key: cord-034438-9kdmljoq
authors: Sepúlveda-Loyola, W.; Rodríguez-Sánchez, I.; Pérez-Rodríguez, P.; Ganz, F.; Torralba, R.; Oliveira, D. V.; Rodríguez-Mañas, Leocadio
title: Impact of Social Isolation Due to COVID-19 on Health in Older People: Mental and Physical Effects and Recommendations
date: 2020-09-25
journal: J Nutr Health Aging
DOI: 10.1007/s12603-020-1500-7
sha: 
doc_id: 34438
cord_uid: 9kdmljoq

OBJECTIVES: To review the impact of social isolation during COVID-19 pandemic on mental and physical health of older people and the recommendations for patients, caregivers and health professionals. DESIGN: Narrative review. SETTING: Non-institutionalized community-living people. PARTICIPANTS: 20.069 individuals from ten descriptive cross-sectional papers. MEASUREMENTS: Articles since 2019 to 2020 published on Pubmed, Scielo and Google Scholar databases with the following MeSh terms (‘COVID-19’, ‘coronavirus’, ‘aging’, ‘older people’, ‘elderly’, ‘social isolation’ and ‘quarantine’) in English, Spanish or Portuguese were included. The studies not including people over 60 were excluded. Guidelines, recommendations, and update documents from different international organizations related to mental and physical activity were also analysed. RESULTS: 41 documents have been included in this narrative review, involving a total of 20.069 individuals (58% women), from Asia, Europe and America. 31 articles included recommendations and 10 addressed the impact of social distancing on mental or physical health. The main outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. Cognitive strategies and increasing physical activity levels using apps, online videos, telehealth, are the main international recommendations. CONCLUSION: Mental and physical health in older people are negatively affected during the social distancing for COVID-19. Therefore, a multicomponent program with exercise and psychological strategies are highly recommended for this population during the confinement. Future investigations are necessary in this field.

The COVID-19 pandemic due to SARS-Cov-2 has rapidly spread all over the world since last December. Although its prevalence in the community is uncertain due to the asymptomatic cases, all age groups seems to be similarly affected (1) . However, older people are at higher risk of suffering negative outcomes, which can lead to an elevated rate of mortality, being five times higher than the global average for those older than 80 years old (2) . Over 95% of fatalities due to COVID-19 in Europe and around 80% in China have included people older than 60 years-old (3, 4) . In the US, 80% of deaths were among adults 65 and over (5) . Hence, health strategies to avoid spread of coronavirus (such as quarantine and social distancing) are important (6, 7) .

The World Health Organization (WHO) describes a close relationship between physical and mental functions with the level of self-governance and social participation in the community [8] . Social participation has been defined as active participation in a religious, sports, cultural, recreational, political, and volunteer community organizations (9) (10) (11) (12) . Various studies have reported protective effects of social participation for the health of the elderly, being considered as a stimulus to increase the level of physical activity and cognitive functions (9, 13, 14) . The social participation has been associated with a better quality of life, more muscle mass, balance, cognition and lower comorbidities and disability in older people (9, 13, (15) (16) (17) (18) (19) (20) . Participating in social meetings and activities are stimuli that increase the level of physical activity as well as the interaction with other older adults stimulating sensory systems, self-esteem, affectivity, emotional and psychological support (9, 13, 21) . As a preventive measure during the COVID-19 pandemic, community organizations have closed. Old people are constrained from visits with family members, therefore the social participation have been restricted (7) . Thus, the decreasing of social interaction produced by social distancing could have a negative impact on mental and physical health in older people (22) (23) (24) , since it has limited the social participation in community organizations and in family activities (23, 25) .

WHO defines the 'intrinsic capacity' as the 'composite of all the physical, functional, and mental capacities of an individual' (26) (27) (28) , changing the focus from a negative aging (disability) towards a positive one (optimal aging), being related to the onset of autonomy decline, falls and death (27) . Physical activity has a positive impact on the health and quality of life, reducing the risk of functional and cognitive impairment, falls and risk of fractures, depression, disability, risk of geriatrics syndromes, hospitalization rates and, consecutively, mortality in older people (29) .

Not only the physical activity is affected during quarantine, but also mental health. Several studies have described mental health consequences in previous quarantines, such as higher risk of depression (30) , emotional disturbance (31) , stress (32), low mood (33), irritability (33) , or insomnia (33) , being also associated with higher rates of suicide in elderly population (34) . However, the effects of COVID-19 quarantine on the health of older adults have not yet been broadly studied. Hence, the aim of this review is to analyse the potential effects of social isolation caused by COVID-19 pandemic on mental and physical health in older adults. Additionally, we have analysed the recommendations and proposed activities to avoid mental and functional decline to carry out at home.

