Our Elderly ’ s Mental Health in Times of COVID-19

The present COVID-19 pandemic threatens humanity in various ways, especially due to the unpredictable nature of its course and progress. The impact of COVID-19 on mental health varies from place to place, but it is widely felt all over. Moreover, the impact is more pronounced on vulnerable groups within every population. In this study, we focus on the pandemic impact on the elderly’s mental health in Malta. Data gathered from ongoing surveys from Richmond Foundation Malta, found in the public domain, highlight 1) the COVID-19 pandemic as increasingly seen as a bigger threat; 2) the handling of the pandemic by local health authorities first took a dip in general trust, only to recover at more recent times; 3) mixed results regarding intra-personal domain (with an increase in self-care tendencies, but also an increase in social isolation and loneliness); and 4) an increase in elderly’s quest for interpersonal contact.


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Introduction
COVID-19 is a pandemic with global health threats. To say that its impact is enormous is an understatement. It reaches far and wide, both with short and long term consequences. Even though recent news about progress on vaccines are promising, the reality remains that strict precautions and health protocols will remain in place for the foreseeable future. This is mostly due to the unpredictable nature of the situation. This is hugely impacting our mental health, not to mention the physical health as well. One reason for this is that very little is yet known on the broader impact of COVID (Mukhtar, 2020). The situation on the ground is grim. The WHO COVID-19 Situation Update Worldwide Report (20 Nov 2020) shows that almost 57 million cases of COVID-19 have been reported, in accordance with the applied case definitions and testing strategies in the affected countries, and almost 1.4 million deaths recorded so far. 220 countries or regions are affected worldwide. Facing this unfolding tragedy, our attention naturally falls on vulnerable groups within our societies that are at the higher risks of contracting the virus and even dying from it. Philip and Cherian (2020) indicated that the elderly face special challenges, and it's imperative that healthcare professionals identify and highlight their special needs so that they can be adequately protected and supported through these trying times. Unless care is taken, the elderly as a group may face significant fallout with regard to their mental and psychological wellness. The reasons why the elderly constitute an especially vulnerable group include: 1) Advanced age (itself a predisposing factor to physical and mental health issues); 2) They are prone to social isolation even under normal circumstances; 3) The issue of access to medicine and health facilities, in which they can encounter physical difficulties that make this difficult, 4) News on the COVID-19 may be overwhelming, leading to more anxiety and stress; and finally, 5) The impact of current epidemic on mental health of elderly is profound but may be as easily missed.
Two things need to be given their due attention here. First, how this COVID-19 pandemic affects the mental health in general of the elderly. Mukhtar (2020) had indicated that isolation, social distancing, social disconnectedness and loneliness mediated depression and anxiety. According to Hudson et al. (2020), older people are among the most vulnerable during epidemics. The elderly naturally have a relatively less effective immune system than young people, and are more susceptible to developing critical illness. Limited access to healthcare services increases vulnerability of elderly. The pandemic's economic crisis will also affect mental health of elderly while significantly reducing their mental health care.
Moreover, social distancing further restricts socializing, which may reinforce selfdestructive tendencies (from a view: "I am not necessary…", "I have been for-gotten…", to "I am alone and lonely…").
Secondly, when certain mental health conditions are critically analyzed vis-avis this pandemic, plus taking into consideration the cultural and socio-economic status of this geriatric population, a clearer picture is furthered for our understanding of such a complex topic (Mukhtar, 2020). Brown et al. (2020a) emphasized that social distancing effects are also reflected in people with dementia due to withdrawal from important non-pharmacological therapies to treat comorbidities, such as social activities, physical exercises, and group therapies. Like dementia, psychosis requires special attention. Social distancing measures can increase psychotic patients' stress, just like precautions related to disease spread have been associated with increased paranoia (Brown et al., 2020b). Hu et al. (2020) found that COVID-19 is linked to a 25% increase in incidence of psychotic outbreaks. On the other hand, elderly who suffer from OCD have higher chances of experiencing obsessive thoughts due to precautionary measures (Haider et al., 2020). Quite naturally, depression takes center stage among all such conditions. The rapid transmission of COVID-19 outbreak, higher mortality rate, self-isolation, social-distancing and quarantine could exacerbate the risk of mental health problems. For example, Mukhtar (2020) found that reliance on social media could act as a tool against loneliness, boredom and tediousness in the young. But for older age groups, need of social support, liveliness, and daily functioning remain unmet. The mass quarantine and transport restraint have inevitably constricted activities of older adults (regular walk and talk in the square, acquaintance meetings, social care, limited contact with plants and animals, and obstacle on accessing prescribed nutrition, medication, and treatments). Haider et al., (2020), found that almost 4 in 10 of elderly experiences increased levels of depression and anxiety during the pandemic.

