To date, the majority of COVID-19–related deaths in the United States have occurred among adults age ≥65 (Centers for Disease Control and Prevention [CDC], 2020), and approximately one fifth of deaths have occurred in nursing homes (National Centers for Health Statistics, 2020), making older adults a vulnerable population in this pandemic (Dichter et al., 2020). Although social distancing is a way to slow contagion, can it have unintended consequences?
The ongoing COVID-19 pandemic has brought changes to health care delivery. Although policies enforcing social distancing are reasonable to enact during this time, they could negatively impact older adults' mental health via social isolation. Perceived social isolation has been linked to adverse health outcomes, such as depression, anxiety, cognitive decline, and impaired immunity at every stage of life (Smith et al., 2020). Specifically, with sustained social distancing, social isolation is disproportionately affecting older adults due to diminished social networks, living arrangements, and transportation limitations (Morrow-Howell et al., 2020).
In addition, the health care system has narrowed its focus to managing COVID-19 cases, meaning other health care appointments and procedures are being delayed (Morrow-Howell et al., 2020). Non-essential visiting in nursing homes (CDC, 2020) and non-urgent provider visits are being restricted. The critical question we aim to ask is: On what grounds are support services (e.g., visits with family or friends, personal care assistance) for older adults considered non-essential? Canceling social interactions may increase the risk of adverse mental health outcomes (CDC, 2020). In contrast, increasing social integration and higher levels of support are linked with decreased levels of inflammatory cytokines, such as interleukin-6 and C-reactive protein (Smith et al., 2020). Therefore, decreased social integration might be associated with increased inflammation (Smith et al., 2020), which impairs immune functioning and adds a greater risk for coronavirus infection (Van Orden et al., 2020).
Technologies provide a solution for older adults to communicate with their family and maintain social interactions. These technologies can also be used for health care visits. Examples include social networking applications (apps), fitness apps, telemedicine apps, and medication-related apps (Banskota et al., 2020). Technologies restore the connection between older adults, their family, and health care providers. However, technology cannot be substituted for all in-person care (Banskota et al., 2020).
“Connections Plans” conducted by the HOPE (Helping Older People Engage) Lab provide clinicians with evidence for developing the most effective strategies to promote social connections and belonging in later life (Table 1) (Van Orden et al., 2020). Connections Plans, similar to safety plans for suicide risk, include coping strategies for preventing social isolation during the COVID-19 pandemic via telephone visits (Van Orden et al., 2020). A Dutch national study found that family visitation in nursing homes had a positive impact on older adults' well-being (Verbeek et al., 2020). As such, they developed guidelines that strategized how to open nursing homes for visitors during the COVID-19 pandemic (Verbeek et al., 2020). In addition, the John A. Hartford Foundation launched a free COVID-19 Rapid Response Network for nursing homes (access http://www.ihi.org/Engage/Initiatives/COVID-19-Rapid-Response-Network-for-Nursing-Homes/Pages/default.aspx), which has featured daily 20-minute National Nursing Home Huddles with practical solutions that can be implemented to address challenges posed by COVID-19 (Institute for Healthcare Improvement, 2020).
Cognitive-Behavioral Strategies and Resources for Preventing Social Isolation
Transitioning in Hope
Jones-Schenk (2020) points out that hope is not mindless optimism, but rather looks upon hope as strength through “cognitive pathway development and concurrent viewing of the now and the horizon of the future” (p. 204). Life is more difficult than it was before COVID-19 in terms of emotional support and the ways that we live. In the face of this pandemic, we fix our sights on the hope that Jones-Schenk (2020) encourages.
Building a New Way to Live Without Fear
Hope is a construct of resilience that can serve as a buffer against day-to-day disappointments (Jones-Schenk, 2020). There is no time like the present to begin learning a new way to live without fear but with hope. Hope may not be here and now or beyond (Jones-Schenk, 2020), but hope exists throughout life as an impetus that supports individuals to cope with changes as they continue functioning during this unprecedented time.
Hope and change are intertwined (Jones-Schenk, 2020). Nurse leaders can bring about change by advocating for hope, and how it makes a difference in the lives of individuals in nursing homes who are eager to return to a new normal. Building a new way to live without fear is not about what a new normal will be; it is about how we can continue building an inclusive society for older adults.
