1 INTRODUCTION

There has been ongoing concern regarding the mental health impacts of the coronavirus disease 2019 (COVID-19) pandemic, including the restrictive measures required for infection control.¹ However, real-world data are essential in order to understand whether and how these anticipated consequences have borne out, particularly for vulnerable groups. This will be key to optimising policy and clinical practice to effectively and efficiently mitigate mental health impacts both during the ‘acute’ pandemic and in subsequent recovery phases.

Based on the relative severity of restrictions experienced, known access barriers to mental health interventions, historical epidemic data and evidence from other quarantine settings, people living in residential aged care (RAC) and older people living with existing mental health disorders (including neurocognitive disorders such as dementia) were identified as key vulnerable groups early in the pandemic.^{2, 3} However, subsequent studies in the general population have consistently found that increasing age may, instead, offer relative protection from adverse mental health impacts seen in younger age groups.^{4, 5} Findings have also been mixed regarding the experiences of adults living with existing mental health disorders, and of older people living in RAC. Some studies have reported increased neuropsychiatric symptoms (NPS) in dementia, loneliness and depression,^{4, 6-8} but others have found either no change in mental health symptom burden,^{6, 9-11} less change than in people without existing mental health disorders¹² or improvement for some symptom types or NPS domains.^{11, 13, 14}

In light of this indication that mental health impacts are more nuanced than initially anticipated, ensuring detailed understanding of specific patterns in key populations and subgroups is imperative. However, there has not yet been any investigation of pandemic-related mental health effects for older people who both reside in RAC and live with existing mental health disorders. Prevalence of most mental health disorders is substantially higher in RAC than community-dwelling older populations.¹⁵ This group also commonly lived with marginalisation or complex needs prior to the pandemic and has experienced some of the most severe and prolonged public health restrictions, or ‘lockdowns’.^{16, 17} Consequently, they may be particularly vulnerable to adverse pandemic-related mental health effects, and policy and clinical-service responses will require particularly careful planning and resourcing. Specific data to guide these responses are needed urgently.

To help address this knowledge gap, we analysed data from existing medical records in a specialist aged mental health clinical service, to obtain a longitudinal perspective of the impact of the COVID-19 pandemic on mental health symptom burden for a sample of older people already living with mental health disorders in RAC. Given suggestions in the earlier literature that baseline diagnosis and the severity of isolation may influence impacts, we examined associations with these factors.^{4, 12} We hypothesised that symptom burden would increase, and that greater increase would be associated with longer and more severe restrictions.

2 METHODS

3 RESULTS

In total, 91 patients had NPI-NH scores recorded for at least two of the three timepoints of interest (78% of 116 eligible patients; i.e. individuals who were patients of BASICS during at least two of the three timepoints). Data for all three timepoints were available for 59 patients. Baseline scores were not available for seven patients, and wave 2 scores were not available for 25. Wave 1 scores were available for every patient. All missing data at wave 2 related to patient discharge (due to symptom improvement or death that was not related to mental health diagnosis). Unfortunately, no reasons for other missing data were documented in files. Twelve patients developed COVID-19, and three of these patients died. COVID-19 restriction severity levels were recorded for all patients.

Baseline demographic and clinical characteristics are summarised in Table 1. The mean age of the cohort was 75.9 (SD 7.9) years, 56% were female, and they resided in 63 different RAC facilities. Eight per cent had a primary diagnosis of a schizophrenia spectrum disorder, affective disorder or anxiety disorder, although comorbid neurocognitive disorder was present in over 50% of these patients. Baseline symptom burden was high (median NPI-NH 17.0, IQR: 10.0–27.0). The sample had a significantly lower percentage of patients with primary diagnosis of a neurocognitive disorder (20%) relative to all patients seen by the service (28%) (χ² (1) = 6.12, p = 0.013). The proportions of patients in other diagnostic categories were not significantly different to the wider AMHS (all p-values >0.06). There were no significant differences between the proportion of samples at each timepoint on diagnostic category (all p-values >0.3).

Raw scores suggested a small increase in median total NPI-NH scores during wave 1 (Med = 19.0, IQR: 8.0–30.0), followed by a small decrease to below baseline scores during wave 2 (Med = 15.5, IQR: 7.0–28.0) (Table 2 and Figure 1). However, these changes did not reach significance when comparing wave 1 to pre-pandemic baseline scores (z = 1.06, p = 0.293); wave 2 to pre-pandemic baseline scores (z = 0.10, p = 0.921); and wave 2 to wave 1 scores (z = −1.92, p = 0.054). Friedman test also indicated no significant difference overall across the total NPI-NH scores (p = 0.081).

Correlations between baseline, wave 1 and wave 2 NPI-NH scores were all significant and of medium size, indicating good rank order stability over time and suggesting valid results.

