Throughout the course of the pandemic, the mental health of many has suffered due to social isolation, disruptions to daily living, and limitations in participating in previously enjoyed activities. This article provides an overview about the mental health impacts of COVID-19 in the lives of older adults, with a special focus on isolation, loneliness, and trauma. The author elucidates the inequities seen in mental health impacts and offers a call to action for the future of older adult mental health care.
older adults, intersectionality and mental health, remote and mobile-based interventions
The COVID-19 pandemic has led to serious impacts on the psychological well-being of older adults. Factors such as social distancing guidelines, disruptions to daily routines, and limited access to medical and mental health care (Haider, Tiwana, & Tahir, 2020) have created an unprecedented risk for worsening mental health. In a recent review examining the impact of COVID-19 on the mental and physical health of aging populations, findings suggest that close to 30% of older adults reported loneliness and among those in this group, they were 17.2 times more likely to be at risk for depression and 10.8 times more likely to experience anxiety (Robb et al., 2020).
The pandemic also has been seen as a potential traumatic stressor, particularly for older adults with chronic post-traumatic stress disorder (PTSD). While COVID-19 remains a public health threat, with an increased push toward returning to pre-pandemic activities, the mental health impacts exhibited during this time by older adults warrant further attention. Closer examination of the mental health impacts of social isolation, loneliness, and trauma among older adults is important as it may lead to differential outcomes regarding their future psychological care needs. These long-term impacts also can adversely affect older adults’ ability to bounce back. The focus of this article is to clarify mental health considerations around social isolation, loneliness, and trauma among older adults, and to bring attention to multicultural ramifications.
COVID-19 and Social Isolation
Historically, older adults have been more socially isolated than younger adults (e.g., due to changes in social relationships, and changes in health), yet they derive great meaning from the relationships they have (Gorenko et al., 2021). During the pandemic, social isolation has been even more pronounced for adults older than age 65, those who are immunocompromised, and those with preexisting conditions that put them at heightened risk for contracting COVID-19 (e.g., lung cancer).
As public health officials implemented recommendations to reduce transmission risk, for many older adults mandates for social distancing led to unintended consequences severely impacting their psychological well-being. Social isolation now is considered a major public health concern—one in two older adults are at risk for the condition (Fakoya, McCorry, and Donnelly, 2020). The necessity of older adults being more socially isolated due to COVID-19 restrictions has magnified the development and exacerbation of depression and anxiety symptoms (particularly among those with preexisting mental health conditions).
Also, it is important to note that among older adults who were living in long-term care (LTC) communities, social distancing rules created significant limitations in their ability to meaningfully engage with others. Many of these older adults residing in LTC often needed around-the-clock support to perform activities of daily living and to cope with difficulties that arose from living with chronic health conditions (e.g., diabetes, stroke, and dementia). During this time of social distancing as well as recommendations made by the Centers for Disease Control and Prevention (CDC) (CDC, 2020a) created limits as to who and how often family members, nonessential personnel, and volunteers could visit residents. For LTC residents who were isolated and experiencing anxiety about contracting the virus (due to the high volume of COVID-19–related deaths in LTC) many became highly vulnerable to increased symptoms of nervousness, worry, and depression (Haider, Tiwana, & Tahir, 2020; Manca, De Marco, & Venneri, 2020).
For isolated LTC residents experiencing anxiety about contracting the virus, many became highly vulnerable to nervousness, worry, and depression.
These mental health impacts were not only widespread among those living in LTC settings without cognitive impairment, but even greater among those with dementia. Recent data suggests that upward of 60% of patients exhibited worsening cognitive decline due to social isolation (Boutoleau-Bretonnière et al., 2020).
There also was an increase in challenging behaviors among those with dementia (Padala, Jendro, & Orr, 2020) or with serious mental illness (Fahed, Barron, & Steffens, 2020). Unfortunately, due to the shortage of providers and care workers in LTC settings, challenging behaviors became increasingly difficult to manage among staff (Manca, De Marco, & Venneri, 2020).
