Coronavirus Lockdown: Forced Inactivity for the Oldest Old?

To the Editor:

According to the WHO, as of March 15, a total of 153,517 patients have been diagnosed with coronavirus disease 2019 (COVID-19) worldwide—with a death toll of 5735 (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200315-sitrep-55-covid-19.pdf?sfvrsn=33daa5cb_6). These heartbreaking figures have led the most affected countries (notably, Italy and Spain) to implement strict national lockdowns, ordering people to stay home—except for essential reasons such as going to work, medical appointments, or buying food—in order to reduce virus spread.

This exceptional situation is having important consequences for everyone in general but for the oldest old—those aged 85 years and older—in particular. This population segment is indeed very vulnerable, especially under stressful situations that challenge body functional reserve. On one hand, older adults present the greatest risk of mortality for COVID-19 (odds ratio per year increase of 1.10, 95% confidence interval 1.03 to 1.17),¹ and therefore require strict protection measures against the infection. On the other hand, prompting the oldest old to stay home might further increase sedentary behavior, a situation that is likely to contribute to aggravating sarcopenia, frailty, and age-related functional decline, and to increase the risk of all-cause mortality.²

Important lessons can be drawn from other confinement conditions in the oldest old such as mainly hospitalization, where they spend most of the time in bed, including those who are able to walk independently.³ This scenario can lead to major negative health consequences even when the illness that prompted hospitalization is successfully treated. Ten days of bed rest suffices to result in marked impairments in muscle mass and strength, walking speed, and functional ability among individuals aged about 70 years.⁴ Approximately one-third of older adults lose their ability to independently perform 1 or more activities of daily living from hospital admission to discharge,⁵ which has important short- and midterm consequences—including a higher risk of nursing home admission, hospital admission, and mortality.⁶

There is growing evidence that the oldest old people can adapt to exercise just like younger individuals and deserve to benefit from it.⁷ The incidence of functional decline during hospitalization has been inversely associated with the levels of physical activity.⁸ A recent randomized controlled trial from our group showed that even a simple exercise intervention (doing uncomplicated exercises such as walking back and forward along a corridor and rising from a chair twice a day for ∼20 minutes in total) was safe and significantly reduced functional decline (by 64%) in oldest old people (aged 88 years on average) who had been hospitalized for a median time of 7 days.⁹ Furthermore, the intervention proved especially effective in those with a worse functional status at baseline.¹⁰

The situation for the oldest old is especially dramatic in light of the recent recommendations from the Italian Society of Anesthesiology and Intensive Care for “exceptional conditions of imbalance between needs and available resources” in intensive care unit admissions of this country (http://www.siaarti.it/SiteAssets/News/COVID19%20-%20documenti%20SIAARTI/SIAARTI%20-%20Covid19%20-%20Raccomandazioni%20di%20etica%20clinica.pdf). The considerations for potential triage during the ongoing COVID-19 outbreak in Italy include a patient's age and chance of survival. Under these circumstances, it is not surprising that some oldest old Italians are gripped with fear and stuck to immobility.

The need for avoiding virus infection should not overshadow the deleterious effects that disuse can impose in all individuals and particularly the oldest old. Public health efforts to promote physical activity and “break” sedentary behavior—which can be achieved with simple home exercises such as rising up from a chair several times a day and avoiding continuous sitting for long hours—during lockdown are to be recommended.