The coronavirus pandemic has had a profound impact on all our lives, forcing us to stay inside and reduce our contact with friends and family. And while some people will see lockdown easing as a welcome relief, many will be feeling anxious about how to stay safe. How, then, has lockdown, and the prospect of it ending, affected the mental health of older people? Has it brought existing issues to the fore, or provoked entirely new ones?
Carolyn Chew-Graham is a GP Principal in a large practice in central Manchester. She is also a professor of General Practice Research at Keele University, with a focus on research of primary care mental health, particularly in older adults. She is currently working on a study that will test an intervention aimed at preventing or lessening the onset of depression and loneliness among the most vulnerable as a result of the COVID-19 lockdown. What’s more, she’s visiting professor at the University of York.
As someone who’s been speaking directly to older people during this period, and involved in studies of management strategies for older adults with mild/established anxiety and depression, Carolyn is well-placed to provide insights into the challenges in ‘coming out’ of lockdown.
Tell us about the concerns you’ve heard most from older people during the pandemic...
“My colleagues and I noticed from the beginning of lockdown that we were getting fewer phone calls from our older population. As GPs, we were concerned that older adults weren’t consulting. We were concerned that people with long-term conditions who may not be necessarily managing them particularly well were not asking for help. We were also concerned that people with new symptoms, which might represent a cancer or other serious problem, were reluctant to contacting the practice and certainly didn’t want to come into the health centre. This was partly, I think, because of the messages, ‘Save the NHS, don’t contact your practice.’ But also, when people did contact us and we said, ‘Actually, I think you need to be seen,’ they’d say, “I’m not coming in.’ There was a lot of fear, particularly in the older population.”
We have had new cases – people without depression in the past or certainly not recent past.
How many calls would you say have a mental health implication to them?
“People dealing with anxiety and depression have talked about a downturn in their mood. We have had new cases – people without depression in the past or certainly not recent past, who are talking about anxiety, talking about stress and being depressed and down, and we’re managing most of those on the telephone. In the past month, all my colleagues have noted increasing numbers of people consulting because they are distressed.
“I think we have are also aware that people may be using alcohol more than usual during the COVID-19 restrictions. I certainly ask anyone who describes symptoms of anxiety or low mood about their alcohol consumption.”
When older people are articulating what’s bothering them, mentally, what are the common things you’re hearing?
“I think being labelled ‘vulnerable’ was difficult for some people – that’s quite stigmatising and made them quite fearful. Even though the restrictions have started to be lifted people are saying, ‘Actually, I don’t want to come out, I wouldn’t go to a pub. Am I safe to go to a supermarket? Am I safe to come to the health centre to pick up a urine pot,’ say, when we’ve asked them for a specimen.
“I spoke to somebody this week who’s got an abnormal chest X-ray, and one of the first things in his response to having to be referred to hospital was, ‘I’m frightened of going to hospital. I’d rather wait a bit.’ I ended up saying, ‘Well, actually, this is quite serious, and you do need to go to hospital, because we’re worried about this,’ to which he said, ‘Well, I’m frightened of getting COVID: is the hospital safe?’ So I think that is still a worry in people’s minds, that going to the hospital will put them at increased risk.”
I think being labelled ‘vulnerable’ was difficult for some people – that’s quite stigmatising and made them quite fearful.
This is a period that some people of a particular age can lose confidence quickly. How can this be avoided?
“Try and keep safe, so remember to wash your hands, keep your physical distance, wear a mask or a face covering. That’s what we’re saying that to people if they are coming into the practice.
“Stay connected to people. Some previous research I did suggested older adults would use Skype or FaceTime to contact relatives, but they’re a bit loath to use the telephone for healthcare. However, we have been surprised over the last month that an increased number of older adults are ringing up and having a conversation over the phone, and mastering video calls.
“Even if you’re not able to get out of the house, try and be active in the house: do your stairs, go out in the garden if you’ve got a garden, do some armchair exercises. Even if you’ve got stiff knees and you really feel you can’t go up and down the stairs more than once a day, those are some great exercises to try.
“It’s difficult to discuss worries over the telephone, but I try and talk to people about breathing exercises, and encourage them to try them, as well as mindfulness exercises. I might send them a link to some information, a link to some reading material, just to try and help them manage their worry, and say, ‘Yes, you are worried and it’s understandable, but this is what you can do to manage it’. But then underneath that, I’ll make sure, by asking questions, to establish if they need some more formal support.”
A lot of older people aren’t connected digitally, so the phone becomes a more essential avenue; presumably calls are more involved as a result?
“Yes, telephone calls can take longer than a face-to-face consultation, but the advantage is that the person doesn’t have to attend the practice – which is good if they have mobility difficulties and if they are worried about attending the health centre. In my practice we allocate 10 minutes for a telephone consultation – the same as a face-to-face appointment – but we can take longer if that is needed. I think we are offering follow-up more frequently, when we are aware people are distressed, and again, this may be more convenient for patients. One of the disadvantages of telephone consultations is the lack of non-verbal cues. We can use video consultations to get over this.”
