Impact of COVID-19 pandemic on the elderly in the United Kingdom: A review study

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has significantly altered the lives and lifestyles of several older populations in the United Kingdom. It was important to note how it has affected their physical, mental, and social health and well-being during the first wave of the Covid-19 pandemic. To study the impact of the Covid-19 pandemic and the imposed restrictions on the day-to-day lives of the elderly population in the United Kingdom. A review of the published literature on the first wave of the Covid-19 pandemic and its consequences on the older population in the United Kingdom is done. Search engines used for medical databases were Pubmed, Google Scholar, and Internet Explorer. It was found that physical as well as mental well-being was affected in the elderly citizens of the United Kingdom. Mental health studies noted an obvious increase in anxiety and depressive symptoms. Social isolation and reduced access to healthcare services had a deteriorating impact on their social health. Covid-19-related lockdown and pandemic-associated physical, mental, and social well-being effects have been evident in the elderly population in the United Kingdom. The reasons identified for such findings are lack of physical activity, poor social interactions, social isolation, the perceived threat of a pandemic, and poor access to healthcare facilities.

Introduction

The pandemic of coronavirus disease 2019 (Covid-19) has considerably transfigured the lives of people. All the different strata of society have had grave impacts on their day-to-day lives. However, the impact has been magnified in the elderly population, given the various unmet social and healthcare needs for them. The UK government imposed its first social distancing restrictions and “lockdown” on March 23, 2020. As the elderly population is deemed to be more vulnerable to health conditions, especially to shield them, a closing down of public spaces and a ban on non-essential travel was imposed.

Existing concerns about older adults’ well-being were exacerbated when the WHO declared a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic.

It was thought that due to the specific isolation rules for older adults and their heightened risk from the virus, psychosocial consequences such as loneliness would be exacerbated in older age groups, leading to negative effects on mental and physical health. In trying to do away with limitations to healthcare access, assisting older adults with telecare can be a useful opportunity for a few fitness concerns. The common threats to well-being as perceived by the elderly population in the United Kingdom were end-of-life concerns, fear of aging and frailty, fear of seeking help due to a perceived lack of service availability, fear of leaving the house, and grieving the loss of normality more relevance to primary care can be reviewed in Supplementary Material.[1] Several protective measures taken by people in anticipation were taking out more time for exercise and new hobbies, time for introspection, organizing affairs, helping others, and keeping themselves busy with social obligations.

This review article comprises various observational studies as mentioned in Flowchart 1 and Table 1 done on emerging concerns for the elderly population in the United Kingdom during the havoc of the COVID-19 pandemic as well as its short-term and long-term implications on their lives.

Flowchart 1.

PRISM - Flow diagram for screening of articles included in the review

Table 1.

Results

Study/article	Year of Publication	Type of Study	Place	Results/Conclusion
1. The influence of COVID-19 measures in the United Kingdom on physical activity levels, perceived physical function and mood in older adults: A survey-based observational study	2020	Observational Study	United Kingdom	Increased depression in active older adults with sedentary behaviour as an independent risk factor.
2. Impact of COVID-19 related social support service closures on people with dementia and unpaid carers: a qualitative study	2020	Cross-Sectional Study	United Kingdom	Significant reduction in social support service usage since the outbreak, which greatly affected carers and people living with dementia (PLWD).
3. Dementia, prevention, intervention, and care: 2020 report of the Lancet Commission	2020	Review Article	United Kingdom	Cognitive training in healthy older people, those with mild cognitive impairment and those with dementia found that most were of low standard, were positive and most reached statistical significance.
4. Loneliness, Social Integration, and Incident Dementia Over 6 Years: Prospective Findings From the English Longitudinal Study of Ageing	2020	Longitudinal Study	United Kingdom	Development of dementia had no association with social isolation.
5. The initial impact of COVID-19 and policy responses on household incomes	2020	Cross-sectional study	United Kingdom	Negative effects on the living standards—considered broadly—of lower-income working-age families than of higher-income families.
6. A qualitative study about the mental health and well-being of older adults in the UK during the COVID-19 pandemic	2021	Cross-Sectional Study	United Kingdom	Participants described potential threats to their well-being during the pandemic, including fears of mortality, grieving normal life, and concerns for the future.
7. A longitudinal analysis of loneliness, social isolation, and falls amongst older people in England	2020	Longitudinal Study	United Kingdom	Loneliness, living alone, and low social contact were all associated with a higher hazard of falls leading to hospital admissions.
8. Associations of Social Isolation with Anxiety and Depression During the Early COVID-19 Pandemic: A Survey of Older Adults in London, UK	2020	Longitudinal Study	United Kingdom	Since the lockdown, 12.8% of participants reported feeling worse on components of depression on the HADS and 12.3% reported feeling worse on components of anxiety.
9. Mental health and social interactions of older people with physical disabilities in England during the COVID-19 pandemic: a longitudinal cohort study	2021	Longitudinal Study	United Kingdom	During the pandemic, significantly more people with ADL impairment had clinically significant symptoms of depression, anxiety, and loneliness than people without ADL impairment. Significantly more people with ADL impairment also had impaired sleep quality and poor quality of life than people without ADL impairment.
10. The ongoing effects of the COVID-19 pandemic on perceived physical activity, physical function, and mood of older adults in the U.K: A follow-up study	2021	Longitudinal observational study	United Kingdom	Physical activity levels were maintained but changes in types and effort of intensity were noted. Sedentary time was increased with the follow-ups.

