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 Table of Contents  
COMMENTARY
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 215-218

Mental health aspects of the geriatric population: Focus on COVID-19 outbreak


Department of Psychiatry, PGIMS, Rohtak, Haryana, India

Date of Submission12-May-2020
Date of Decision05-Jun-2020
Date of Acceptance21-Jun-2020
Date of Web Publication24-Sep-2020

Correspondence Address:
Dr. Shipra Singh
Department of Psychiatry, PGIMS, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_37_20

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  Abstract 


The new coronavirus has had a multifaceted impact on humans and has affected nearly everyone, some more than the other. The elderly is one such population, which has been hit in various ways. They are a vulnerable group of being the frequent victim of the infection and also getting succumbed to it. In addition, the mental health issues posed by the effect of this pandemic and the measures adopted to curb its spread have taken a toll and probably would continue long after this is over. In the scenario, with respect to geriatric mental health, emphasis may be made on individual and societal responsibilities rather than solely depending on the specialized mental health-care services. This article observes the vulnerabilities and mental health issues of the elderly in relation to this pandemic and possible measures at various levels.

Keywords: COVID-19, elderly, mental health


How to cite this article:
Khurana H, Singh S, Bhardwaj S, Parkash R, Bhardwaj A, Deshwal S, Aggarwal N, Batra I. Mental health aspects of the geriatric population: Focus on COVID-19 outbreak. Ann Indian Psychiatry 2020;4:215-8

How to cite this URL:
Khurana H, Singh S, Bhardwaj S, Parkash R, Bhardwaj A, Deshwal S, Aggarwal N, Batra I. Mental health aspects of the geriatric population: Focus on COVID-19 outbreak. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Jan 22];4:215-8. Available from: https://www.anip.co.in/text.asp?2020/4/2/215/295905




  Introduction Top


COVID-19 or “2019 novel coronavirus (2019-ncov)” is a new type of viral pneumonia, which has impacted several lives and has been steadily increasing its reach to the extent of becoming a pandemic. The virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus, was initially detected in Wuhan, China, in 2019 and has spread to several other countries since that time.[1] The new coronavirus is structurally similar to the SARS virus; however, it differs in other aspects. As compared to the SARS virus and Middle East Respiratory Syndrome virus, the estimates of case fatality rate (CFR) for SARS-CoV-2 are less, but the spread is much higher, making it less deadly but more infectious than similar viruses of its kinds.[2]

According to the Centers for Disease Control and Prevention, the virus has been detected in over 215 countries as of the beginning of the 1st week of June 2020. At this point, around 6.4 million people are affected by COVID worldwide, and mortality is nearing to 0.38 million. It spreads to humans primarily through aerosols or respiratory droplets, direct contact, and fomites. COVID-19 causes mild or uncomplicated illness in the majority of the affected people, around 14% develop severe disease requiring hospitalization, and 5% require admission to an intensive care unit. The mortality rate of COVID-19 is found to be 3.4% as of the beginning of March 2020. COVID-19 pandemic is a public health disaster, which has grave social, psychological, economic, and mental- and health-related consequences and complications.[3]


  Elderly and Vulnerability Top


This pandemic has a widespread impact, more so, for the elderly population. It has been found that the elderly are at elevated risk of developing serious illness and death due to novel coronavirus. The case–fatality ratio increases with age; for <60 years is 0.318% and >60 years is 6.38%.[4]

The elderly are a source of experience and wisdom and have a historical memory of how, over time, populations have dealt with critical situations. However, they run the risk of being vulnerable to ill health (physical, psychological, and social) due to various reasons, which are applicable in the face of the current pandemic as well. To begin with, they generally have preexisting comorbidities, and most of the chronic illnesses contribute to deteriorating one's immune system. According to a study on the current pandemic, patients who did not have any comorbidities had lower CFR (proportion of people who die from a specified disease among all individuals diagnosed with the disease over a certain period) of 0.9%, whereas those who had comorbid conditions had higher CFR (10.5% for those having preexisting cardiovascular disease, 7.3% for those having diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer).[5] In addition, there is a decline in immunity with aging.[6]

The graying population has another disadvantage in terms of health in the face of COVID. As the virus has taken a heavy toll on the health-care system of nearly every country, it has become difficult for the elderly to seek treatment for their other chronic conditions, to have regular visits to their physicians, to get their investigations done routinely as the laboratories are also having exhausting lists, to get the blood samples taken at home as now they fear the risk of getting infected, etc., Even at times of critical health due to infection by the COVID, the triage system now implemented in few countries puts the elderly lower down on the list to be treated aggressively.

