By Mark D. Miller, M.D., and Charles F. Reynolds III, M.D.
Let’s first define “older” as those at least age 60. This segment of the population is on track to soon become 22% of the whole. It is a heterogeneous group comprised of a reasonably healthy, mobile, and digitally savvy subgroup on one end of a spectrum of “functional capability” and those that are quite impaired in their functioning due to chronic medical or mental illness, chronic pain, isolation, lack of mobility, poverty, substance abuse, and/or lack of an adequate social support system. The latter group is more vulnerable to the unprecedented strains caused by the pandemic from COVID-19 we have all been thrust in to.
As both authors of this article personally meet the age cut-off for being elderly (one of us is a grandfather already and the other would like to be one soon), we will therefore digress momentarily and speak from our own qualified experience. We have both been fortunate to be well educated, enjoy supportive family and friends, financial comfort, and a variety of purposeful participatory activities that make us both look forward to getting up every day. That said, this COVID crisis has also upended our respective lives and has heightened our own fears of facing death in the too-near future. The daily news is a very scary tally of climbing death totals and abounding economic hardship. We too struggle with restlessness, our own fears, boredom, and restrictions on mobility and cultural fulfillment despite all the digital connectedness at our command. We continually search for ways to compensate for feelings of uneasiness and try our best to ward off demoralization as the quality of life we have become accustomed to is on hold. Whatever the strains we feel in our personal lives, we know that many of our patients who suffer from depression and anxiety are faring worse.
Through the practice of geriatric psychiatry, we know that the long-term stability of our geriatric-aged patients who suffer from anxiety and depression severe enough to impair their function can be a delicate thing even in good times. Depression and anxiety can exacerbate each other, often coexist, and can each complicate the treatment of the other. Our own research has shown that those elders who suffer from depression, must remain vigilant for the rest of their lives after recovering from their index episode, as it commonly recurs. Preventing such recurrences often requires rigorous lifelong compliance taking antidepressant medication. Ongoing emotional support, if not professional psychotherapy, can also improve resiliency in the face of everyday stresses. Seminal stressful life events, such as bereavement or role transitions typical for this age group (such as transitioning to retirement, leaving one’s home, facing an empty nest, or facing increasing dependency on others) may require even more intensive support to avert a downward spiral of demoralization and descent into depression or anxiety.
Medical conditions can both exacerbate anxiety and depression; and, in turn, chronic medical conditions such as ulcers, colitis, and rheumatoid arthritis can be made worse from stress and increasing levels of anxiety and depression. As we demonstrated earlier, a worldwide pandemic with rapidly mounting death totals is a stressor extraordinaire that can unnerve even the steadiest psyches, and therefore be devastating to the most vulnerable.
The stress on a given depression or anxiety sufferer will, however, be lightened by a robust social support system and vice versa. Single or widowed elders risk loneliness on a daily basis unless they have built a network of regular contacts through family and friends, places of worship, hobby and club participation, volunteerism, exercise classes and regular meal sharing with family and friends. Constantly having something to look forward to is a hedge against depression returning.
Those individuals who have seen their support system crumble in the face of the COVID-19 required social distancing restrictions are thus at higher risk for worsening depression and anxiety. A recent study of 3005 American adults aged 57-85 published in Lancet Public Health by Santini et al  showed a robust statistical relationship between social disconnectedness, perceived social isolation and depression and anxiety that was bidirectional. In other words: isolation worsens depression and anxiety, and depression and anxiety create more perceived social isolation and eventual social disconnectedness.
As it appears that the elderly are among the most vulnerable to dying from COVID-19, mounting death tolls across the nation that now include the familiar faces of celebrities, are increasing anxiety and depression severity as it becomes clear that sooner or later, personal acquaintances or family members will be next -- if not succumbing yourself. Those confined to long-term care facilities or aging prisoners fear they are like sitting ducks for a highly contagious virus to spread quickly from person to person, even if just one employee or visitor carries the virus inside the walls unknowingly.