The main objective of this review article is to synthesize and collaborate on the existing research on the effect of COVID-19. Furthermore, we aim to investigate the impact of the COVID-19 pandemic on various well-being aspects including physical, mental, and social health.

Methodology

A narrative review of both published and unpublished articles was performed. Keywords used for the search were pandemic, lockdown, elderly population, geriatric population, physical health, and mental health. The databases covered were PubMed Google Scholar, and Internet Explorer browser. Inclusion criteria involved studies conducted on populations above 65 years of age during the first wave of the Covid-19 pandemic and consequential lockdown in the United Kingdom. Case reports, case series, literature reviews, clinical trials, cohort, and case-control studies, written only in the English language were reviewed. Commentaries, letters to editors, book chapters, and newspaper articles were excluded. The initial search of the database yielded 85 articles, of which 75 were rejected due to not meeting inclusion criteria, irrelevant outcomes, and duplicity. To improve the quality of the review, critical appraisal tools like AMSTAR-2[20] and ROBINS 1[21] were used to randomize the search.

Results

It was found that physical as well as mental well-being was affected in the elderly citizens of the UK. Mental health studies noted an obvious increase in anxiety and depressive symptoms. Social isolation and reduced access to healthcare services had an deteriorating impact on their social health.

Discussion

Effect on the physical health of the elderly population

Following the onset of COVID-19, fluctuating restrictions have greatly impacted the daily lives of the elderly population living in the United Kingdom. Subsequently, the longer-term effects of COVID-19 on physical activity levels perceived physical function, and mood of older adults were unclear.[2]

Being physically healthy can improve brain health, manage weight, reduce the risk of diseases, toughen bones and muscle groups, and enhance your capacity to do regular activities. Everyone can enjoy the health benefits of physical activity irrespective of their age but the pandemic of Covid-19 has changed the overall lifestyle of every single living being on this earth. We are all experiencing the impact of ongoing disruption to our daily routines and uncertainty about the future. It is important to remember that many older people were already dealing with significant health challenges before Covid-19 was ever heard of. Unfortunately, the pandemic appears to have exacerbated some as well as brought forward the emergence of others. Getting older can make us more vulnerable to a wide array of physical health conditions.

Aging is related to sarcopenia which causes loss of muscle mass and strength with a decline in performance.[3] The longer periods of inactivity may lead to a transient worsening of age-related muscle waste as a result of mechanical unloading, accelerating the progression of sarcopenia and the development of comorbidities.[4] Sarcopenia is further accelerated by physical inactivity although regular exercise and physical activity have been promising in preventing or even reversing such effects related to aging.[5] Staying at home may have protected them from the virus but it has led to the development of other serious issues like loss of function due to poor mobility, and balance problems with increased risk of falls. Their other untreated medical conditions significantly get worse due to the inability to access medical or social care.

The mobility and movement of the elderly have been significantly affected during the pandemic. They have found it difficult to cope with activities of daily living and have become more dependent on others. Clinically, they have developed muscle weakness, deconditioning, and joint pain due to reduced physical activity during the pandemic times. The risk of falls and fractures has also increased in this population due to possibly worsening sarcopenia and osteoporosis with a more sedentary lifestyle. Fear of falling and loss of confidence in performing day-to-day activities, for example, cooking, washing, going short distances, etc., have been greatly impacted. Some of the elderly people have put on weight which has again impacted their mobility.

