In March, as communities shut down, Robert Roca, M.D., and his wife brought home his 96-year-old mother-in-law from an assisted living facility. “Had she stayed, she would have been alone in her room all day with no visitors.” Soon his brother-in-law moved in, and so did his daughter and son-in-law. His daughter was eight months pregnant, and they’d been living in Brooklyn, New York, when Covid cases skyrocketed all around the city. “It was an unusual and beautiful moment in our lives where our house filled with generations of loved ones at the same time. It wouldn’t have happened otherwise.”
Dr. Roca, chair of the American Psychiatric Association’s Council on Geriatric Psychiatry, says the pandemic is littered with stories like his but also with the painful challenges and decisions older people and their families have faced.
From the onset of the pandemic, he notes there’s been a tension between avoiding contagion and the need to mitigate the toxicity of isolation. His patients frequently share two common concerns: fear of the virus and distress from separation from family and friends. Many Americans, especially older adults, says Dr. Roca, must carefully assess the costs and benefits of their decisions.
“Every day, they’re determining how much of a chance they’re willing to take,” he says. “The chronic weighing that’s happening is our existential reality at the moment.”
Communities across the United States are shutting back down as Covid infection rates continue to rise and vaccine rollouts have a stuttering start in many places. No state is experiencing a sustained decline. To date, there have been over 25 million known cases and 419,263 deaths. Early in the pandemic, incidence of the virus was highest among older adults, but that has since changed. For example, over the summer, prevalence of the virus was highest in adults ages 20-29. Yet deaths have continued to disproportionately affect older people and marginalized populations. The CDC’s provisional death count illustrates that 79% of people who’ve died from the virus were over 65 years old, with 31% older than 85.
CDC guidelines for older adults are not ambiguous, stating they should limit their interactions with other people as much as possible. How this population does the cost-benefit analysis Dr. Roca mentioned depends on each person’s predominant concern. For example, some older people’s anxiety over the virus has meant they’re “stringently imposing isolation on themselves.” Others are more apt to take potentially lethal risks because they find the alternative, the constriction on day-to-day life, unbearable.
“We each have our own risk meter, and there’s variance in how persuaded people are that there’s a risk in the first place,” he says.
As the pandemic lingers, some older adults continue to isolate while others take graded steps back into society, going to the grocery store and testing the waters of other activities. Dr. Roca says proximity to the virus often affects the calculus. “If they’ve fallen ill themselves or known someone who has, they might weigh their decisions differently than those who continue to view the virus as remote. Decision-making isn’t always rational.”
While it’s personal how much risk a person will take and how much isolation, what we know is that physical distancing requirements to halt the spread of Covid have had a disproportionate toll on older Americans. In fact, 27% of people age 60 and older live alone, potentially resulting in not just physical distancing but physical isolation. Also, social support systems for older adults and other at-risk populations are often inadequate. This has caused experts to turn their lens to the existing literature on the relationships between isolation, loneliness, and health outcomes.
Isolation is calculated by the size of a person’s social network, along with frequency and closeness. These social supports are positive for mental health and general outcomes. “People with limited social networks typically fare worse,” says Dr. Roca. He’s careful to point out that doesn’t prove causation, just that there’s a relationship between social connectedness and health.
“It doesn’t mean isolation made the person unwell,” he says. “Perhaps being unwell made them more isolated. The direction of the causal arrow is not clear.”
While isolation is an objective state, loneliness is an emotional and subjective one where a person hurts for contact. Dr. Roca says the size of a person’s social network doesn’t necessarily determine whether a person feels lonely. For instance, people might surround a person, and still, the person experiences loneliness, while someone else may have a small social network that includes a few important people and not be lonely at all.
The health implications of loneliness remain unclear, with some study outcomes showing it’s just as toxic as obesity or smoking, while others are less concrete. Dr. Roca says loneliness, at a minimum, is a marker for health risk. Whether it causes bad health outcomes is another question. “The jury is still out on causation, but someone reporting loneliness is likely more at risk of adverse physical and mental health outcomes.”
Contrary to stereotype, loneliness doesn’t primarily affect older adults. Before the pandemic, the health insurer Cigna reported that 61% of people surveyed in 2019 said they were lonely, with 81% of Gen Z and 61% of Millennials saying they felt lonely compared to 49% of Baby Boomers.
However, the pandemic might cause shifts in isolation and loneliness among older adults because of increased limitations on social interaction. Over the summer, 56% of people over the age of 50 polled by the National Poll on Healthy Aging said they felt isolated, compared to 27% in 2018, and 46% of older adults said they infrequently—once a week or less—interacted with friends, neighbors, or family outside their household.
Polled older adults who interacted with neighbors at least once a week during the pandemic were less likely to report loneliness.
Older adults, like many Americans, are also feeling anxious and depressed. In October, using data from the Census Bureau and CDC’s Household Pulse Survey, Kaiser Family Foundation researchers found that one in four older adults screened positive for anxiety or depression. This isn’t the same, says Dr. Roca, as an anxiety disorder or major depressive disorder, but is a sign that older people are unhappy and on edge. “There’s no question the pandemic has had those kinds of effects.”
Experts don’t yet know whether the heightened symptomology people are experiencing will lead to a higher prevalence of formal syndromes. Dr. Roca says older Americans are likely experiencing a spectrum of mental health challenges, ranging from unhappiness at the changes in their lives, including isolation and adverse economic impacts, and people who have a full-blown anxiety or depressive disorder. “There’s a whole range of phenomena happening under one rubric.”
What’s of particular concern to Dr. Roca is what happens if the virus persists, or even worse, resurges. He says to some extent, people learn to endure and acclimate, pointing to the Blitz, a WWII German bombing campaign against the U.K. in 1940 and 1941. “People went to work and went about their daily lives. It became the new normal to live with that level of vigilance.”
He says what may be even more devastating than the continued pandemic and isolation for older people is if the virus wanes and then there’s another peak. “That’s going to be a real test of resilience for us all if we find ourselves more intensely locked down and having to adapt our lives yet again.” That’s when people’s patience wears thin, defense mechanisms fray, and people lose trust that there will be a new day.
“When people’s confidence in the future wavers is when the most dire psychiatric events happen,” says Dr. Roca.