COVID-19 and Loneliness
During the pandemic, loneliness was another growing concern for older adults that is distinct from social isolation. As reflected in the research literature, individuals who are socially isolated may not always feel lonely and those with full access to large social circles can still experience a sense of feeling alone. Recent data highlight that almost half of the older adult population will experience periods of loneliness later in life (Grover, 2019) and that close to 5% will report chronic loneliness (Berg-Weger, 2020).
For those experiencing loneliness, reports also suggest that these individuals are at heightened risk for impaired physical health (Molloy et al., 2010), worsening cognitive functioning (Lara et al., 2019), as well as high levels of depression (McHugh Power et al., 2020). Older adults experiencing feelings of loneliness may also inadvertently put significant strain on their caregivers, thereby impacting interpersonal relationships.
Of note, there have also been associations linking loneliness and reactivity to negative events and life stressors. For example, loneliness has been associated with greater anxiety, depression, increases in cognitive decline, impaired health, and even increased mortality risk. More recently, research on loneliness in older adults during the pandemic has received increased attention with two key studies highlighting important findings. In one study by Parlapani and colleagues (2020), 82% of older adults reported severe depression, 85% reported moderate to severe anxiety, and close to 40% indicated disruptions in sleep. Those who reported living alone versus with spouses or family members indicated higher levels of loneliness.
In a second key study by Kotwal and colleagues (2021), community-dwelling older adults and those receiving outpatient geriatric care in an academic practice self-reported on their loneliness and mental health symptoms during the pandemic. Among this participant population more than 60% lived alone, more than half had hearing impairment, and close to a third said they had difficulty with bathing and grooming. Study findings indicated that participants shared experiencing increased loneliness as a function of the pandemic; and the loneliness was associated with worsening depression and anxiety. Nearly 75% of all participants noted reduced or limited socialization with video-based technologies. Overall, study results revealed that older adults were having difficulty coping, were struggling with significant emotional difficulties, and exhibited high discomfort in using new technologies.
COVID-19 and Trauma
A burgeoning area of clinical research needing greater attention is the potential of experiencing traumatic symptoms due to acute (and now prolonged) life-stressors brought on by the pandemic. Susceptibility to traumatic emotional responses in older adults during this time falls into two categories. The first is increased trauma symptomatology due to preexisting post-traumatic stress disorder (PTSD). The second is experiencing trauma or PTSD resulting from being a COVID-19 survivor.
In one study, 82% of older adults reported severe depression, 85% reported moderate to severe anxiety, and nearly 40% indicated disruptions in sleep.
To the former, a recent study examining differences in older adults with PTSD, and older adults exposed to traumatic events (with no history or diagnosis of PTSD), found higher levels of depression and anxiety among those with chronic PTSD (Rutherford et al., 2020). They also were more likely to live alone, experience hypervigilance to media coverage of the pandemic, and said they had more physical ailments. No group differences on changes in depression during the pandemic were found; however, older adults with PTSD who did not identify as a racial or ethnic minority admitted to having greater depression compared to Black or Hispanic participants with PTSD.
The above findings highlight important areas for future research. Specifically, contextualizing how the pandemic is experienced by diverse older adults with a history of PTSD is needed. Moreover, the study of differential impacts of the pandemic across sub-groups of older adults can reflect how prior sources of resiliency and post-traumatic growth can buffer against the adverse effects of the COVID-19 pandemic. Among older adults surviving the coronavirus, it remains to be seen how such an acute stressor can later converge to a formal diagnosis of PTSD. Lastly, the trauma of this pandemic is also an important consideration for older adult providers in the healthcare system.
The pandemic also has highlighted notable health and mental health disparities among racially and ethnically diverse older adults. Of late, greater attention has been given to the concept of intersectionality and its relevance to the impacts and challenges presented by COVID-19. The concept of intersectionality posits that holding multiple intersecting identities, which historically have been marginalized (e.g., based on age, race/ethnicity, gender, disability status, socioeconomic status), create disadvantages among groups leading to differential access to resources, opportunities, and access to care.
In the United States alone, rates of hospitalization as well as COVID-19–related deaths in older adults has been greater among communities of color. Black, Latino/Latina/Latinx, and Indigenous people have a higher risk of contracting COVID-19 compared to Whites (CDC, 2020b). Within communities of color, African Americans and Blacks have been most severely impacted with higher rates of infection, hospitalization, and death.
