The implementation of public health measures designed to limit the spread of coronavirus disease 2019 (COVID-19) has been applied particularly stringently to people at high risk of complications, such as individuals older than 70 years and people with concurrent health morbidities like chronic respiratory or cardiovascular diseases. Older adults suffering from mental disorders are an especially high-risk group not only because of their age but also because the prevalence of chronic somatic conditions is disproportionately high in this group. Data on hospital admissions for people with mental disorders during the COVID-19 pandemic are yet to be published, although preliminary evidence suggests that adults with BD have been reporting increasing psychological distress and symptoms of anxiety and depression. Further emerging evidence suggests that the pandemic has been associated with a marked drop in hospital admissions for all causes other than COVID-19 related,¹ raising concerns about how this might affect the management of people with chronic health conditions and their access to services, including people with BD. At this point in time, it is unclear how the pandemic will affect older adults with BD (OABD), although withholding action until more evidence becomes available is unlikely to be helpful. A high proportion of OABD have concurrent chronic somatic morbidities and cognitive deficits² and therefore deserve particular attention as the medical and psychiatric community responds to the pandemic. We anticipate that the impact of the COVID-19 pandemic on this group will unfold along four overlapping stages (Table 1). Here, we will describe the expected complications of the pandemic and suggest mitigating measures for each stage.

The first, direct impact, may result in a high number of OABD developing severe somatic complications as a result of the viral infection, leading to a large number of deaths among a group of people who already have decreased life expectancy. For example, about 35% of people infected with COVID-19 develop neurological symptoms during the course of their illness, including confusion, dizziness, headache, anosmia, encephalitis and stroke.³ Potentially lingering executive dysfunction after recovery has also been reported, but it is unclear whether these deficits are likely to persist in the long term. These findings raise concerns that infection with COVID-19 could worsen the cognitive deficits that are already present among people with OABD. Future research should clarify this issue and determine whether the direct and indirect effects of the COVID-19 pandemic have affected the course of OABD.

Next, the worldwide introduction of measures designed to increase the capacity of health services to manage the acute medical complications of COVID-19 together with the various public health measures introduced to contain the spread of the virus in the community will most likely decrease access to specialized mental health services (resource restriction – stage 2).⁴ Access to acute treatment (such as ECT) may be hampered, and the regular monitoring of symptoms and of the possible adverse effects of medications, which are often magnified in late life, may be compromised. This, in turn, could increase the risk of medicine-related toxicity, sub-therapeutic use or discontinuation of treatment.

The prolonged disruption of care (stage 3) may increase the risk of relapse or recurrence of affective symptoms, leading to functional decline and, potentially, health complications, increased general hospital admissions and increased cost of care. This, together with the widespread public health measures for social distancing and isolation, may strain social networks of support which, often, are already fragile. These factors could result in the collapse of social networks, loss of income and financial strain, increased use of substances (such as alcohol) and feelings of helplessness and hopelessness. An increase in the incidence of suicide attempts would not be unexpected (stage 4). However, this potentially bleak progression of events for OABD is not inevitable.

The timely introduction of risk-mitigating strategies could circumvent most of the complications that OABD might experience in association with the COVID-19 pandemic (Table 1). Education and access to relevant resources is critical to maintaining engagement with management plans and social support. For example, active mental health surveillance and treatment are accessible via telehealth or web-based interventions and should be considered, even though supportive evidence of the efficacy of these approaches is currently limited. In addition, activity scheduling and the embracing of innovative approaches to encourage social interactions (e.g. web-based book club, choir or exercise group) would allow for enhancement of social engagement in the face of physical distancing and maintenance of a healthy lifestyle and sense of control. When access to such programs is not feasible, health services must consider alternative approaches to remain in active contact with OABD and safeguard the continuity of their care – some of these community-based approaches have already proven clinically useful.⁵

