Outpatient care

COVID-19 has had a significant impact on routine medical appointments for psychogeriatric care in Turkey (Psychiatric Association of Turkey, 2020). Many patients postponed outpatient psychiatric visits as they did not leave home to reduce the risk of exposure to virus. Health providers advised older adults to admit to hospitals only in case of emergency. The number of in-person visits was limited in many psychiatric clinics. Follow-up appointments were suspended and planned after the outbreak (Psychiatric Association of Turkey, 2020). However, some outpatient clinics continued to manage psychogeriatric care for patients who were in their follow-up via telephone and video (Medimagazin, 2020). But there is no legal basis for this care in Turkey. On the other hand, to provide maintenance medication, the governor’s emergency order provided access to 30-day refill of prescription medications for chronic conditions from the local pharmacies without visiting the family physicians or other outpatient settings to get the previously required code (Turkish Ministry of Health, 2020c). This order covered drugs that are under more strict prescription control.

The solution to this challenge could be telemedicine, which can be useful for outpatient clinical care of patients with chronic conditions (Punia et al., Reference Punia2020). Accumulating evidence supports that live-video conferencing is a helpful and safe way to manage mental health problems, and improves both psychological well-being and chronic medical conditions in older adults (Batsis et al., Reference Batsis2019; Punia et al., Reference Punia2020). Incorporating telemedicine into outpatient health care may yield favorable outcomes in the long term (Batsis et al., Reference Batsis2019). However, it is also noteworthy that many older adults face a lot of difficulties in adopting digital technologies such as lack of necessary skills and incentives, limited access due to economic obstacles, and disability. Therefore, digital technology training is required to be widespread among older adults.

Nursing home care

There are about 400 nursing homes and long-term care facilities in Turkey housing about 30,000 people (Sahinli and Tarım, Reference Sahinli and Tarım2019). As of the day this paper was submitted, information on confirmed cases and deaths in these settings was not available to the public.

As of March 2020, a guideline developed by the Turkish Ministry of Health and targeted at reducing the impact of the outbreak on nursing homes was released and updated to reduce the risk of contamination during nursing home care (Turkish Ministry of Health, 2020d). The measures in this guideline taken against COVID-19 were as follows: infection prevention and control principles to protect residents and staff, implementing some of the practices in case of identifying suspected patients, monitoring all residents daily, testing residents every 14 days, restriction all visitors, canceling all group activities and communal dining, and 14-day shifts for staff.

On the other hand, families were concerned about the health status of residents, after banning visits to nursing homes. To reduce fear, loneliness, and coping with stress at this time, nursing homes offered residents communicate with loved ones by telephone or video calls (Anadolu Agency, 2020d).

Home care services

There are about 500,000 entirely or mostly homebound older adults living in Turkey, who receive care and follow-up by home health professionals (Turkish Ministry of Family and Social Policies, 2019a). Home health services are given by the Ministry of Health, which was covered by SCI’s home health benefits, and SCI-certified private agencies.

The outbreak led to an increased demand for home health care, especially some non-homebound older adults who want to receive this without admission to the hospital (Anadolu Agency, 2020e). Although home care services continue for homebound older adults at this time, supporting and boosting the capacity of home health care are required to respond timely and appropriately to coming to other disasters.

Caregiver burden

The pandemic could also raise the stress of caregivers of individuals who needs assistance with physical or cognitive limitations. The behavioral and psychological symptoms such as anxiety, panic attack, depression, and delirium could be aggravated in those vulnerable people at this time, which can be physically and emotionally exhausting and stressful to caregivers. This condition could adversely affect the mental and physical health of caregivers and increase the risk of abuse and neglect to an older adult.

With the aim of reducing this burden, the telephone intervention called “COVID-19 Psychosocial Support service” by a team of psychologists and social workers is available to support the caregivers of individuals with dementia in Turkey (Turkish Ministry of Family and Social Policies, 2019b). But there is a need for broader information across the country on this service that can help caregivers overcome encountered challenges. Past pandemics revealed that caregivers suffer significant morbidity from the care of patients with various diseases (Ho et al., Reference Ho, Chee and Ho2020). Lack of available information worldwide on the impact of COVID-19 on mental health and caregiver burden requires further investigation.

