|Year : 2020 | Volume
| Issue : 2 | Page : 113-117
An insight into the elderly mind during COVID-19 pandemic: World Mental Health Day 2020
Ramya Vadakkayil Balan1, Divyamol Karunakaran Sasidharan2, Jishnu Sathees Lalu3
1 Consultant Psychiatrist, Sacred Heart Mission Hospital, Pullur, Thrissur, India
2 Consultant Geriatrician, National Program for Healthcare of Elderly, Chicalim, Goa, India
3 Officer-in-Charge, Station Health Organisation, HQGNA, Indian Navy, Vasco-Da-Gama, Goa, India
|Date of Submission||12-Oct-2020|
|Date of Decision||02-Dec-2020|
|Date of Acceptance||13-Dec-2020|
|Date of Web Publication||18-Jan-2021|
Surg Lt Cdr (Dr) Jishnu Sathees Lalu
Officer in Charge, Station Health Organisation, Goa Naval Area, Vasco Da Gama, Goa
Source of Support: None, Conflict of Interest: None
About one third of the elderly suffer from mental illness due to psychosocial issues such as loss of spouse, social and financial insecurity, low support from families, inadequate nutrition, uncontrolled hypertension, impaired vision, deafness, and arthritis. Psychological stress can have harmful impact on the immune system, making the elderly more susceptible to SARS-Co-V2. Stigma associated with the disease, risk of developing complications during the course of the disease and relatively high mortality rates put the elderly under immense stress. The older population though knowledgeable are ignorant of their own health. The prevalent COVID-19 pandemic imposes more challenges to the elderly population which demands a holistic approach directed to meticulous solutions.
Keywords: COVID-19, elderly care, geriatrics, mental health, pandemic
|How to cite this article:|
Balan RV, Sasidharan DK, Lalu JS. An insight into the elderly mind during COVID-19 pandemic: World Mental Health Day 2020. J Mar Med Soc 2020;22:113-7
| Introduction|| |
Psychiatric epidemiology continues to remain a challenge in India. As per the National Mental Health Survey 2016, 150 million individuals suffer from some or the other mental health disorders with about 85% treatment gap for overall mental morbidities. This gap reflects on the availability of capacity and trained workforce. Mental health issues of the elderly population are unique as well as neglected due to various social factors such as stigma, discrimination, fear, and sometimes hostility toward the mentally ill. A meta-analytic study in which majority (80%) of the articles used Geriatric Depression Scale, elderly population living in India suffer from 34.4% of depression of which the estimate among the female population is higher. Risk factors such as loneliness due to loss of spouse, social and financial insecurity, limited support from families, inadequate nutrition, uncontrolled hypertension, impaired vision, deafness, and arthritis make elderly vulnerable to mental illness.,,, The degree of disability of an older adult with mental illness is greater than those with physical illness alone.
An inverse relationship between psychological stress and parameters of the immune system makes the elderly more susceptible to viral infections. The elderly are emotionally vulnerable and even a seasonal flu brings them immense stress and anxiety worsening their existent morbidities. In addition to this, the current COVID-19 pandemic has imposed more challenges such as nonavailability of house-help to assist in daily chores, difficulty as well as fear in accessing health-care facilities, loneliness due to lockdown, stigma in the family and society, elder abuse, and abandonment. Older age is considered as an end stage of life and hence the elderly themselves and the family members prefer prioritised care of the children at home than to the elderly.
A survey showed that during lockdown there was an overall rise of 20% in the number of people seeking help for mental health issues. There exists a gap between the general awareness on emotional well-being, the assistance available in honing mental health and overall quality upliftment it brings to lives of the elderly. Measures need to be implemented in all stratas of the society to improve overall attitude toward people living with mental illness. Similarly, at the administrative level, mental health issues among the elderly caregivers, homeless, and orphaned elderly are largely neglected due to the lack of resources, geriatric care providers, and poorly framed policies. Social protection offered through financial security schemes, shelter homes, and creation of geriatric friendly environment is yet to cover these disadvantaged citizens. Inclusion of 17 packages for mental illness in Ayushman Bharath, a flagship scheme of Government of India, is a step toward universal health, however, presently, the facilities are applicable only to public sector hospitals.
