COVID-19: Psychiatrists assess geriatric harm from

social distancing
Publish date: May 27, 2020, By Bruce Jancin

One of the greatest tragedies of the first wave of the COVID-19 pandemic has been
the failure of health policy makers to anticipate and mitigate the enormous havoc
the policy of social distancing would wreak on mental health and cognitive function
in older persons, speakers agreed at a webinar on COVID-19, social distancing, and
its impact on social and mental health in the elderly hosted by the International
Psychogeriatric Association in collaboration with INTERDEM.

“Social distancing” is a two-edged sword: It is for now and the foreseeable future
the only available effective strategy for protecting against infection in the older
population most vulnerable to severe forms of COVID-19. Yet social distancing also
has caused many elderly – particularly those in nursing homes and other long-term
care facilities – to plunge into a profound experience of loneliness, isolation,
distress, feelings of abandonment, anxiety, depression, and accelerated cognitive
deterioration. And this needn’t have happened, the mental health professionals
asserted.

“When are we going to get rid of the term ‘social distancing?’ ” asked IPA
President William E. Reichman, MD. “Many have appreciated – including the
World Health Organization – that the real issue is physical distancing to prevent
contagion. And physical distancing doesn’t have to mean social distancing.”

Social connectedness between elderly persons and their peers and family members
can be maintained and should be emphatically encouraged during the physical
distancing required by the pandemic, said Myrra Vernooij-Dassen, PhD, of
Radboud University in Nigmegen, the Netherlands, and chair of INTERDEM, a
pan-European network of dementia researchers.

This can be achieved using readily available technologies, including the telephone
and videoconferencing, as well as by creating opportunities for supervised masked
visits between a family member and an elderly loved one in outdoor courtyards or
gardens within long-term care facilities. And yet, as the pandemic seized hold in
many parts of the world, family members were blocked from entry to these
facilities, she observed.

Impact on mental health, cognition

Dr. Vernooij-Dassen noted that studies of previous quarantine periods as well as
preliminary findings during the COVID-19 pandemic demonstrate an inverse
relationship between social isolation measures and cognitive functioning in the
elderly.

“A striking finding is that lack of social interaction is associated with incident

dementia. Conversely, epidemiologic data indicate that a socially integrated
lifestyle had a favorable influence on cognitive functioning and could even delay
onset of dementia,” she said.

INTERDEM is backing two ongoing studies evaluating the hypothesis that

interventions fostering increased social interaction among elderly individuals can
delay onset of dementia or favorably affect its course. The proposed mechanism of
benefit is stimulation of brain plasticity to enhance cognitive reserve.

“This is a hypothesis of hope. We know that social interaction for humans is like
water to plants – we really, really need it,” she explained.

Diego de Leo, MD, PhD, emeritus professor of psychiatry and former director of the
Australian Institute for Suicide Research and Prevention at Griffith University in
Brisbane, was living in hard-hit Padua, Italy, during the first surge of COVID-19.
He described his anecdotal experience.

“What I hear from many Italian colleagues and friends and directors of mental
health services is that emergency admissions related to mental disorders declined
during the first wave of the COVID pandemic. For example, not many people
attended emergency departments due to suicide attempts; there was a very marked
decrease in the number of suicide attempts during the worst days of the pandemic,”
he said.

People with psychiatric conditions were afraid to go to the hospital because they
thought they would contract the infection and die there. That’s changing now,
however.

“Now there is an increased number of admissions to mental health units. A new

wave. It has been a U-shaped curve. And we’re now witnessing an increasing
number of fatal suicides due to persistent fears, due to people imagining that there
is no more room for them, and no more future for them from a financial point of
view – which is the major negative outcome of this crisis. It will be a disaster for
many families,” the psychiatrist continued.

A noteworthy phenomenon in northern Italy was that, when tablets were made
available to nursing home residents in an effort to enhance their connectedness to
the outside world, those with dementia often became so frustrated and confused by
their difficulty in using the devices that they developed a hypokinetic delirium
marked by refusal to eat or leave their bed, he reported.

It’s far too early to have reliable data on suicide trends in response to the
pandemic, according to Dr. de Leo. But one thing is for sure: The strategy of social
distancing employed to curb COVID-19 has increased the prevalence of known risk
factors for suicide in older individuals, including loneliness, anxiety, and
depression; increased alcohol use; and a perception of being a burden on society.
Dr. de Leo directs a foundation dedicated to helping people experiencing traumatic
bereavement, and in one recent week, the foundation was contacted by eight
families in the province of Padua with a recent death by suicide apparently related
to fallout from the COVID-19 pandemic. That’s an unusually high spike in suicide
in a province with a population of 1 million.

“People probably preferred to end the agitation, the fear, the extreme anxiety about
their destiny by deciding to prematurely truncate their life. That has been reported
by nursing staff,” he said.

The Italian government has determined that, to date, 36% of all COVID-related
deaths have occurred in people aged 85 years or older, and 84% of deaths were in
individuals aged at least 70 years. And in Milan and the surrounding province of
Lombardy, it’s estimated that COVID-19 has taken the lives of 25% of all nursing
home residents. The North American experience has been uncomfortably similar.

“Almost 80% of COVID deaths in Canada have occurred in congregate settings,”

observed Dr. Reichman, professor of psychiatry at the University of Toronto, and
president and CEO of Baycrest Health Sciences, a geriatric research center.

“Certainly, the appalling number of deaths in nursing homes is the No. 1 horror of
the pandemic,” declared Carmelle Peisah, MBBS, MD, a psychiatrist at the
University of New South Wales in Kensington, Australia.

The fire next time

The conventional wisdom holds that COVID-19 has caused all sorts of mayhem in
the delivery of elder care. Not so, in Dr. Reichman’s view.

“I would suggest that the pandemic has not caused many of the problems we talk
about, it’s actually revealed problems that have always been there under the
surface. For example, many older people, even before COVID-19, were socially
isolated, socially distant. They had difficulty connecting with their relatives,
difficulty accessing transportation to get to the store to buy food and see their
doctors, and to interact with other older people,” the psychiatrist said.

“I would say as well that the pandemic didn’t cause the problems we’ve seen in
long-term congregate senior care. The pandemic revealed them. We’ve had
facilities where older people were severely crowded together, which compromises
their quality of life, even when there’s not a pandemic. We’ve had difficulty staffing
these kinds of environments with people that are paid an honest wage for the very
hard work that they do. In many of these settings they’re inadequately trained, not
only in infection prevention and control but in all other aspects of care. And the
pandemic has revealed that many of these organizations are not properly funded.
The government doesn’t support them well enough across jurisdictions, and they
can’t raise enough philanthropic funds to provide the kind of quality of life that
residents demand,” Dr. Reichman continued.

Could the pandemic spur improved elder care? His hope is that health care
professionals, politicians, and society at large will learn from the devastation left by
the first surge of the pandemic and will lobby for the resources necessary for much-
needed improvements in geriatric care.

“We need to be better prepared should there be not only a second wave of this
pandemic, but for other pandemics to come,” Dr. Reichman concluded.

The speakers indicated they had no financial conflicts regarding their

presentations.