Apart from physical factors, the elderly are a vulnerable group because of other reasons. In many countries, a large number of elderly are residing in settings such as a nursing or retirement home, where the risk of getting infected increases. The elderly might also have isolation or mobility challenges. They might be living alone, without a family, or without an adequate social support network. This can become a hindrance in receiving appropriate and timely information about the status of the disease, what to do, and what not. In many societies, seniors are more likely to live in poverty, which makes it more difficult for them to meet their daily requirements and take care of themselves.[7]

Harassment and maltreatment by family members frequently become hindrance among the elderly in getting proper health care due to their physical and economic dependence, along with interpersonal issues and declining moral values in the younger generation.[8]

Resilience, i.e., the ability to stand up to adversity and to “bounce back” or return to a state of equilibrium following individual adverse episodes gets affected with aging. Physical resilience gets compromised; however, mental/psychological resilience often gets stronger with aging. In general, with adversity continuing, resilience as the ability, or learning how, to cope with or manage that adversity in the longer term is also compromised. Thus, even during pandemic situations like COVID-19, the elderly, instead of being considered vulnerable and passive recipients of care, should be allowed to take part in the caregiving process. They should be cared for in a manner so that they participate in society, realize their potential, and maintain social and mental well-being while getting adequate protection and security from society. Unfortunately, this aspect of care is not yet highlighted in the scientific literature and popular media during this pandemic time. Such an approach would also ensure their autonomy and dignity in the whole process of caring and getting cared for.[9],[10]


  Covid-19 and Mental Health Issues in Elderly Top


In terms of mental health, a major epidemic implies psychosocial disturbance that can exceed the affected individual's capacity to handle the situation. The effects on mental health are usually more marked among populations living under precarious circumstances, who have limited resources and access to social and health services. Various mental health issues related to epidemics, which can be classified as follows: emotional (heightened emotional reaction including fear, shock, irritation, anger, sadness, and apprehension), psychosomatic (in the form of disturbances sleep and appetite, palpitation, headache, breathlessness, etc.), cognitive (which in the postepidemic phase can occur in the form of recurring thoughts and memories of untoward incidents, nightmares, flashbacks, memory issues, difficulty concentrating, etc.), and behavioral and attitudinal (in the form of interferences in social connectedness, disruption of routine and habits, motivation, loss of energy and interest, etc.)[11] An overall increase in psychiatric morbidity is observed in the face of such disasters. This pandemic is no different and may lead to various such issues:

Mental health issues in the elderly in general

Fear of uncertainty is something specific to such pandemics, where we can see our fellow countries, which encountered this condition before us and are still fighting with the gradual exhaustion of their resources and still unable to find the end of it.

Second, the fact that the severe symptoms and mortality is higher in the elderly and repeated reminders of these by their family members and media can lead to excessive anxiety. Excessive concern and worry for their spouses and children may also increase the stress level in older individuals.[12]

Lockdown and social distancing have also hit the elderly,[13] who are already experiencing loneliness. Moreover, in times, such as these, when they are advised not to go out of the house, their available contacts and social encounters also get compromised, leading to further isolation. Staying at home continuously may lead to anxiety on the one hand and boredom on the other, generating out of a monotonous routine.[7] With not many activities left that can be done, access to excessive information about infection through various social media networks may cause additional stress. Lockdown, thus, generated a sense of insecurity and helplessness coupled with multiple health issues.

Elderly affected with COVID

There may be a feeling of ostracism, abandonment, and being neglected in the elderly when they are isolated and might also avoid reporting of being affected. They can develop fear and anxiety, thinking about the worst possible outcomes. In addition, they might develop undue guilt for possible spread of infection through them and consequently worrying about the safety of the family members. Moreover, in case, if quarantined, they may feel lonely, isolated, stressed, or even bored. They may become sad, angry, or agitated due to the uncertainties waiting ahead and for not being able to be present with the family at such critical time.

