Working in old age psychiatry during the COVID-19 pandemic

For many of us living longer is a blessing, an achievement of our modern society.

After every sunset we wake up wiser, more experienced, but ultimately older.


At the beginning of the coronavirus pandemic in Stockholm I worked in an old age psychiatry community-based unit, but now I have moved into an inpatient geriatric ward (in reality it was a inpatient psychiatric ward transformed during the corona crisis into an inpatient geriatric ward). The average age of our patients is above 70 years and many of them, when not in hospital, live at home with help from social workers or in different forms of nursing/care homes.


During these pandemic times, people like our patients are way too often referred to as “people at risk”, or “older and with underlying conditions”. But for me they are wonderful people with amazing life stories.


Photography from WHO

For me, coming from an ex-communist country, all these stories are from another world, like letters to my grandparents. I am just the postwoman. My patients’ stories are from the other side of the wall, stories from a country without wars for the last 200 years.


Most of the patients referred to our unit suffer with anxiety and/or depression and some of them had previously attempted suicide or have a high suicide risk.


In pandemic times, the recommendations are that people over the age of 70 should follow strict social distancing. They should isolate at home and no visits are permitted to care homes for unnecessary medical visits. We say “NO” to many of our medical visits at our outpatient unit or at home.


Face to face visits are very rare and reserved for psychiatric emergencies. All other evaluations are done over the phone or very rarely by video-calls. The circumstances in which we deliver care are new for medical staff and for the patients. Humans are creative and adaptable.


At the beginning of the pandemic I called as many patients as possible, even patients that in other conditions I would have assumed are in a stable situation. I worried that their anxiety, depression, and/or feelings of loneliness will worsen, that they will start drinking more alcohol or that they will avoid seeking medical help for other life threatening medical conditions.


Headlines from media during the pandemic (photography done with a little help from Kristian Reveles Jensen)

At the beginning, the mediatic cover of the coronavirus pandemic was very intense for me, as for many others. My worries at times were probably disproportionate, but it was a new situation for all of us and it took me some time until my worries calibrated to a new normal.


COVID-19 news coming from Italy and Spain about how medical staff needed to make difficult ethical decisions on who will benefit the most from an intensive care treatment was overwhelming. And it didn’t take long before many of my patients started to receive news of a relative, or a friend, or a friend of a friend, who died because of the infection or that was in hospital battling pneumonia.


CollectivelyCounting is brought to you by First Fortnight, Ireland's Mental Health Festival, in collaboration with poet Stephen James Smith and director Cra...


“Collectively Counting” by Stephen James Smith summarize the anxiety from the beginning. Many of the questions are still unanswered.

Inevitably, the first part of the conversation with our patients was about the pressure we were all exposed to. Many of the voices were composed, acknowledging that “it is a very difficult situation” and praising our work.

But I could hear some very anxious and trebling voices at the other end of the phone who described the whole situation as a “holocaust” or ‘’ättestupa”. Some of them cleaned their houses and prepared for the worst-case scenario, while others turned off the television and other media channels and tried to do something else to distract.

Somehow the second part of the conversation was about medicines… if you are talking with a doctor you need to ask something about medicines. I received questions about the use of vitamin D, anti-inflammatory treatment as ibuprofen and medication for high blood pressure. Honestly, I lacked the competence in answering these questions.

As the link between psychiatric medication and coronavirus infection were not making the headlines, no patient has yet asked me about the use of their medication for depression, anxiety or bipolar disorder and the risk for infection with coronavirus COVID 19. But for us as professionals it is an everyday question.

Polypharmacy (concomitant use of several medications) is common among elderly and we constantly try to reduce the amount of medication. Other questions are related to side effect of specific drugs on the immune system, kidney function or the impact on the muscle of respiration. There is a lack of evidence on the direct relationship between medication for psychiatric use and coronavirus.


Source: WHO

Everyone does their best to respect the recommendations and adapt to their new life in the best possible way.


But for many of our patients who were already suffering from loneliness, the measures of self-isolation are almost unbearable.


“Loneliness epidemic” made the headlines in our media, and in 2018 the UK government launched their “loneliness strategy”. Loneliness is defined as “situation experienced by the individual as one where there is an unpleasant or inadmissible lack of (quality of) certain relationships. […] Thus, loneliness is seen to involve the manner in which the person perceives, experiences, and evaluates his or her isolation and lack of communication with other people”. In European countries, loneliness increases with age. Around 16.9% of the people over the age of 80 feels lonely almost all the time. The prevalence is higher in Eastern European countries and lowest in Nordic countries.


Source: WHO

It is unbearable not to hug and have a close contact with their family, or not to take a walk and a cup a coffee with their friends. To communicate through videocall is not that easy, sometimes it even requires several hours of preparations.


Very few of them got worse, more anxious, depressed or even suicidal during the pandemic, but together with their family and carers we found solutions, including, if needed, breaching the “No physical visits” recommendation.


But surprisingly, for me, many of them had resources to adapt to the new normal. Sometimes I could hear happy voices, telling me how they succeeded to use these complicated techniques. It was like a personal development.


I realised that getting older is a process, a journey, and all of us, including myself, are in different stages of this process. Probably understanding the beauty and the meaning of this journey is the way in which we come to terms with the unknown, the death, the grief of losing someone dear, but also with the happiness and gratitude about life.


The anxiety from the beginning has diminished, as good news from survivors and scientists are reaching out. We all try to continue living our meaningful and extraordinary life regardless of the pandemic.


Andrà tutto bene! Photography courtesy Jean Pierre Saint-Martin, a photograph from Scotland.

 

Tony Luciani’s “A Life Divided.” photography from SLRLounge