In this narrative review, the literature search was performed by three authors (WSL, IRS and RT). Pubmed, Scielo and Google Scholar databases were consulted using the following terms ('COVID-19', 'coronavirus', 'aging', 'older people', 'elderly', 'social isolation' and 'quarantine'). Articles of any type of methodological design published from 2019 to 2020 (May 20th), in English, Spanish or Portuguese were included. Articles that did not include subjects >60 years old were excluded. Additionally, we have searched papers, guidelines, recommendations and update documents from different international organizations related to mental and physical activity. The lists of articles in the databases were downloaded in "bib format" and stored in Mendeley for analysis of duplicate articles, title, and abstract reading. The content of the review was divided into two main areas: 1) effect of the reduction of social participation produced by quarantine for COVID-19 on mental and physical health in elderly people, and 2) recommendations for mental and physical health of older people during the COVID-19 quarantine.

A detailed summary of the literature search is provided in Figure 1 . Six hundred and ninety unique records were identified through database and handsearching, resulting in ten articles involving 20.069 participants included in the final review (women 58%) from Asia, Europe, and America. Of these, 9 adopted a cross-sectional design, and 1 was a qualitative design. All of them are descriptive studies. Additionally, 31 articles from experts and authors about recommendations were considered in the full-text review. A summary of the characteristics of the included studies is presented in table 1.

Selection process of studies

Our results are based on summary data from eight crosssectional studies (35) (36) (37) (38) (39) (40) (41) (42) . The prevalence of anxiety ranged from 8.3%, 18.7% and 35.1% to 49.7% (36, 38) ; corresponding values from depression were 14.6%, 20.1%, 32.8%, 37.8% and 47.2% (36) (37) (38) . Finally, sleep disturbances were observed in 18.2% (38) and 36.4% (37) among the participants. Six of them (36, (38) (39) (40) (41) (42) pointed out an increased level of psychological stress defined as higher anxiety (36, (38) (39) (40) (41) , depression (36, (38) (39) (40) (41) and loneliness (42) levels and poorer sleep quality (38) during the lock-down by coronavirus. Nevertheless, in one study (35) isolation period by COVID-19 turned out in a mild stressful impact. Additionally, only one study (37) showed that people during quarantine had lower anxiety levels, but more sleep disturbances.

Risk factors associated to these results varied across the studies. Being female (36, 39, 42) , having a negative selfperception of aging (42) , healthcare workers (38) , family and personal resources (42) , time devoted to COVID-19 information (42), having an acquaintance or a family member infected with COVID-19 or a previous history of medical problems (39) seem to act as potential risk factors.

The impact on physical health of the social distancing was studied for two authors (43, 44) (Table 1 ). Goethals et al (43) reported that COVID-19 pandemic has affected the number of seniors attending group physical activity programs. Additionally, Castañeda-Babarro et al (44) observed that the physical activity was highly decreased during confinement in all population, especially the vigorous activities and walking time.

There are several recommendations related to the patient to deal with this social isolation (Table 2A) such as strengthen social connections (43, 45-48) (using internet apps, video chat (45, 47) ), telephone support lines or support groups (23, 35, 49) , changes on lifestyle (regular sleep-wake up circle (50), physical activity and nutrition habits (37, 51) ) and cognitive stimulation (using apps or stimulating mental exercises, especially in those people with previous cognitive impairment (50) (51) (52) ).

Caregivers have an important and crucial role guaranteeing the physical and mental well-being. To reduce anxiety and feeling of usefulness, letting the person participate in adapted daily activities depending on the cognitive status is recommended (51) . The exposure to media must be regulated (53) , avoiding doing it in excess and only from official sources (51, 54) , managing to control the effect of news with traumatic content (51) . Explaining clearly (55) or accompanying information with illustrations (53) may help, especially in people with cognitive impairment.

To improve older people resilience, a combination of health education and psychological counselling could be useful. Reinforcing that being quarantined is helping to keep others safe (23, 35, 46, 49) , adopting inclusive language when talking about the elderly, valuing older people's contributions and avoiding negative emphasis on risk (46) could increase also elderly's resilience. During this COVID-19 crisis, healthcare system have had to change completely implementing virtual consultations and telemedicine (video-tools, telephone hotlines or online consultations (49) , guaranteeing rapid access to health care (52, 56) . Additionally, the SCORARE GA, an assessment tool, has been proposed for doing a telematic geriatric assessment (52) .

In order to minimize isolation related stress, quarantine should be as short as possible. Giving good quality information, using channels that older people use like traditional media is also important for reducing stress (23) . 

