09 May 2022
As part of our celebration of Mental Health Awareness Week, Dr Mani Krishnan, chair of the Old Age Faculty at RCPsych, spoke to us about the effects of loneliness, and the impact it had on the vulnerable during the COVID-19 pandemic.
Ella: thank you so much for joining us for Mental Health Awareness Week. The theme of Mental Health Awareness Week is loneliness, and today we’re going to talk about depression, delirium, dementia; we’re going to talk about inpatient settings, and of course probably reflect on the pandemic, because that will be a time where people were feeling particularly lonely, because they were so isolated, and I guess we did not have the same network around us as we did.
As a mental health professional, what was your experience of the pandemic in terms of loneliness, what did you see patients go through?
Mani: Hi Ella, it is really an important aspect of my day-to-day working life since the pandemic started, even though loneliness is not a new concept, but our patients became even more lonely during the pandemic.
I suppose the way I would put it is the viral pandemic was one aspect, but because of that some of our vulnerable patients, who are also vulnerable to the virus were shielding, and then some of their own family members were shielding; which ended up with not being able to have adequate social connections, or able to meet their friends and family, and not even professional.
So, clearly some of our... especially like our older adults and other vulnerable population including people enduring mental illness.
They were probably quite disabled because of this pandemic, purely from not being able to access adequate physical healthcare, (and) adequate social healthcare.
Ella: We had a little chat just before the podcast started about the end-of-life services and the kind of loneliness people may have been experiencing if they’re approaching the end of their lives. Could you tell us a little bit about that and and how you provided support?
Mani: I think what we found was, obviously, the pandemic hit the whole population, and acute hospitals were overwhelmed, ICUs were overwhelmed, and what we found was many inpatient units were quite overwhelmed with admissions, as well as delay in discharge, and patients who had come for mental health difficulties, having to suffer with COVID and some of them even dying.
So, it was so it was about how we provide that care and support even though we had all the infection prevention control measures to safeguard our staff and safeguard our other vulnerable patients.
We had to take a call on how we support some of our patients, especially the patients who are coming to the end of life.
Unrelated to COVID and then about how we provide support to the family for them to say goodbye, and also for them to have that opportunity to have the interaction.
So, we did various things that supported both the patients and the family.
Because if there was an outbreak within the ward it was very difficult to get external people in, purely because of the fear of spread of infection at the time. But we managed to get like some specific areas where patients could meet their family members, isolated areas, as well as use of iPad technology to make video calls to family, and on case-by-case some patients we would use a barrier method to bring the family member in to support them if that’s what is needed.
So, in summary, even though we couldn’t do everything we did pre-COVID, we were able to do some person-centred approach and provide that compassionate care.
I did a review of some of our COVID deaths in our inpatient unit and I’m very proud to say that from the summary I could see from the evidence was the patients were offered a very good deck in that they had an experience for the families that they were constantly kept in the loop, kept informed, and provided support.
Ella: In terms of dementia, you were with a lot of people with dementia, what would people’s experience of loneliness be like?
Mani When you think of people with dementia, or people who have got some memory problem not yet diagnosed with dementia, those are the people, to me, significantly affected in the last two years.
The first one if you think of people who already who have dementia, but still managing reasonably well in the community; those patients lost their equilibrium, they lost their routine, because they all are used to the routine, you know getting up to go to the bank or a post office to get their pension, and to do their weekly shopping, you know pop in to have a coffee with a friend or a group of people, you know go for anything that they did normally, and go to the club, and meet family members on Saturdays.
So, they just lived for the clockwork type of regular structure that kept them going, and also kept their deterioration slightly under pause.
But unfortunately, with the pandemic, as I mentioned, they were shielding and the family were worried about giving the virus to their loved ones, so, they tried to not see them that often. I could hear stories where the sons and daughters are worried about popping into mums and dads because they worried that they would give the virus to them.
So, they did like a door drop of groceries and things, which significantly distressed our older adults.
And the other group of population, where there are just about developing cognitive impairment, unfortunately they were not able to go to services to be referred for every clinic, but also when they were referred there had been a significant delay in assessments, but also what we found in the last year is that some of those patients, who did not come to the knowledge of secondary services because they had mild memory problem but just about managing.
But the pandemic and the social isolation, even though it’s not evidence based I would say from my clinical experience, almost like fast forwarded their dementia in that they started deteriorating even more rapidly whatever in the few years, and I am seeing a lot of new referrals who were reasonably fine pre-pandemic and then getting worse, so clearly those who have mild problems became moderate, and those who already well established dementia they had a deterioration because of that lack of community engagement and isolation and loneliness.
