What is the impact of the coronavirus pandemic on the mental health of elderly nursing home residents?
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The following information resources have been selected by the National Health Library and Knowledge Service Evidence Virtual Team in response to your question. The resources are listed in our estimated order of relevance to practicing healthcare professionals confronted with this scenario in an Irish context. In respect of the evolving global situation and rapidly changing evidence base, it is advised to use hyperlinked sources in this document to ensure that the information you are disseminating to the public or applying in clinical practice is the most current, valid and accurate. For further information on the methodology used in the compilation of this document – including a complete list of sources consulted – please see our National Health Library and Knowledge Service Summary of Evidence Protocol.
In A Nutshell
The mental health impact of the pandemic on nursing home residents is characterised by various dynamics. Loneliness may have been a problem for some nursing home residents prior to the COVID-19 pandemic; however, the ban on visits during the pandemic has exacerbated the problem and extended its impact to all nursing home residents. Residents struggle with the absence of relatives and their visits. An attempt has been made to replace direct contacts with the use of technology; however, such provision has limited effectiveness on residents with dementia who need social contact or a nearby voice. In some cases, serious discomfort manifests itself as delirium superimposed on dementia; in particular, a hypokinetic type, with consequent refusal of food and difficulty getting out of bed. Older residents who are cognitively intact also breathe the atmosphere of anxiety and anguish7.
Several studies focus on loneliness and its effect on older people4, 6, 7, 9, 12, 13, 14, 22, 30, particularly in the case of cognitive impairment. Depression is identified as a common outcome of loneliness10, 13, 14; other manifestations include anger, anxiety, stress1. Several authors have pointed to media and social discourse which has characterised older people as vulnerable or helpless as a source of ageism and stigmatisation which in turn has exacerbated feelings of isolation and anxiety28, 29.
IRISH AND INTERNATIONAL GUIDANCE
What does the World Health Organization say?
Older adults, especially in isolation and those with cognitive decline or dementia, may become more anxious, angry, stressed, agitated and withdrawn during the outbreak or while in quarantine. Provide practical and emotional support through informal networks [families] and health professionals.
Share simple facts about what is going on and give clear information about how to reduce risk of infection in words older people with or without cognitive impairment can understand. Repeat the information whenever necessary. Instructions need to be communicated in a clear, concise, respectful and patient way. It may also be helpful for information to be displayed in writing or pictures. Engage family members and other support networks in providing information and helping people to practise prevention measures.
Older adults, especially those with cognitive decline and/or dementia, may become more anxious, angry, stressed, agitated and withdrawn, particularly if they are in isolation or quarantine.
What does the European Centre for Disease Prevention and Control say?
Management of visitors to facilities and provision of face masks and introduction of IPC measures will possibly add a substantial additional burden and impact the time available to HCWs for care tasks. Ethical considerations regarding long-term isolation and restriction of visits to residents have to be balanced against the impact of the infection on residents and staff.
INTERNATIONAL LITERATURE
What does the international literature say?
Van Order et al (2020) Strategies to Promote Social Connections Among Older Adults During ‘Social Distancing’ Restrictions[iv]
Older age and medical comorbidity are factors associated with more severe illness and risk of death due to COVID-19 infection. Social distancing is an important public health strategy for controlling the spread of the virus and minimizing its impact on the older adult population; however, social distancing comes at a cost. Loneliness is associated with myriad adverse health outcomes including impaired immune functioning which adds greater risk of coronavirus infection, complications and death. Older adults are at compound risk and the effective management of loneliness and social isolation is a high priority target for preventive intervention. The authors describe a cognitive behavioral framework for social connectedness including evidence-informed strategies clinicians can use to help patients develop a ‘connections plan’ to promote social, mental and physical health during social distancing restrictions.
Gordon et al (2020) [Commentary] COVID in Care Homes-Challenges and Dilemmas in Healthcare Delivery[v]
COVID-19 presents atypically in care home residents and up to 56% of residents may test positive while pre-symptomatic. We provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of PCR testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with quarantine.
COVID-19 guidance [in Britain] recommends that residents are managed in their rooms as much as possible throughout the pandemic. This represents a shielding measure to minimise transmission of COVID-19 by asymptomatic carriers but poses significant challenges. Restricting movement represents a significant loss of autonomy with psychological and physical harms resulting from social isolation and immobility.
