These are unprecedented times, where each day, health professionals are navigating uncharted waters (Fauci et al, 2020). In recent months, there has been a lock-down in the global community. As COVID-19 spreads across the world, national boarders have closed, and local neighbourhoods have been forced to pull together to interpret and translate guidance on how to limit the spread of the disease at both a macro and micro level. In this situation, experts are yet to understand the extent of the physical, psychological and socioeconomic impact of the pandemic, but, often, the potential effect of COVID-19 on an individual's mental health is not adequately considered. Despite the exponential rise in workload, for nurses and health professionals, it remains business as usual. As the UK has moved towards a dictate of mandatory isolation to minimise the spread of COVID-19, there is a population that has substantial risk of mental health sequelae associated with the social isolation process (Brooks et al, 2020).
In the UK, although there has been a slow down in population ageing, the populace aged 65 years and over has continued to increase year-on-year for decades. At present, 18.3% of the UK population is aged 65 or older, and, in the next 50 years, it is predicted that there will be an additional 8.4 million people aged 65 years or older (Office for National Statistics (ONS), 2019). For these people, the risks associated with increased age are well documented and include but are not limited to: increased physical health problems and multiple comorbidities; chronic pain; polypharmacy and medication side effects; change in relationship status and independence; loss of mobility and flexibility; change in work and financial status; and social isolation (Nitschke et al, 2013; Jaul and Barron, 2017).
This article aims to explore the risk of mental health sequelae in older adults required to self-isolate as both preventative and transmission restrictive measures specifically during the ongoing COVID-19 pandemic. It is important to note that mental health is not an isolated construct and needs to be understood in the context of the greater health status of an individual. To this end, the authors have provided context through other components of health status all of which have the potential to impact on mental health. Finally, the authors propose that a holistic framework for assessing the needs of isolated individuals at home will have an impact on the overall mental health of individuals and suggest a specifically tailored model that may be easily adapted into routine practice in the community setting.
COVID-19
COVID-19 is a novel coronavirus and part of a large group of viruses that cause illness ranging widely in severity (Guan et al, 2020). From a historical perspective, the impact of coronavirus-related illness on humans is only pertinent in recent history, with the first severe epidemic occurring in 2003 when severe acute respiratory syndrome (SARS) appeared in China. In 2012, Middle East respiratory syndrome (MERS) appeared in Saudi Arabia resulting in an epidemic. It became apparent across the globe that a novel strain of coronavirus associated with severe illness had broken out in China on 31 December 2019, when the government reported the outbreak to the World Health Organization (WHO) (Scripps Research Institute, 2020). The virus was subsequently designated SARS-CoV-2. As with SARS and MERS, it appears likely that COVID-19 jumped from an animal host to humans as part of the virus's natural evolution (Andersen et al, 2020; Scripps Research Institute, 2020). The spread of COVID-19 throughout the world has been heavily reported through multi-media sources, and the WHO declared the COVID-19 outbreak to be a pandemic on 11 March 2020 (Van Beusekom, 2020).
Although it is a challenge to find scientifically sound and robust data during an ongoing pandemic such as this, it has been suggested from data collected in China that older people (aged 60 years and above) are in a high-risk category for infection with the virus (Guan et al, 2020). It has been proposed that the reason behind this vulnerability does not just relate to an individual's physical health state, but also to social inequalities (World Economic Forum, 2020). While this population may have reduced immune response to infective disease processes, it is also more likely to have underlying comorbidities (e.g. heart, lung and kidney disease). It is widely accepted that these comorbidities further impact on an individual's ability to effectively manage infection. Additionally, older adults are more likely to experience isolation and poverty, and both these factors are recognised to affect an individual's general health status (Cacioppo and Cacioppo, 2014; Cacioppo et al, 2015). Isolation and not being technologically savvy make the identification of accurate information increasingly challenging for older people in a fast-changing environment, where government and healthcare advice changes on an almost daily basis. Poverty adds unique and complex set of challenges for older adults, but, in the present situation of supermarkets lacking products on their shelves, people struggle to find the items required to remain fit and healthy (World Economic Forum, 2020). When considering mental health and wellbeing, it is important to acknowledge that this is not isolated from other components of health, including the physical, pharmacological, social and psychological aspects. Each component of an individual's health is interlinked, and a change in one will have an impact on the others.