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There is an even greater risk that their symptoms go undetected during COVID-19. In a 2020 meta-analysis about ageism, Chang et al. (2020) indicated that 96% of studies found evidence that being exposed to or internalising negative representations of old age influences psychiatric conditions in older adults.
Also, older people might internalise that other individuals, not them, know what is best for their wellbeing. Such paternalism could negatively affect their sense of autonomy and control, if not also feel like a burden on society (Kessler, 2020).
Therefore, in this preliminary study, we sought to outline a clearer picture of the situation in Malta and how the impact of COVID-19 is influencing mental health, particularly of the elderly. We intend also to investigate what recommendations such results point to, as supported by research elsewhere.

Method
The following study is based on data collection done by Richmond Foundation Malta along an eight-month continuum (April-December 2020). Founded in the 1980s, and inspired by the UK-based Richmond Fellowship, the Richmond Foundation Malta started offering services in aid of the psychological wellbeing of the people in the Maltese islands.
As the Foundation itself stated in its website, the Covid-19 has led to heightened awareness of threat in people's lives, whether it was social distancing, school closures, work layoffs and a partial and mandatory lockdown, amongst others, all has affected life in general, with resulting anxiety. To this end, Richmond Foundation decided to survey the country's mental health by monitoring the wellbeing of a cross-section of people. Thus, the Foundation, through assistance by EU funds, contracted a leading research company to carry out "a series of public sentiment surveys and assess the toll that the novel coronavirus is taking on... people's mental well-being". Results, entitled Research on COVID-19-How it is affecting our mental health, are published on the Foundation's website and are in the public domain.
A total of 500 respondents participated in each of Waves 2, 3, and 4 of the study, representing the general population. The study has a 95% confidence in- terval with a 5% margin of error. Fieldwork was carried out between: April 2-9 th (Time 1), June 11-17 th (Time 2), August 19-31 (Time 3), October 5-15 th (Time 4), and November 27-December 10 (Time 5). Results here represent an 8-month period in 2020 (April-December). One can reasonably say that Time 1 was at the height of the first wave of the pandemic's spread in Malta, while from Time 3 onwards we are registering the height of the second wave, of the present COVID-19 pandemic.
The survey covered age groups from 16 to over 65 years old. For the scope of this study, we shall focus on findings covering the 55 -64 and 65+ age cohorts. The research covered all relevant areas about individuals' mental health status, including: participants' perceptions and experiences about the pandemic and their coping skills and strategies to move on with life; their worries, thoughts, and feelings. Moreover, participants were assessed for presence of depression, loneliness, fear, hope, happiness, restless sleep, thoughts of self-harm or suicide, routine status, house chores, physical exercise, healthy diet, and alcohol intake, amongst others.

Findings
Responses come from five different time intervals during 2020. The following Table 1 shows the percentages of the two age cohorts of interest to this study,   together with some demographics of the survey across all age-groups, and broken down according to each Time period. As seen in Table 1, division of ages, gender and employment history are almost similar across all time frames. Some indications regarding older adults' daily perceptions and feelings with regards to their own and others' safety and health, in view of the Covid-19 pandemic, are included in Table 2.   This survey points towards the critical components and areas of respondents' well-being. Results suggest that in general, these participants report an increase in concern about the well-being of those dear to them.

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Participants' thoughts and feelings about their own community (neighborhood, parish, and nation as a whole) showed an increase in concerns. Perhaps the participants' highest concern regards their immediate family and close friends. The responses from Time 2 to Time 5, for both 55 -64 and 65+ age cohorts, are loud and clear, by far indicating the highest increase of concern registered. This is particularly pronounced for the 65+ cohort, who saw an increase of 28%! Indicative is the result that both cohorts of mature adults observed other people's poor hygiene. This is important in that it reiterates that in this pandemic, we all need to take care of each other. Just being careful for oneself may not be enough. Observing others' ways of handling the COVID-19 situation can indeed help in taking better measures for ourselves. Both cohorts took the necessary measures according to the local health directions and stayed away from people as far as possible. This was mostly noted by the 55 -64 year old cohort.

