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Advocacy and Resources

Social Isolation During COVID-19: Impact on Seniors

by Marianne Soueidi, MD and Rita Khoury, MD
Department of Psychiatry and Clinical Psychology; Saint George Hospital University Medical Center; Balamand School of Medicine
Beirut, Lebanon

Key Highlights:

  • The COVID-19 global pandemic is associated with increased risk of mortality in the older adult population, leading to strict social distancing to prevent infection.
  • Social distancing can lead to isolation with negative impacts on both the physical and mental health of seniors.
  • The physical repercussions of social isolation in the elderly include increased risk of mortality, cardiovascular events, and inflammation.
  • The psychological repercussions of social isolation include sleep disturbances, depressive symptoms, and anxiety.
  • Regular communication through internet applications or phone services are essential for the older adult population to communicate with caregivers and healthcare providers to ensure access to essential items like food, medications, etc.

The first case of the novel coronavirus was described in the city of Wuhan, China, in December 2019. The symptoms include fever, cough and shortness of breath that can progress to severe pneumonia, potentially leading to respiratory distress, multi-organ failure and death. This deadly virus, also referred to as COVID-19 by the World Health Organization, is currently causing a worldwide pandemic and posing a serious public health risk: about 750,000 cases have been reported worldwide to date with around 36,500 deaths and exponentially rising numbers [1].

Although many countries are trying relentlessly to find a vaccine or treatment for COVID-19, such a breakthrough is expected to take up to several months. Hence, the best current strategy relies on prevention of new cases through strict hygiene measures like frequent handwashing, isolating diagnosed cases and their contacts, and imposing social distancing measures [2].

Studies from China and Italy (the two countries with the largest number of COVID-19 cases and related deaths) have shown that fatalities are happening mostly in the older adult population [3]. While older people do not appear to be at an increased risk of contracting COVID-19 compared to younger people, they are at much higher risk of developing serious complications due to medical comorbidities, frailty, or complex medical conditions.  Thus, it is important to protect this vulnerable population from contracting the disease by imposing social distancing/quarantine measures. Protective interventions at nursing homes in the United States include restricting all visitors, volunteers, and other non-essential healthcare personnel and cancelling all group activities [4]. We will discuss the important physical and mental health repercussions associated with isolating older adults, and discuss potential strategies aimed at mitigating the impacts especially on those with cognitive impairment. 

The psychiatric repercussions of quarantine in the general population include the emergence or exacerbation of depressive, anxiety, and post-traumatic stress disorder symptoms. Other psychological symptoms include feelings of anger, irritability and sleep disturbances, which can lead to self-medicating with alcohol or other substances and have consequences lasting long after the  duration of the quarantine [5, 6].

Socially disconnected older adults are more prone to report poor physical and mental health [7]. Studies in older adults have shown that objective social isolation and subjectively perceived loneliness are associated with 30% increased mortality, independent from other risk factors like  health status [8, 9]. Social isolation has also been associated with sleep disturbances and depressive symptoms in the older adult population. [10]. In a study of around 3000 community-dwelling older adults, social disconnectedness predicted higher perceived isolation, which significantly predicted higher depressive and anxiety symptoms; this  relationship was also demonstrated as bidirectional [11]. Chronic social stress is found to be associated with increased cardiovascular risks (hypertension, arteriosclerosis, stroke, etc.) due to activation of the sympathetic nerve system, dysregulation of the hypothalamic -pituitary- adrenal axis, secretion of pro-inflammatory cytokines, oxidative stress, and glucocorticoid resistance [12]. In subjects suffering from cognitive impairment, social isolation may be associated with a more rapid progression of the disease.  In fact, it has been reported that a greater number of social networks and more active social engagement were associated with reduced cognitive decline in old age, after controlling for depressive symptoms, physical activity, socioeconomic status and chronic medical conditions [13].

Specific challenges encountered by the elderly during this pandemic are related to separation from caregivers and their emotional support system. Quarantine measures challenge their independence in activities of daily living and trigger fears related to medication and food shortages as well as uncertainties regarding their future with even fear of death. Particularly, patients with Alzheimer’s disease are more affected by the isolation process, as they are not able to provide for themselves, and will frequently forget infection prevention efforts like hand hygiene or the importance of social distancing away from neighbors or family members. Contracting the infection could place these individuals at even higher risk of cognitive decline with risk of institutionalization and further isolation from  relatives [14].

To mitigate these challenges, several basic needs for older adults and their caregivers should be prioritized. Ensuring access to medications and food can be facilitated by having specific shopping times for older adults or have regular meals delivered directly to their homes.