Self-isolation and social distancing
The Government has asked the UK's population, especially older adults and other vulnerable groups, to be compliant with a programme of social distancing and isolation for what may be an indefinite time period. Quarantine or medical isolation is defined as ‘…the separation and restriction of movement of people who have potentially been exposed to a contagious disease to ascertain if they become unwell, so reducing the risk of them infecting others’ (Brooks et al, 2020). Although justified, this imposes significant restrictions on a large proportion of the UK population, and the potential impact of such restrictive practices have been recognised to have a negative impact on all aspects of health and wellbeing (Xyrichis et al, 2018). Nonetheless, it is likely that these measures will reduce the transmission of COVID-19 in what has been defined as a key high-risk population (Hellewell et al, 2020). For these individuals, this means avoiding all contact with people who are unwell but, particularly, individuals with a fever and/or a new or continuous cough. This also means avoiding the use of all non-essential public transport and avoiding peak travel times. Most important of all, social distancing requires the avoidance of all gatherings of people including at home, public places and with family and friends (Public Health England (PHE), 2020).
There were around 1.4 million older adults who were chronically lonely and isolated prior to the COVID-19 pandemic (Age UK, 2020). Thus, it is important to recognise the impact of the current social restrictions on these individuals and acknowledge that, during these unprecedented times, this number is destined to be drastically higher in both younger and older populations.
Where older adults in the community setting are self-isolating, their contact with health professionals will become a key aspect of their social interaction. It is now more important than ever to ensure that effective health promotion and wellbeing advice is given to these individuals and that this information is accurate and, where possible, evidence-based. PHE (2020) has provided guidance on how older or vulnerable adults can access food and medicine resources during isolation. This guidance focuses on getting help from family members, friends and their local community as well as online services (PHE, 2020). This does not account for the challenge of getting support particularly for the most vulnerable older adults who were socially isolated prior to this pandemic. Health professionals must have a good knowledge of the services that are available in each local community enables, as this would help them effectively signpost these individuals to what may be a sustaining force in the coming weeks and months.
Biopsychopharmacosocial model
The biopsychopharmacosocial (BPPS) model is a recognised approach for assessment and management of challenging behaviours and psychiatric illness in both mental health and acute settings (Clark et al, 2017; Hext et al, 2018). The approach looks at the four domains of health, namely, (i) biological; (ii) psychological; (iii) pharmacological; and (iv) social, at an individual level and then in combination, assessing the impact of one domain on the other three within the individual's environment. Furthermore, the model can be used in psychiatric formulation, diagnosis or purely as an assessment tool (Clark and Clarke, 2014). The authors have adapted this model to provide a conceptual method of thinking about the mental health of older adults who are self-isolating due to COVID-19. This could be used to assess the mental health status of this population when making assessments or providing care in home settings. Figure 1 presents the adapted BPPS model with assessment and risk considerations for older adults in the UK isolated during the COVID-19 outbreak.
Figure 1. The biopsychopharmacosocial assessment model for assessing risks to mental health during social distancing and self-isolation
Biological (physical) aspects
For adult nurses working in the community, physical health assessment is an integral component of daily nursing practice, and it is beyond the scope of the article to discuss the process of physical health assessments. Briefly, when assessing either physical or mental health in an individual, it is important to remember that these are inter-dependent and, certainly in the case of mental health, cannot be assessed in isolation.