The social distancing has reduced the levels of physical activity, which could have a negative impact on physical health (43, 44) . In this review, we include recommendations about increasing physical activity levels from the following eight global organizations: American College of Sports Medicine (ACSM) (57), American Heart Association (AHA) (58) , American Physical Therapy Association (APTA) (59) , International Association of Physical Therapists working with Older People (IPTOP) (60), World Health Organization (WHO) (61), World Confederation for Physical Therapy (WCPT) and International Network of Physiotherapy Regulatory Authorities (INPTRA) (62) . They recommended 150-300 minutes per week of moderate-intensity aerobic physical activity and two sessions per week of muscle strength training (57, 61) . Additionally, exercise circuit at home with cardio and strength exercises in short bursts of 30 seconds for up to three minutes. Finally, coordination, mobility and cognitive exercises are also necessary (63) ( Table 2B ).

The role of caregivers during the quarantine is to supervise the exercise in those patients with unstable chronic diseases (64) . For health professionals, the principal elements to consider when designing an exercise program for older people confined at home are exercise modality, frequency, volume, and intensity (63) . It is recommended the telehealth using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) . IPTOP has recommended a list of apps[60] such as "Otago exercise programme", "Clock yourself" and "iPrescribe Exercise". APTA, ACSM and AHA recommended different online videos and websites (58, 65, 66) (Table 2B ).

This review suggests a general negative effect on mental health in general population during social isolation for COVID-19. This implies higher levels of anxiety and depression as well as poorer sleep quality.

The prevalence of anxiety and depression during COVID-19 outbreak, varies across the studies, having a wide range from 8.3% (36) to 49.7% (42) for anxiety or 14.6% (36) to 47.2% (42) for depression, in consonance with previous studies of other epidemics. For instance, 39% of prevalence of anxiety was observed in France due to avian influenza (67); 48% of the general population in Sierra Leone experimented symptoms of anxiety or depression 1 year after Ebola outbreak (68); in Hong Kong due to the SARS epidemic, 73% and 57% of individuals presented low mood and irritability (respectively) (33) , as well as depression in 31.2% of 129 quarantined persons for SARS epidemic in 2003 (69) . The lower rates of anxiety and depression observed in some studies of our review during

Activities to improve the mental and physical health at home coronavirus pandemic could be explained for several reasons. The first one is that, based on previous epidemics, strong and quickly measures to keep mental health could have been taken by the governments, avoiding a bigger psychological impact. As time goes by, there was more information about SARS-Cov-2, which could also lead to a better management of the situation. However, data were collected in a very earlier stage of the pandemic, hence, these results should be taken with caution.

Some of the risk factors associated to a higher risk of psychological distress have been also described in previous literature. After Ebola outbreak, people who knew someone quarantined due to Ebola or with any Ebola experience were at higher risk of anxiety, depression and post-traumatic stress disorder (68) . Additionally, being older than 60 or worried about the recurrence of SARS have been also found as risk factors in previous studies (70) . However, we cannot conclude the same in this review, where a more intense effect on older people has not been reported. Another parameter that should be taken into account is the duration of isolation, since it is related to the severity of psychological symptoms. A non-significant impact on patients' well-being has been demonstrated during short-term isolation (71) .

Health providers need to be aware that older adults are at higher risk of having mental health concerns during isolation, and they may have less resources to mitigate them. They should encourage old adults and their families to contact each other daily, as much as they can, to reduce isolation in this population. Additionally, maintaining a positive life-style behavior such as regular sleep and meal times, keep a healthy diet, cognitive stimulation and perform physical activity need to be recommended. Also, relaxation techniques which may include diaphragmatic respirations or muscular relaxation, practicing a regular routine, alternating with different activities during the day could be useful. It is important for people to be informed by reliable sources and spending a limited time for searching information, maximum once or twice per day. Information given to the elderly should be simple, frequent, and displayed in appropriate media.

This review has reported that social distancing because of the COVID-19 pandemic could lead to negative consequences for the physical health of older adults. This is caused by the decrease of physical activity levels due to the total or partial restriction of social participation in community groups and family activities during the pandemic (42, 43, 44) .

Social participation has several positive effects on physical health in elderly people (72) . Studies have reported that older adults who were enrolled into social activities presented better dynamic balance and muscle strength, healthy lung function and lower disabilities and chronic inflammation compared to those without social participation (14, 72) . For this reason, attending social activities is an important component for successful aging (14, 72) .

