COVID-19, Aging, and Mental Health: Lessons From the First Six Months.

The earliest epidemiological findings from the COVID-19 pandemic have made clear that the disease had a disproportionately high impact on mortality and morbidity in older adults. Over the subsequent 6 months leading up to the time of writing, a significantly more complex picture is emerging that points to a much broader impact on the mental health of older adults. While the initial focus has been on understanding the impact of the virus itself on infected older adults, clinicians and researchers around the world have recognized that there are also major challenges arising from the resulting lockdown and quarantine measures. These include the disruption of regular clinical services, challenges around transitioning services to telecare and most notably, the disproportionate impact on older adults in nursing homes.

In response to a clear need for evidence to guide clinicians, researchers, administrators, and policymakers, the American Journal of Geriatric Psychiatry issued a global call for submissions focused on COVID-19 on March 20, 2020. This call for papers was met with an overwhelming response from the international community. In the month of April 2020 alone, the Journal received nearly four times more submissions than it did in April 2019, and almost as many submissions as the prior 3 months combined. In order to expedite dissemination of this information, all accepted papers are published online with complimentary Open Access immediately after acceptance (at https://www.ajgponline.org/covid19). Readers should note the dates when these papers were published electronically, given how quickly guidelines and care protocols are evolving. Many of the early papers published in March and April, several of which are correspondences, serve the essential function of capturing a specific moment in time during this crisis. These papers serve as a chronicle of an evolving response shaped by quickly changing realities, and may inform future responses to other healthcare crises from similar or different causes.

At the time of writing, we remain in the midst of a situation that continues to evolve rapidly, and the field of geriatric psychiatry will bear the onus of responding accordingly in the interest of the well-being of older adults with mental health needs. In fact, we may still be in the very early stages of recognizing how vast and deep the impact of the pandemic will be on the field. However, some key themes are beginning to emerge from the published literature thus far, and are represented in this special issue.

ATYPICAL CLINICAL PRESENTATION

Early reports indicate that similar to other medical illnesses, COVID-19 may present atypically in older adults. Two studies by Ward and colleagues and Isaia and colleagues indicate that 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.

CLINICAL MANAGEMENT CHALLENGES

A major focus of the early literature has been management of older adults with pre-existing neurocognitive disorder or other psychiatric issues such as mood or anxiety disorders in the context of COVID-19 and subsequent social distancing measures. In a comprehensive commentary that addresses persons with dementia, Brown and colleagues discussed anticipated challenges and potential solutions in a number of settings including the community, group in assisted living, long-term care, and hospitals. The authors also discuss the impact of COVID-19 on research in the immediate term, as well as longer term risks and challenges with COVID-19 research, especially on the development of new disease modifying agents. Cipriani and Di Fiorino comment on the need for urgent action in intensive care unit settings, based on the experience in Italy where 12% of deceased COVID-19 patients had dementia. The authors offer a critique of guidelines issued by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care which originally suggested the possibility of an age limit for access to intensive care. Special situations such as the management of alcohol and substance use disorders, conducting electroconvulsive therapy , and managing ketamine treatment among older adults are also discussed. Husebø and Berge stress the importance of advanced directives and care planning among patients in nursing homes. Special considerations around inpatient care and outpatient collaborative care are also reviewed. In addition, with the majority of clinical services worldwide shifting to virtual care, Gould and Hantke offer guidelines on how clinicians may facilitate technology use among older adults by considering access to technology, promoting technology literacy, promoting patient buy-in and creating familiarity with the technology tools.

DEALING WITH CONSEQUENCES OF SOCIAL DISTANCING AND LOCKDOWNS

In an effort to enforce social distancing policies, there have been lockdowns of varying stringency in most parts of the world. Because of their being at a higher risk of negative outcomes from COVID-19, older adults may self-restrict their activities and interactions even beyond the general population. This, in turn, appears to trigger a range of impact including increasing isolation and loneliness, disrupting daily routines and activities, changed access to essential services such as doctor's visits. The impact can also include some positive changes such as adopting newer technologies, renewed focus on enhancing relationships, and identifying resilience. We are also learning that there may be predictors of how older adults react to social distancing and isolation, and we anticipate that future research will shed light on these factors. The efficacy of cognitive and behavioral interventions in reducing the burden of isolation has been well established. Two recent reports demonstrate how these approaches can be translated to virtual care and how clinicians may implement strategies to mitigate isolation worsened in the context of social distancing measures. , It is likely that this specific issue will receive greater attention as we better understand its longer-term consequences. Koenig discusses how of religion and spirituality can play a role as a risk or protective factor. On the one hand, religious older adults may experience additional strain from not being able to participate in services. Simultaneously, for these adults, their faith may also serve as a major coping mechanism. In addition to impact on patients, we are learning how COVID-19 can impact staff who care for them as well. DeCaporale-Ryan and colleagues discuss the importance of addressing staff well-being at skilled nursing facilities and present a telemedicine-based approach to support care professionals working under isolation measures.

GLOBAL PERSPECTIVES

As the pandemic has spread across the world, lessons learned from the countries affected earlier have played an important role in informing the actions of nations impacted later in the crisis. While 6 months is a relatively short window and the worldwide spread of the pandemic has been dramatic, experiences from a geriatric psychiatry inpatient unit in China and Italy provide early evidence that older adults in hospital based settings may experience worsening of psychiatric symptoms under lockdown measures. Over the coming months, these initial experiences may help providers elsewhere anticipate and plan care more effectively. It is also noteworthy that there is relative consistency in reported observations and findings across the world. ,

In conclusion, we recognize that much remains to be learned, and the response of geriatric psychiatry, and indeed all of healthcare to COVID-19 and its broader impact will change considerably over the next few months and indeed years. However, the early lessons learned so far and initial reported observations and findings will serve as a foundation for the field to broaden and deepen its fund of knowledge.