Elderly with preexisting mental illness

A significant number of patients with mental illness require continued and long-term treatment. COVID has created a disruption in the continuity of their treatment in various ways: routine outpatient services in various hospitals are suspended, the probability of getting infected if going out,[14] disruption in the supply of medications, etc., In addition to this, patients with conditions such as anxiety or depression might get overwhelmed with the information overload. Such elderly (especially those with cognitive decline), when symptomatic or in quarantine/lockdown, may experience severe symptoms or may become excessively agitated or withdrawn.


  Measures Top


Within the available framework of services, in the current scenario, rather than extending the mental health plans to provide specialized services, emphasis should be on individual and societal responsibilities.

Role of elderly individuals

The elderly should be allowed to keep themselves aware of the outside world and of the news and advisories issued by the government and clinicians, which are directly useful to them. They should be provided a reasonable amount of information as per their need and interest, such as the need for sanitization and social distancing, which is vital for their care.

Utilizing their psychological assets and social status in Indian families, they should be involved in instructing other family members and creating an environment of care within the family. Such involvement would automatically remind them of taking care of themselves also, thus reducing the burden of care on the family. Involving them in the care and well-being of others would improve their self-esteem and feeling of well-being and make them empowered.

Overloading them with information about COVID can be counterproductive due to their cognitive vulnerabilities. Any information such as new cases, death statistics, etc., frequently being informed through popular media does not constitute an essential piece of information for them. This information may be shared with them depending upon their interest. In any instances, where such information creates any unpleasant emotions among them, the family members should be sensitive enough to address their worries adequately and provide them such information judiciously.

They should try to maintain proper hygiene and nutrition. Taking care of any comorbid condition is equally essential, and therefore, it is preferable to have adequate ongoing medications with them. They must try to maintain physical distancing and preferably stay at home. However, at the same time, it should not mean isolation or loneliness to them. The elderly should be allowed to remain connected with the family members following social distancing, through technology (call or videoconferencing) if not staying with them. Connecting with friends and neighbors is also important. As having tremendous life experiences, they can be a source of help and support to others as well. By narrating their experiences, they can encourage the young family members to face the situation boldly. This may be the best time to keep calm with spiritual practices. Exploring one's interests and hobbies can put them at ease and take their minds off the infodemic prevailing at present. Helping little children learn old-time games and craft can be the favorite time pass in many families.

Those having preexisting mental illnesses should be careful of treatment adherence. They may utilize the resource of telemedicine provided by many clinicians and agencies, thus avoiding the hospital visit. Moreover, one must understand that experiencing occasional anxiety would be probably normal, keeping in mind the uncertainty of this pandemic.[15]

Role of caregivers

Dependency creates a feeling of despondency and loss of self-esteem. Let, the caregiving process toward the elderly not create such feelings. The family caregivers and the elderly can share the mutual role of caregiving for each other. The young family members can be physically active in arranging assets for the family, whereas the elderly can help them in planning and foreseeing the family needs with their experience and vision. Besides that, the caregivers can help the elderly become involved in activities like some household chores as per their interest and physique, such as engaging children in activities such as puzzles, and storytelling. Making them organizing old photos and sitting through with their inspiring stories can help them reminisce about their old times. Helping them learn how to do video chats or learn applications on devices can make them feel empowered and independent. If staying far, one must try and ensure the availability of essentials to them, can have a friend or neighbor, and take a regular check on them.[16] Such maneuvers would make them feel useful and valued to the family as desired for everyone in the family.[8]

Role of community

There have been repeated evidence that the society has a negative stereotyped attitude toward the elderly, which ultimately leads to loss of dignity and empowerment of the elderly.[9],[17] Such stereotypes may lead to inadequacies in the care of the elderly in the pandemic situation.[18] Everyone has a role to play in this time of the pandemic. As an administrator, it is essential to provide adequate facilities at the hospitals and elderly care homes. As a neighbor in the community, one should be available and check on elderly people living in our neighborhood or community and help them so they are going out of home also could be avoided, and they remain safe. In addition, it would help them being socially connected give a sense of belongingness and valued.

