Mental Health in Older Adults
On October 10, 2020, the World Health Organization (WHO) will host its annual mental health day, highlighting the need for expanded mental health services around the world. The thrust this year is on the impact of COVID-19 on mental health. As we recognize the importance of the work being done by the WHO we want to take note of the impact of the pandemic on our frail elders in the post-acute, long-term care world as well.
Mental Health in Frail Elders Every Day
The mental health of the residents in the post-acute and long-term care world is always important and worthy of our attention. The WHO puts mental health problems as present in 15% of adults over age 60 (Fact Sheet). That figure is higher if the person resides in a nursing home for their mental health is affected by both psychological diagnoses and also neurological conditions as well. Depression and dementia are the two more common forms of mental illness in institutionalized older adults and to that, we would add neurologically driven mental health problems such as Parkinson’s’ Disease Psychosis.
Mental health issues are often underdiagnosed by clinicians and under-reported by nursing home residents. There is still a stigma attached to mental health diagnoses and a somewhat common acceptance by the resident of their mood or feelings being the result of aging rather than a sign of a diagnosis that could be treated. As professionals caring for this population, we need to be aware of the potential for mental health issues and be prepared to act.
Risk Factors for Mental Health Problems Among Our Residents
Many of our residents suffer from chronic depression. It may have been treated at one point in their life and now recurred or it may have been present all along but underreported or inadequately treated. Some will become depressed as they contemplate the losses occurring as a result of their frailty and its impact on the abilities they used to have but have no more.
Some physiological conditions have higher rates of associated mental illness. For example, those with heart diseases have a greater incidence of depression. Likewise, untreated depression will impact cardiac outcomes and pain management (Fact Sheet). Finally, as noted earlier, neurological diagnoses are often accompanied by mood and behavioral disorders.
In the current nursing home environment, where quarantine, isolation, and restricted visitors are now the norm, we are seeing an increase in depression and anxiety and the long-term mental health impact from the pandemic is yet to be known.
Specific Mental Health Conditions
Dementia is a syndrome in which there is deterioration in memory, thinking, behavior and the ability to perform everyday activities. It is estimated that 50 million people worldwide are living with dementia and a significant number of nursing home residents have dementia. The degree of cognitive impairment, from dementia, runs parallel to the degree of frailty present in the resident (Rockwood, 2005). So the resident who is moderately demented is likely moderately frail, needing help with personal care, and experiencing behavior changes, such as wandering and repeated questioning.
Age is the strongest known risk factor for dementia, but it is not an inevitable consequence of aging. There is no treatment proven to prevent dementia or medication to cure it. Studies show that people can reduce their risk of dementia by getting regular exercise, not smoking, avoiding harmful use of alcohol, controlling their weight, eating a healthy diet, and maintaining healthy blood pressure, cholesterol, and blood sugar levels.
For the nursing home resident with dementia, it is not feasible to implement many of these risk-reducing options. Their dementia is usually advanced and possibly the reason why they no longer reside in the community. In caring for them we:
- Optimize their physical health, cognition, activity, and well-being
- Identify and treat accompanying physical illness
- Detect and treat challenging behavioral and psychological symptoms
- Manage their physiological frailty to prevent worsening of their dementia
Depression is a common mental disorder, both globally and in the nursing home population. Depression affects functioning in older adults and is often dismissed because the signs and symptoms are similar to those of concurrent illnesses. Depression in the nursing home population often presents as somatization, with physical complaints not grounded in physical illness. Since there are quality of life consequences for those living with depression it is incumbent on professionals in the nursing home setting to assess the resident for depression. Fortunately, there are effective psychological and pharmacological treatments for moderate and severe depression.
To treat we must assess and diagnose the presence of depression. The Patient Health Questionnaire (PHQ-9) and the Patient Health Questionnaire Observational Version (PHQ-9 OV) are available In the nursing home to assess for the presence of depression. They both provide an overview of depressive symptoms and are used to provisionally diagnose depression and grade severity of symptoms. These are reliable and validated assessment tools and an excellent starting point in the plan to treat the resident with depression.
Anxiety is also a common mental health condition among older adults, affecting as many as 10-20 percent of the older population, though, like depression, it is often undiagnosed. Older adults often do not recognize or acknowledge their symptoms. Some residents have suffered symptoms of anxiety for most of their lives and believe the feelings are normal. Others may dismiss the anxiety as something expected “under the circumstances” and not expect it should or could be relieved. Since untreated anxiety can lead to cognitive impairment, disability, poor physical health, and a poor quality of life, we must be diligent in diagnosing and treating the condition. Fortunately, anxiety is treatable with prescription drugs and therapy.
How Has The Pandemic Impacted the Mental Health of Nursing Home Residents
Older adults, especially in isolation and those with cognitive decline or dementia, often become more anxious, angry, stressed, agitated, and withdrawn during the outbreak or while in quarantine. Many residents have sustained severe and potentially irreversible physical, functional, cognitive, and mental health declines. (Stall, 2020) One impact of note has been weight loss and anxiousness created by isolation, fear of caregivers in PPE, inadequate available staff to help at meals, and the overall change in routine and increased chaos. (Danlivoch 2020)
There is more debate now in the media and medical literature about this collateral damage caused by protecting the residents from the harm of COVID while increasing the risk for other negative outcomes. The right balance of risk and benefit is now being given more thoughtful consideration and as some nursing homes are slowly opening up to volunteers and visitors it is anticipated that some of the mental health and physical impacts can be modified, reversed, stabilized, or managed.
It is anticipated that the level of frailty present in the residents will also increase as residents have not received the same amount of exercise, therapy, and activities. The functional declines may be reversible as therapy resumes but it will take time and likely medication to manage and reverse the emotional toll taken by the months of isolation, inactivity, and separation from support systems and significant relationships.
The pandemic is not likely to go away for many more months and new approaches are needed if further declines are to be prevented. While physical health and well being are very important and scrupulous infection control is required, there is also a critical need to rethink many of the other policies put in place at the outset of the pandemic.
As the World Health Organization holds forth in recognition of the need for mental health services around the world, professionals caring for the frailest and most vulnerable residents can be challenged to reflect on the mental health conditions present in the nursing home and refocus our efforts on addressing the most pressing issues now while we wage a war against the coronavirus.
Danilovich MK, Norrick CR, Hill KC, et al. Nursing Home Resident Weight Loss during COVID-19 Restrictions. JAMDA (2020), doi:https://doi.org/10.1016/j.jamda.2020.08.032.
FACT SHEET, Mental Health of Older Adults, World Health Organization, December 12, 2017.
Rockwood K. Clinical Frailty Scale. Division Of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada 2005.
Stall NM, Johnstone J, McGeer AJ, et al. Finding the Right Balance: An Evidence-Informed Guidance Document to Support the Re-Opening of Canadian Nursing Homes to Family Caregivers and Visitors during the Coronavirus Disease 2019 Pandemic. J Am Med Dir Assoc. 2020 Oct;21(10):1365-1370.e7. doi: 10.1016/j.jamda.2020.07.038.