The Impact of COVID-19 on Mental Health in Long-Term Care Settings

November 11, 2020
Marc E. Agronin, MD

The COVID-19 pandemic has affected the mental health of residents in 2 fundamental ways; directly through infection, and indirectly, but more insidiously, through social isolation and other psychological stresses.

CONFERENCE REPORTER

“Nursing home residents aren’t getting half of our resources or half of our attention, yet they account for roughly half the deaths.”

- David Grabowski, PhD, Harvard Medical School1

Nursing homes and other long-term care settings provide an unfortunate perfect storm for pandemics. Most of the residents are old, ill, frail, often immunocompromised, and live in close quarters with roommates and others during congregate dining and activities.2 They are cared for by staff living in the community, many with young children, who then come into the facility and circulate among them every day, in addition to multiple family members who visit frequently. Combine this with unfortunate but inevitable slips in infection control, and a single infectious staff member or visitor can be like a spark to kindling. The rapid onset of the coronavirus disease 2019 (COVID-19) pandemic has highlighted all of these risk factors for infectious spread. There are hundreds of thousands of confirmed or suspected cases in United States nursing homes, and many deaths.3

Direct neuropsychiatric eeffects

The COVID-19 pandemic has affected the mental health of residents in 2 fundamental ways; directly through infection, and indirectly, but more insidiously, through social isolation and other psychological stresses. In addition to its known pulmonary and other systemic effects, the coronavirus known as SARS-CoV-2 can infect the nervous system, with one pathway being directly through the olfactory bulb, and cause a variety of neurological and psychiatric symptoms in at least one-third to one-half of symptomatic individuals.4 Common acute neurological symptoms have been headache and loss of smell and taste, while more concerning symptoms include peripheral neuropathy, delirium, stroke, encephalitis, neurocognitive impairment, psychosis, and mood and anxiety disorders.5 These symptoms are seen acutely and can linger for weeks to months afterwards.6

For any susceptible older individual in long-term care, key indicators of infection may include changes in energy, alertness, concentration, orientation, sleep, and appetite. COVID-19 testing is appropriate for any suspected situation with neuropsychiatric changes, regardless of whether there are respiratory symptoms or classic symptoms of fever and cough. Patients need early psychiatric consultation to ensure rapid identification and treatment of these symptoms, since acute changes can easily lead to long-lasting sequelae. Older individuals, especially those with frailty and dementia, need to be physically mobilized as soon as possible to reduce deconditioning, build confidence, and promote engagement with others.

The impact of stress and social isolation

For the past 7 months, long-term care residents have been confined to their rooms without congregate dining, activities, and in-person family visits. They lack exercise, direct sunlight and fresh air, and a normal level of social interaction. At times, residents have had limited access to medical, mental health, and other therapeutic services. Because the majority of residents are not tech-savvy or even tech-capable, they have been fully and passively reliant on the time and availability of staff to facilitate video chats with family and other loved ones.

The psychological stress of social isolation can be particularly jarring for these individuals, even those already acclimated to some degree of pre-existing social isolation. They spend most of their time alone in their rooms, without in-person contact with family and other loved ones. They are surrounded by staff members rendered less familiar due to masks, gowns, and face shields. Hearing and visual loss can make effective communication very difficult through multiple layers of personal protective equipment (PPE). Residents may be confused and frightened seeing everyone wearing PPE.

Patients may be traumatized by the news on radio or TV, seeing other residents ill or dying, being ill themselves, and by experiencing the disruptions and losses brought on by COVID-19 spreading throughout the facility. Even under the best of circumstances, residents are often bored, lonely, anxious, sad, and confused. Trying to communicate with them can be limited by generational differences across residents and younger staff and family members, further complicating their ability to understand and cope with what is happening.7 These emotional disruptions can lead to new or recurrent mental health conditions, post-traumatic symptoms, and even life-threatening states due to failure to thrive, especially in those who survived infection.5

Is there a solution to these challenges, other than the end of the COVID-19 scourge? Rigorous infection control, including the screening and regular testing of all employees, along with proper and consistent use of PPE, can reduce the risk of residents being infected. Equally important are efforts to attend to the minds and souls of staff and residents with dedication and creativity. Here are several suggestions to help reduce social isolation and improve engagement with residents:

  • Staff have to become like surrogate family members with frequent and more lengthy contacts, and wear photos and name tags on top of their PPE
  • Regular video chats with family members facilitated by social work and/or therapeutic programming staff are essential
  • Regular telehealth visits should be provided by doctors and other therapists
  • Celebratory, fun, and interesting snacks, treats, and programming (eg, music therapy) can be brought to the door, room, and bedside
  • Drive-thru family visits to the facility can be set up, using masks and social distancing
  • Activities can be brought to rooms via video and/or closed-circuit TV

At the same time, the enormous stress on staff from actual and feared exposure at work, financial loss if they miss extended work time when quarantined or sick, and the physical burden of wearing restrictive and hot PPE all day must be recognized and addressed. During previous pandemics, front-line staff have faced an increased risk for anxiety, panic attacks, depression, acute stress reactions, PTSD, and even suicide. Several ways to build up the “emotional PPE” for staff and support them include:

  • Provide multi-lingual staff education on stress identification and reduction 
  • Focus on deep breathing, hydration, taking breaks, and sleep hygiene
  • Hold daily staff huddles with safe social gathering to provide updates, reassurance, inspiration, education, and opportunities to vent and ask questions
  • Teach about proper use of PPE
  • Have a confidential mental health hotline
  • Provide on-site counseling and referrals to Employee Assistance Programs (EAP) or other professional mental health services

We must remember that these frontline caregivers are true heroes, facing daily stress that can be overwhelming. There are effective ways to support them over time, augmented by calling upon the many individuals in the community who want to help. Find them and engage them!

Dr Agronin is a geriatric psychiatrist and senior vice president for Behavioral Health and the chief medical officer for MIND Institute at Miami Jewish Health. His discussed these issues during his “The Top Dos and Don’ts in the Psychopharmacologic Treatment of Geriatric Patients: Focus on Dementia and Late-Life Depression and Anxiety” presentation at Virtual Psych Congress 2020.

References

1. Godfrey E. ‘We’re Literally Killing Elders Now’ - Thousands of Americans in long-term-care facilities have died from COVID-19. My grandmother just became one of them. The Atlantic. April 29, 2020. Accessed September 18, 2020. https://www.theatlantic.com/politics/archive/2020/04/coronavirus-especially-deadly-nursing-homes/610855/

2. Paulin E. How to Track COVID-19 Nursing Home Cases and Deaths in Your State. American Association of Retired Persons. Updated June 11, 2020. Accessed September 18, 2020. https://www.aarp.org/caregiving/health/info-2020/coronavirus-nursing-home-cases-deaths.html

3. COVID-19 Nursing Home Data. Centers for Medicare and Medicaid Services. Updated September 6, 2020. Accessed September 18, 2020. https://data.cms.gov/stories/s/bkwz-xpvg

4. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun, 2020;87:18-22.

5. Rogers JP, Chesney E, Oliver D, et al. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020;7(7):611-627.

6. Varatharaj A, Thomas N, Elllul MA, et al. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study. Lancet Psychiatry. 2020;7(10):875-882.

7. Agronin M. Why It’s So Hard to Talk to Your Parents About the Coronavirus (and Vice Versa). Wall Street Journal. April 29, 2020. Accessed September 18, 2020. https://www.wsj.com/articles/why-its-so-hard-to-talk-to-your-parents-about-the-coronavirus-and-vice-versa-11587236112