Opportunities for the advanced practice nurse in improving the wellbeing of older adults during the COVID-19 pandemic

Abstract

The prevalence of stress, anxiety, and depression have increased during the coronavirus disease (COVID-19) pandemic across age groups. Older adults may additionally be experiencing accelerated cognitive decline and increased behavioral and psychological symptoms of dementia related to the pandemic and associated isolation precautions. The advanced practice nurse has an opportunity to holistically intervene to mitigate the negative effects of isolation and promote older adults’ wellbeing during challenging times.

Introduction

During the coronavirus disease (COVID-19) pandemic, the prevalence of depression in adults in the U.S. has increased 3-fold, and persons with lower income, less savings, and greater exposure to stressors may experience the greatest symptom burden.¹ Psychologic factors including worries about personal or loved ones’ health, difficulties with sleep, economic uncertainty, and social isolation have been observed internationally during the pandemic.² A meta-analysis of global studies estimated the prevalence of stress, anxiety, and depression in adults during the pandemic to be 29.6%, 31.9%, and 33.7% respectively.³

Reports specifically describing older adults’ psychological responses to the COVID-19 pandemic have been more mixed. In the years prior to the pandemic, researchers observed an association between loneliness/social isolation and depression/anxiety in older adults⁴, so the expectation of many researchers and clinicians was that the pandemic and associated social distancing could increase loneliness and thus worsen mental health in older adults. Longitudinal surveys assessing older adults’ psychological symptoms before and after the pandemic have noted higher loneliness, depression, and anxiety scores.^{5 , 6} However, studies assessing the effects of the pandemic across the lifespan have noted a relatively lower prevalence of depression and anxiety in older adults compared to younger adults.7, 8 One highly publicized multi-site study in the U.S. using a mixed methods survey/interview design with 73 older adults with pre-existing depression noted that the participants were resilient through the first two months of the pandemic, with unchanged depression, anxiety and suicidality scores.⁹ Notably, the sustained effect of the pandemic and the durability of older adults’ resilience remains uncertain.

Persons with dementia have been vulnerable to unique adverse effects of the pandemic and social isolation. Prior to the pandemic, researchers observed an association between loneliness and new or worsening dementia.^{10 , 11} Evidence is emerging that persons with dementia and their caregivers may often subjectively assess the person with dementia as experiencing accelerated cognitive decline during the pandemic.¹² Many emerging reports also describe deterioration of behavioral symptoms of dementia during social isolation, with apathy, irritability, insomnia, agitation, and anxiety being particularly prominent.12, 13, 14, 15, 16 Alongside deterioration of behavioral symptoms of dementia, informal caregivers of persons with dementia have reported increased caregiver burden and stress during the pandemic.12, 13, 14

Due to the diverse vulnerabilities and experiences of older adults during the COVID-19 pandemic, advanced practice nurses (APNs) must take a patient-centered approach to addressing wellbeing, including new or worsening stress, depression, anxiety, and dementia-associated neuropsychiatric symptoms. The purpose of this paper is to describe an evidence-based, patient-centered approach for the APN in assessment and treatment of wellbeing in older adults living during the COVID-19 pandemic.

Assessment

Assessment of an individual's wellbeing may occur in-person or via telehealth. Social chit chat and relationship building prior to formal assessment has been observed to enhance patient-centered communication by increasing rapport and trust¹⁷; these conversations may also provide the APN with valuable information about a patient's lived experience during the pandemic. Recognizing that each person may experience pandemic-related stress differently, the APN may consider a myriad of assessment tools based on patient factors and visit considerations (e.g., visit length, in-person vs. telehealth). Table 1 contains a list of tools to consider along with notes about tool length and special populations for which each tool might be appropriate. COVID-specific stress scales are emerging with initial validation data; no single instrument has emerged as most appropriate for use in clinical practice with older adults.

Table 1.

Screening tools for assessing wellbeing in older adults.

