We’re better off when we age with resilience

During the earliest days of the pandemic, younger people were told to protect the older adults in their lives from COVID-19 by isolating at home. Concerns about the virus and pandemic restrictions have taken a toll on everyone’s mental well-being. But it turns out that when it comes to mental health, older adults might actually be faring better than their children and grandchildren. On this episode of Better Off, aging and mental health expert Oliva Okereke explains why.

Guest: Olivia Okereke, associate professor in the department of epidemiology at Harvard Chan School, director of geriatric psychiatry in the department of psychiatry at Massachusetts General Hospital, and associate professor of psychiatry at Harvard Medical School.

Episode transcript

Anna Fisher-Pinkert: From the Harvard T.H. Chan School of Public Health, this is Better Off. A podcast about the biggest public health problems we face today . . .

Olivia Okereke: I think we all recognize that there isn’t really going to be a new normal [laughs] we’re sort of in this dynamic transitional state.

Anna Fisher-Pinkert: . . . and the people innovating to create public health solutions.

Olivia Okereke: We should be thinking about how every type of space needs to potentially change, adapt, because of what we’ve learned.

Anna Fisher-Pinkert: I’m your host, Anna Fisher-Pinkert.

More than 16% of the U.S. population is over the age of 65, and that percentage is growing as baby boomers age. And during the COVID-19 pandemic, seniors were the population that were most vulnerable to the virus. And during the earliest days of the pandemic, there was an intense and immediate focus on seniors’ health and safety. The message was clear: Stay home, mask up, protect your elders. But there was less discussion about seniors’ mental health.

I wanted to find out what we can we learn from the pandemic about what allows seniors to flourish, and what challenges older adults face when it comes to mental health. So this week – we’re better off with Olivia Okereke, expert in aging and mental health.

Olivia Okereke: Well, I think that the mental health challenges that older adults have faced during the pandemic have evolved in nature over the last year.

Anna Fisher-Pinkert: Dr. Okereke wears a lot of hats.

Olivia Okereke: I am director of geriatric psychiatry in the department of psychiatry at Massachusetts General Hospital in Boston. And I’m an associate professor of psychiatry at Harvard Medical School and associate professor in epidemiology at the Harvard Chan School of Public Health.

Anna Fisher-Pinkert: At first, she and her colleagues mostly saw seniors experiencing acute anxiety related to the dangers of the virus itself. But over time, that changed.

Olivia Okereke: What emerged over time were problems with grief, isolation, and loneliness as people experienced losses either in their family members, because of other older adults who had been very hard hit by the pandemic in terms of deaths, or because of losses they may have experienced by getting ill and surviving, but surviving with impairments and changes in their function. And then of course, the social isolation related to strict social distancing requirements, especially during the earliest phases of the pandemic.

Anna Fisher-Pinkert: But there’s an interesting twist in this story. There are some ways in which older adults actually seem to be doing better than younger adults when it comes to mental health.

Olivia Okereke: Compared to younger people, on the whole, older adults have been more psychologically resilient. While anxiety and depression are clearly issues that people have been dealing with during this pandemic, compared to younger people, older adults have seen not as dramatic an increase in some of the mental health challenges of anxiety and depression that have been seen in young adults. So that is notable. There’s been publications about this in the research literature. But really, not that many.

Anna Fisher-Pinkert: Psychological resilience can be defined a few different ways, but in essence, it’s your ability to manage challenges in life, to maintain optimism when things go wrong.

Olivia Okereke: Sometimes people talk about the term grit. That’s kind of become a trendy word.

Anna Fisher-Pinkert: It shouldn’t be surprising that older adults, generally speaking, have displayed this resilience through the pandemic.

Olivia Okereke: Through their life experiences, they may have had more time, more opportunities, to develop resilience techniques. You know, taking a step back, taking perspective, you know, taking their time, and just sort of an ability to believe that this too shall pass. All those kinds of things that may inform the experiences of older adults, might be contributing to this finding.

Anna Fisher-Pinkert: Last year, I heard a lot of stories that bore this out. Millennials, now in their 30’s, were arguing with their 65+ Boomer parents to take the virus more seriously, to stay socially distant and wear masks. In March of 2020, Guardian columnist Brigid Delaney tweeted, “In an unsettling reversal of my teenage years, I am now yelling at my parents for going out.” But, for many Boomers, what might seem like a carefree or even careless attitude toward COVID was driven by a different set of worries.