A cross-sectional observational study[2] conducted across the United Kingdom measured the lockdown effects within the first 6 weeks of the elderly population. It was an online survey with a self-administered questionnaire with 117 participants aged between 70 and 80 years. They found that this group generally maintained physical activity by involving themselves more in household work, however, sedentary time was increased. Further, looking at the data, the participants were all active healthy older adults who were keen to maintain good physical activity to counteract the effects of the lockdown. This study sample could not be generalized as the authors suggested that most individuals were from a similar ethnic background with high socio-economic status. However, in the same study, they found that even in this group incidence of depression increased during the lockdown.

The COVID-19 outbreak has been linked to a reduction in possibilities for structured physical activity for older persons,[4] likely leading to increased sedentary behavior, which has been linked to unfavorable changes in both physical and mental health. Indeed, just 14 days of fewer steps/day was demonstrated to diminish knee extensor muscular strength by 8% in older persons, a significant drop that did not recover after two weeks of resuming normal activity levels.[6] Muscle strength maintenance is critical for maintaining functional independence and quality of life. This underlines the significant negative consequences of even brief periods of decreased physical activity and increased sedentary time on older persons in the context of a pandemic-related lockdown.

Although social distancing and isolation measures can flatten the epidemic curve, there is solid evidence that isolation has various severe health consequences, particularly for older folks. This is significant since the timetable for UK lockdown measures was undetermined. Feelings of social isolation are linked to lower self-rated physical health, faster cognitive decline, and increased vulnerability to social dangers. Longer quarantine duration, virus fears, annoyance, boredom, and insufficient supplies can all contribute to negative psychological impacts such as post-traumatic stress disorder, hostility, and bewilderment.[7] Physical activity offers beneficial psychological advantages such as reduced anxiety and depression symptoms, but it can also have detrimental consequences on physical and mental well-being.

A telephonic survey was conducted to look at the impact of Covid-19 on the lives of older people in the United Kingdom over 75 years of age on 171 participants.[8] It showed around 60% of participants were carrying out physical activities, mostly outdoors and every day. More than 40% reported having reduced physical activity as compared to before the lockdown. This survey also included a questionnaire on mental health problems related to the pandemic where they concluded that the elderly felt in good health with low levels of health-related anxiety and depression during the lockdown period.

Effect on the mental health of the elderly population

With unprecedented population aging, the consequences of social isolation on the mental well-being of the elderly population are emerging as a significant public health concern, which was further intensified as a result of the COVID-19 pandemic. Following the cancelation of family gatherings and the closing down of spiritual institutions, the access of the elderly population to recreation and entertainment was severely affected. There is strong evidence that mental health and well-being in the United Kingdom worsened during the COVID-19 pandemic with the largest decline occurring in April.[9] Lack or loss of close contact and reduced socialization have been proven to be one of the major predictors of the prevalence of depressive mental disorders in the elderly population.[10] And it has been found that self-isolation per se does not necessarily lead to the onset of depression but that perceiving COVID-19 symptomatology (e.g. dry cough, fever) and being exposed to news reporting about the pandemic does. This is in line with recent research that has found in a UK sample that those who perceived COVID-19 symptomatology were more at risk of depression and anxiety disorders.[11]

In adults, loneliness is on occasion assessed with an unmarried face-legitimate query that asks people to grade the frequency of their emotions of loneliness. Still, the preferred measures are validated scales such as the De Jong-Gierveld Loneliness Scale[12] and the UCLA Loneliness Scale,[13] each of which keeps away from the terms “lonely” or “loneliness” to lessen reaction bias. One of the articles has focused on the health-relevant correlates and consequences of social isolation across different lifespans. The article has conclusively reported a robust association between loneliness and depression in the elderly population. In addition, jeopardized sleep quality, increased cognitive decline, and dementia were noted in late adulthood with a lack of social connectivity.[14]

A survey of older adults in the United Kingdom very thoroughly studied the parallelism between social isolation with anxiety and depression during the early phase of the Covid-19 pandemic.[15] Depression and stress levels have been measured using the Hospital Anxiety and Depression Scale (HADS) which incorporates 14 questions about emotions associated with tension and depression. There turned into a distinguished and dose-reaction affiliation between loneliness and worsened additives of hysteria and melancholy at the HADS. Individuals who reported that they “often” felt lonely had a 17.24 times higher risk of further feeling worse in components of depression and a 10.85 times higher risk of reporting feeling worse in components of anxiety, in comparison to folks who in no way felt lonely.[15]