Assess:	Tool	Notes
Depression	Geriatric Depression Scale18	Short version: 15-item scale Long version: 30-item scale
	PHQ-219	2-item scale
	PHQ-919	9-item scale
	Cornell Scale for Depression in Dementia20	For use with formal or informal caregiver of person with dementia
Anxiety	GAD-719	7-item scale
Stress	Perceived Stress Scale21	10-item scale
Behavioral and Psychological Symptoms of Dementia	Neuropsychiatric Inventory Questionnaire (NPI-Q)22	For use with formal or informal caregiver of person with dementia; 13-item scale
Caregiver stress	Caregiver Stress Scale23	For family member caregivers

Advanced practice nurses may also consider assessing for new or worsening cognitive impairment when there is concern for such on the part of the patient, caregiver, or APN. Cognitive screens can be more challenging than psychological screens to adapt to telehealth as many involve drawing, reading or other activities that are easier to facilitate face-to-face. Providers who are engaging in these screenings more frequently via telehealth may find it useful to use camera-facilitated visits and to send lists of supplies for patients or their caregivers to gather in preparation for the visit. The general practitioner assessment of cognition (GPCOG)²⁴ and Mini-Cog²⁵ screening tools have good sensitivity and may be useful for initial screening in primary care.

Diagnosis

As providers evaluate older adults’ wellbeing, consideration should be given to mental health diagnoses including adjustment disorder, major depressive disorder, generalized anxiety disorder, and cognitive impairment. Adjustment disorder may be particularly pertinent during the COVID-19 pandemic^{26 , 27}; the DSM 5 defines adjustment disorder as “the development of emotional or behavioral symptoms in response to an identifiable stressor(s)”.²⁸ Symptoms typically present within 3 months of the stressor and may persist until 6 months after the stressor is terminated.²⁸ The adjustment disorder may be designated as acute if the duration of symptoms has been 6 months or less and chronic if symptoms persist past 6 months.²⁸ Adjustment disorders are coded as having depressed mood, anxiety, or a mix of depression or anxiety.²⁸

Treatment

Treatment plans should be selected in partnership with the patient and/or caregiver, with attention to individual factors and needs.

Pharmacologic

Pharmacologic management may be indicated when symptoms impair function. Clinicians may follow typical guidelines for stepwise therapy for relevant disorders, even if symptoms have emerged or worsened in response to specific stressors such as a pandemic. There is a paucity evidence for successful pharmacologic or nonpharmalogic management strategies for adjustment disorder²⁷; if symptoms are interfering with function, it would be reasonable to initiate therapy according to the associated mood effects (depression vs. anxiety vs. mixed).

Nonpharmacologic

A myriad of nonpharmacologic strategies may be applied to address wellness in older adults during the COVID-19 pandemic. One study found that during the pandemic, Italian older adults were less likely to engage with healthy activities they previously enjoyed such as exercise, eating a Mediterranean diet, and engaging in social activities.²⁹ Advanced practice nurses can explore patient history to determine whether there are healthy practices that have bolstered wellness for the person in the past that could be safely resumed during the pandemic. A survey of older adults in Spain specifically observed that healthy diet, avoiding reading an excess COVID-related news stories, following a routine, engaging with hobbies, and going outdoors were associated with fewer depressive symptoms.³⁰ Similarly, a survey in the U.S. and Canada noted that even light exercise seemed to have a protective effect on mental health during the pandemic.³¹

Advanced practice nurses can also discuss with patients ways to safely mitigate the effects of social isolation and reduce a sense of loneliness. Interestingly, Krendl et al.⁵ noted that the perceived strength of older adults’ relationships with others inside or outside their household modulated the effect of loneliness on depression and anxiety symptoms. Advanced practice nurses can assess for important relationships in patients’ lives and help patients brainstorm ways to maintain those connections while ensuring safe physical distance.

Persons with dementia and their family caregivers may benefit from frequent check-ins (virtual or in-person) while socially isolating. A recent review of the evidence indicated that technology-facilitated visits incorporating individualized psychosocial or psychoeducational strategies for the patient-caregiver dyad can be useful for reducing behavioral symptoms of dementia and for promoting wellbeing for patients and caregivers.³² Flexible mobilization of memory care services to telehealth platforms using geriatric-trained clinicians is essential for reducing disease and caregiver burden during periods of social isolation.^{33 , 34}

Conclusions

The coronavirus disease (COVID-19) pandemic and associated social isolation measures have resulted in widespread increases in global stress, depression, and anxiety. Evidence is emerging to describe the unique experience of older adults in the U.S. during the pandemic. While older adults have been highly resilient, they may have other unique vulnerabilities. The advanced practice nurse may play a formative role in patient-centered assessment, diagnosis, and treatment to optimize wellness in persons living during the pandemic.