Diagnostic overshadowing is the risk associated with undertaking an assessment of one component of health without incorporating the other dimensions. This can happen when secondary symptoms are not explored, but attributed to a primary diagnosis. It is a common problem in patients with both physical and mental health problems, as physical health symptoms (e.g. confusion) are credited to the mental health problem (or treatment) and not to a potential physical health cause (Hext et al, 2018). The impact of this can be enormous and could account for some of the high levels of mortality and morbidity among people with mental health problems and intellectual disability (Shefer et al, 2014; Javid et al, 2019). Assessment should consider the impact of physical health problems including significant comorbidities as these have been recognised to haver an effect on mental health (The King's Fund, 2012). Key areas to consider include changes in mobility and exercise, ability to self-care, continence and personal hygiene. Changes in these biological and behavioural factors can be key early indicators of negative change in mental health. For older adults in isolation due to COVID-19, it is likely to be challenging to reach out for medical support. Access through GPs and NHS 111 have already been restricted, and these restrictions are likely to become tighter over time. For older patients where physical health needs are unmet due to resource limitations, there is a likely negative impact on all other components of health, including mental health.
Psychological aspects
Loneliness is an important issue in an ageing population without the added burden of imposed social isolation. Risk factors include the female gender, living alone, poor financial status, lower educational level, unsafe neighbourhoods, poor quality of social relationships and poor reported health and functioning, bereavement, shame and fear (Cohen-Mansfield et al, 2016). Such factors are often compounded by deteriorating physical health issues and sensory loss, such as sight and hearing (Weinstein et al, 2016), which have a considerable impact on social and emotional loneliness in an already isolated population.
Sedentary behaviour has been shown to have an impact on life satisfaction. For many, engaging in regular physical activity is a global indicator of well-being and is associated with greater social interaction with other individuals with shared goals. Avoiding sedentary behaviours is critical in the prevention of physical, psychological and social health problems (Maher et al, 2017). Therefore, imposed isolation with the resultant reduction in physical activity will impact on life satisfaction and, ultimately, on mental health status.
For many frail older adults, the main informal carer may be their spouse or relative. The informal carer may have previously benefited from social interaction and support through regular family visits or brief outings to a support group. Imposed social isolation will also have an impact on the mental health of these informal carers.
Mortality is a basic fear factor surrounding COVID-19, especially in the older population, and it is postulated that many are already suffering signs of anxiety and depression surrounding this. Due to social isolation, the media, particularly television and radio, has become even more important. However, in this climate, news coverage may conversely cause distress and heighten anxiety.
For those older adults already known to mental health services, it is important to note that the COVID-19 crisis is already impacting on an over-stretched mental health service. Community mental health teams, including home treatment and specialist older adult mental health services, will also be potentially subject to increased staff sickness. Due to an anticipated staffing crisis in the mental health service system, plans for temporary changes to the Mental Health Act (1983) have been introduced through parliament. These will not apply immediately but will be activated should the situation worsen (Rethink, 2020).
Pharmacological aspects
With regard to the impact of pharmacological status on an individual's mental health, there are several factors that need to be considered. When undertaking an assessment, it is important to consider whether the patient is established on any psychiatric medications (e.g. anti-psychotic medication, mood stabilisers). The implication of running out of these medications for patients who rely on them to maintain psychiatric functioning is clear and has the potential to be a significant stressor for an individual (Iseselo and Ambikile, 2017). Similarly, for patients established on long-term analgesic agents or life-sustaining medication used in chronic disease management, it is likely that the pharmacy supply chain will remain a great stressor during any episode of isolation. In these cases, it will become imperative for health professionals to reassure patients and ensure they have a clear understanding of the local processes for accessing stocks of these medications. Further, where regular therapeutic monitoring of drug serum levels, adverse effects or reactions or drug effectiveness is required, it will become increasingly important to support patients in ensuring they can access this facility in the community (Kang and Lee, 2009; Padoin, 2017).
