Graphical Abstract
The year 2020 brought many changes to assisted living and long-term care communities that staff, residents, and families were not prepared for. In a matter of months, the COVID-19 pandemic infiltrated senior living spaces and brought medical challenges, isolation, and emotional trauma. Residents went through quarantine periods and social withdrawal to prevent the spread of the coronavirus, but tragically some communities still experienced a death rate as high as 50%. The impact of losing friends, the fear of contracting the virus, and the lack of connection with loved ones have led to psychiatric problems in older adults that have yet to be resolved or even addressed.
To provide answers, mental health care professionals are using innovative ways to treat, diagnose, and counsel while educating frontline workers caring for residents in these tough situations. To implement a plan, we must begin by looking at what assisted living and long-term care communities have faced in the past year and how we can prevent these problems going forward.
The Psychological Toll on Residents
Older adults have experienced a disproportionate number of adverse effects since the start of the pandemic. The Centers for Disease Control and Prevention reported that between August 2020 and February 2021 the percentage of adults with recent symptoms of an anxiety or depressive disorder increased to 41.5%, and the percentage of those reporting an unmet mental health care need increased to 11.7%. Though few statistics on this issue are presently available for assisted living or long-term care communities, research has shown that grief and isolation put residents at much higher risk for mood disorders, which often go undiagnosed.
In a study of electronic health records from multiple institutions in the United Kingdom, researchers estimated the incidence of neurological or psychiatric sequelae in 236,000 individuals who were infected with COVID-19. During the 6-month follow-up period, 13% of patients who’d had no history of neurological or psychiatric conditions received a first diagnosis of such a condition. Another 21% of patients who’d had past neurological or psychiatric conditions developed new conditions. The most common diagnoses were anxiety disorder (17.4%), psychotic disorder (2.8%), ischemic stroke (2.1%), dementia (0.7%), and intracranial hemorrhage (0.6%) (Lancet Psychiatry 2021;8:416).
One study on the serious side effects of social isolation concluded that over 50% of the residents living in full-time care or assisted living communities reported feeling lonely during the pandemic (J Am Med Dir Assoc 2020;21: 966–967). Other investigations have found an increase over the last year in the types of mental illness that can be born out of loneliness, including post-traumatic stress disorder (PTSD). In Italy, 30% of COVID-19 survivors were diagnosed with PTSD. The mean age of their sample was 55, all patients were White, and most had been hospitalized during their illness (81.1%), with a mean hospital stay of 18.41 days (MedPage Today, Feb. 18, 2021; https://bit.ly/3B2Qkvf). (Note that psychiatrists are hesitant to formally diagnose PTSD without the three recurring symptoms: flashbacks, nightmares, and present-day triggers cause individuals to reexperience the trauma.)
The evidence is compelling of a global trauma that needs to be treated. Loneliness can accelerate feelings of deliriousness and prompt substance abuse and suicidal thoughts, which makes uncovering the psychiatric needs for older adults so crucial. The older adults who were interviewed by the media frequently expressed the feeling of being “in prison,” both physically and emotionally.
The limitations placed on visits to residents from outside have been especially challenging for those with cognitive impairment and dementia to understand and endure. Their resulting distress has extended the challenges to caregivers and their fellow residents. In addition to having their routines and interactions disrupted, patients with neurocognitive disorders have difficulty interpreting expressions and communicating when faces are obscured by masks.
As more research is collected, we aim to move in a direction that helps older adults feel safe in their living space as well advocated for by the mental health community.
The Challenges for Staff
Dealing with the aftermath of COVID-19 has also had a heavy impact on the caregivers in assisted living and long-term care communities. Treating sick patients and the fear of putting family members at risk caused increase in stress for 8 out of 10 frontline workers, according to a Kaiser Family Foundation survey. Of that population, 34% of those who worked at hospitals or nursing homes say that at some point they experienced a shortage of personal protective equipment (PPE), which only added to their safety concerns.
For about 3 in 10 frontline health workers, the mental health challenges led just under a third of health care workers to obtain mental health care or medications (13%) or to acknowledge the need for such services without actually pursuing them (18%) because they were too busy (27%), afraid or embarrassed about seeking care (17%), unable to afford it (16%), or unable to get time off work (14%) (KFF Newsroom, Apr. 6, 2021; https://bit.ly/3xaXICA).
In an electronic survey, staff at assisted living communities and skilled nursing facilities reported guidance and changing regulations as one of the biggest challenges they faced (J Am Med Dir Assoc 2021;22:199-203). Direct-care staff — and certified nursing assistants (CNAs) in particular — cited fears of becoming infected and of possibly infecting their families.
Another recent report found that 36.3% of health care workers hospitalized with COVID-19 worked in nursing occupations, including nurses and CNAs (MMWR Morb Mortal Wkly Rep 2020;69:1576–1583). The CDC has estimated that at least 585,666 nursing home staff have been infected, and 1,938 have died (CMS, “COVID-19 Nursing Home Data,” June 27, 2021; https://bit.ly/3dupPES).
The complexities frontline workers have faced in assisted living communities and skilled nursing facilities will unveil mental health concerns and the need for better structure and support in times of crisis.
We aim to move in a direction that helps older adults feel safe in their living space as well advocated for by the mental health community
Adapting for the Future
Today, some states are taking steps with technology to combat the problems that manifested during the pandemic. Activities involving visitors typically have required social distancing, PPE, and limited time to meaningfully connect. Technology may provide answers for the residents who will continue to face isolation from loved ones for the foreseeable future.
Telehealth has emerged nationwide. The clinicians who were forced out of assisted living and long-term care communities during the pandemic are now able to connect virtually with their patients.
Reaching the world’s most vulnerable community electronically is an important component to addressing the problems COVID-19 has created. This challenges mental health care professionals to adapt, advance, and analyze these issues, which ultimately will prepare us for the future.
Ms. Coniglio is the president, CMO, and founding member of Psych360 (http://Psych360.org) and a member of the Behavioral Health Council of AMDA – The Society for Post-Acute and Long-Term Care Medicine.
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