Is Extended Isolation Killing Older Adults in Long-Term Care?

In February, Lorri Evans’ mom, Helen, was walking the equivalent of four blocks, twice a day, around her memory care facility in Santa Cruz, California. “She used a walker for support,” Evans says, “but her legs worked fairly well for someone who is 99…Just a year ago, she was dancing at my daughter's wedding.

When the coronavirus pandemic hit the U.S., sending long-term care facilities into lockdown, Helen was confined to the second floor of her complex — where her room was located — for months. Her outdoor walks ceased, and so did her mobility. She became bedbound. Her mind, already battling dementia, deteriorated, too.

In May, she was placed in hospice. In July, Evans brought her home to begin the final months of her mother's life – Helen passed away on September 18^th.

"Look, I'm sure she would have declined somewhat, but I know in my heart the isolation accelerated it,” Evans says. “She would have made it to well over 100 but that's not going to happen now. ... She's collateral damage of this COVID-19 seclusion, passing away because of a broken heart."

Data on the mental health effects of the long lockdown at America's nursing homes and other long-term care facilities is scant. But experts, resident advocates, and those with loved ones on the inside say that lockdown is fueling a mental health crisis that's amplifying the devastating impacts of the pandemic on the long-term care industry, where long-term care residents and staff account for 4 in 10 pandemic deaths. They say that feelings of loneliness, abandonment, despair and fear among residents — and their toll on physical and neurological health — are only pushing the pandemic's death toll higher.

Even before the pandemic, social isolation (the objective state of having few social relationships) and loneliness (the subjective feeling of isolation) were considered serious health risks for older Americans.

A body of evidence shows that these factors significantly increase a person's risk of mortality from all causes, potentially rivaling the risks of smoking, obesity and high blood pressure. Social isolation and loneliness are also associated with higher rates of clinically significant depression, anxiety and suicidal ideation.

But there is more than mental health at stake. Isolation and loneliness are associated with a 50 percent increased risk of developing dementia, a 32 percent increased risk of stroke, and a nearly fourfold increased risk of death among heart failure patients, according to separate studies. With 43 percent of adults age 60-plus in the U.S. reporting feeling lonely, the rates of social isolation and loneliness were already at the level of “a public health crisis,” according to Perissinotto, a coauthor of the report.

Lockdown measures appear to be exacerbating that crisis in long-term care facilities. “We're seeing an increase in depression, anxiety, frustration and irritability,” says Heather Smith, lead psychologist at the Milwaukee Veterans Affairs Medical Center. “We're also seeing an uptick in dementia-related behaviors,” she says, noting that a significant percentage of long-term care residents — at least half, according to the Centers for Disease Control and Prevention (CDC) — suffer from dementia diagnosis of some kind. “So what we're seeing is not a surprise.”

"We're faced with this heart-wrenching tension,” says geropsychologist Sheri Gibson, a private practitioner and clinical supervisor at the University of Colorado Colorado Springs, “between protecting the medically fragile older adults from the virus and cutting them off from outside support and connection, which we know is vital to their overall well-being.”

For many residents, the mental tolls are leading to declines in physical health. “We're seeing withdrawal from care,” says Smith, the psychologist in Milwaukee, “so refusal to eat or take medication or engage in self-care, like showers or exercise."

Those behaviors can lead to increased weakness, weight loss and pain perception, which put people more physically at risk. Weakness, for example, can contribute to falls, which in turn can produce other life-threatening health problems.

Still, there has been a “surge of creativity” by some long-term care operators amid the crisis, says Gibson, who has been running webinars on maintaining connectivity during the pandemic for the national long-term care ombudsman program. Many facilities are hosting window visits to facilitate contact with loved ones, she says. Others are using videoconference platforms like FaceTime and Zoom to enable virtual visits.

AARP is advocating for federal and state laws that would require long-term care facilities to facilitate such virtual visits, although its ultimate goal is “to make it safe for all families and friends to visit residents in person again,” says Elaine Ryan, AARP vice president for state advocacy and strategy integration.

The reintroduction of socially distanced day-to-day activities, like bingo games and church services, at many facilities has also kept residents connected and engaged.

As the crisis continues, Gibson encourages the family, friends and representatives of residents to talk about mental health: “The most important thing that any of us can do is validate how difficult this is and normalize for the resident their anxiety or feelings of loneliness or hopelessness.” Make sure that everyone knows that they are not alone in this experience.