip V. Jeste, M.D.
Senior associate dean for Healthy Aging and Senior Care, Distinguished Professor of Psychiatry and Neurosciences, Director of the Sam and Rose Stein Institute for Research on Aging at UC San Diego. djeste@uscd.edu

American Association for Geriatric Psychiatry — their “find a local psychiatrist” search feature may help you locate a nearby expert

Story ideas

• How is your nursing home or local health system addressing the mental health needs of seniors during the COVID-19 pandemic?
• How have city/county aging or mental health programs/agencies stepped up to proactively mitigate some of the mental health effects of isolation, loneliness or depression? Here are two recent examples:
• Has there been an increase in calls to local or national suicide hotlines by older adults? How are they receiving help?

• How are cities/communities addressing technology challenges among older adults so they can stay connected with family, friends, and medical providers?