During this crisis, the perspective needs to shift to a much broader and feasible area, such as humanitarian and social assistance; mass communication aimed to restore dignity, preventing stigma and abuse along with empowering the elderly both during and after the pandemic.[19]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res 2020;7:4.  Back to cited text no. 1
    
2.
Are Coronavirus Diseases Equally Deadly? Comparing the Latest Coronavirus to MERS and SARS. Available from: https://www.nbcnews.com/health/health-news/coronavirus-diseases-comparing-covid-19- sars-mers-numbers-n1150321. [Last accessed on 2020 May 06].  Back to cited text no. 2
    
3.
Mental Health and Psychosocial Considerations during COVID-19 Outbreak. World Health Organization; 2020. p. 1-6.  Back to cited text no. 3
    
4.
Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, et al. Estimates of the severity of coronavirus disease 2019: A model-based analysis. Lancet Infect Dis 2020;20:669-77.  Back to cited text no. 4
    
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Surveillances V. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly 2020;2:113-22.  Back to cited text no. 5
    
6.
Nikolich-Žugich J. The twilight of immunity: Emerging concepts in aging of the immune system. Nat Immunol 2018;19:10-9.  Back to cited text no. 6
    
7.
Aravind I. Covid-19: Why social distancing is a big worry for senior citizens. The Economic Times; 2020. Availablefrom: https://m.economictimes.com/news/politics-and-nation/covid-19-why-social-distancing-is-a-big-worry-for-senior-citizens/articleshow/74866566.cms. [Last accessed on 2020 May 06].  Back to cited text no. 7
    
8.
World Health Organization. Active Ageing: A Policy Framework. Geneva: World Health Organization; 2002.  Back to cited text no. 8
    
9.
Lothian K, Philp I. Care of older people Maintaining the dignity and autonomy of older people in the healthcare setting. Br Med J 2001;322:668-70.  Back to cited text no. 9
    
10.
Press Trust of India. Over 71 pc Senior Citizens in India Victims of Abuse by Family Members: Survey. Economic Times. Press Trust of India; 2019.  Back to cited text no. 10
    
11.
Satapathy S. Mental health impacts of disasters in India: Ex-ante and ex-post analysis. Economic and welfare impacts of disasters in East Asia and policy responses. ERIA Research Project Report. 2011;8:425-46.  Back to cited text no. 11
    
12.
Parkar SR. Elderly mental health: Needs. Mens Sana Monogr 2015;13:91-9.  Back to cited text no. 12
[PUBMED]  [Full text]  
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Melamed S. Isolation is linked to decline for seniors. That makes social distancing a frightening prospect. Philadelphia Inq 2020. Available from: https://www.inquirer.com/health/coronavirus/coronavirus-covid-elderly-safe-visit-loneliness-isolation-social-distancing-20200409.html. [Last accessed on 2020 May 05].  Back to cited text no. 13
    
14.
Yao H, Chen JH, Xu YF. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry 2020;7:e21.  Back to cited text no. 14
    
15.
Health Advisory for Elderly Population of India during COVID19. Available from: https://www.mohfw.gov.in/pdf/AdvisoryforElderlyPopulation.pdf. [Last accessed on 2020 May 06].  Back to cited text no. 15
    
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Coronavirus and COVID-19: Caregiving for the Elderly. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-caregiving-for-the-elderly. [Last accessed on 2020 May 06].  Back to cited text no. 16
    
17.
Gallagher A, Li S, Wainwright P, Jones IR, Lee D. Dignity in the care of older people – A review of the theoretical and empirical literature. BMC Nurs 2008;7:11.  Back to cited text no. 17
    
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Davis Y. How Government 'Failed the Elderly' in the Coronavirus Pandemic. New York Times; 2020. Available from: https://www.nytimes.com/2020/04/22/opinion/letters/coronavirus-nursing-homes.html. [Last accessed on 2020 May 06].  Back to cited text no. 18
    
19.
Gomes R. UN Urges Respect for Rights, Dignity of Elderly During Covid-19. Vatican News; 04 May, 2020. Available from: https://www.vaticannews.va/en/world/news/2020-05/un-guterres-elderly-rights-dignity- covid-19.html. [Last accessed on 2020 May 06].  Back to cited text no. 19
    




 

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