For some patients, it will become increasingly challenging to source over-the-counter medications such as paracetamol. With the growing fear over self-management of viral illness symptoms at home, it might be necessary to support older adults in accessing these medications, if required. There have also been growing concerns voiced through the media about the potential risks associated with the use of ibuprofen when symptomatic for COVID-19. Although there is no strong evidence available at this point to prove or disprove this, there are new recommendations in place suggesting that ibuprofen should be avoided by anyone with symptoms of COVID-19 (Day, 2020). As it is often difficult for patients to unravel the true medical meaning of research or advice, particularly when presented through the media, it is important to consider how this information may be interpreted or misinterpreted within the community. Similarly, there has been speculation over the risk of severe symptoms for patients with COVID-19 who were established on angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) (Fang et al, 2020). The guidance supports continuing treatment with these medications, but patients may need education and reassurance to ensure they remain concordant with their prescribed medications (European Society of Cardiology, 2020). What is consistently clear when assessing the link between a patient's pharmacological status and their mental health is the level of fear and anxiety associated with maintaining adequate access to both the health system and their supply of medications. Health professionals in the community setting are in a unique position to provide support, education and reassurance throughout this extended period of isolation.
Social aspects including environmental considerations
Activities such as going to church, the hairdresser or cinema, meeting for a coffee or gentle exercise with friends add pleasure to an often otherwise humdrum weekly routine. The impact of removal of such treats through social isolation may lead to feelings of negativity.
Despite social isolation, younger generations can keep in touch with friends and family through technology and social media. However, a lack of IT skills may be noticeable in older generations, and some remain internet naïve, especially those with poor financial status and a lower educational level (Vaportzis et al, 2017; Berkowsky et al, 2018). It is important that, where older adults are socially isolated, they are assisted with accessing means of staying in contact with family members and friends, and this is likely to be the most effective method in improving an individual's mental health during COVID-19 isolation (Cotten et al, 2013).
The need for access to fresh air, adequate temperature and good ventilation is paramount even if it is too cold to be outside for long periods. Encouragement to spend time in a private outside space such as a garden, courtyard or balcony is helpful. Moreover, walks in parks and green spaces (while adhering to social distancing) have been shown to enhance physical and mental wellbeing by providing sensory experiences (Franco et al, 2017).
Physical environment, as well as social contact, has been shown to have association with depressive symptomology in older adults living alone (Park et al, 2019). Hygiene may be a factor for consideration, especially if the older person is deprived of social or family help around the home during the COVID-19 crisis. Sensitively tackling hand and personal hygiene, continence care and hygienic management of equipment such as commodes, handrails, wheelchairs, bathrooms and lavatories are essential. Poor home hygiene, especially around the kitchen and food preparation areas, may lead to cross-contamination. There could also be implications for the care of pets, particularly their food and hygiene.
Formulating the assessment
After completing an assessment using the BPPS, it is important that the data are formulated for both outcome and coping mechanisms. Formulating a mental health ‘diagnosis’ is often more complicated than in physical healthcare, as there is less delineation within these disorders, and a great deal of experience is required (Aultman, 2016). For health professionals in contact with and caring for isolated older adults, it is important to be aware of potential mental health disorders associated with isolation, including depression and anxiety. Table 1 presents an overview including the symptoms relating to mental health problems associated with isolation and red flags for professionals to be aware of (Mayo Clinic, 2018a; 2018b). It is important to note that, although anxiety and depression are likely to be the most common mental health problem community healthcare professions identify during assessment, there are many other mental health, psychiatric and physical health problems that can mimic these mental health problems in older adults (i.e. delirium caused by infection). Where symptoms are identified that do not fit the anxiety and/or depression picture, these should be escalated for medical review.
