Older adults and virtual mental health
LEAVING THEM BEHIND: OLDER ADULTS AND VIRTUAL MENTAL HEALTH CARE IN THE ERA OF COVID 19: EXPERIENCES FROM A NIGERIAN HOSPITAL
Piwuna Christopher Gosona,b Ojeahere Margaret Isioma c
a. Department of Psychiatry, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
b. College of Health Sciences, University of Jos, P.M.B 2084, Jos, Plateau State, Nigeria
c. Department of Psychiatry, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
The coronavirus, SARS-CoV-2-causing Coronavirus Disease-19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization (WHO) on the 11th of March 2020.1 COVID-19 is a highly transmissible disease affecting all ages with a disproportionate impact on older adults, especially those with comorbidities.2 To mitigate the spread of the disease, various preventive measures were taken by governments and public health authorities including Nigeria, such as hand washing with soap and water, using face masks, and physical distancing. Community and religious leaders were also recruited to help in public enlightenment exercises. Varying degrees of lockdown and restrictions were imposed across the country resulting in the utilization of telecommunication tools to provide mental health services by some facilities.
The Jos University Teaching Hospital is a 530-bed capacity hospital established in 1981 which has two (2) out-posts in the rural communities of Gindiri and Zamko in addition to the main hospital located in the state capital of Jos (urban area). It has over 130 specialists in different fields including Psychiatry, Neurology, Community medicine, Family medicine, Internal medicine, Surgery, Paediatrics, Obstetrics and Gynaecology, Haematology, Microbiology and Radiology amongst others.
MENTAL HEALTH SERVICE DELIVERY PRE-COVID-19 ERA
It is estimated that about 6% of Nigerians are 60 years and above, and a considerable proportion reside in the rural communities.3,4 These communities are fraught with challenges such as poor facilities, limited access to mental health care (as the bulk of mental health practitioners practice in tertiary health care facilities in the big cities of Nigeria) and poverty.5,6 Prior to COVID-19, mental health service delivery to older adults in Nigeria was subpar, especially in the Northern parts of Nigeria.7 There already exists a huge gap of unmet mental health services for older adults, which have been fuelled by factors such as stigma, poor awareness that older adults suffer from mental illness, deficient primary health care services, inadequate community health care workers and few psychogeriatricians.6,8 Furthermore, the existing cultural practices and belief systems encourage the perception of mental illnesses in the older adults as a punishment by a deity for a past misdemeanour. 9 However, with increasing awareness and enlightenment, the general public are beginning to realize that older adults can suffer from mental illnesses and recognize the benefits of orthodox management of mental illnesses.
Consultations in northern Nigeria had always been face to face, requiring older adults with mental health problems to access care at secondary and tertiary mental health facilities mostly located in big cities. Most of our patients travel at least 63 miles to access services at our facility, a teaching hospital located on the outskirts of the state capital, and they are usually conveyed via commercial vehicles accompanied by relatives or caregivers. We run weekly Psychogeriatric clinics in the Teaching Hospital; however, this does not deny access to daily consultations at the emergency units. An average of 35 patients are seen at the weekly Psychogeriatric clinic with an average of 3-5 new cases per week. Depending on severity of symptoms, some may require admission, but most are managed on an outpatient basis. Commonly seen cases among older adults are depression, dementia, late-onset psychosis and substance-related problems. Interestingly, most are referred by friends or family members with a few from other specialties in the hospital. Nursing homes are still a relatively novel concept in Nigeria, and currently no documented findings are available from the few in existence.
MENTAL HEALTH SERVICE AMID THE COVID-19: SETBACKS AND SUCCESSES
The fragile nature and obvious weaknesses of the health care system in Nigeria such as poor funding, inadequate and ill-equipped health facilities and inequitable distribution of resources was thoroughly exposed by the outbreak of COVID-19.10 With the total restriction of movement imposed during the lockdown, public transportation was banned making it difficult for patients to access care. The hospital’s outpatient services were suspended in the initial weeks of the lockdown. Private pharmaceutical stores were either closed or had run out of most medications leaving hundreds of our patients unattended for over 2 months.
The unavailability of care was frustrating for patients, and they did not know when they would see their doctors again which had detrimental effects. We received telephone calls and messages from caregivers with complaints such as agitation, disorientation, elopement, aggressiveness and lack of sleep. The uncertainty and fear of infection with COVID-19 through hospital visits persisted long after the lockdown ceased. Most of the patients who had comorbid medical conditions or exacerbation of pre-existing mental illness were discouraged by relatives/caregivers to come for care in the hospital.