Social isolation and loneliness have been associated with an increased prevalence of vascular and neurological diseases and premature mortality. Additionally, it is well known that social exclusion is significantly associated with higher risks of cognitive impairment which in turn increases the risk of Alzheimer’s disease and accelerates disease progression of existing conditions. Emotional distress aggravated by the current pandemic is another risk factor for premature death since anxiety is known to predict all-cause death and is especially detrimental in persons aged 75 and older. Apart from the psychological burden of isolation, reduced opportunities for physical activity represent an additional health-damaging burden in the long run. This applies not only to home residents, but also to older people living alone. Eventually, the impoverished environment and lack of regular social, cognitive and sensorimotor stimulation of isolated people may lead to severe conditions and premature death: a human as well as medical-ethical debacle.
Healthy residents should have the opportunity to be visited by their [healthy] relatives in compliance with hygiene regulations and precautionary measures. They should be allowed to leave their room: eg to go for a walk in the garden. In order to be able to retain hygienic standards, the flow of visitors must certainly be reduced and visit plans may be introduced. Coordination and scheduling should be the responsibility of the nursing homes. Special attention should be paid to the dying: people in institutions have the right to a dignified death and palliative care, even in isolation. With adequate hygienic measures in place, healthy relatives should be admitted to the dying as they should be enabled to accompany the dying process.
Trabucchi and De Leo (2020) Nursing homes or besieged castles: COVID-19 in northern Italy[vii]
During the COVID-19 epidemic the nursing homes of northern Italy are isolated citadels with very little connection to the external environment. Loneliness is the general condition with no one entering or exiting. The prevailing feeling is of living in a trap in a generally modern residence where everything happens in the most complete closure to defend those on the inside from the risk of contagion and those on the outside from the possibility of witnessing the progressive, unavoidable and unmodifiable shutdown of many lives.
The situation is characterised by various dynamics. Residents struggle with the absence of relatives and their visits. An attempt has been made to replace direct contacts with the use of tablet computers; however, this provision has limited effectiveness on residents with dementia who need a caress, a massage or a nearby voice. In many cases, serious discomfort manifests itself as delirium superimposed on dementia; in particular, a hypokinetic type, with consequent refusal of food and difficulty getting out of bed. We are not yet able to measure the frequency of these reactions, but empirical observation indicates a prevalence of over 50% of the residents. Older residents who are cognitively intact also breathe the atmosphere of anxiety and anguish even if staff try not to convey their worries and fears.
Webb (2020) COVID-19 lockdown: a perfect storm for older people’s mental health[viii]
A problem inherent in the pandemic strategy to date is that avoiding under-reaction requires provoking population anxiety and heightened threat awareness, while promoting altruism emphasises the neediness of the elderly population. Media stories of elderly deaths contributes to heightening anxiety for people self-identifying as at risk. At the same time, giving over-simplified messages risks stereotyping the vulnerable in the eyes of the majority. This has the unfortunate effect of reducing resilience and marginalising the stereotyped group from wider society.
Brooke and Jackson (2020) Older people and COVID-19: Isolation, risk and ageism[ix]
Over the course of the pandemic, we have seen evidence of openly ageist discourse which complicates the experiences of living through COVID‐19 for older people. There have been distressing reports of older people abandoned in care homes and concerns about the representation and positioning of older people in the social media discourse around COVID‐19.
These ageist discourses and the subtext of negativity and devaluing of older people can and will very likely contribute to feelings of worthlessness in older people, a sense of being burdensome and having no value. These factors when considered in relation to current social restrictions make older people particularly vulnerable to a range of negative health and social outcomes, particularly social isolation and loneliness.
We must support older people to have and retain their connectedness and communality with others to better enable a sense of belonging. One immediate factor that needs to be highlighted is the possibility of previously vigorous older people becoming increasingly frail due to reducing their activities ¾ especially walking ¾ and leading an enforced more sedentary lifestyle which will impact their mobility and wellbeing over time.
Social workers in residential facilities have faced a variety of challenges. With families not being able to visit, they have been forced to develop innovative approaches to family visits from window visits to FaceTime to developing meaningful activities that can be facilitated in the residents’ rooms or re-thinking how to offer group activities with appropriate social distancing. Social workers have organized compassionate visits for persons at the end-of-life. Providing daily updates on residents to family members has been a mainstay of social workers’ routines. These include a variety of digital approaches such as FaceTime, WhatsApp, Skype and Zoom. There will be a need to learn to identify post-traumatic stress disorder symptoms such as fear, sleeping disturbances, poor concentration and flashbacks.
Kar (2020) Coping with Mental Health Challenges During COVID-19[xi]
As this pandemic has been spreading rapidly across the world, it is bringing a considerable degree of fear, worry and concern among certain groups, particularly in older adults and people with underlying comorbid disorders. It has a potential impact on existing diseases and may lead to psychiatric symptoms related to the potential interplay of mental disorders and immunity. The symptoms of COVID-19 can also worsen cognitive distress and anxiety among people who have poor mental capabilities previously.