Table 1. Mental health formulation, with signs, symptoms and red flags
| Disorder | Signs and symptoms | Red flags |
|---|---|---|
| Anxiety |
|
|
| Depression |
|
|
Brooks et al (2020) have identified the potential negative impact of self-isolation and social distancing on individuals' mental health in the general population during COVID-19. It is essential that health professionals in the community setting are able to signpost individual's to coping mechanisms. These include regular exercise (within the limits of the home environment, garden or out in an open public space) and ensuring there is adequate ventilation throughout the home. Other advice may include identifying what an individual may enjoy doing while at home (e.g. reading, cooking) and maintaining a healthy well-balanced diet and adequate hydration. It is also important to recognise the signs of altered mental health, which may include low mood, worrying and anxiety, problems sleeping and feeling confined or restricted. This can turn into unhealthy patterns of behaviour, including the use of illicit drugs and excessive use of alcohol and tobacco, and these are likely to have a negative impact on mental health and wellbeing (PHE, 2020). Health professionals working in the community should help isolated individuals plan safe and entertaining activities, as this has the potential to impact substantially on short- and long-term quality of life.
Using BPPS for care planning
The BPPS model is a logical and systematic process to focus on the assessment of the mental health of older adults during social distancing and isolation during the COVID-19 pandemic. This approach is likely to alert health professions to subtle changes in an individual's mental health. It is essential that the outputs are used in the planning of the care for this vulnerable population. Examples of these patients' needs may include meeting unmet healthcare needs, planning activities and health promotion or home-care activities. It is important to acknowledge that, for many community practitioners, all of these aspects of assessment will be part of practice, but the BPPS provides a structured framework to draw these aspects of daily care together. Although this may initially appear to be more time consuming, this simply represents a logical thought process. To take this to a higher level, additional training may be required for some practitioners. However, this model could be integrated into future education programmes for health professionals working in the community. It should now be clear that the construct of mental health is dependent on all other domains of health. Where these other domains are impacting on an individual's mental health, it is important to recognise the increased potential risk for worsening prognosis over time if left unmanaged. As with all assessment frameworks, this framework has been constructed as guidance for professionals and is not exhaustive. In the context of clinical practice, the model does not supersede the experience of an individual practitioner but acts as a guide during this ongoing pandemic where providing community healthcare is becoming increasingly challenging. The BPPS has demonstrated good transferability, and this model may be appropriate for use with other vulnerable population including long-term conditions, learning disabilities, etc. (Baker and Clark, 2020).
Conclusion
The COVID-19 pandemic is likely to become the greatest challenge for healthcare systems globally for many generations. While the most pronounced focus remains on treating the systemic effect of the virus among affected patients, it remains key that nurses do not lose sight of the impact of social distancing and isolation on older people and globally on their local community. There is a growing body of knowledge regarding the impact of isolation in this context, and it will become increasingly important for community health professionals to assess the impact of this on vulnerable people. Further research will be required to fully understand the impact of the COVID-19 pandemic on loneliness and isolation in both older and younger populations of the UK, which is likely to be underestimated and represented in the literature. The BPPS model can be used to guide assessment of isolated patients' mental health and provides a structured approach that considers all domains of health and wellbeing. Most importantly, the outputs from these assessments could be used to plan the evolving mental health needs of older adults who are likely to remain in isolation for an undefined period.
KEY POINTS
- The COVID-19 pandemic is placing extreme pressure on the NHS
- Social distancing and isolation will limit transmission but are likely to result in poor mental health for the older population
- Community nurses can play a key role in the assessment and management of mental health for these individuals
- A systematic approach to mental health assessment that covers physical, psychological, pharmacological and social domains of health is needed to identify subtle changes in mental health
- Health professionals must understand the inter-relationship between each domain and the impact a change in any one domain has on the other three
- The bio-psycho-pharmaco-social model is one method of systematic assessment of mental health in this population
CPD REFLECTIVE QUESTIONS
- Consider the impact of social distancing and isolation on older adults receiving community nursing care
- What factors put these patients most at risk for poor mental health?
- Consider what local resources are available that may improve the mental health of older adults in the coming months
- What advice would be most helpful to older adults in the community during social isolation?
- Reflect on how the model proposed in this study could focus the mental health assessment skills of community nurses