COVID-19 has spread across the globe and galvanized the world. The practice of social distancing has made life difficult especially for the elderly. There have been marked changes in behavioural patterns and shutdown of usual day to day life. Though these steps are significant in mitigating the transmission of this disease, they will have short- and long-term consequences on the physical and mental health of the elderly. On World Mental Health Day 2020, we aim to highlight common geriatric mental health issues existent during COVID-19 pandemic and its mode of interventions.
| Mental Health Issues in Geriatric Population During COVID-19|| |
Medical facilities have witnessed cases of elderly patients suffering from COVID-19 being abandoned at the hospital, quarantine centers and other COVID care facilities due to fear of contracting the infection among the family members. Similarly, various psychosocial factors affecting mental health of the elderly are shown in [Table 1]. Insomnia, boredom, anxiety symptoms, panic attacks, nightmares, feeling of emptiness, fear of contracting COVID-19, fear of spreading the infection to others, health anxiety, anxiety related to the uncertain future, worsening of preexisting loneliness and social isolation due to the call for social distancing and quarantine, consequences during the course of disease and death, getting admitted alone in hospital and dying without any relatives around them are some of the evolving mental health issues associated with the elderly during the prevailing pandemic. These stressors may contribute to depression, anxiety disorders, hypochondriasis, posttraumatic stress disorder, substance abuse/withdrawal, and related psychiatric disorders.
|Table 1: Psychosocial risk factors of mental health among the elderly during COVID-19|
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| Elderly with Subsyndromal Symptoms|| |
”Subsyndromal Psychiatric Disorders” (SPD) is characterised by the presence of elevated psychiatric symptoms that do not meet full diagnostic criteria for a specified disorder. It is also known as subthreshold or minor psychiatric disorders. The diagnostic and Statistical Manual of Mental Disorders, Fifth edition has reclassified it as other specified depressive disorder; depressive episodes with insufficient symptoms. The occurrence of SPD in the geriatric age group ranges from 8% to 30% with a predominant presentation as subsyndromal anxiety. Degeneration of brain regions associated with inhibiting anxiety, increases in life stressors, cardiovascular changes, and polypharmacy are major etiological factors in older adults. Minimal mental health issues like anxiety and depressive symptoms can be managed by brief psychological and psychosocial interventions. These interventions can be delivered by any health care personnel or volunteers with some guidance and training by mental health professionals. Their major role will be to provide reassurance to both patients and family members on various mental health issues which are nothing but normal reactions to the abnormal stress occurring during the ongoing dynamic pandemic situation and clarifying inappropriate and false information about the pandemic. Maintaining a daily routine, physical exercise, yoga, meditation, healthy diet, and mental stimulation through home-based activities with appropriate safety precautions have found to be effective in preventing subsyndromal depression and its progression to Major Depressive Syndrome.
| Mental Health Issues in Older Adults with Pre-Existing Mental Illness|| |
Older adults with preexisting mental illness are at risk of relapse or worsening of depressive symptoms. The common cause in this current scenario may be psychological stress, poor coping as well as noncompliance to medications due to difficulty in accessing healthcare. The restriction for mobility due to home isolation and/or lockdown measures and worsening of preexisting medical illness can give rise to delirium. Individuals with cognitive impairment have behavioural problems and difficulty in understanding the COVID-19 pandemic. This poses a challenge during the pandemic due to their incapability of following preventive measures. The mental health condition of those living in old age homes/residential set-ups or living alone worsens since most of the facilities are functioning with scarce resources and space. Preexisting mental illness may worsen in the background of nonavailability of routine clinical follow ups and resultant drop in compliance to prescribed therapy.
| Geriatric Mental Health Disorders|| |
The morbidity of psychiatric illness is directly proportional to age with an estimated prevalence in geriatric population and in the younger population is 43.3% and 4.66% respectively. Aging also impairs the cognitive functioning due to senile changes. Therefore, it is important to direct efforts towards acute and preventive intervention focusing on the elderly to cope with the continuously changing environment during the prevailing pandemic. According to the Centre for Disease control and Prevention, older adults with COVID-19 are more likely to be hospitalized (31%–59%) and succumb to it (4%–11%). This risk is much higher in elderly above the age of 85 years. Previous studies on mental health consequences of disasters are almost accompanied by increase in depression, posttraumatic stress disorder (PTSD), Anxiety disorders and substance use disorders. Though depression, delirium, and dementia are the most prevalent mental illnesses among the elderly, the following mental health disorders were found to be relevant during COVID-19 pandemic:-
Generalised anxiety disorder
Generalised anxiety disorder (GAD) followed by phobias and panic disorders are the commonest forms of anxiety seen among the elderly in India with an overall prevalence of 10.7%. GAD is characterized by excessive worry and anxiety that are difficult to control, cause significant distress and impairment and occur on more days than not for at least 6 months. GAD is a relatively common disorder, most often with an adult onset and chronic course. GAD can lead to significant impairments in role functioning, diminished quality of life, and high healthcare costs. In the current pandemic, increased awareness on mortality in elderly, rise in COVID-19 cases, railing death rates, social isolation, children stranded at disease endemic locations, neighbours or other people being infected with the disease, fear about their children and grandchildren contracting the disease and apprehension about institutional quarantine, admissions and Intensive Care Unit (ICU) stay cause anxiety in elderly.
