Mental Health Care of Older Adults during Coronavirus Disease (COVID-19) Pandemic: Challenges and Way ahead in India.

Dear Editor,

India is home to 103.8 million people above 60 years as per the 2011 census. The older adults in India are facing unique challenges due to the increasing burden of non-communicable diseases (including mental disorders), adverse socioeconomic conditions, and sociocultural changes. The COVID-19 pandemic has a potentially enormous impact on everyone’s mental health, with particularly more risk for the older adults. This unique situation, with the limited existence of geriatric mental health care services in India, has brought many challenges in the mental health care of the older adults.

Reasons for the Increase in Mental Health Issues

Any crisis or disaster will have a maximum impact on the vulnerable population, including the older adults. It was evident during the previous disasters such as the tsunami and the severe acute respiratory syndrome epidemic: there was a sharp increase in the mental health issues among the older adults.[1, 2] Possible reasons include decreased flexibility among them in adjusting to new demanding situations, contributing to the increase in their stress levels and the risk for mental health issues. A higher proportion of the older adults are likely to suffer from loneliness and isolation, and the current restrictions in traveling and the quarantine and reverse-quarantine measures to prevent COVID-19 will further increase isolation.[3] Many of the older adults have limited ability to use smartphones and modern methods of technology for communication and this further compounds the problem. The worsening of physical illnesses in the older adults during the COVID-19 pandemic is another important issue.[4] This could be due to lack of physical activity, lack of scheduled visits to physicians as hospitals are discouraging non-emergency consultations and affliction with COVID-19 itself. Poor physical health can, in turn, contribute to increased risk of mental illness. Older adult individuals placed in institutional quarantine or those traveling long distances to native places using alternate transport methods (non-passenger vehicles, mopeds, walking on foot) due to COVID-19 restrictions are likely to have inadequate nutrition and hydration, contributing to increased risk for delirium. Older adults with cognitive impairment are likely to have difficulty in following restrictive measures and maintaining self-hygiene. This can contribute to a worsening of their behavioral problems. Excessive exposure to the continuous media coverage of the pandemic about the increased vulnerability and dire situation across the regions, in general, is likely to have a significant adverse impact on the mental health of the older adults. Poor family support, financial constraints, dependency, and living alone are other important factors that can contribute to a higher risk of mental health issues among the older adults.

Common Mental Health Issues

The mental health problems can be specific psychiatric symptoms such as sleep disturbances, feeling isolated, boredom, anxiety, fear of entrapment, fear of acquiring or spreading the infection, or paranoia on other people. Minor psychiatric disorders can be adjustment disorder, mild depression, acute stress reaction, or insomnia. A proportion of the older adults can present with major depression, post-traumatic stress disorder, substance use, suicidal behaviors, or delirium (as a complication of stress, substance withdrawal, or medical and nutritional complications). In the older adults with pre-existing psychiatric illness, there can be exacerbation or recurrence of the disorder.[5-7]

Challenges in Delivering Mental Health Care

A few of the challenges include (a) restriction in terms of travel and mobility (b) majority of the psychiatric hospitals limiting their services to emergencies (c) general advisory to the older adults to avoid hospital visits for minor and non-emergency issues (d) the fact that in India, while nearly 70% of the older adults reside in the rural areas,[8] the psychiatry services are predominantly limited to urban areas, unlike in developed countries, which makes accessibility a challenge (e) family members prioritizing medical issues and neglecting mental health issues (f) decreased rates of identification and referrals for mental health issues, probably due to the busier work schedule of doctors (g) decreased income of family caregivers, which can lead to change in priorities and provision of less importance for mental health issues of the older adults.

Possible Solutions and Way ahead

These are a few solutions,[9, 10] including (a) utilizing digital media such as video-conferencing and social media for increasing the awareness about the mental health issues in the older adults, (b) starting mental health helpline for the older adults, (c) telephonic consultations by mental health professionals to address minor psychiatric issues, (d) older adults with pre-existing psychiatric disorders can be reached on scheduled appointment using telephone calls or video-conferencing,[11] (e) using brief tools (e.g., telephone version of the mini-mental status examination, telephone Montreal cognitive assessment) for cognitive assessment during telephonic interview,[12] (f) using an electronic prescription for dispensing medication, (g) referral to a nearest health professional for older adults requiring depot antipsychotic, (h) home visits for wheelchair-bound/bedridden older adults with mental health issues, (i) in-person evaluation for older adults with psychiatric emergencies, and (j) conducting online support group programs.

We should also consider the positive aspects of aging in terms of resilience among the older adults.[13] This was evident from the resilience shown by older adults during 1997 flood in the North Dakota, USA.[14] Contrary to the popular belief that older adults are at risk of psychosocial adversities during a disaster, the inoculation hypothesis states that prior experience with natural disasters tends to protect or insulate individuals from a strong emotional reaction to future natural disasters.[15] Many of the older adults, with higher resilience and reasonable support systems, may be able to overcome the current crisis with the support of the wisdom and learnings from the past experiences of disaster situations and epidemics.