Older adults are worthy of hope, dignity, and honor. Our health care system needs to find ways to minimize the negative outcomes of the mental health burden posed by social distancing and find new ways to keep older adults connected. Hope will happen when social inclusion of older adults occurs, even with the challenge of social distancing.
Shih-Yin Yu, MSN, RN
PhD Nursing Science Student
School of Nursing
University of Washington
Hsiao-Fang Hung, PhD, MS
National Tsing Hua University
Institute of Molecular & Cellular Biology
- Banskota, S., Healy, M. & Goldberg, E. M. (2020). 15 smartphone apps for older adults to use while in isolation during the COVID-19 pandemic. Western Journal of Emergency Medicine, 21(3), 514–525 doi:10.5811/westjem.2020.4.47372 [CrossRef]
- Centers for Disease Control and Prevention. (2020). Preventing the spread of COVID-19 in retirement communities and independent living facilities. https://www.cdc.gov/coronavirus/2019-ncov/community/retirement/guidance-retirement-response.html
- Dichter, M. N., Sander, M., Seismann-Petersen, S. & Köpke, S. (2020). COVID-19: It is time to balance infection management and person-centered care to maintain mental health of people living in German nursing homes. International Psychogeriatrics. Advance online publication. doi:10.1017/S1041610220000897 [CrossRef]
- Institute for Healthcare Improvement. (2020). COVID-19 rapid response network for nursing homes. http://www.ihi.org/Engage/Initiatives/COVID-19-Rapid-Response-Network-for-Nursing-Homes/Pages/default.aspx
- Jones-Schenk, J. (2020). Hope as a generative force: Lifting our gaze to the future. Journal of Continuing Education in Nursing, 51(5), 203–204 doi:10.3928/00220124-20200415-03 [CrossRef]
- Morrow-Howell, N., Galucia, N. & Swinford, E. (2020). Recovering from the COVID-19 pandemic: A focus on older adults. Journal of Aging and Social Policy, 32(4–5),526–535. doi:10.1080/08959420.2020.1759758 [CrossRef]
- National Centers for Health Statistics. (2020). Provisional death counts for coronavirus disease (COVID-19). https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm
- Smith, K. J., Gavey, S., Riddell, N. E., Kontari, P. & Victor, C. (2020). The association between loneliness, social isolation and inflammation: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 112, 519–541 doi:10.1016/j.neubiorev.2020.02.002 [CrossRef]
- Van Orden, K. A., Bower, E., Lutz, J., Silva, C., Gallegos, A. M., Podgorski, C. A., Santos, E. J. & Conwell, Y. (2020). Strategies to promote social connections among older adults during ‘social distancing’ restrictions. The American Journal of Geriatric Psychiatry. Advance online publication. doi:10.1016/j.jagp.2020.05.004 [CrossRef]
- Verbeek, H., Gerritsen, D. L., Backhaus, R., de Boer, B. S., Koopmans, R. & Hamers, J. (2020). Allowing visitors back in the nursing home during the COVID-19 crisis: A Dutch national study into first experiences and impact on well-being. Journal of the American Medical Directors Association, 21(7), 900–904 doi:10.1016/j.jamda.2020.06.020 [CrossRef]
Cognitive-Behavioral Strategies and Resources for Preventing Social Isolation
| Design instructions for guiding older adults to engage in a mindful activity or prayer to connect with a sense of their shared humanity and that “we are all in this together.”||Headspace app (including loving kindness meditation): http://headspace.comTara Brach, PhD; Guided meditation: https://www.tarabrach.com/meditation-times-of-pandemic/|
|Change Body Sensations|
| Practice tolerating feelings and body sensations instead of resisting them and pushing them away.
Read stories of care and watch video messages of hope for residents and staff, or upload your own message to be shared on social media||Download the free PDF Tolerance for Uncertainty: A COVID-19 Workbook: https://www.baypsychology.ca/workshops#CareNotCOVID: https://www.carenotcovid.com|
|Change Ways to Connect|
| Connect with people in safe ways via phone/video calls or support hotlines.||GeroCentral is a clearinghouse of resources for clinicians, older adults, and families that includes links to virtual activities: https://gerocentral.org/clinicaltoolbox/covid-19-resourcesAdults age ≥60 can call the Institute on Aging's 24-hour, toll-free Friendship Line at 800-971-0016 or the National Suicide Prevention Lifeline at 800-273-8255, or use the online Lifeline Crisis Chat: https://suicidepreventionlifeline.org/chat|