The relationship between social interaction and physical health may operate through different pathways (14, 72) . A possible explanation for these findings is that participating in meetings or social activities stimulates the musculoskeletal, cardiovascular, respiratory and nervous systems through physical activity and social interaction (73) . Physical activity generates benefits for the physical health of older adults, stimulating muscle contraction, energy expenditure, decreasing systemic inflammation and oxidative stress, reducing prevalence of chronic diseases, and geriatric syndromes such as sarcopenia, osteosarcopenia and frailty (74) .

As expected decreasing or total restriction of social interaction could generate negative consequences for the health of elderly people, especially in those with chronic diseases, disabilities and geriatric syndromes (14, 63) . Evidence has demonstrated a relationship between social isolation and loneliness with disability, chronic diseases, risk of mortality and physical inactivity in elderly population (9, 19, (75) (76) (77) (78) (79) . However, the effect of increased sedentary behavior and decreased physical activity on elderly people during the COVID-19 pandemic is unclear.

Isolated older people have less physical activity and more sedentary behavior than those non-isolated [80] . Physical activity is described as any body movement using skeletal muscle that results in energy expenditure > 1.5 metabolic equivalent of task (MET), while sedentary behavior is defined as any waking behavior characterized by an energy expenditure 1.5 or less MET while in a sitting, reclining or lying posture (81, 82) . Increased sedentary behavior has been associated with the prevalence of different comorbidities in elderly people (83) . Since a direct association has been reported between sedentary time and time spent at home in elderly people (84) , recommendations have to be made to prevent health consequences in people with social isolation associated to the pandemic COVID-19.

The global expert organizations included in this review have highlighted the importance of increasing or maintaining the physical activity levels during the pandemic (57-62). Although those organization recommended different types of activities or exercises, they are in agreement of using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65). ACSM and WHO recommended 150-300 minutes per week of aerobic physical activity and 2 sessions per week of muscle strength training (57, 61) . However, recommendations for people with social isolation could consider studies that have reported benefits of replacing sedentary time with physical activity. For example, replacing sedentary behavior with 30 minutes of light physical activity and 20 minutes of moderate to vigorous physical activity could have beneficial effects on all cause mortality (85) . In addition, replacing 30 minutes per day of sedentary time with moderate to vigorous physical activity has been associated with a decreased frailty in older people (86) . This information could be used to recommend physical activity as appealing and feasible (87) . Additionally, balance, coordination, mobility and cognitive exercises to stimulate neurological system are recommended for older people to reduce the risk of falls and cognitive declining (63) . In those older adults with geriatrics syndromes or unstable chronic diseases, it is recommended the supervision of caregivers to avoid falls, exacerbations and injuries during the exercise (64) . In addition, the health professionals should design the exercise program for older people confined at home with a specific exercise modality, frequency, volume, and intensity (63), using online videos, apps online platform for phones and tablets through the internet system (60, 62, 65) .

Finally, the quarantine implied a radical change in the lifestyle of elderly people, reducing the social interaction, participation in exercise group, religious or spiritual group which have negatively affected the mental and physical health in this population (88) . Therefore, to maintain an active lifestyle at home is important for the health of older adults, especially those with chronic diseases and geriatrics syndromes. To summarize all the recommendations and articles included in this review, we have proposed different activities to improve the mental and physical health at home in Figure 2 .

To the best of our knowledge, this is the first review that includes assessing the physical and mental effects of social isolation by COVID-19 among older people. However, this study has some limitations, which deserve to be mentioned. Studies included in this review were cross-sectional design and not specific in elderly population. As all of them are descriptive studies, no control group was used. Additionally, there is also a lack of evidence regarding the most appropriate psychological and physical recommendations and most of the interventions suggested are based on expert opinions and not on high evidence studies. Future investigations should consider a longitudinal or cross-sectional design in older individuals, with larger sample size and different outcomes related to mental and physical health.

In conclusion, our study suggests that the mental and physical health in older people are negatively affected during the social distancing for COVID-19. The main mental and physical outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. Experts organizations and WHO have given different recommendations to keep older people mentally and physically healthy. Therefore, an integrated and multidisciplinary assessment between geriatricians, psychiatrists and physiotherapists could be needed.

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Declaration of Conflict of Interest: None.Declaration of Sources of Funding: co-financed by the European Regional Development Funds (RD120001/0043) and the Centro de Investigación Biomédica en Red en Fragilidad y Envejecimiento Saludable-CIBERFES (CB16/10/00464).Author's contribution: Study concept and design: all authors. Data collection: WSL, IRS, RT. Draft of the manuscript: WSL, IRS, PPR, FG, RT. Full access to all of the data in the study and responsibility for the integrity of the data: WSL, IRS. Study supervision: LRM. All authors reviewed the manuscript for important intellectual content and approved the final version.