Olivia Okereke: So, for example, many older people, especially those dealing with health challenges, may have found it anxiety-provoking going into strict social distancing requirements because they didn’t know, well, how many more Thanksgiving holidays will I get with family? How many more graduations will I be able to attend of family members? So there is the sense that there isn’t unlimited time and maybe there isn’t enough time for waiting for this all to pass, you know?

So that is kind of balanced with, you know, some older adults kind of, you know, pulling on that sort of resilience of saying, you know, we can wade our way through this and it will pass. So, you can kind of see both halves to that. That some people were experiencing a feeling of urgency around what was going on with a pandemic and how it was affecting their lives.

Anna Fisher-Pinkert: Not everyone fits into these broad generational trends. Psychological resilience varies from person to person. There are things we can do to support resilience as we age – and most of them overlap with the things that we should do to maintain mental health during the pandemic.

Olivia Okereke: So, for example, one of the things that seems to be protective both in terms of reducing the risk of mood decline and depression during aging, as well as protective for folks right now, is exercise and lifestyle habits. My colleagues and I have done a fair amount of work finding that people who participate more regularly in exercise are significantly less likely to develop depression in later life. And certainly one of the recommendations that we’ve been making for people to try to preserve mental wellness during the pandemic is trying their best to adhere to routines that involve healthy eating, exercise, and lifestyle habits, but in particular, physical activity.

Another really big-ticket item that also overlaps with some of the recommendations we’ve made during the pandemic is sleep. So, we have seen that sleep disturbances and a difficulty with sleep, is not just sort of correlated with poor mood, that if we study it carefully – and we’ve done some work on this, Harvard Chan-affiliated investigators and others – we’ve seen that, sleep difficulty is an independent predictor of people developing, depression during aging. And certainly one of the recommendations in terms of self care that we have focused on during the pandemic is regular sleep.

Anna Fisher-Pinkert: In addition to getting plenty of exercise and sleep, we should all be engaging in more self care.

Olivia Okereke: Whether it’s meditation, progressive relaxation and breathing, gratitude, the practice of remembering what one is grateful for, people attending spiritual or religious services, if that is something that’s part of their life. . . Those are the kinds of things that might protect people or, or enhance, I should say, enhance their resilience.

Anna Fisher-Pinkert: As we’ve said many, many times on this podcast: Not everyone is having the same experience with the pandemic. Black, Latinx, and Native communities have had higher rates of death and serious illness from COVID-19.

Olivia Okereke: So, this has broad implications in terms of how people are experiencing, emotionally, what this pandemic has meant for them. That said, at least in some of the early months of the pandemic, there were still these signals of resilience that we were seeing. That individuals, even from more disadvantaged or less privileged backgrounds, if there were community factors or familial factors that tended to enhance sort of cohesion and resilience and an enhanced social support or a feeling of communality, that that tended to mitigate some of the experience of stress.

Anna Fisher-Pinkert: Even though these mitigating factors might exist, people’s experience with the pandemic is still shaped by privilege.

Olivia Okereke: Anecdotally, I’m speaking about my colleagues, you know, in our group, but I can imagine this pertains to many people who care for older patients, we found in those first several months of the pandemic, there was not a single appointment that we would have, where, even with all the other issues related to mental health, specifically, we were discussing, we wouldn’t ask, you know, some questions: “Tell us, how are you getting food? How are you getting meals? How are you accessing your medication?” Even sort of putting people in touch with resources, for medication and food delivery, because that’s a major issue. And especially if there’s any kind of pre-existing food insecurity, it’s just, you know, potentially, increased, by COVID. So, I just think there’s a whole range of ways that we’ve seen inequalities, healthcare inequalities, economic inequalities, play out in this pandemic.

Anna Fisher-Pinkert: Some patients also found it challenging to access care at all, once their visits with their primary care doctors, therapists, and psychiatrists went from in-person appointments to telehealth.

Olivia Okereke: Minority patients were more likely to see a drop-off related to health care utilization because of, maybe, lower access to using video technology to do video telehealth. So, it was just kind of like a lower proportion of those visits being completed using those platforms compared to, let’s say telephone, or just missing appointments.