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Of particular importance to this study, participants in both cohorts felt the need to talk to someone about their concerns on their COVID-19 fears. Clearly indicative is the concern by the 65+ year cohort, who saw an increase of more than 100% over the time period in question. In many respects, it is healthy that individuals, especially those who fall within the vulnerable groups of the population, deem it fit and a requirement to seek out help and assistance, and share their fears and concerns with others, rather than distance themselves from society. This is more relevant during such a critical period in everyone's life.
Finally, solace in prayer was strongly indicated by both cohorts, where the 55 -64 age cohort reported a 21% increase. The 65+ age cohort reported a 13% increase over the time period studied.
Self-care is a vast domain that implies both what one can do for one's own protection, together with maintaining a healthy well-being, both physical and mental. Self-care is normally negatively impacted when there is a crisis. Findings from this survey indicate that the picture may not be so straightforward. Participants in both age cohorts (55 -64 and 65+) steadily increased their self-care tendencies (physical exercise, keeping a routine, healthy diet) over the 8 month period (April -December) covered. This obviously needs to be commended and encouraged. Also noteworthy is one's vigilance against the pandemic. Participants in the 55 -64 age cohort reported a constant finding on their extra efforts to avoid the virus. More positively though, an increase of 12% was noted in the 65+ cohort. Consistent with this is participants' concern about one's own health status. Findings show a steady increase from Time 2 to Time 5 for both cohorts.
This was reported to be a daily concern.
Respondents indicated a mixed bag of feelings and emotions. It is encouraging to note that for both cohorts, feelings of happiness and hopefulness increased across the board along this time period, whereas feelings of fear and depression both decreased over time. With regards to loneliness, the 55 -64 year old cohort showed an increase in feeling lonely, while the 65+ year old cohort showed a decrease over time.
As indicated in our studies, a natural consequence of the pandemic and the health and safety measures taken, older adults feel socially isolated, on a daily basis. This was indicated mostly among the 65+ cohort. This may result in restless sleep. In fact, whereas the 55 -64 year old cohort reported less problems with restless sleep across time, the 65+ cohort indicated the same results from Time 1 to Time 5.

Discussion
In consideration of these findings, one can conclude that along this eight-month continuum, since the first wave of the pandemic's impact was felt in April 2020 till December 2020, we notice that: a) COVID-19 is increasingly seen as a bigger threat, thus creating more anxiety and concerns among people; b) handling of the COVID-19 situation by local authorities took a dip at first, being perceived as becoming more laxed over time especially after the beginning of the second wave, but then it has increasing again in trust momentum closer to Time 5. Van Tilburg et al. (2020) found that personal losses, worries about COVID-19, and a decline in trust in societal institutions were associated with increased mental health problems and especially emotional loneliness; and c) an increase in interpersonal contact (via video calls, social media, etc.) to family and friends, concern about the well-being of family and close friends, seeking out assistance and talking to others about personal concerns; together with an increase in prayer which was found to be a solace at this time of peril.
Two major domains result from these results: one has to do with participants' interpersonal domain, and two, their intrapersonal domain.
First, participants have scored high on their interpersonal domain. They are concerned about others' well-being, they are very conscious of other people's poor hygiene, thus moving them to take precautions, have instilled in them a need to talk and share their personal concerns to those whom they trust, and finally, participants sought refuge in prayer and their faith.
Secondly, participants' results indicate a mixed bag with regards to their intrapersonal domain. Results suggest an increase in self-care tendencies, especially in physical exercise, keeping a routine and adhering to a healthy diet. Moreover they are keeping extra vigilant during this risky time. This is consistent with subjects' own concern on their health status. It is indicative that participants' feelings of happiness and a sense of hope have increased, while fear and depression have decreased over this time period. On the other hand, feelings of loneliness showed mixed results. Most of respondents in these two cohorts felt socially isolated, which is a matter of concern, even if it is an expected result. With regards to daily house chores, one needs to investigate further the reasons why the 55-64 age cohort have reported a decrease in daily chores, which was not reflected in the other cohort.
Besides the obvious increase of worry and anxiety noted globally due to the COVID-19 pandemic, consistent with that found in this study, these results point also at an increase in interest in the "Me-You" interpersonal relationship domain, in letter (c) above. It is expected that when people suffer from more fear and anxiety, plus being socially more distant from each other, they feel more the need to reach out and connect with their loved ones. According to Banerjee, (2020) pandemics have significant psychosocial impact. Health anxiety, panic, adjustment disorders, depression, chronic stress, and insomnia are the major offshoots. Misinformation and uncertainty give rise to mass hysteria. Social distancing is also a major cause of loneliness, especially in nursing-care or old age home settings (a risk factor for depression, anxiety disorder and suicide). The more individuals feel anxious and stressed by the present pandemic, the more they seem to look outside of themselves to connect with family members and close friends. This comes at the price of neglecting some of their own needs at times, such as neglecting house chores. Banerjee (2020) found that the elderly are most vulnerable for severity and mortality, and most susceptible to mental health problems to such pandemics.