Linear regression examined the effect of diagnostic category and of restriction severity level on changes in NPI-NH scores between pre-pandemic and during pandemic measures, adjusting for age and gender (Table 3). For the effect of diagnostic category (with schizophrenia spectrum disorders as reference), the estimated mean change in NPI-NH scores from baseline to wave 1 for those with affective or anxiety disorders was −1.14 (95% CI: −9.18,6.89, p = 0.778), and the estimated mean change in NPI-NH scores from baseline to wave 1 for those with neurocognitive disorders was 10.28 (95% CI: 0.18,20.38, p = 0.046). Diagnostic category was not significantly associated with mean difference in NPI-NH scores between pre-pandemic baseline and wave 2 (all p-values >0.5). Finally, no significant association was seen between wave 2 restriction severity levels and mean difference in NPI-NH scores between wave 1 and wave 2 (all p-values >0.5) (Table 3).

4 DISCUSSION

This study is, to our knowledge, the first examination of the effects of the COVID-19 pandemic on mental health for older people living with mental health disorders in RAC and accounting for pre-pandemic symptoms. Contrary to our hypotheses, we found no evidence of increased symptom burden during first two waves of COVID-19, although the reduction in mental health symptom burden between pandemic waves approached significance. Further, an association between a primary diagnosis of neurocognitive disorder and greater increase in the NPI-NH score during wave 1 was of marginal significance only, with wide confidence intervals indicating likely negligible clinical significance. We found no other significant associations between diagnosis or RS and overall change in symptom burden from pre-pandemic through wave 2.

The absence of any meaningful differences or associations is itself an important finding. This is consistent with an emerging body of Australian and international evidence indicating that the anticipated mental health consequences have not eventuated for older people.^{4-6, 10, 11, 27} Recent studies including people living with existing mental health problems (older and general adult samples) similarly have not identified substantial deterioration, potentially suggesting that the pandemic has led to a greater prevalence of mental ill-health but not to increased severity for existing disorders.^{5, 6, 9, 12} This study adds to the growing evidence by providing the first data indicating similar experiences specifically for older people living with a range of significant mental health disorders and in RAC.

Our findings also suggest that people living with neurocognitive disorders and NPS similarly did not experience significant symptom exacerbation. This is in contrast with some earlier findings⁷ but, importantly, is consistent with more recent and nuanced qualitative and quantitative data.^{11, 14}

The reasons for these findings are unclear, and different factors may interact. Some authors have suggested greater resilience in older populations and related this to psychological mechanisms such as increased wisdom in ageing.²⁸ However, as seen in both this and earlier reports, high baseline symptom burdens, limited movement and significant baseline isolation could suggest, instead, that the imposed restrictions caused little further deterioration as the impacts of these social/environmental determinants were already at saturation.¹² The substantial pre-pandemic symptom burden seen also suggests that earlier cross-sectional studies may have over-estimated pandemic-related effects, highlighting the importance of longitudinal data.

In contrast, our analysis of only total NPI-NH scores may have prevented identification of more nuanced findings such as concurrent exacerbation and improvement for different NPS domains. The absence of any association between RS and change in mental health symptom burden may also have been influenced by interventions and supports implemented during the study period. These may have meant the RS measure did not provide the expected reflection of social isolation. Even when experiencing severe restrictions, patients usually still had access to meaningful behavioural and social support. For example, our service increased the frequency of supportive contact (in-person or using video-call) with patients, staff and families, and extended the duration of episodes of care. The Australian Commonwealth Government also supported resident access to technology to maintain social and clinical connections. Such practical, person-centred interventions to preserve social connectedness have previously been shown to mitigate adverse mental health impacts of more COVID-19 restrictions and of isolation that is more broadly endemic in RAC.^{12, 14, 28, 29}

5 CONCLUSIONS

While small and necessarily pragmatic, this study provides an important additional insight into the mental health impacts of the COVID-19 pandemic for vulnerable populations. It provides the first data specifically for people living with mental health disorders in RAC and engaged with specialist AMHS. It adds to related evidence by suggesting that mental health impacts of the pandemic for this group may be relatively limited and highlights the need for more research to explore more nuanced impacts and the underlying reasons for relative stability.

For clinicians and future planning, our results offer hope that mental health deterioration is not inevitable for these individuals during the pandemic, although mental health needs overall are substantial. Hence, optimising access to appropriate mental health care for these individuals, as well as resources and supports for RAC staff who primarily care for them and may be vulnerable to stress and burnout in the pandemic context, is crucial. Given ongoing pandemic challenges and increasing evidence both in pandemic and non-pandemic contexts, it may be particularly fruitful for service planners to direct clinical resources and develop care models to support delivery of relatively simple person-centred interventions with patients, families and, in particular, RAC staff. These should support social connectedness and aim to prevent or address distress in both patients and carers. This approach may offer benefits for a vulnerable and marginalised population that far outweigh and outlast the current pandemic.

CONFLICTS OF INTEREST

No conflicts of interest declared.