Moreover, this supports past research that has found that exposure to sensationalist media coverage of public health crises, such as the Ebola outbreak, led to depression and psychological distress even in people with no symptoms of the disease. However, the healthcare institutions quickly adapted to telemedicine, leaving some individuals too afraid to seek in-person medical assistance and lacking the necessary telemedicine equipment. On the other hand, persons with internet access became overwhelmed, anxious, or skeptical as a result of “information overload” about the virus’s hazards from scientific and media articles. The 8-item Center for Epidemiological Studies Depression (CESD-8) Scale, 7-item Generalized Anxiety Disorder Scale, and 12-item Control, Autonomy, Self-realization, and Pleasure scale were utilized to quantify the level of depression, anxiety, and quality of life in elderly individuals during the pandemic era.[16] One of the longitudinal studies utilizing the 12-item General Health Questionnaire (GHQ) reported the increased prevalence and incidence of common mental disorders (CMD) in the UK adult population during the peak phase of the COVID-19 lockdown.[17]

Adults who reported COVID-19 symptoms were about 1.6–2.0 times more likely to develop CMD compared to those who did not report any symptoms. Loneliness was the major determinant of CMD during the lockdown among adults in the United Kingdom. Despite some reduction in levels of stressors by the middle of 2020, an increase in unemployment as the recession unfolds and related financial stressors are also likely to lead to increased levels of CMD.[17]

Effect on social care and services

Despite several established preventive and community screening programs running in the country, the elderly population is mostly picked up with a chronic disease when they enter general practitioner (GP) practices or emergency services with symptoms. This impact has further deepened with this pandemic significantly in the older population in the United Kingdom. A recent Care Quality Commission (CQC, 2022) survey found many initiatives, good practices, and significant drive from healthcare providers and commissioners, aiming at integrated healthcare delivery for the older population. They surveyed eight different sites and highlighted that despite great commitment and efforts, many organizational barriers were making it difficult to identify the elderly population at risk or to prevent an unplanned urgent admission to acute hospitals. This survey also found that lack of proper connection between different care services resulted in older people falling through the gaps and they were only being identified in response to a health crisis. They recommended that healthcare leaders should develop a shared understanding of local integrated care, should involve elderly people in an informed decision-making process about their own care needs, support family, and carers, and improve access to health and social care. In the United Kingdom, the elderly have great community support from social care teams, understandably, who had their own challenges to reach out due to lockdown effects or lack of manpower.

An interesting telephonic survey[18] was conducted nationwide in the United Kingdom during and after the lockdown in April–May 2020 on people living with dementia (PLWD) and unpaid carers using a standard questionnaire to explore the effects of the Covid-19 pandemic on access to social care services. The study concluded that many were unable to access social care and support services during the peak of the Covid-19 pandemic owing to several public health restrictions. Of everything, the most concerning was the fear many participants had in leaving the house to access routine or preventative healthcare, which may have longer-term implications for public health services. It has further contributed to poor quality of life and anxiety in those affected by dementia and older adults. This study is indeed one of its kind to explore the pandemic and lockdown effect on people with dementia and older adults regarding social service availability and access. It has also provided insights into the well-being of unpaid carers which has indirectly affected care for PLWD. Covid-19 and pandemic-related closures have also affected older adults in their access to community services and social activities, for example, art and hobby groups. This study has concluded that Covid-related service loss has negative psychosocial effects on vulnerable groups with lockdown restrictions, social distancing, and poor access to community services and support.

Generally, social media and digital alternatives have helped a great deal to bridge the information and care gaps in the Covid-19 pandemic. People have changed their lifestyles and adapted to new digital alternatives to eliminate social isolation in response to lockdown during a pandemic. However, most older adults who were already struggling with skills and access to make use of new technology have not benefited much from these technological solutions and as a result, had to suffer from social isolation and loneliness.