“As a frontline physician involved in the care of older adults living in long‐term care facilities, I have witnessed profound isolation in this population; my patients have become prisoners in their one-bedroom homes, isolated from each other and the outside world. This extreme loneliness should raise concern as it is a known risk factor for poor health outcomes, including anxiety, depression, malnourishment and worsening dementia. One way of palliating social isolation would be to integrate technological advances in the care of populations at risk of being further secluded during health outbreaks.
For older patients isolated in long-term care facilities, providing them with these technology-dependent amenities and social contacts could potentially decrease their sense of loneliness and increase their self-perceived health, similarly to the benefits seen with physically going outdoors. These applications have shown positive impact, even in individuals with physical and cognitive impairment. And yet, none of these technologies was available in the centers I visited and making them available at the present time would be impossible given the risk of disease exposure. I believe there are two reasons we have deprived the older population of technological advances: our inherent bias of assuming the aging population is passive and lacks the ability to learn; combined with the fact that this is a population who does not advocate for itself.”
Santini et al (2020) Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis[xiii]
Research indicates that social isolation and loneliness increase the risk of mental disorders, but less is known about the distinct contributions of different aspects of isolation. We aimed to distinguish the pathways through which social disconnectedness ¾ eg small social network, infrequent social interaction ¾ and perceptions of social isolation ¾ eg loneliness, perceived lack of support ¾ contribute to anxiety and depression symptom severity in community-residing older adults aged 57–85 years at baseline.
Gardiner et al (2020) What is the prevalence of loneliness amongst older people living in residential and nursing care homes? A systematic review and meta-analysis[xiv]
The number of older people living in residential and nursing care homes is rising. Loneliness is a major problem for older people, but little is known about the prevalence of loneliness among older people living in care homes.
The prevalence of both moderate loneliness and severe loneliness among care home residents is high enough to warrant concern. However, the significant variation in prevalence estimates warrants further research.
Goodman-Casanova et al (2020) Telehealth home support during COVID-19 confinement: Survey study among community-dwelling older adults with mild cognitive impairment or mild dementia[xv]
Television stood out as the preferred technological device to access COVID-19 information, watch as a recreational activity and perform memory exercises as an intellectual activity.
Mendes (2020) Nurturing care home mental health amid COVID-19 outbreak[xvi]
With the spread of COVID-19 and the most fatal consequences faced by older people and those with pre-existing conditions, residential services will be taking precautions to keep residents safe, ranging from restricting visitation to particularly thorough hygiene and cleaning procedures. However, beyond these necessary measures, what more can be done to ensure residents are in optimal mental health? WHO2 has produced guidance on the significant mental health considerations with a specific section concerning older people, care providers and people living with an underlying health condition.
The guidance in this section is particularly pertinent to people living and working in the care home setting
Clay (2020) COVID-19 isn’t just a danger to older people’s physical health[xvii]
As the world grapples with COVID-19, psychologists are pointing to a major new report that underscores the prevalence — and risks — of loneliness in older people and urges health-care providers to take action to help.
From the report Social Isolation and Loneliness in Older Adults[xviii]:
Nicol et al (2020) Action at a Distance: Geriatric Research During a Pandemic[xix]
Social isolation and loneliness are serious yet underappreciated public health risks that affect a significant portion of the older adult population. Approximately one-quarter of community-dwelling Americans aged 65 and older are considered to be socially isolated, and a significant proportion of adults in the United States report feeling lonely. People who are 50 years of age or older are more likely to experience many of the risk factors that can cause or exacerbate social isolation or loneliness, such as living alone, the loss of family or friends, chronic illness and sensory impairments. Over a life course, social isolation and loneliness may be episodic or chronic, depending upon an individual’s circumstances and perceptions.
A substantial body of evidence demonstrates that social isolation presents a major risk for premature mortality, comparable to other risk factors such as high blood pressure, smoking, or obesity. As older adults are particularly high-volume and high-frequency users of the health care system, there is an opportunity for health care professionals to identify, prevent, and mitigate the adverse health impacts of social isolation and loneliness in older adults.
Social Isolation and Loneliness in Older Adults summarizes the evidence base and explores how social isolation and loneliness affect health and quality of life in adults aged 50 and older, particularly among low income, underserved and vulnerable populations. This report makes recommendations specifically for clinical settings of health care to identify those who suffer the resultant negative health impacts of social isolation and loneliness and target interventions to improve their social conditions. Social Isolation and Loneliness in Older Adults considers clinical tools and methodologies, better education and training for the health care workforce, and dissemination and implementation that will be important for translating research into practice, especially as the evidence base for effective interventions continues to flourish.
