Covid-19 has had a profound impact on all of our lives. Whilst attention was initially paid to reducing the number of hospital deaths, concerns about the mental health consequences of ‘living in lockdown’ are beginning to be recognised. For some older people, particularly those who live alone, have care and support needs, or reside in a care home, the impact has been significant.
For those considered ‘at risk’ one of the key recommendations is to self-isolate. Close to 1.5m vulnerable people are self-isolating in their own homes; many are older people who are essentially in solitary confinement. Self-isolation includes avoiding social contact with family members and friends, organising the delivery of essential items such as groceries and medications, and where contact is unavoidable, maintaining a distance of two metres. Although initially for 12 weeks, the guidance now states that self-isolation may need to be in place for an additional three to four months.
The extent to which social isolation may turn into loneliness has been downplayed. Loneliness, especially persistent loneliness, increases older people’s risk of anxiety, depression and suicide; it is also associated with reduced cognitive function. Persistent loneliness may be as harmful to your health as smoking 15 cigarettes per day. There is an association between risk of loneliness and the following characteristics: living alone, being female, being aged 75 years or over, living on a low income, being disabled or in poor physical health, having a mental health problem(s), and having experienced a recent ‘adverse life event’ such as loss of a spouse. Confinement amplifies the risk of loneliness, in good part because the factors that protect against it – access to a social network, feeling part of a community, going out regularly, and taking exercise – are not available.
People living with dementia, especially those who live alone, are at particular risk of loneliness. Dementia carries an inherent risk of self-isolation: people with symptoms tend to avoid social contact and dementia related distress and/or agitation may deter family and friends from visiting. These issues have been made much worse by enforced isolation and by the suspension of support from formal services such as day care. This is not only about loss of stimulation but is also about disruption of the usual routine; routines tend to be very important to people living with dementia.
This has placed additional strain on family carers of older people who are now doing more with no (or very limited) access to external support. A recent survey from Carers UK reported that for 70% of carers lockdown has ‘severely affected their sense of control and autonomy’; many feel more isolated and are much more anxious about no longer being able to care due to becoming ill. The risk of abuse for carers and/or those being cared for is also heightened as a result of being indoors 24/7, a likely increase in challenging behaviours amongst people living with dementia, and fear about the future.
As care homes support some of society’s most frail older people, the majority are by definition in the at risk group. The mental health of care home residents is undermined by the intersecting impact of self-isolation, staff shortages, and curtailed visits from family and friends. The constant presence of death and fear about becoming ill are also omnipresent threats. Official figures suggest that the virus has been recorded in two fifths of care homes in England and three fifths in Scotland. Dozens of people have died in a short period of time: between a quarter and a third of residents dying in a single care home is not uncommon. Official figures estimate that overall, 22,000 care home deaths are linked, either directly or indirectly, to Covid-19.
Residents in care homes are effectively trapped in their bedrooms with little interaction with visitors, even digitally or via phone. Residents with dementia rely on regular contact with family and friends to reinforce their sense of self, identity and belonging. There is reduced interaction with staff too and familiar staff members may be of sick or self-isolating for health reasons. There are also greater demands on staff who are required to prioritise 1:1 ‘isolation care’ to residents with the virus and those discharged from hospital. The reduction in staff attention is not just about loss of communication and engagement, it is also about the loss of relationships, touch and comfort. Care homes are tactile environments where staff help residents with meals and personal care; they also offer familiarity, a kind touch and security.
The decision to exclude visitors to care homes contributes to them becoming (more) closed as institutions. This increases the risk that residents are denied access to primary or hospital care; there are a number of recorded instances of GPs refusing to attend residents and care homes being discouraged from sending residents to hospital for treatment. It also increases the risk of abuse and neglect and of poor practices being accepted e.g. not sitting with residents at mealtimes. All of these issues contribute to residents’ feelings of fear, anxiety, worthlessness, isolation and loneliness. Before the virus, many care home residents were lonely. Covod-19 has undoubtedly made things much worse.
Research has identified a number of micro-cultural factors that enhance residents’ mental health. These include: ongoing ties with family and friends, having links with the local community, flexible routines, staff being ‘present and engaged’ and a homelike atmosphere. They are either curtailed or undermined by responses to the pandemic.
Some commentators consider that the lack of attention paid to care homes by the UK government and the public agencies tasked with protecting care home populations (e.g. Public Health England, the Care Quality Commission) is a clear example of structural ageism. Care home residents are simply not considered to be important, or sufficiently visible, to justify the deployment of resources or inclusion in pandemic planning.
It is not the only example. There has been sustained criticism of the role ‘age’ has played in relationship to both risks and rights. The ‘cut-off age’ of 70 years being automatically linked to vulnerability has been criticised as both arbitrary and inaccurate: many people aged 70 or over are perfectly fit and a significant number of those aged under 70 years are not. The biggest danger of this is the use of ‘old age’ as one of the criteria for consideration of who has access to scarce resources. Age UK has raised concerns about the inclusion of age – alongside frailty and underlying health conditions – in an NHS ‘scoring tool’ to help clinicians decide who to admit to intensive care units. The charity is also concerned about reports that some care homes and a number of GPs have been asked to pressure older people into signing DNR forms. This narrative positions older people as more expendable than people in other age groups and underscores the use of age as a legitimate basis for rationing care and treatment.
Ageism, in all its forms, has a pernicious negative effect on older people’s mental health. It contributes to feelings of worthlessness, despair, fear, frustration, helplessness, hopelessness and to low self-esteem, loneliness, depression and anxiety. In the current climate it seems very likely that these risks are greater. It is also likely that they will be particularly profound for older people from black and minority ethnic communities, care home residents, older women, and older people with co-morbid health conditions. Ageism intersects with other discrimination(s) and risks to increase its impact on older people’s mental health and wellbeing.
It is important to recognise that whilst Covid-19 enhances the risk of some older people becoming ill and/or being exposed to poor mental health outcomes related to self-isolation, it did not create those risks; they were already there. As Gilleard and Higgs (2020) suggest the virus acts like ‘a magnifying glass amplifying but not fundamentally altering’ the unequal nature of ageing and the impact of social and structural inequalities on health. A lifecourse characterised by poverty for example, shortens life expectancy and contributes to the development of chronic ill health at an earlier life stage. Poor older people are also at greater risk of experiencing loneliness, stress, anxiety and depression. The pandemic will have heightened these risks, but the root causes lie in the lifecourse.
The relevance of the lifecourse, and of social and structural inequalities, in influencing older people’s mental health is explored in my book Mental Health in Later Life: taking a lifecourse approach. It offers a detailed analysis of the meaning and determinants of mental health among older populations and new ways to think about preventing mental illness and promoting mental health. The book is directly relevant to understanding and responding to the mental health needs of older people both during the Covid-19 pandemic and after the crisis is over.