旨在限制 2019 年冠状病毒病 (COVID-19) 传播的公共卫生措施的实施特别严格地适用于并发症高风险人群，例如 70 岁以上的人以及同时患有慢性呼吸道疾病或慢性呼吸道疾病等疾病的人。心血管疾病。患有精神障碍的老年人是一个特别高危的群体，不仅因为他们的年龄，还因为该群体中慢性躯体疾病的患病率异常高。尽管初步证据表明患有双相情感障碍的成年人报告了越来越多的心理困扰以及焦虑和抑郁症状，但有关 COVID-19 大流行期间精神障碍患者入院的数据尚未公布。更多新出现的证据表明，大流行与除 COVID-19 相关以外的所有原因导致的住院人数显着下降有关， ¹引发了人们对这可能会如何影响慢性病患者的管理及其获得服务的机会的担忧，包括患有双相障碍的人。目前，尚不清楚这种流行病将如何影响患有双相情感障碍（OABD）的老年人，尽管在获得更多证据之前不采取行动不太可能有帮助。很大一部分 OABD 患者同时患有慢性躯体疾病和认知缺陷² ，因此在医学和精神病学界应对这一流行病时值得特别关注。我们预计 COVID-19 大流行对该群体的影响将沿着四个重叠的阶段展开（表 1）。 在这里，我们将描述大流行的预期并发症，并建议每个阶段的缓解措施。

第一个是直接影响，可能会导致大量 OABD 由于病毒感染而出现严重的躯体并发症，导致预期寿命已经下降的人群大量死亡。例如，大约 35% 的 COVID-19 感染者在患病过程中出现神经系统症状，包括精神错乱、头晕、头痛、嗅觉丧失、脑炎和中风。 ³也有报道称康复后可能会出现持续存在的执行功能障碍，但尚不清楚这些缺陷是否可能长期持续存在。这些发现引发了人们的担忧，即感染 COVID-19 可能会加剧 OABD 患者已经存在的认知缺陷。未来的研究应该澄清这个问题，并确定 COVID-19 大流行的直接和间接影响是否影响了 OABD 的病程。

接下来，在世界范围内采取旨在提高卫生服务能力以管理 COVID-19 急性医疗并发症的措施，以及为遏制病毒在社区传播而采取的各种公共卫生措施，很可能会减少获得专门治疗的机会精神卫生服务（资源限制——第二阶段）。 ⁴获得急性治疗（如 ECT）可能会受到阻碍，并且对症状和药物可能产生的副作用（这些副作用在晚年往往会放大）的定期监测可能会受到影响。反过来，这可能会增加药物相关毒性、亚治疗使用或停止治疗的风险。

护理的长期中断（第 3 阶段）可能会增加情感症状复发或复发的风险，导致功能下降，并可能导致健康并发症、普通住院人数增加和护理费用增加。再加上广泛的社会疏远和隔离公共卫生措施，可能会给本来就脆弱的社会支持网络带来压力。这些因素可能导致社交网络崩溃、收入损失和财务紧张、物质（如酒精）使用增加以及无助和绝望的感觉。自杀未遂发生率的增加并不出乎意料（第四阶段）。然而，OABD 事件的这种潜在暗淡进展并非不可避免。

及时引入风险缓解策略可以避免 OABD 可能遇到的与 COVID-19 大流行相关的大多数并发症（表 1）。教育和获得相关资源对于保持参与管理计划和社会支持至关重要。例如，可以通过远程医疗或基于网络的干预措施进行积极的心理健康监测和治疗，并且应该予以考虑，尽管目前这些方法有效性的支持性证据有限。此外，活动安排和采用鼓励社交互动的创新方法（例如基于网络的读书俱乐部、合唱团或运动小组）将有助于在保持身体距离的情况下增强社交参与度，并保持健康的生活方式和归属感。控制。当无法获得此类计划时，卫生服务机构必须考虑替代方法，与 OABD 保持积极联系并保障其护理的连续性——其中一些基于社区的方法已被证明在临床上有用。 ⁵