Anna Fisher-Pinkert: Now, I thought that the switch to telehealth would be solely a negative thing for seniors. I have trouble getting into my telehealth appointments, and I think I’m pretty tech-savvy. So, I figured it must be even harder for people in their 70’s or 80’s. But again, there’s a twist: it turns out that telehealth has some unexpected benefits for seniors seeking out mental health care.

Olivia Okereke: There’s some challenges to be worked out, but overall, it’s made a positive difference in a number of ways.

So, access is probably, first and foremost, the most important way. So, it can mitigate care disruptions. So even if people are not seeing us face to face in the office, we can keep the appointments going. We can keep the continuity going. Because, as you may know, and this is one of the earliest red flags that went out about COVID during the pandemic, there was such concern about people missing or delaying their routine care appointment. And what that might mean, uh, down the road long-term in terms of secondary health consequences, that has yet to play out. We have to see what the long-term impact will be. But folks were definitely missing appointments or delaying appointments. And so to the extent that telehealth was available, it mitigated this in mental health in particular because we are less dependent, compared to other specialties, on the specific procedures that can only be done in person. So, we actually saw, in the earliest waves of the pandemic, a huge surge in utilization of our mental health care services.

And some of that may have been, of course, because of people experiencing challenges and stresses and challenges and coping difficulty. But we saw compared, for example, let’s say compared year over year to utilization levels, pre-pandemic, there was actually more utilization and that was made possible by telemedicine. That would not have been possible without telemedicine. And so, we were able to maintain continuity with people who really need it.

Anna Fisher-Pinkert: But there’s even more to it: Olivia Okereke and her colleagues at Mass General surveyed their patients about their experiences with technology during the pandemic, and they found something really unexpected.

Olivia Okereke:  Many older adults because out of necessity, right? They had to acquire new skills in technology. The fact that they enhanced their facility with using technology actually increased their sense of self-esteem and self-efficacy. They had a positive experience because, wow, they learned this new thing and now they can do it.

Anna Fisher-Pinkert: And the benefits went beyond telehealth.

Olivia Okereke: People weren’t just chatting with, let’s say family members on video chats, they were picking up new interests. They were participating in social clubs, but virtually. They were going to meetings. They were part of music groups, book groups, all kinds of things. They were even starting new activities, not just continuing the old activities such as religious or spiritual services that had moved online, which was something they would have done previously. But they were participating in new things, perhaps aided by the sense of confidence that they got for being able to use these new technologies. So, even though there was unevenness where there were inequalities in terms of access to some of these things, for those people who were able to mobilize it to any extent, it did seem for older adults, there were these unanticipated benefits, and I think that’s something we should continue to kind of look at.

Anna Fisher-Pinkert: [As a new parent, I also enjoyed this change. I tried out a virtual embroidery class while my daughter took a nap in the other room. I heard one of my favorite musicians perform live while I cooked dinner. I probably could have sought those things out before the pandemic, but they became more common in the last year, easier to find. What’s unclear is whether these virtual communal experiences are going to stick around as we enter a “new normal.” As concert venues reopen, restaurants reopen, what happens to people who struggled to enter those spaces and navigate them in the first place?

Olivia Okereke: I think we all recognize that there isn’t really going to be a new normal we’re sort of in this dynamic transitional state, right?

It’s this dynamic evolving space and, and we’re moving to a new place. And so it doesn’t have to look like exactly where we were before, pre-pandemic. And you do wonder about, you know, maybe some of these developments, these positive developments related to use of technology among older adults is something that can be preserved – because you can see the advantages of this for homebound older adults. A notable percentage of older adults, who for a variety of reasons are largely homebound, it’s a source of isolation. It’s a source of numerous challenges. And these changes that were brought about by necessity by the pandemic and social distancing may actually have a role, moving forward, in helping folks.

Anna Fisher-Pinkert: As of July, 88% of seniors in the U.S. have been vaccinated against COVID-19. This summer, while some are eagerly visiting loved ones and returning to in-person activities, others are anxious about variants, or just having trouble adjusting. So, if you know an older person who is struggling, how do you help?