Alternatively, fear of deteriorating chronic medical problems that might require a hospital visit, risk a fatal Coronavirus exposure and make those normally safe havens places to avoid. Putting off usual check-ups or tolerating worsening medical problems can result in precipitating a medical crisis that then triggers worsening depression or panicky anxiety. If an elder becomes hospitalized, even for non-COVID-19 reasons, they become off-limits for concerned family as far as personal visits go, even if critically ill or dying. Attending funerals is even impacted by social distancing restrictions. Traditionally, funerals are rituals for support in the collective expression of grief and their absence will delay and complicate the grieving process, raising the risk for developing Prolonged Grief Disorder (https://www.psychiatry.org/psychiatrists/practice/dsm/proposed-changes)
now being considered for inclusion in the official lists of mental health diagnoses (DSM-V).
Telephone contacts are critical to maintaining some connectedness for older individuals suffering from depression and anxiety, but it has its limits. A larger subset of elders compared to younger groups do not have the option of video chats or the myriad of other accessible entertainment via the internet that has been helping sustain so many others during this crisis as many elders do not have access to computers or smartphones. For sufferers of chronic depression or anxiety, beginning a downward spiral can lead to less self-caring, less resourcefulness for problem-solving, and, eventually, may cause the sufferer to reach the false conclusion that one can do without medication. Feelings of demoralization, hopelessness, and even the wish for death can follow such a downward spiral. In particular, the toxic blend of high anxiety and severe depression causes a state of agitated depression leaving the victim at high risk for suicide that is often described as an escape from pain. It is also important, in this context, to acknowledge the role of alcohol or other forms of unauthorized self-medication that can be turned to in a vain effort to seek relief (even though it actually compounds the problem further).
Fortunately, one remarkable transformation that has been a direct result of this pandemic crisis has been the meteoric adaptation of telemedicine, and specifically tele-psychiatry. The concepts and practice have been around for decades and are ideal for delivering care to practitioner shortage areas such as rural sites, nursing homes, and prisons. Given the risk of a fatal infection for both patient and clinical practitioner alike, safe and flexibly scheduled tele-visits have become the new norm. Insurance payers have balked at covering tele-services in the past but almost overnight, these modalities are now the primary way to deliver non-emergent medical and psychiatric care directly to patients in their homes. Given the risky alternative of office visits during the COVID-19 crisis, even plain old telephone calls are now being paid for by Medicare (at least for the time being). The ease with which this transition has taken place has transformed our attitudes toward the delivery of medical and psychiatric care and these tele-services are likely to continue post-pandemic.
As our global society marches toward a higher proportion of older individuals (the approaching silver tsunami), more research is needed to better delineate the risks of social disconnectedness and the benefits of strategies to combat it in the aging population. Now that tele-medicine/psychiatry are front and center in the new normal of the care delivery paradigm shift that is a direct result of the COVID-19 pandemic, we must work on figuring out how to integrate the two seamlessly. Older individuals in a modern society need not live in physical proximity to be truly and robustly socially connected, thus reducing their risk for debilitating depression and anxiety symptoms.
Future medical research will certainly help unravel the mysteries about why the elderly are more susceptible to dying from COVID-19 in disproportionate numbers. Prevention, with all its restrictions and worsening isolation, is still the best hope for coping with COVID-19, even among those elders who suffer excess anxiety and depression. Helping them to cope optimally is our professional goal that requires your help. If you know of individuals who suffer from excess anxiety or depression, check in with them frequently, especially now. Offer to help procure their prescribed medications, suggest healthy coping mechanisms, encourage regular exercise and good nutrition, and help them to connect digitally to social supports and cultural enrichment in their community in addition to offering your own.
- Santini Z, ose P, Corwell E et al: Social Connectedness perceived isolation, and symptoms of depression and nxiety among older Americans (NHAP): a longitudinal analysis. Lancet Public Health. 2020;5; e62-e70
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
- Newman M, Zainak N: The Value of Maintaining Social Connections in Older People. Lancet Public Health. 2020;5;p e12-13