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MARCH 28, 2020 -- With a growing number of state and regional directives to shelter in place because of the COVID-19 pandemic, it's important clinicians pay close attention to the mental health of all patients, but particularly the elderly.
Currently, there are more than 50 million Americans aged 65 years and older. Physical distancing during this public health crisis is essential in preventing the spread of the virus, but it can come at a high cost to seniors' mental health and well-being, resulting in loneliness, anxiety, depression, and cognitive problems.
There are now more than 40,000 cases of coronavirus in the United States; and the CDC reports that 80% of deaths associated with the disease have been in those 65 years of age or older.
These data are driving seniors' residences, nursing homes, and other long-term care facilities to go into lockdown and shutter their doors to visitors.
"Everyone in the healthcare system is now under siege. We're at war with this virus, and we need to approach it like that while making sure we attend to the mental health needs of our older patients," co-president of the American Association for Geriatric Psychiatry (AAGP) Brent Forester, MD, told Medscape Medical News.
"Research has demonstrated that social connectedness and engagement with other people are important to promote successful aging; but that's being directly challenged" by physical distancing policies, he said.
Against this somewhat bleak background, experts note there is a wide variety of high- and low-tech strategies to help seniors stay socially connected and mentally healthy.
Forester, who is also vice-chair of the Council on Geriatric Psychiatry for the American Psychiatric Association and chief of the Division of Geriatric Psychiatry at McLean Hospital, notes that after President Trump's recent announcement that Medicare will now reimburse for all telehealth services, his outpatient clinic is becoming entirely virtual.
A Lasting Legacy
Maintaining seniors' connection to their healthcare providers using the telephone or video telehealth platforms is critical and "may be the most important thing we do as mental health professionals," said Forester.
Ipsit Vahia, MD, medical director of geriatric psychiatry outpatient programs and medical director at the Institute for Technology and Psychiatry at McLean Hospital, agrees and said the accelerated shift to telemedicine because of COVID-19 will have a lasting legacy.
"After this crisis passes, I predict that we'll see a permanent shift in care models that incorporate telemedicine to a greater extent," he told Medscape Medical News.
In addition to setting up online connections to their healthcare providers, there are other strategies to help older patients maintain social contact. These include greater use of computers or tablets to stay connected to family, loved ones, and friends through video chats and playing online games.
"Seeing each other's faces, hearing their voices, and sharing the experience that we're going through can be therapeutic for everybody," Forester said.
For seniors who may not have the technology or know-how to use these devices, getting tech-savvy, healthy young family members to come by and help seniors get online "would be a really good thing," he added.
Forester noted that mindfulness-based interventions and relaxation techniques could also be helpful.
"There are many computer-based applications for these mindfulness exercises that folks can try out. This is an area of extraordinarily high interest in psychiatry overall, but particularly in older adults," he said.
Vahia also recommended picking up the phone, whether it's to use smartphone apps or just "old school" talking with others.
AAGP past-president Iqbal "Ike" Ahmed, MD, clinical professor of psychiatry at the Uniformed Services University of Health Sciences and of psychiatry and geriatric medicine at the University of Hawaii, Honolulu, said it is important to stay in touch with older people now more than ever.
"Even older people who are cognitively healthy are at risk, because cognitive reserves are down. Tele–hook-ups are important for contact and to make sure [the elderly] are doing well," Ahmed told Medscape Medical News.
A Silver Lining?
Both Ahmed and Forester recommend that all clinicians, including those on the front lines of the pandemic, screen patients for loneliness, depression, and cognitive impairment.
In addition to picking up the telephone, other low-tech options that may help seniors stay mentally engaged include practicing hobbies or activities such as knitting, crossword puzzles, "or whatever else works for them. Whatever helps them cope and keeps them occupied during self-quarantine should be encouraged," Ahmed said.
"I recently read about people rediscovering analog games, such as Hangman, that they may not have played for decades. People are finding pleasure in activities that they may have enjoyed as children in a predigital world," Vahia said. He added that it's okay and even essential to have fun, even in today's environment.
"I agree with Dr Vahia's 'fun approach.' Humor is one of the best medicines we have in good times and in bad," Forester noted.
For patients with Alzheimer disease or other cognitive problems, maintaining routine is important, Ahmed said.
Forester noted that it's also important for healthcare workers to develop ways for hospitalized patients to safely engage with other patients and staff.
These include having a staff member come into a patient's room, sit a safe distance away, and have a conversation. "As long as that staff member hasn't been exposed and is otherwise healthy, that's completely fine," he said.
As for inpatient group therapy, "even in an older-adult population," being together in limited numbers and maintaining distance "is going to be more therapeutic than dangerous," Forester said.
If there is a positive aspect to the COVID-19 pandemic, it's that it has forced people to slow down and connect with each other, said Forester.
Vahia agreed. "Given that the number of distractions are lower, we may find that people actually have time to engage in deeper conversations. In this time, I think connectivity is proving to be our friend," he said.
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