Action at a distance may be the new norm for clinical researchers in the context of the COVID-19 pandemic that may require social distancing for the next 18 months. We must minimize face-to-face contact with vulnerable populations; but we must also persist, adapt, and help our older patients and study participants during the pandemic. Implement technology now: minimize face-to-face contact with participants by utilizing digital solutions, shifting to electronic informed consent and digital HIPAA-compliant tools such as email surveys or telehealth assessments. Assess the psychological and social impact of COVID-19: How are participants coping? What health or social behaviors have changed? How are they keeping up with current events? What are they doing to stay connected to their families, friends and communities? Are healthcare needs being met? Current studies should be adapted immediately.
Adamo et al (2020) Coronavirus Disease 2019 in Geriatrics and Long‐Term Care: The ABCDs of COVID‐19[xx]
In this article we provide information, insights and recommended approaches to COVID-19 in the long-term facility setting.
This policy brief sets out the American Geriatrics Society recommendations to guide federal, state and local governments when making decisions about how best to care for patients with COVID‐19 in nursing homes and other long-term care facilities. The American Geriatrics Society continues to review guidance set forth in peer-reviewed articles and editorials, as well as ongoing and updated guidance from the CMS, CDC and other key agencies to inform AGS policies and recommendations.
The isolation of nursing home patients has led to some negative consequences. Fall rates in isolation facilities are much higher than that in general wards. Restraint use has also increased whereas our geriatric medicine ward practices a no-restraint policy. Nursing home patients in particular have higher rates of dementia, delirium and behavioral issues that require greater nursing care which is challenging in isolation facilities, especially in the context of a global pandemic.
Older adults are at a high risk of loneliness, which impacts their health, well-being and longevity. While related to social isolation, loneliness is a distinct, internally experienced, distressing feeling. The present qualitative study sought to identify characteristics of loneliness in older adults living independently within a senior housing community which is typically designed to reduce social isolation.
Gardner et al (2020) The Coronavirus and the Risks to the Elderly in Long-Term Care[xxiv]
Locking down long-term care facilities ¾ probably for several months and perhaps longer ¾ raises its own concerns. Many long-term care residents are elderly and socially isolated; they depend on frequent visits from family and friends to socialize with them. Without these visits, residents may feel increasingly lonely, abandoned and despondent. That is a medical problem in its own right, leading to depression, weight loss and disruptive behavior.
As troubling, family visits are a crucial technique for monitoring quality of care. With visits curtailed and staff absenteeism rising, the quality of care ¾ already low in many facilities ¾ may decline further. And we will have only limited visibility into the full scope of the problem.
States have extensive licensure and inspection data on existing facilities that could be used to target institutions with a history of poor compliance. If we do not watch closely, there is an acute risk that millions of elderly people might be effectively abandoned as the outbreak intensifies.
Increased attention is urgently needed for a particularly vulnerable group of older adults: victims of elder mistreatment and those at risk of victimization. Elder mistreatment is common, affecting as many as 10% of community-dwelling older adults each year, with nursing home residents also at risk. This mistreatment may include physical abuse, sexual abuse, neglect, verbal/emotional/psychological abuse and financial exploitation, with many older adults suffering from multiple types concurrently.
Media coverage of COVID-19 is contributing to already heightened anxiety. Some of the media reports have implied that the lives of older people are not as important as younger people.
Wand et al (2020) COVID-19: the implications for suicide in older adults[xxvii]
Whether the COVID-19 pandemic influences suicide rates in older adults is not yet known; however, the pandemic may result in a confluence of the risk factors for suicidal behaviours. The authors examine the links between suicide in older people and the COVID-19 pandemic, provide the perspectives of psychiatrists from 4 regions [China, Hong Kong, Italy and Australia] facing different challenges and sociocultural contexts, and propose solutions to support older people.
Flint et al (2020) Effect of COVID-19 on the mental health care of older people in Canada[xxviii]
The long-term care sector is in need of innovative solutions to provide psychiatric care to residents and support for staff. Long-term care facilities are typically understaffed and many of the available staff do not have the knowledge and skills to adequately manage psychiatric symptoms and problematic behaviors. In addition, some facilities have limited access to smoking areas which creates a challenge in managing residents with chronic mental health conditions and nicotine dependence. Long-term care facilities rely on the resources and expertise of psychogeriatric outreach teams to provide guidance in managing residents with dementia as well as older individuals with serious and persistent mental illness. In lieu of providing on-site support during the COVID-19 outbreak, psychogeriatric teams are exploring ways to provide impactful digital support.