The cumulative disadvantages among diverse older adult communities raised above underscore continued disparities also seen in mental health. In a national U.S. study by Bui and colleagues (2021) examining emotional distress among racially and ethnically diverse older adults during the COVID-19 pandemic, findings suggest that older adults of color compared to Whites endorse high rates of stress and emotional distress. Results from multiple race-ethnic group analyses indicated that in Latinx older adults the association between distress and expected household income loss was higher compared to White older adults. For older African American and Black older adults, they reported significantly higher rates of COVID-19–related stressors than older White adults.
Asian Americans also have been experiencing compounding stressors during the pandemic because of hate crimes, stigma, and racial discrimination. Depression rates prior to the pandemic compared to now have nearly doubled (Lozano et al., 2021). Asian American older adults also exhibit higher levels of emotions distress, food insecurity, and lower rates of delayed or skipped medical care compared to White older adults (Bui et al., 2021). In a global study of mental health during the COVID-19 pandemic, participants from Central Asia reported higher depression than those from 33 other countries, and higher anxiety than older adults from Latin America and the Caribbean (Tyler et al., 2021).
Depression rates prior to the pandemic compared to now have nearly doubled in older Asian Americans.
Similar trends in mental health also have been found among diverse older adults living alone with cognitive impairment. Via use of ethnographic interviews in 24 diverse older adults, Portacolone and colleagues (2021) highlighted significant unmet needs in this older adult population. Qualitative analysis revealed that diverse older adults with cognitive impairment faced extreme isolation, held beliefs based upon inaccurate and misleading misinformation, and experienced symptoms of distress, fear, loneliness, and confusion about the pandemic. Overall, these findings underscore how diverse older adults living with late-life disabilities can be severely impacted by the current pandemic.
Call to Action for New Solutions and Approaches
Clearly, there is a need for mental health or supportive interventions that offer older adult populations opportunities to socially engage with others via telephone, video, or through social media platforms. And recent literature reviews have examined how said interventions reduce isolation, loneliness, and other symptoms of distress.
Of note, interventions that incentivize older adults to pursue activities that keep them engaged (i.e., behaviors that “activate” healthy emotions and thoughts) can significantly help reduce loneliness, isolation, cognitive decline, depression, and anxiety. As COVID-19 restrictions remain in place in some areas, now more than ever the availability of remote-delivered interventions to reduce mental health symptoms as well as loneliness is critically important. Despite misconceptions surrounding older adults’ disinterest in or aversion to using technology, many are comfortable in using digital platforms. Upward of 73% of people ages 65 and older use the internet, and close to 60% say that technology has a positive impact on society (Anderson & Perrin, 2017).
Older adults with access to computers, smartphones, and other technology can actively engage in interventions that support their well-being. Among those that might feel more technology adverse, when given the opportunity to be oriented to using technology, several endorse greater likelihood of participating in interventions that can help address mental health concerns, or cognitive difficulties (O’Connell et al., 2021).
For older adults without access to digital technology, finding ways to link them to agencies in the community, libraries equipped with computers, and clinics using telehealth will be vital. To date, several remote interventions available for older adults with a cognitive behavioral therapy (CBT) focus suggest that remote-delivered interventions are acceptable and feasible for older adults (Whitfield et al., 2021). Not all intervention requires a therapist, and some offer opportunities for self-guided interventions (Titov et al., 2016). Mobile-assisted CBT interventions also are gaining traction with a high potential impact on improving public health more broadly (e.g., by increasing access and improving equity).
The COVID-19 pandemic has had an adverse negative impact on the mental health of individuals across the lifespan and in particular among older adults ages 65 and older. As we continue to live through this pandemic and uncover the continued effects of COVID-19 it is important that we pay close attention to the mental health and well-being of older adult populations. Finding new solutions as well as approaches that can improve the overall psychological health of older adults is more than warranted.
Katherine Ramos, PhD, is an assistant professor in Psychiatry and Behavioral Sciences, an assistant professor of Medicine, an assistant professor in Population Sciences, a senior fellow in the Center for the Study of Aging and Human Development, and a member of the Duke Cancer Institute at the Duke University School of Medicine in Durham, NC.
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