The elderly people with anxiety have been presenting with vague pains all over the body, decreased sleep, difficulty in relaxing, headaches, pain especially around the neck, shoulder and back as their presenting symptom and may have repeated visits for the same to the healthcare facility. Further evaluation may reveal a very anxious personality along with other social stress adding up to their symptoms. Elderly with COVID-19 may present with symptoms such as breathlessness, palpitations, and headaches due to anxiety. These patients with normal oxygen saturation and pulse rate feel symptomatically better with reassurance. Anxiety in elderly increases symptoms of Gastro-oesophageal Reflux Disease (GERD) clinically presenting with bitter taste in mouth (dysgeusia) and dyspepsia. Treatment of GERD along with anxiety management improves their symptoms and quality of life.
Anxiety disorder can be effectively treated with psychotherapy, medication or a combination of the two modalities. One of the therapies is Cognitive Behavioural Therapy, which is based on evidence that shows that persons with GAD engage in overestimations and catastrophizing of negative events, show limited confidence in problem solving; requirement of additional evidence before making decisions; lower tolerance to uncertainty, an iterative problem-solving style, and numerous behavioural and cognitive strategies that may actually be counterproductive and help maintain the self-perpetuating cycle of worry.
Patients with depression must have two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms such as loss of confidence or self-esteem, inappropriate guilt, recurrent thoughts of death or suicide, diminished ability to think/concentrate or indecisiveness, change in psychomotor activity with agitation or retardation, sleep disturbance, change in appetite with fluctuation in weight. Depression is a major public health challenge in India with a prevalence estimated to be 21%–39%. The severity of depression increases with age and number of co-morbidities. Many factors aggravate depression in elderly, as they are now facing many challenges as mentioned in [Table 1].
Depressed elderly usually present to the clinic with symptoms such as insomnia, memory problems (pseudo dementia) lack of interest in their day to day activities including personal care such as taking bath, grooming, loss of appetite, loss of weight, increased anger, frustrations, increased substance abuse such as alcoholism and some may even present with increased hunger and overeating, and increased sleep as their symptom. Many at times depression in elderly is overlooked and hence it is underdiagnosed, this is mainly because it is considered as a normal part of ageing and the benefits of addressing it early is not widely known. Depression impairs quality of life and leads to higher dependency on others. It is also a leading cause of recurrent thoughts of death or attempt suicides especially in major depressive illness.
The term late-life depression includes both aging patients whose depressive disorder presented in earlier life, and patients whose disorder presents for the first time in later life. Depressive illness in the older population is a common and serious health concern that is associated with co-morbidity, impaired functioning, excessive use of health care resources, and increased mortality (including suicide). Over 80% of mental health treatment for depressed older adults is delivered in the primary care setting. Depression often goes undiagnosed in primary care and is often left untreated, even after diagnosis. Recognition and management of late-life depression is an important responsibility of the primary care clinician.
The severity of depression is assessed using various clinical scales such as the Geriatric depression scale. Either pharmacotherapy or psychotherapy can benefit the patients. The treatment is initiated after ascertaining the precipitating factors for depression in the elderly. Group counselling techniques along with family is beneficial with those having social risk factors, whereas pharmacotherapy may be beneficial for elderly with other risk factors. Brief relaxation exercises and supportive therapy can be done for those having severe psychological distress. Often outdoor games benefit a lot, but this should be done at home with adequate precautions. Online, clinician-guided self-help or pure self-help cognitive-behavioural therapy may also be beneficial if available. Depression should be re-assessed from time to time to know the response to treatment.