These challenges made it necessary to utilize innovative services using available and accessible telecommunication tools such as telephone calls and SMS messages; this would reduce the risk of COVID-19 transmission to relatives / care-givers and community healthcare workers, while meeting the mental health care needs of older adults. Some older adults and their relatives and caregivers could readily access virtual consultation and psychotherapy sessions from their health care providers. However, only an infinitesimal proportion of our patients benefited from this level of care.
With the easing of restrictions almost all older adults who could readily communicate preferred face-to-face consultations despite access to varying levels of consultation via digital tools; they report that routine trips to the hospital gives them a “breath of fresh air” and a sense of relevance and belonging. The isolation and loneliness from not seeing their younger relatives frequently during the periods of total lockdown were particularly difficult for them. It also exposed feelings of neglect associated with not being informed of happenings around them by their relatives in a society that operates a strong extended family system.11
Our experiences show that the use of virtual platforms and Tele-psychiatry will improve health care delivery.12 However, implementing Tele-psychiatry in Nigeria, a Lower Middle-Income Country comes with several limitations. These includes the apparent inability of health facilities to liaise with telecommunication organizations, funding, sustainability, poor literacy using electronic devices, and a high level of poverty among older adults. These serve as obstacles in preventing older adults’ access to simpler and affordable forms of telecommunication such as smartphones, which in turn could be used for consultations.
Delivery of health care service using virtual means may be the solution to meeting the mental health gap. There is a need to balance virtual consultations with face-to-face appointments in older patients to avoid social isolation which can worsen mental health conditions. Hence, there is a need for countries like Nigeria to address these challenges to enable a robust Tele-psychiatric practice, thereby ensuring that older adults in Nigeria are not left behind.
- WHO Director-General’s opening remarks at the media briefing on COVID-19 - 5 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---5-march-2020 (accessed July 30, 2020).
- McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. N Engl J Med. 2020;382(21):2005-2011. doi:10.1056/NEJMoa2005412.
- United Nations (UN) Population division.2005. World population prospects: Projected population for ageing in Africa, West Africa and Nigeria. The 2004 Revision [Internet WWW.URL] http://esa.un.org/unpp.
- Reed HE, Mberu BU. Capitalizing on Nigeria's demographic dividend: reaping the benefits and diminishing the burdens. Etude Popul Afr. 2014;27(2):319-330. doi:10.11564/27-2-477.
- Oyekale AS. Assessment of primary health care facilities' service readiness in Nigeria. BMC Health Serv Res. 2017;17(1):172. Published 2017 Mar 1. doi:10.1186/s12913-017-2112-8.
- Odejide O, Morakinyo J. Mental health and primary care in Nigeria. World Psychiatry. 2003;2(3):164-165.
- Said JM, Jibril A, Isah R, et al. Pattern of Presentation and Utilization of Services for Mental and Neurological Disorders in Northeastern Nigeria: A Ten-Year Study. Psychiatry Journal, 2015.
- Amoo G et al. Prevalence and Pattern of Psychiatric Morbidity Among Community-Dwelling Elderly Populations in Abeokuta, Nigeria. Journal of Geriatric Psychiatry and Neurology. Jan 2020 doi:10.1177/0891988719892327.
- Ojeahere M.U. “The Rarity of Elder Abuse in Nigeria: a Misconception or Reality?”. Premium Times (14/03/2020). https://opinion.premiumtimesng.com/2020/03/14/the-rarity-of-elder-abuse-in-nigeria-a-misconception-or-reality-by-margaret-uddin-ojeahere/[Accesssed Jul 30 2020].
- Ohia C et al. “COVID-19 and Nigeria: putting the realities in context.” International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases vol. 95 2020; 279-281. doi:10.1016/j.ijid.2020.04.062.
- Omotara BA, Yahya SJ, Wudiri Z, et al. Assessment of the Determinants of Healthy Ageing among the Rural Elderly of North-Eastern Nigeria. Health, 2015; 07(06), 754–764. https://doi.org/10.4236/health.2015.76090.
- Orlando JF, Beard M, Kumar S. Systematic review of patient and caregivers’ satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients’ health. PLoS ONE 2019;14(8): e0221848. https://doi.org/10.1371/journal.pone.0221848.