Other measures include ensuring paid leave to caregivers and expanding telehealth services in all medical specialties, including psychiatry [15]. Psychological services can be provided online: an eight-week internet-based treatment containing cognitive behavioral therapy (CBT) components targeting loneliness was found to be significantly effective in alleviating feelings of loneliness [16]. These services should implemented in each elderly home and fully covered by Medicare or other insurances depending on the country [15]. It is of utmost importance to realize that social distancing does not necessarily mean isolation or giving up on one’s support system and means of communication. Older adults can still get in contact with their loved ones via online technologies. In the case of unfamiliarity with digital resources, older adults must seek help from a relative in the household. Other practical interventions include daily phone calls with family members and loved ones as well as healthcare professionals. In addition, for patients with dementia, visual aids and regular reminders about staying home and washing hands can be used to improve adherence to preventative strategies against the COVID-19 infection.

It is also important to encourage elderly people to carry on with routine activities they find enjoyable and keep mentally, physically and spiritually active; it has been shown that these activities are associated with both physical and mental wellbeing and can delay the onset and progression of dementia [17]. Television channels adapted for older adults with exercise programs, mindfulness exercises, and simply-worded talk-shows with information related to COVID-19 could be very helpful. Also, maintaining a regular sleep schedule is important for seniors with access to pharmacotherapy (i.e. melatonin) if needed, for insomnia.

In conclusion, several efforts need to be put in place to protect seniors and their caregivers from COVID-19 without compromising physical and mental health. Evaluation for other psychiatric comorbidities like post-traumatic stress disorder, alcohol and substance use disorders, and suicidality is also important during the pandemic. Research efforts on investigating the long-term impacts of this pandemic on cognitive functioning should also be explored longitudinally.

For further reading:

  1. WHO Coronavirus disease (COVID-19) Situation Dashboard, available from https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd. Accessed March 30, 2020.
  2. Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/.
  3. Porcheddu, R., et al., Similarity in Case Fatality Rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. J Infect Dev Ctries, 2020. 14(2): p. 125-128.
  4.  https://www.cms.gov/newsroom/press-releases/cms-announces-new-measures-protect-nursing-home-residents-covid-19. Accessed March 28, 2020.
  5. Brooks, S.K., et al., The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet, 2020. 395(10227): p. 912-920.
  6. Hawryluck, L., et al., SARS control and psychological effects of quarantine, Toronto, Canada. Emerging infectious diseases, 2004. 10(7): p. 1206-1212.
  7. Cornwell, E.Y. and L.J. Waite, Social disconnectedness, perceived isolation, and health among older adults. J Health Soc Behav, 2009. 50(1): p. 31-48.
  8. Holt-Lunstad, J., et al., Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci, 2015. 10(2): p. 227-37.
  9. Tabue Teguo, M., et al., Feelings of Loneliness and Living Alone as Predictors of Mortality in the Elderly: The PAQUID Study. Psychosom Med, 2016. 78(8): p. 904-909.
  10. Choi, H., M.R. Irwin, and H.J. Cho, Impact of social isolation on behavioral health in elderly: Systematic review. World J Psychiatry, 2015. 5(4): p. 432-8.
  11.  Santini, Z.I., et al., Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysis. Lancet Public Health, 2020. 5(1): p. e62-e70.
  12. Xia, N. and H. Li, Loneliness, Social Isolation, and Cardiovascular Health. Antioxidants & redox signaling, 2018. 28(9): p. 837-851.
  13. Barnes, L.L., et al., Social resources and cognitive decline in a population of older African Americans and whites. Neurology, 2004. 63(12): p. 2322-6.
  14. https://www.alz.org/help-support/caregiving/coronavirus-(covid-19)-tips-for-dementia-care. Accessed March 28, 2020.
  15. https://www.americangeriatrics.org/media-center/news/covid-19-response-congress-administration-ags-calls-access-medical-supplies. Accessed March 28, 2020.
  16. Kall, A., et al., Internet-Based Cognitive Behavior Therapy for Loneliness: A Pilot Randomized Controlled Trial. Behav Ther, 2020. 51(1): p. 54-68.
  17. Khoury, R. et al., Can lifestyle modifications delay or prevent Alzheimer’s disease? Current Psychiatry, 2019. 18(1): p. 29-38.

Dr. Rita Khoury is an assistant professor of clinical psychiatry at Balamand University, Beirut Lebanon. She practices adult and geriatric psychiatry at Saint George Hospital University Medical Center, Lebanon. Her research interests include the pathophysiology and treatment of neurocognitive disorders (dementias).

Acknowledgements

Acadia Pharmaceuticals Avanir Pharmaceuticals Cambridge University Press
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