The recent global severe acute respiratory syndrome coronavirus 2 pandemic will leave
its shadow over mental health in our society, especially among the most vulnerable
such as elderly populations and those living with mental health disorders, including
Alzheimer’s disease (AD) and related dementias. Cognitive impairment and/or dementia
itself does not increase the risk for coronavirus disease 2019 (COVID-19). However,
people living with cognitive impairment might have difficulties understanding public
health information or remembering safeguard procedures (Wang et al., 2020). New measures
taken at country level to prevent the spread of the disease are also likely to increase
or worsen other mental-health-related disorders like anxiety, depression, substance
abuse, post-traumatic stress disorder, and domestic violence (Galea et al., 2020).
In early March 2020 Cuba, Dominican Republic and Puerto Rico reported their first
COVID-19 cases, and various strategies are underway to tackle with the raising number
of cases. The double hit of COVID-19 in elderly populations and among those with comorbid
conditions has raised significant concerns in the Caribbean region. In light of these
concerns, health care providers and caregivers should pay extra attention to those
in most vulnerable situations. In addition, due to the potential impact of COVID-19
on mental health in the elderly population living in the Caribbean area, immediate
efforts focused on prevention and early detection of mental health disorders related
with the outbreak are required. On this commentary, we examined current situation
and impact of COVID-19 on mental health in the Caribbean Hispanic region (Cuba, Dominican
Republic, and Puerto Rico). Furthermore, we provide recommendations to health care
providers and caregivers to better cope and manage the impact of COVID-19 in our region.
Aging and mental health in the Hispanic Caribbean in the context of COVID-19
The novel COVID-19 has highlighted the vulnerability of aging populations to emerging
diseases, recent data indicates that this virus is of particular risk for older persons,
especially those with multimorbidity (Lai et al., 2020). The Caribbean Hispanic represent
57.6% of the Caribbean population (Cuba = 11,326,616, Dominican Republic = 10,847,910,
Puerto Rico = 3,193,694) (Quashie et al., 2018). The Caribbean region might be disproportionally
affected by the COVID-19 due to a variety of social factors including high proportion
of older persons, chronic levels of poverty, income insecurity, and fragile economies
that rely heavily on tourism (Quashie et al., 2018). Moreover, in many communities,
people live together in close quarters and with extended families which makes social
and physical distancing, a critical prevention strategy, more difficult. Among those
factors, the aging population and the high prevalence of mental health disorders,
including dementia, will pose the higher challenges. During the last decade, the Hispanic
Caribbean islands experimented an accelerated demographic aging, due to improved health
care standards and high rates of emigration by young adults combined with significant
rates of returning nationals at retirement age. At the same time, age-related non-communicable
diseases, including mental-health-related disorders, are reported at high prevalence
and incidence. For example, according to epidemiological studies in the region, using
the same methodology in all three countries, the prevalence of dementia in individuals
65 years and older is approximately 11.7% in Puerto Rico, 11.6% in the Dominican Republic,
and 10.8% in Cuba (Rodriguez et al., 2008), being significantly higher than in similar
countries in Latin America (Rodriguez et al., 2008). Furthermore, dementia and mental
health disorders in general are among the major causes of disability and dependency
in older people, representing one of the most serious medical and social issues confronted
by Caribbean health systems. In addition, dementia and other mental health disorders
overwhelmingly impact not only the people who have it, but also their caregivers,
families, and society in general. Depression affects between 10% and 20% of older
people and is frequently a comorbidity with anxiety disorders (Rodriguez et al., 2008;
Guerra et al., 2016) Therefore, it is expected that the effect of the COVID-19 in
the region will have a higher impact on our elderly population and among those with
mental health disorders.
The COVID-19 outbreak started in the region in early March, the first cases were reported
in the Dominican Republic (March 1, 2020), followed by Cuba (March 11, 2020), and
Puerto Rico (March 17, 2020). To date (April 29, 2020), according to local governments
reports, more than 86,791 COVID-19 tests have been performed (Cuba = 47,347; Dominican
Republic = 26,981; Puerto Rico = 12,463), and 9,873 have been confirmed positive (Cuba = 1,501;
Dominican Republic = 6,972; Puerto Rico = 1,400). Cuba reports the lowest number of
confirmed cases with 126.9 cases per million people, followed by Puerto Rico and Dominican
Republic with 489.4 and 591.5 cases per million people, respectively. The total number
of deaths has risen to 456 (Cuba = 61; Dominican Republic = 301; Puerto Rico = 94).
