1. The knowledge of being vulnerable and the involuntary and inescapable self-isolation are both creating anxiety and maybe other psychiatric signs and symptoms. This will be not only in the known psychiatric patients, but also in the general older population.
The COVID-19 pandemic has changed everyday life tremendously in a short period of time. The threat of contamination is especially frightening for older persons, as chronological age is a major risk factor for a severe course and mortality [1] . Social distancing and self-isolation have been imposed by the authorities to contain or delay the spread of the SARS-CoV-2 virus (COVID-19) and to prevent a shortage of hospital intensive care beds. These measures may have a disproportionately large impact on the older age group since personal assistance on (I)ADL has to be minimized and the prohibition of family and other social contacts may worsen feelings of loneliness [2] .
This impact on (older) persons, which is already high, may increase even more in the presence of a psychiatric disorder [2] and in the case of lower socio-economic status and smaller social networks [4] .
A brief timeline of the Dutch situation and our management strategy to adapt geriatric mental health care is presented below, followed by a case-series to illustrate the specific challenges facing geriatric psychiatrists. This case-series included patients treated at GGNet, a large mental health care center covering a population of around 800,000 in the eastern part of The Netherlands, and the Psychiatry Department at University Medical Center Groningen in the northern Netherlands.
On February 27 th 2020, the first person tested positive for SARS-CoV-2 in the southern part of the Netherlands, followed by the spread of the virus throughout the country.
Measures were applied in rapid succession, since mental health centers are not prepared for the management of communicable diseases. Initially, handshakes were prohibited and social distancing was applied in the conversation room. One week later, only urgent visits were allowed to our outpatient clinics; group sessions were restricted to a maximum of three persons and one week later prohibited entirely. Finally, by mid-March, older outpatients were confined to their homes due to the lockdown in the Netherlands.
Many aspects of mental health care facilities make older patients with psychiatric disorders susceptible to the rapid spread of COVID-19 [5] . In long-term care facilities and acute inpatient wards, communal meals and different group activities, combined with an inability to follow hygienic and sanitary rules, hinders the prevention of transmission. As a result, older inpatients in acute and long-term care mental health care have been locked-up. Beginning on March 20, contact with their closest family members was prohibited. This latter restriction may cause iatrogenic damage, as social isolation of older adults is associated with a higher risk of the onset of chronic diseases such as cardiovascular, autoimmune, neurocognitive, and affective disorders [6] [7] [8] .
To comply with national policies on the spread of COVID-19 and protect geriatric psychiatric patients, specific COVID-19 isolation units with 5-9 beds were set up in most mental health centers. In addition to the fear of infection of our patients, we also in the quarantine ward until they were free of symptoms for 24 hours before isolation was concluded. One patient, suffering from a chronic psychotic disorder, destabilized in isolation and became severely psychotic over the next three days. She refused to cooperate with our program and medication, which resulted in coerced admission and compulsory treatment.
Members of the clinical staff were allowed to return to work when they were completely free of symptoms for more than 24 hours.
Case B -In the long-stay ward for older patients, Mrs. B, an 83-year old woman, was admitted 7 months ago after the death of her husband. She had a long history of recurrent affective psychosis in the context of a schizo-affective disorder. During the admission, her psychiatric status stabilized and the following month she was transferred to a geronto-psychiatric ward of a nursing home.
She complained of pain in her left cheek, which showed some redness and a palpable swelling, suspected to be a local pustule. Initially, there were no other symptoms.
However, over the following days, she developed a high fever, her entire face became red, and she felt very ill and stayed in bed, which was quite unusual for the patient in question. Her oxygen saturation was 91%, low for a patient with no history of COPD.
She showed no signs of cough or respiratory illness, and her pulse and blood pressure were normal. Although a beta-hemolytic group A streptococcus infection (erysipelas) was considered the most likely cause, for which antibiotics were started, we also decided to isolate her in the 'COVID' unit. Her dosage of clozapine was reduced by half, her leucocyte count was checked, and she was supported with extra oxygen (2l/min).
Her oxygen saturation improved. The COVID-19-test was negative and her blood level of clozapine and leucocyte counts were fine. The isolation was stopped and she recovered. While her condition, especially her anxiety, deteriorated rapidly at home, she gradually improved over the course of the first two weeks of the online group therapy. Her husband no longer pressured us to admit her to an inpatient ward and was happy to have her at home isolated from family and friends.
The case-vignettes described above illustrate the immediate clinical challenges we faced in our mental health services for older people during the initial weeks of the COVID-19 outbreak in the Netherlands.
1. The awareness of vulnerability as well as the involuntary and inescapable selfisolation both generate anxiety and possibly other psychiatric signs and symptoms.
This will be the case not only in known psychiatric patients, but also in the general older population (see case D). 5. Since national policies have restricted outpatient care programs, we rapidly transformed individual and group therapy sessions into E-health programs using telephone or video platforms. For older people, this is not always possible, because they lack the knowledge and experience in the use of these new technologies, and sometimes lack the appropriate resources required for this kind of connection to begin with. It is important to avoid ageism, since most of our patients seem to adapt easily to these opportunities. Some patients need additional support to get online, e.g. by setting up online connections with their healthcare providers, and by ensuring that the family will support online access by providing computers or tablets to stay connected. Assisting these older people to digitize will also probably lead to easier access to other health care service providers and help them to stay in touch with friends and relatives. A digital day-treatment program can combine these interventions and could be an alternative for the in-person day-treatment (see case E2). Nonetheless, some psychiatric conditions may prevent the successful application of online therapy (see case E1).
In conclusion, this crisis has had an enormous impact on older persons in our society, and we have to be prepared to face these upcoming challenges and respond to them with sustainable and effective strategies and solutions. Our primary concern is our vulnerable older psychiatric group, which is at major risk of contracting COVID-19
themselves. Isolation and rapid recognition of the infected group is our primary goal.
After this, we have to take special care of this group, because they will suffer more from the social isolation and lock-down and are at risk of deterioration from these measures themselves. But this crisis may also offer opportunities. For example, speeding up individual and group E-health therapies and E-health visits is a major task for us now.