Olivia Okereke: Well, I think we could kind of follow some of the same recommendations, interestingly enough, that we were using when the pandemic had first begun. So for example, when the pandemic had started and many older adults were faced with having to use technology, right? Ordering thing, online: Medication, food, groceries, whatever. Things that they had not previously done. It will be important for friends, family, health care providers, anybody who’s part of the support network of that person to help decompress the task load. Right? I think a parallel process may apply here.

Anna Fisher-Pinkert: In other words, if you helped your parents or a loved one get signed up for grocery delivery at the start of the pandemic, maybe now is the time to check in again on whether they need help getting food, medications, or just getting around.

Olivia Okereke: And that’s particularly important for older adults because even as older adults are aging without any issues, let’s say of a clinical – dementia or Alzheimer’s or anything like that – even with just normal aging, there are changes to the way cognition works. There are changes to the way, you know, the processing and speed of how people think through things. And when people are kind of flooded with a lot of new things that they have to do this kind of ramps up the task load for older adults in a way that’s harder for them potentially to manage than younger people.

And so this whole idea of decompressing that, the supports, the family, the friends taking on that auxiliary role of decompressing that task load? That’s pretty big. That is something that can do a lot of good for people.

Anna Fisher-Pinkert: If you were one of the people who woke up at 5 a.m. to hunt for a COVID-19 vaccination appointment for a senior, you’ve already done something to lower the task load for that person.

Olivia Okereke: You can just imagine going to those sites and constantly checking or refreshing and seeing, you know, what’s coming up. I mean, it’s something that could be really overwhelming as just yet another thing that has to be done for an older adult who already is going to have, just by nature of some of the cognitive changes that happen with aging, a little bit less tolerance of all the multitasking that that would involve. That’s a perfect example of the kind of thing that . . . It seems small. Something that seems small, you know, all those things really add up in terms of doing a real benefit.

Anna Fisher-Pinkert: Now, friends and family can only do so much. Over the last several months, everyone has had a lot on their plates – but people in caregiving roles have had a special burden. The pandemic has made it incredibly obvious that there are big gaps in how health systems serve seniors.

Olivia Okereke: So in the home, outside in the community, the outpatient setting of health care, in the inpatient setting. . . We should be thinking about how every type of space needs to potentially change, adapt, because of what we’ve learned about how this pandemic has played out in terms of the mental health challenges.

Anna Fisher-Pinkert: So, if we go back to an issue we talked about earlier – access to health care – the amount that friends and family can help you get access to that care is shaped by privilege, too. Figuring out how to connect a loved one with the right specialists and get them to appointments – that takes time and resources.

Olivia Okereke: Essentially what, what a lot of family and friends have done, is they’ve been navigators, right?

They’ve been de facto health care navigators. And maybe what needs to happen at a policy level is that this becomes more formalized so that it’s not left to chance that some people have more help than others and navigating this very complex space of using the technologies they need – getting online to check appointments, get vaccines.

It should be less left to chance. And perhaps more formalized what it is that these de facto informal healthcare navigators, which are typically friends and family, are doing.

Anna Fisher-Pinkert: But the bigger issue of racial inequity in our health care system? That is going to take change at every level.

Olivia Okereke: I think another larger lesson learned in terms of policy pertains to the consequence of many years, many decades of insufficient attention to the true meaning of the racial, ethnic inequities in this country. When you see it play out in the way that it did with COVID, this was catastrophic. You see threefold mortality rates. This is not something that’s subtle, right?

These inequalities just have broad and deep implications for health. Mental health, for physical health. And there need to be structural changes to mitigate these health impacts of structural racism or structural inequalities that played out in a terrifying way with the COVID pandemic.

Vaccines are great. We’re, getting them mobilized and getting people vaccinated, but we are not out of the woods. So this is an evolving space, and I acknowledge that, but I do think that there are still some policy lessons that we can take away based on what we know now.

Anna Fisher-Pinkert: If we really want to protect our elders, it will take more than vaccines – more than face masks and staying 6 feet apart. It’s going to mean ensuring that everyone – not just the privileged few – can age with dignity – and with resilience.

That’s all for this week!

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I’m Anna Fisher-Pinkert, host and producer of Better Off a podcast of the Harvard T.H. Chan School of Public Health.