The COVID-19 fatality rate (confirmed cases vs. confirmed deaths) has been higher
in Puerto Rico (6.1%), followed by Dominican Republic (4.5%) and Cuba (4.0%). The
overall fatality rate within the region (4.9%) is lower than the average reported
in Europe (11.6%) and similar to the average reported in North America (5.8%) and
in other South American countries (4.8%).
Early measures to avoid the spread of the disease have been implemented by local governments
since mid-March 2020. A general overview of the measures carry out within the region
is provided below.
On March 13, Puerto Rico closed all public schools, and several universities followed
canceling in-person classes and switching to remote education. On the same day, Puerto
Rico imposed people’s temperature check at all ports of entry. Stay-at-home orders
and social distancing guidelines were in place in Puerto Rico by March 15. People
could only go out to purchase essential items or obtain essential services from 5:00
AM to 9:00 PM. All businesses, with the exception of grocery stores, supermarkets,
gas stations, pharmacies, and medical providers, were required to close.
Dominican Republic declared a state of emergency on March 17, and country authorities
announced a series of measures to try and stop the spread of the virus, including
the closure of all borders, and suspension of all schools and non-essential commercial
businesses. To protect those most at risk, Dominican Republic imposed stay-at-home
orders for citizens over 60 years old and those with pre-existing health conditions.
Stay-at-home orders were quickly (March 20, 2020) extended to all between 8 PM and
6 AM. On March 26, 2020, the government prolonged the night curfew to 13 hours: from
5 PM to 6 AM.
On March 20, the Cuban Government announced a strict lockdown for vulnerable populations
(older adults and people who have serious underlying medical conditions including
long-term health conditions, such as diabetes, heart disease, lung disease, autoimmune
disease taking immunosuppressive drugs, and people with acquired immunodeficiency
syndrome); provisions for home working, employment protection, and social assistance
plans were also put in place. On March 24, Cuba closed its borders to international
flights and restricted entry to Cuban residents and foreigners residing on the island.
As more cases were confirmed, the Cuban Government adjusted its response by the end
of March by shutting down public transportation and extending stay-at-home order to
the general population (not including essential workers). Rather than opting for mitigation,
Cuba has also bet on its primary care system and added a containment plan (prevention
and control). Medical students were mobilized nationwide for door-to-door surveys
to proactively detect coronavirus cases in the population; possible cases identified
through a general screening questionnaire are followed by a community doctor and referred
to COVID-19 testing centers. After testing, if confirmed positive, cases will need
to stay in isolations facilities. Furthermore, contact tracing and isolation procedures
have been imposed to all confirmed cases. If Cuba’s community screening, contact tracing
and testing regime get the disease under control, its experience might offer lessons
for controlling the pandemic to the rest of the region.
Social and physical distancing measures, taken throughout the region by end of March
2020, are likely to reduce transmission and delay the peak of cases. However, social
isolation and loneliness will also have a toll on those at risk for cognitive decline
and in our elderly populations by increasing the risk for affective disorders, especially
in the most vulnerable groups (Gerst-Emerson and Jayawardhana, 2015).
Physical distancing has precluded our communities from engaging in regular exercise
that promotes physical and mental health, and from essential social contact. According
to regional statistics, more than 900,000 older adults will not be able to participate
in government-run programs aimed to facilitate physical and mental health. The reduction
of mobility and not being able to go to social and cultural activities will also have
a direct impact on their physical and mental well-being (Santini et al., 2020).
Furthermore, patients with Alzheimer dementia and other dementia disorders are at
higher risk to suffer from social isolation and the related stress due to the pandemic.
Recent studies have shown lower stress coping ability in AD individuals specially
in those with higher burden of tau pathology (Arenaza-Urquijo et al., 2020). People
with dementia will face difficulties adjusting to changes in their routine caused
by social isolation and restrictions on leaving their homes. This situation may produce
more disorientation, sleep disorders, and behavioral changes, such as increased anxiety
and agitation.
The novel COVID-19 will also have a significant impact on families caring for someone
with dementia or other mental health disorders. Due to the closedown of local supporting
services, caregivers have experienced increased physical and emotional overload. As
a result, since the beginning of the pandemic, we have observed an increased report
on behavioral changes usually related to the alteration in the care arrangements and
daily routine.