Ella: With having such extreme lockdowns, do you think this was a catalyst for people’s dementia, so not having routine, not having people in their life, and you said earlier family and friends dropping off a shop at the door rather than going in; why is this kind of thing distressing for somebody with dementia?
Mani: It is not just about getting the materials. Normally the sons or daughters would have popped in and had a coffee with their mum and dad, or they would have said “come let’s nip out for a coffee”, “let’s nip out for a fishy Friday,” so they have that social connection.
The other thing I would say is that touch and feel, that is something important to our vulnerable people and older adults. So, I remember reading in social media (they said) “I would die to have a hug with my dad,” so it’s like that skin-to-skin touch, interaction, some tactile support is important. So, we found in our acute hospital when patients have delirium, which is another condition, the only way we could contain some of their agitation was just holding their hands. So, just dropping groceries on the doorstep ticked the material needs, but it did not tick the emotional and psychological need.
Ella: That’s really sad to hear. And also, it just shows you that skin-to-skin contact isn’t just important for babies and young children, it’s so important for our lives and do you think that the government were right to put in place such intense rules, considering how much it has affected people?
Mani: Unfortunately, we are in a bit of a Catch 22, I don’t think it’s easy to say you know one is wrong and the other one is right; however, I suppose people became innovative, I don’t know whether you have seen it social media, somebody wore a space suit type of thing and then went and hugged one of their loved ones.
So, people were making various ways of how they can overcome it.
Like, people were hugging them with their aprons, and the were using masks that have a transparent window so that they could see the face. Because masks is another one, especially our older adults, may have (been) hard of hearing, so they will usually lip read, and because of the masks even today I was struggling to communicate with one of my patients because they absolutely could not hear me because of my mask.
So, it can be tricky, (but) I think the government had to do what they had to do, but it is about that person-centredness. You know, having that allowance that if there are reasons to believe something else would help, how we can overcome it and support. That could have been my way of tackling that.
Ella: You also mentioned delirium earlier as well - so delirium and dementia are similar but there are some differences. Would you mind talking to us through the differences in how loneliness can affect someone with delirium?
Mani So, delirium is an acute condition unlike dementia, which is like a chronic condition.
Delirium is an acute episode of somebody getting confused, (an) acute change in the mental state from their normal mental state. Generally, for delirium there is an underlying cause, whereas with dementia it is due to the degeneration of the brain cells.
So, delirium is an acute onset syndrome whereby there is a problem with people’s attention, alertness, and consciousness.
So, there is a problem in their attention, whereas in dementia there is it there is also a problem attention and their cognition, but it is a long-standing, it is an ongoing thing, so, with delirium there’s usually an underlying cause, something like an infection, or something like dehydration, and for that matter even this lockdown there are patients who suffered from delirium because their a routine was affected.
So, when people do not take their medication, or take more medication, not adequately drinking, all of them can cause delirium. Delirium is an acute change in mental state usually caused by an underline physical health problem or environmental problem.
I also want to make a very important point; this is something people question; can people with dementia get delirium? So, this is really really important (and) I just want to hit hard on this in fact. Delirium, even though it’s an acute confessional state, it doesn’t mean that people with a long-standing memory problem cannot develop delirium. So, there is a term, we call it delirium superimposed dementia.
So, people who have long-standing dementia, when their physical health or mental health is altered the can from delirium, so we need to be mindful. Just because somebody has got dementia doesn’t mean that they can’t get delirium, so that is important. Another important point is delirium should be detected and prevented.
Because if we manage the risks, the severity of the delirium can be reduced, and the risk of developing delirium can be reduced. What they found (is) there was a recent paper during the pandemic done by one of your colleagues, Sarah Richardson in Newcastle, it’s called ‘The Side Study’.
She talks about the (more) severe the delirium, the longer the delirium, their cognitive impairment may end up with a longer-term cognitive impairment. So, it’s almost that paper indicates that it may be a potential like a preventative measure for people developing dementia, if you tackle delirium somebody developing dementia could be either delayed or prevented. So, it is important to prevent and detect delirium.
Ella: People can have multiple mental health needs and multiple disorders. The last one we want to talk about was depression. How many older people do you work with who struggle with depression?
Mani: I would say 30 to 40% of our older adult mental health do have depression. So, obviously (it’s) a significant number (that) I deal with dementia, but I do have a significant amount of patients who develop depression, as well as some of our early dementia patients can have coexisting depression as well. So, depression is almost like, they will say, it’s another global pandemic, especially in olde adults it can be quite debilitating and restricting.