Psychological and behavioral impacts on engagement with novel preventive measures

As mentioned earlier, following the announcement of the COVID-19 outbreak as a pandemic, many countries urged people to stay at home in self-quarantine until a second statement. Turkey subsequently announced restrictions for older adults with chronic illnesses to stay home (Anadolu Agency, 2020f). Nevertheless, despite massive, nationwide campaigns, many older individuals have initially failed to engage in staying at home and tried to go out for various reasons such as exercising, meeting friends, dog walking, and shopping (Daily Sabah News, 2020; Hurriyet Daily News, 2020; LabMedya Media Channel, 2020). Interestingly, a widespread perception has been young people adhered to this rule more than older adults (ABC News, 2020). What could underlie such a non-adherence with staying home that aged people showed at the cost of putting their lives at risk?

Several cognitive and psychosocial factors can cause an unwillingness to stay at home among older adults. First, aging is associated with a broad range of cognitive changes from mild cognitive impairment to dementia. Age-related decline in specific cognitive tasks such as working memory, processing speed, perception, executive function, language, and visuospatial functions is a part of the normal aging process (Harada et al., Reference Harada, Natelson Love and Triebel2013). In line with this, older people may have difficulty in searching and learning new methods (Frey et al., Reference Frey, Mata and Hertwig2015). Cognitive aging may also impair the ability to make intelligent decisions (Frey et al., Reference Frey, Mata and Hertwig2015). These may partly explain why many older individuals remained less responsive to action calls and campaigns in Turkey and other countries during the early period of the pandemic.

Second, mood disorders such as anxiety and depression are more common in multimorbid individuals but often subtle. Patients with anxiety/depression are more likely to show poor compliance, suggesting that accelerated decline in cognitive abilities might impair understanding, appreciation, and reasoning (Piotrowicz et al., Reference Piotrowicz2016). In rare instances such as the COVID-19 pandemic, mood disorders may reduce prompt compliance of older people with preventive measures at the population level. Moreover, low compliance may, in part, associate with self-neglect, which is more frequent in depression (Papaioannou et al., Reference Papaioannou, Räihä and Kivelä2012). Thus, new approaches for those with mood disorders may be necessary to engage in self-isolation during such outbreaks.

Lastly, some older people might show an unintentional self-reaction to isolation to maintain their social contacts that merely occur out of the home, such as at daycare services, senior centers, living communities, and places of worship, with the risk that this population feels lonely (Armitage and Nellums, Reference Armitage and Nellums2020). Mainly older adults who have lower education levels have the habit of spending time by talking to each other, and walking outside may be an underlying reason for this situation. Conversely, more educated older people have a positive attitude toward technology and have a better time at home, using the Internet and social media (Chiu and Liu, Reference Chiu and Liu2017). Also, providing and maintaining self-isolation in older adults can be difficult in collective, life-loving societies like ours.

How to increase engagement with isolation and social distancing among older people?

Remote treatment options via television, Internet, and mobile phone applications may potentially help adapt or overcome it (Khosravi and Ghapanchi, Reference Khosravi and Ghapanchi2016). As such, several types of cognitive-based interventions have been found effective in older adults (Lautenschlager et al., Reference Lautenschlager, Anstey and Kurz2014). These include cognitive stimulation, cognitive training, cognitive enrichment, and cognitive rehabilitation (Lautenschlager et al., Reference Lautenschlager, Anstey and Kurz2014). Cognitive-behavioral therapy delivered by the Internet for depression and anxiety helps to reduce disease-related symptoms, functional impairment, and distress in primary care (Newby et al., Reference Newby, Mewton and Andrews2017).

Older individuals warrant particular attention in promoting an active lifestyle at home during a pandemic. Encouraging older adults to develop a daily routine, make telephone or video calls with family members and friends, engage in joyful and pleasant home activities, and maintain regular exercise during this outbreak are other interventions that may improve psychosocial function and quality of life and provide staying indoors.