Finally, it is worth mentioning that by the time the first cases were reported the
region was still recovering from major natural disasters, such as Hurricane Maria
(September 2017), and the 2019–2020 earthquakes in Puerto Rico. Natural disasters
have already put a high burden on our economies and population health. Mental health
disorders related to these natural disasters have been widely reported and are likely
to be exacerbated by the new pandemic.
Opportunities for success and recommendations during the COVID-19 outbreak
The Caribbean Islands may have powerful advantages in mounting a successful response
to the pandemic. During the last decade, the Caribbean region has faced several epidemics
including Dengue, Zika, and Chikungunya, and their experience may prove to be an advantage.
Despite previous experiences, the highly transmissible rate and unique characteristics
of the novel COVID-19 will require a coordinated response at all levels. Mental health
services are posed to offer immediate and long-term actions. In this commentary, we
urge policy makers in the Caribbean region to work with researchers and take decisive
actions toward the prevention of the direct and indirect effects of the novel COVID-19
on mental health. With the pandemic coming to its peak in the Caribbean region, immediate
actions are required. Furthermore, at some point, the acute phase of the pandemic
will end and local health care systems should be prepared for the long-term mental
health effects of the pandemic in society. Below we provide general recommendations
tailored to our region.
1.
Special attention should be put on long-term care (LTC) facilities. Prevention measures
should include families will not be able to visit LTC facilities; LTC should operate
with essential personnel only, health care providers and staff on these centers should
be screened with rapid test on a daily basis. It is worth noticing that locking down
LTC facilities to family visits will increase social isolation, loneliness, and vulnerability
to abuse and neglect, leading to depression, weight loss, and disruptive behavior
(Gardner et al., 2020). Therefore, LTC should create spaces for online technologies
harnessed to provide interaction with family members, and health care providers should
monitor changes in behavior and mental state. Institutions with limited access to
online technologies could implement more frequent telephone contact with significant
others, close family, and friends. Early measures taken in nursing homes in Santo
Domingo, which are mostly run by nuns, have proven to be successful, no COVID-19 cases
reported to date.
2.
Develop 24/7 helplines and other communication services to support patients, families,
and caregivers. Some of these services are already in place, including virtual epidemiological
screening.
3.
Create screening services to monitor anxiety, depression, and other mental health
disorders. Monitoring should target vulnerable populations including elderlies with
cognitive impairment/dementia and previous psychiatric comorbidities.
4.
Mental health clinics should take extra measures to prevent transmission from health
care providers and staff to patients, including expanding symptoms-based screening
criteria, facilitating testing, and creating flexible sick leave policies in case
of respiratory symptoms.
5.
Individuals with mental health issues and elderly populations are more prone to COVID19
atypical presentations or are unable to provide an accurate history. Therefore, health
care providers and caregivers should be aware of atypical presentation (Tay and Harwood,
2020), including delirium (hypo and hyperactive), sudden change in behavior, fatigue,
falls or loss of appetite. Frontline experience also shows that only 20–30% of geriatric
patients with this infection present with fever.
6.
Caregivers working with mental health patients will need extra support. Possible strategies
may include caregiving training and coping strategies tailored to the current situation.
Local resources with information for families and caregivers are already available.
7.
Caregivers should encourage their loved ones to engage in mentally healthy behaviors,
such as reading, playing table/cards games, and other meaningful activities aligned
with their cognitive capacities. One important measure to lower the risk of being
infected with COVID-19 is to practice social and physical distancing, not meaning
social isolation or loneliness. Therefore, caregivers might help their loved ones
to access online services and maintain contact with relatives and friends via phone
or video calls.
8.
At local level, communities’ health care services should optimize opportunities for
social connectedness without breaking stay-at-home rules. A possible alternative could
include virtual support groups. The Dominican Alzheimer’s Association has implemented
weekly online social support groups and caregiver training sessions. In Puerto Rico,
online courses are given to Dementia caregivers and relatives by the School of Medicine.
9.
Future research will be needed to better understand the short- and long-term psychological
impact of the current pandemic in our societies. Therefore, local governments, funders,
and international help will be required to support research in these areas.
Finally, as the new pandemic spreads through the Caribbean, our society, governments,
and health care systems will need to be resilient and adjust to the so called “New
Normal.” All measures needed to protect those at higher risk in our society should
be warranted by the support of local governments and policy makers.