Lisa Lind, Ph.D.
Lisa Lind, Ph.D.

Restricting visitation to nursing facilities was intended to improve infection control and prevent the transmission of COVID-19 to a potentially vulnerable population, but its potential impact on the mental health of long-term care (LTC) residents is yet to be seen.

During this time when many residents are quarantined to their rooms, with no visitors allowed, decreased social activities, eating meals in their rooms, and sometimes decreased access to their mental health providers, they are faced with increased time to ruminate over current circumstances. What can unfortunately occur is a situation where an individual, who may already be struggling with emotional symptoms, is faced with an unprecedented stressor in an environment that lacks the needed emotional connection and support to foster resiliency. Furthermore, individuals with a history of trauma are particularly vulnerable to having symptoms of PTSD or anxiety triggered at times of increased stress.

In order to ensure that your residents’ emotional well-being is being addressed during this time, here are some tips:

  • Be proactive in identifying the potential negative impact the COVID-19 pandemic may be having on your residents. Ask designated facility staff to screen residents routinely for symptoms of anxiety and depression and make referrals to appropriate mental health professionals when symptoms are present. Ask your mental health consultant for suggestions for appropriate mental health screening instruments which may be best suited for use with your residents if needed.
  • Verbally assess for subtle signs of change in mental health status. Some of the usual behavioral signs we watch for may not be the most helpful at this time. For example, we normally would watch for increased withdrawal and social isolation as possible signs of depression. However, these are behaviors that most residents are displaying during this time of being quarantined. Assessing for more subtle signs of changes in mood and/or anxiety may be accomplished better through conversation with the resident. Listen for the following occurrences (examples have been provided):

    -Negative rumination: “The news said 45,000 people have died from it. Lots of them are in nursing homes. Lots of people in nursing homes are dying.”
    -Worrisome thoughts: “I’m afraid my son is going to lose his job.” or “I’m afraid I may get it.”
    -Catastrophic thinking: “Everyone is going to get it.” or “Everyone is going to die.”
    -Hopelessness: “I might as well give up, I am going to die anyway.”
    -Helplessness: “I don’t have any control over what I can do these days.”
    -Fearfulness: “I’m afraid the food they’re serving might be contaminated with the virus so I’m not eating.”
  • Offer emotional support to all residents, not just those with a prior mental health history. Just as most Americans are experiencing some level of stress during this time, most residents are also likely experiencing stress. Offering informal support could occur in ways such as ADONs making rounds and checking in with residents on an assigned hall each shift, or asking CNAs to ask residents during direct care tasks “How are you doing today?” If during such conversations it becomes apparent that residents could benefit from additional mental health support, make a referral to your mental health provider.
  • Ensure that residents with a prior mental health history who had been receiving mental health continue to be able to receive mental health services. An abrupt halt in receiving psychological services by those residents with a mental health history, especially during a time of stress and increased social isolation, can have a potentially negative impact. Discuss with your mental health provider what the best service delivery option is given your situation. Continuing in-person psychological services is the most impactful, but if telehealth is the only option then problem solve around issues to make this occur (e.g., who can facilitate). During times when no facilitator may be available, keep in mind that  CMS and commercial insurance carriers allow for telephone service delivery of mental health services during this crisis. Assist in figuring out how your mental health provider may be able to reach your residents via telephone, at the very least, to ensure they continue to receive much needed mental health support.
  • Pay particular attention to your residents who have a history of trauma. Many individuals with a trauma history benefit from a feeling of safety and security in their everyday lives and in their environment. When their normal routine changes and they experience events that are out of their control, it can contribute to increased anxiety and depression. Being quarantined to their rooms can also lead to feelings of claustrophobia. Watching constant media coverage related to death tolls can lead to increased anxiety. Be aware of potential environmental triggers and make necessary adjustments as necessary in order to prevent possible retraumatization. For those LTC residents who have a history of trauma, it is vitally important for them to continue receiving psychological services to address anxiety management during this anxiety-provoking pandemic.
  • Educate staff that it is not beneficial to offer commentary on current events to residents, or to other staff in front of residents. It is important that facility staff are careful to not express their fears, or repeat stressful media coverage, to the residents that they are working with, as this can exacerbate the residents’ current emotional symptoms. Some residents are already experiencing anxiety and they look to staff to help provide a sense of support and normalcy.
  • Offer resources to your staff. The mental health status of your staff can have a direct impact on the mental health status of your residents. Make sure they are aware of how to access your Employee Assistance Program, if available, or offer a list of local resources for emotional support. Your mental health provider may be able to offer online training and/or resources to your staff focused on stress and anxiety management. For example, a colleague of mine and I recently put together a PowerPoint presentation on helping LTC staff manage anxiety during the pandemic, which can be found here.

Overall, making sure we are not emotionally distancing during this time of social distancing will likely have a long-lasting impact on the emotional, behavioral, and physical wellbeing of LTC residents.

Lisa Lind, Ph.D., is a licensed psychologist who provides psychological serves to residents in long-term care settings and currently serves on the Chief Clinical Leadership Team at Deer Oaks – The Behavioral Health Solution. She also is the current President of Psychologists in Long-Term Care (PLTC).