Without visual cues, what are the things that you’re listening out for during these conversations?
“Well, I suppose I’d be asking them questions about how they feel, what they think their mood’s been like, what have other people said about their mood. Have they felt irritable? How are they sleeping? Are they sleeping too much or are they sleeping too little? Do they worry? Do they feel stressed? Are they eating? Are they over-eating? Do they have thoughts that they might harm themselves? Do they have any plans that they might harm themselves?
“I have to say that my colleagues and I feel that we are seeing – across the age range – more people with thoughts of self-harm, because of the COVID situation and its impact. You may have older people who haven’t seen adult children for 4 months, they haven’t seen their grandchildren, and worry they may have grown apart. Will the grandchildren remember them? They may get into a cycle of rumination and hopelessness and this feeling of, ‘Well, what’s the point?’
“So I’m listening out for those thoughts and feelings of hopelessness and if somebody says, ‘What’s the point?’ then I ask quite directly about self-harm and suicide: have they got any plans? What stops them? But it’s easier in a consultation where you’re face-to-face, put your hand on theirs and look to see whether they’re making eye contact.”
Presumably, some older people will something out loud they’ve never said to anyone. Does just having a conversation already find them in a better headspace?
“A lot of people say, ‘I feel better now I’ve spoken to you,’ and that could be face-to-face or that could be on the telephone. I will suggest to people that they might wish to be referred to our social prescribing scheme, or to the ‘Improving Access to Psychological Therapies” service. I try to emphasise that a ‘talking therapy’ might be helpful for them.
“If I am concerned about low mood, and I feel an antidepressants is indicated, I will suggest that to the patient to see how they feel about tablets.”
I use a technique called behavioural activation, which is saying to people, ‘Why don’t you keep a diary’, because we know that if you do pleasurable things, that can make you feel better.
What advice would you give to older people who feel under pressure to do things coming out of lockdown and may not be comfortable with the idea?
“I use a technique called behavioural activation, which is saying to people, ‘Why don’t you keep a diary’, because we know that if you do pleasurable things, that can make you feel better. Now, what did you do before lockdown? Oh, you went for coffee with a friend. OK, so you may not feel comfortable doing that – either because you’re shielding or your friend’s shielding or the cafes weren’t open till this week – but could you have a coffee virtually; could you make a coffee then Skype your friend and have a chat? That might make you feel better. Oh, you used to like going to the allotment; can you still go to the allotment? Well, keep a diary or get a notebook and write down, for each day, something good that you’re going to do, and that may be inside the house, it may be making bread or it may be doing a crossword with a friend, or it may be outside the house, going to the allotment or walking round the shops.
“But write it down, and write down how you feel after it, and then try to do something each day, and then, after a week or so, try and put two things in a day, to see if you can increase the amount of activity. But do it slowly, try not to worry about it. If it’s causing you worry, then think of something different to do that’s not going to cause you worry.”
What about the residual effects of this period on the mental health of carers?
“I think carers have perhaps been neglected, because a lot of their support has been withdrawn with the restriction of services. So people might have had a full care package and 4 carers coming in a day, but their care organisation said, ‘Well, we can only manage 2, and we’ve got to try and maintain the same person, and therefore it can only be on 5 days.’ I think some people have found that the care has been withdrawn, or at least reduced, or they’re coming in and only doing some bits of the care but not doing others, because of not wanting to have bodily contact. It’s fallen on carers to pick up the pieces.
“I’d say that to anybody who’s depressed or anxious, ‘What do you do for yourself?’ The answer is often, ‘I don’t have time for myself,’ and I might say, ‘That’s part of the problem, isn’t it?’ It’s really important to make time for yourself, and that’s where it comes to writing this diary, that actually you can write down, and go, ‘Right, well, I’m going to make sure that somebody comes and sits with my husband who’s got dementia so that I can go out for a walk in the park on that Thursday afternoon, and I can look forward to that for a couple of days, and I’ll feel the benefit for a couple of days, and then on Sunday, I’m going to take my husband out in his wheelchair, whatever the weather, we’re going to do that, and we’re going to go and have a takeaway coffee.’ And I have very basic conversations with people. asking: ‘What, specifically, are you going to do? You need to write it down,’ because that forces people then, it commits it to, ‘That’s what I’m going to do on Thursday,’ and they can tick it off, and they hopefully will feel better that they’ve done it, they’ve achieved it.”
What would you say to older people avoiding contact with doctors because they're worried about being an inconvenience or having to come into a surgery?
“I would want to reassure people that practices are open. It is likely that people will need to contact practices by telephone or on-line in the first instance. They are then likely to be contacted by telephone in the first instance by a Nurse Practitioner or a GP. If the nurse or doctor feels that a person needs to be seen face to face, they will be offered an appointment. Please don't worry that you are being a burden on the NHS – if you have a worry, do look at NHS 111, talk to your pharmacist or contact your practice.”
Feeling anxious or low about coronavirus?
It's natural to feel anxious, worried and overwhelmed during this period. There are, however, things you can do to help look after yourself mentally - and support available to you.