Ella: That’s actually a much higher percentage than I thought you were going to say. I thought it would maybe be somewhere in the region of 10 to 15 percent.
Mani No that’s my caseload, so in the community is slightly lower so do you want me to reframe it for you?
Ella: Yes, please.
Mani So, depression is quite common, especially in older adults, but there is a variability in how depression presents in the community or in secondary care. So, about I think 20 to 25 percent of the population in the community could have depression (older adults). Probably only half of them will go and seek support in the primary, but even in those half of them would seek that support, only probably third of them will get some form of medication and there is significant lower number who will get psychological support. And then when it comes to depression in the patients’ household, it’s generally 9 to 10 percent. Whereas in institutions like care homes you can be up to 42% so there is a significant number of patients in institutions that can have depression. So, in the community it’s probably about 9 to 10 percent. Does that sound more coherent, Ella?
Ella: Yes, it does yes, but still in your own caseload 30 to 40% is still really high.
Mani It is, yes.
Ella: if somebody has depression would they feel loneliness more acutely, or will they interpret things as feeling lonely more easily? Can you explain it a little bit more?
Mani So, obviously depression in older adults can present as slightly different. Obviously older adults, they have multiple physical health problems as well. As well as environmental restrictions due to mobility and frailty, so even to start with, they may feel that they have not up to the mark. Sometimes they will try to normalise it; “I’m bound to be a bit low,” so they may not even seek help, because they may not be able to understand actually, they are going through depression. The other bit is when people are isolated, people are lonely, it can trigger changes in the moods. Especially, we noted during the pandemic some of our older adults lost a spouse, who have been together for 50-60 years. And grief is one thing that people develop from depression, so that’s another thing we have seen.
And also, people who are living alone, they manage to live alone with a good network of friends and families, and the social connection, as well as having a routine. The routine was significantly damaged and disrupted during the pandemic, which caused significant amount of distress, in turn it caused worsening, or new onset depression. For example, there are patients who will walk around supermarkets, who will walk round the town centre just to get their day pass by. (They will) go sit and have a coffee and a chat with known and unknown people, and then get home, which will be their routine, but that routine was disrupted and significantly some of the community hubs and community day support facilities all have stopped, which meant that their lifelines, some of the community support was disrupted and it did affect their mood. So, loneliness definitely had an impact on either new onset depression or depression getting worse.
Ella: And that kind of reminds people that if you see someone sitting by themselves, having a coffee by themselves, or just kind of meandering around it might be nice to speak to them.
Mani I think it is, especially I know in this current world people are always frightened of having a chat, what do they think, but again our generation of older adults are very sociable people. They will just start commenting it’s a nice day and it is nice to have a chat. I remember talking to people in airports, or in supermarkets, or in like a big shopping mall. And sometimes it’s nice to give it to the community, like hold their hands to cross the road or something. It is about the community involvement that really helps and in one of our hospitals we have a lot of volunteers, who will sit with them, sing a song for them, or paint their nails, getting them engaged in activities really helped them to flourish.
Ella: Thank you so much for sharing that. What do you find works best with patients in terms of combatting loneliness, if let’s say they don’t have friends or family visiting? How would you manage somebody’s loneliness?
Mani Yeah, I think the key points I would say are number one, having some routine, having a routine is really helpful. Because if somebody is lonely it’s easy for them to say “I’m only lonely, I don’t need to get up and get ready. What am I getting ready for?”
So, it is about having that regular habit, and also reaching out even though they may not have very close family or friends, but they could reach out. At the same time, the services can’t reach out as well, like social prescribing. I have a patient who likes the trains, so we tried to link that person with the local train museum, and also people like fishing, people like to go to the shops.
So, it is about linking people with their interests and social prescribing definitely helps, which can be accessed through their local GP surgery. And then having that regular conversation if possible, and also even doing some charitable work just because somebody’s older doesn’t mean that they can only receive help. They can actually provide help, they can support, they can do some talking to people even older than them, people who are (more) vulnerable than them, which many of my older adults do actually.
They will ring their friends, they will ring their cousins, so not only receiving help, (but) providing help, like people who go to church. They can go to church groups; they can have common interests like rambling groups or various things. You know, they can all provide and support each other (and) that is important. Having adequate exercise, whether you like it or not, go out and get fresh air, and adequate food; make sure that they’ve got food adequately, and getting their physical health regularly checked. You know, having a healthy body and mind is really important to keep on tackling the loneliness.
Ella: Thank you so much Kris, it was lovely speaking to you.
Mani Thank you so much Ella, take care.