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Thus, special care needs to be taken for geriatric mental health during such crises. Mental health is the cornerstone of public health, more so in the elderly. Lessons from earlier pandemics like SARS have proved that regular telephonic counseling sessions, healthy contact with the family, relevant and updated information, caring for general medical and psychological needs, and respecting their personal space and dignity are important components of mental health care in the elderly.
In presenting proposals in view of the impact of COVID-19, Hu et al. (2020) suggested a) the expansion of telehealth services for the elderly; b) using telepsychiatry as a screening tool for cases of elderly with mild/moderate psychiatric disorders; c) preparing training materials for health professionals based on past experiences to qualify them to provide care and act as multipliers of good mental health practices in the pandemic; d) advertisement and educational materials for greater awareness, need to maintain regular contact online, through telephone during COVID-19, and health promotion measures to fight and e) introducing social security measures to fight economic exclusion of these individuals.

Recommendations
It is therefore pertinent to this study's scope to highlight recommendations for better attention to help address and contain the complex impact of COVID-19 pandemic on elderly's mental health. Recommendations will focus on the intrapersonal and the interpersonal domains, which have been identified from the results as being the most pertinent of this study.
1) Attention to the Intrapersonal domain Three points result from this domain. First, the importance of establishing structure and routine. Loss of structure and routine is already identified as a major mental health issue for the elderly. During this pandemic, this issue is bound to worsen. Elderly who are moving to being "self-isolated" to protect themselves from infection, need to establish a new routine as quickly as possible. Ensuring a routine about bedtime and waking times, mea times, "work" activity, "online" times, and getting outside to exercise, are crucial. Working around a R E T R A C T E D timetable and adhering to it indeed does help. Considering that alcohol is a significant problem among the elderly, care-workers and family members do well to keep an eye on their elderly against alcohol misuse. In lieu of this, one needs to be cautious at social media overload. Keeping abreast with the latest information, from the right sources, is healthy. Dramatic data and unnecessary news are not.
Secondly, staying cognitively active is crucial. For people with dementia, but also for others, cognitive exercises are very beneficial. For example, Cohen (2020) identifies that this may include board games, word games, engaged in cooking, gardening, housework, playing music, support groups online for dementia sufferers, and even practicing mediation.
Thirdly, being physically active is a great asset during these pandemic times. Social distancing measures still allow us to go outside, provided one is careful about contact with others. Regular walks, practicing Yoga are also helpful (Cohen, 2020).
2) Attention to the Interpersonal domain Social isolation has been noted consistently as being another public health concern, more relevant now due to physical distancing measures (Chang et al., 2020).
Two points are relevant here. First, social connectedness with loved ones or close friends. This may also mean that the elderly be involved in decision-making at familial levels, during such crisis times, not to feel left out. In these times, when we are seeing an increase of the phenomenon known as 'aging in place', this pandemic makes it more of a must to get our aging friends online. In the US, over 70% of older adults are already using the internet. But it is likely important to help them pick and choose the news they consume. Because news can be overwhelming, cutting down on news updates gives our mind a break, and avoid anxiety (Lipkin, 2020). Van Tilburg et al. (2020), emphasized that the consequences of long term social isolation and well being must be closely monitored.
Secondly, assisting our elderly to socialize appropriately is a huge help. Activities such as online courses, social media platforms, regular phone calls to friends are all crucial, as is checking in regularly on the aging adults in your life. This way, they feel connected. It is important to not assume but take the initiative and give them the extra call to see if they need anything.
Finally, results in this study have shown that more than 45% of respondents found solace and strength in their faith or through prayer. Galea (2012) has highlighted the relevance of spirituality in view of critical moments. Religious services streamlined on the internet and on a number of social media platforms are another way how elderly may also keep up-to-date with their own religious activities. Staying socially connected, even remotely, is crucial.

Conclusion
In conclusion, results have highlighted the impact of COVID-19 on the mental and physical health of respondents, consistent with research elsewhere. Most

R E T R A C T E D
importantly, this study has emphasized that the more individuals feel anxious and stressed by the present pandemic, the more they look to connect with family members and close friends, which is a natural tendency. Furthermore, although older adults in Malta seem to be coping well despite the harsh reality we are living in at present as indicated from this survey, there are also some worrying realities that need to be factor in, in order to present a truer picture of the holistic mental health of this vulnerable group within society.
This study thus calls for more attention to the holistic self-care of the elderly.
A number of concrete suggestions were therefore provided. Supporting and protecting older people living alone in the community is everyone's business. Having to socially keep distance, should never mean isolation.