Fraser et al (2020) Ageism and COVID-19: What does our society’s response say about us?[xxix]
The goal of this commentary is to highlight the ageism that has emerged during the COVID-19 pandemic. Over 20 international researchers in the field of aging have contributed to this document. The commentary discusses how older people are misrepresented and undervalued in the current public discourse surrounding the pandemic; it points to issues in documenting the deaths of older adults, the lack of preparation for such a crisis in long-term care homes, how some protective policies can be considered patronizing and how the initial perception of the public was that the virus was really an older adult problem. The authors also call attention to important intergenerational solidarity that has occurred during the crisis to ensure support and social-inclusion of older adults, even at a distance.
Ageism reached a new level with the hashtag #BoomerRemover. This vulgar concept highlights two prevalent ageist attitudes in the COVID-19 pandemic response:
- Older adults are vulnerable and helpless against COVID-19. High mortality rates amongst older adults are considered an inevitable and normal outcome of the pandemic.
- Healthy younger adults may perceive themselves as invulnerable to COVID-19 and, as a result, may not realize the importance of following public health advice and policies on infection prevention.
Prejudices and discrimination towards marginalized individuals such as aged subjects with mental disorders may be generally reinforced in situations of social crisis, fear, frustration and uncertainty. Stigma is a relevant predictor of negative outcome and represents an important barrier to care, particularly when it coexists with social isolation.
Specifically, we directly observed a rapidly growing request of psychiatric interventions in aged patients with COVID-19 infection due to the emergence of severe delirium ¾ mainly hyperkinetic ¾ which was reported in approximately 30% to 50% of cases, increasing with age, psychomotor agitation, anxiety and depressive symptoms. When compared with younger subjects, we found that subjects aged 65 or above with prolonged hospitalization are more vulnerable to: 1. environmental factors such as social isolation and distance from family members, stay in intensive or subintensive units, communication difficulties due to therapeutic devices; 2. individual factors such as COVID-19 possible neurotropic properties, impairments in insight and cognitive dysfunctions, comorbid medical conditions and use of multiple medications.
Lithander et al (2020) COVID-19 in Older People: A Rapid Clinical Review[xxxi]
Social distancing and isolation offer both protection and risk to some of the most vulnerable individuals in society. Future focus on aspects such as loneliness, deconditioning, progression of frailty and neglect of comorbidities are warranted as well as measures that might mitigate these harms.
Social workers are familiar with the challenges brought on by the coronavirus pandemic; and we apply three gerontological social work perspectives that might increase our chances of minimizing negative outcomes and improving health and quality of life for everyone. First, the reality that the older population is very heterogeneous challenges ageism and age-stereotyping that has surfaced with COVID-19. Second, concepts of cumulative disadvantage and intersectionality offer clear explanations of the disparities that are being illuminated and lead us to advocate for fundamental changes to reduce disparities in later life and for people across the life course. Third, a strength-based perspective highlights the assets of the older population and the opportunities for positive developments coming out of the crisis. We can capitalize on momentum to increase advance care planning, to reduce social isolation, and expand the use of online technology for service provision. We can bolster our arguments to support older workers, volunteers, and caregivers. The fact that these social work perspectives are so applicable to the coronavirus situation reminds us of their fundamental relevance. Gerontological social work has much to offer in our roles as researchers, educators, practitioners and advocates during this crisis.
OTHER SOURCES
The Alzheimer Society of Ireland (2020) Tips for Nursing Home Restrictions
[i] World Health Organisation (2020) Mental health and psychosocial considerations during the COVID-19 outbreak. https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf.
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[iii] European Centre for Disease Control and Prevention. Surveillance of COVID-19 at long-term care facilities in the EU/EEA. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-long-term-care-facilities-surveillance-guidance.pdf. [Accessed 21 May 2020]
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Produced by the members of the National Health Library and Knowledge Service Evidence Team†. Current as at 24 May 2020.This evidence summary collates the best available evidence at the time of writing and does not replace clinical judgement or guidance. Emerging literature or subsequent developments in respect of COVID-19 may require amendment to the information or sources listed in the document. Although all reasonable care has been taken in the compilation of content, the National Health Library and Knowledge Service Evidence Team makes no representations or warranties expressed or implied as to the accuracy or suitability of the information or sources listed in the document. This evidence summary is the property of the National Health Library and Knowledge Service and subsequent re-use or distribution in whole or in part should include acknowledgement of the service.
Anne Madden, Librarian, St. Vincent’s University Hospital [Author]; Brendan Leen, Area Library Manager, HSE South [Editor]
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