PTSD is a severe, often chronic and disabling disorder, which develops in some persons following exposure to a traumatic event involving actual or threatened injury to themselves or others. Elderly with PTSD experiences marked cognitive, affective, and behavioural responses to stimuli leading to flash backs, severe anxiety, fleeing or combative behaviour. The person may change totally and may get very affected on recalling the traumatic incidents. Studies have shown that PTSD can result in significant immune-suppression leading to recurrent infections including susceptibility towards SARSCoV2. Elderly who have experienced stress in various forms be it in losing loved ones to the virus to those who have had severe phase of the disease in ICU poses risk for PTSD. They may show signs of emotional numbing, diminishing interest in everyday activities and detachment from others. Delirium is a modifiable clinical risk factor for PTSD in patients who receive ICU treatment. The prevalence of PTSD following ICU stay is estimated to be up to 75%. Critical illness and resultant ICU stays commonly expose patients to extreme physiological and psychological stressors that are life threatening and traumatic and can frequently precipitate preexisting psychiatric illness.
Effective treatments for PTSD include psychotherapies and medications. However, a substantial proportion of patients have symptoms resistant to treatment. It is often necessary to switch or combine treatments to achieve a satisfactory therapeutic response. Psychotherapies found to be effective for PTSD in multiple clinical trials include exposure therapy (e.g., prolonged exposure), a combination of exposure and a cognitive therapy (also referred to as trauma-focused cognitive-behavioural therapy; e.g., cognitive processing therapy), or eye movement desensitization and reprocessing therapy.
| Other Management Modalities|| |
In the current scenario, people are restricted to visit hospitals/clinics for their scheduled appointments for health issues forcing us to use other modes of communication with doctors and other health care professionals. Psychiatrists and other speciality doctors should create awareness among older adults, general population and the family members about mental health issues as a first step of prevention through online media platforms such as online programs, websites, online forums, group E-mails and messages. However, the following management modalities may be suitable for the elderly population in India:-
Community health workers or social workers
The lay community workers/social workers trained to use simple psychological assessment scales may be positioned as frontline healthcare workers to screen for mental health illness among older adults. The old age home staffs conversant with technology can assist in-living elderly to undergo mental health screening process through digital platform. Establishment of helpline numbers manned by such trained staffs may be utilised to address mental issues faced by the public during a disaster for aiding minor mental health issues. Community involvement using self-help groups and nonmedical lay persons to narrow this gap was found effective in a study conducted in Goa.
Psychiatrist consultation for basic assessment followed by a brief psychological intervention may be beneficial using tele services. Telemedicine can be used for consultations requiring more detailed psychiatric evaluation and prescription of medication especially for those with preexisting mental illnesses. Patient contact through voice or voice plus video may be superior to text messages and E-mails. Multiple studies suggest that outpatients and their psychiatrists are generally satisfied with the transition to telemedicine with video visits and/or phone visits. To prevent possible relapse/recurrence of psychiatric disorders there should be “after care” that is to follow up the already consulted patients. Utilisation of paramedical staffs for consulting patients for follow up and service of the psychiatrists may be utilised in case requiring specialist intervention. However, patients requiring immediate care needs to be evaluated by a psychiatrist for providing optimal care.
Home visit by a nurse/social worker augmented with tele-consultation with psychiatrist through video conference may be adapted among the elderly with severe mental illness along with physical disability. This modality is not suitable in psychiatric emergencies such as suicidal risk, severe agitation, catatonia, refusal of food or delirium, in which the elderly would require personal evaluation in emergency settings with appropriate precautions against COVID-19. Concurrently, elderly adults need to be empowered with self-care ability, participation in social activities, focus on mental health, and enhancement of financial well-being.
| Conclusion|| |
Geriatric mental health care should start from the primary health care level for early identification of mental health illness, counseling, and initiation of therapy. Psychological care is one of the components while treating other morbidities of the geriatric population. Therefore, it is proposed that the National Program for Health Care of the Elderly and elderly care services of the National Mental Health Program should be amalgamated for strengthening the services of geriatric care in India. Training of the existing healthcare workforce on geriatric issues and care is the need of the hour. Utilization of lay health counselors in collaboration with primary health-care providers and consulting mental health specialists may help in facilitating intervention by means of frequent visits, counseling, and improvement in adherence to medication to address depression, anxiety, schizophrenia, and delirium.
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Conflicts of interest
There are no conflicts of interest.
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