In this research, we will look at the aspects of whether older populations were able to use the healthcare services they needed during the primary wave of the pandemic and lockdown within the United Kingdom, whether those with higher socio-economic status were more ready to use the services they needed within the health and social care system. The healthcare system within the United Kingdom is basically funded through general taxation. A founding principle and duty of the National Health Service (NHS) is to ensure equal access for equal needs regardless of age, location, or ability to pay, as restated within the 2012 Health and Social Care Act. To address the COVID-19 pandemic, the United Kingdom reallocated resources within the health and social care systems to handle COVID-19 cases. This affected the NHS and social care system to satisfy the healthcare needs of the general population due to other health conditions, illnesses, or health emergencies. In March 2020, NHS trusts redesigned their offerings to launch capability for COVID-19 patients by discharging thousands to unencumbered beds and postponing planned treatments (NHS Providers, 2020). In the United Kingdom, resources were allocated within the health and social care system to tackle the rising Covid-19 pandemic wave. This led to the redesigning of services to free up more beds to treat Covid-19 cases. Although this infrastructural change was inevitable, it has led to delayed planned treatments and postponed regular health checks. According to new research from the University of East Anglia (UEA) published by health economonics group of University of East Anglia (UEA), how only one-third of the population in the United Kingdom was able to access the much-needed healthcare during the first wave of Covid-19.[19]

We are currently unsure about the long-term effects of this pandemic and what measures to be taken to mitigate the risk. Although coming back to a normal routine will help identify the gaps in medical and social care to further plan strategies to address these concerns in the near future.

This research paper aims to explore how the pandemic has affected the older population in the United Kingdom during the first half of 2020. It has compiled the research articles published during and after the first wave of the Covid-19-related pandemic and lockdown and its effect on the elderly in the United Kingdom.

Limitations

This article, however, should be viewed in the light of its limitations. The data and the articles picked up for this literature research are mostly from the first wave of the Covid-19 lockdown and it has not captured the effect of subsequent lockdowns on the mental and physical health of the elderly in the United Kingdom. Most of the online and telephonic surveys included people from similar ethnic backgrounds so the cohort could not be generalized. Moreover, this article does not highlight the direct pathological effects of Covid-19 disease on the elderly in terms of its morbidity and mortality.

Conclusions

The pandemic of Covid-19 has had a profound effect on every level of the healthcare systems and population in the United Kingdom. However, elderly people have been confronting the greatest number of difficulties. The studies related to physical activity in the lockdown did show that most of the elderly population had increased fall risk due to the deconditioning of muscles in the lockdown, they developed a loss of balance, and reduced physical activity has also affected mood and cognition up to some extent. Few studies however revealed that healthy older adults remained physically active and were rather more active during the lockdown and maintained their day-to-day exercise regimen at home. Older adults with disabilities have suffered most in this group as the social support system designed for their care was not regularly accessible to them. The mental health and well-being of the elderly have been negatively impacted during the lockdown period in the United Kingdom. It has been suggested by several studies that people have developed anxiety and depressive symptoms. These symptoms were commonly reported due to the indefinite lockdown period, feelings of fear among the elderly due to social media hype of agism, loss of near ones due to Covid-19, living alone, and poor social interaction with neighbors and friends.

Recommendation

However, the elderly in the United Kingdom and worldwide have been affected by this pandemic and lockdowns in other ways, for example, increased mortality in an older population, prolonged Covid syndrome, financial burdens, and crisis which is beyond the scope of this article and further research may be needed to look at these aspects. Another perspective that can be further looked at is long-term covid pandemic-related complications like how has it affected the elderly population in the long run after they have missed their healthcare checks during a pandemic and the implications it carries on medical and social care services whether they are overburdened in the post-covid era. As one of the Public Health England studies has suggested, an increased risk of falls after a lockdown in the elderly population due to deconditioning, it will be interesting to look at how these older people manage daily life activities and whether or not they are back to a pre-covid functional level.

Efforts to lower the prevalence of depression in the elderly should target the risk factors in the order of their significance. This would seem to require general improvement in the prevention and treatment of chronic somatic and mental illnesses, provision of adequate social support, and prevention of social isolation. Moreover, in the case of functional impairment secondary to chronic mental and somatic illnesses, compensatory arrangements should be established to compensate for the health-related functional impairment.

Contributions

Anurag Sharma and Sucheta Sharma contributed equally to this work as the first authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary Material

The study Covid 19 pandemic in the UK and its impact on elderly care was planned keeping various aspects in mind for example physical health, mental well being and social impact on elderly care in the community. It is especially relevant to family medicine/General practice as most relevant research papers which were analysed were from community which clearly suggested, how covid 19 pandemic affected GP services in the UK. In our study, we collated the data from all the published research articles in open access which were mainly from the well indexed community portals. It was noted that there was interruption and delays in seeking and providing family medicine/General practice care that further affected elderly care. We have realised that during the peak of first pandemic GP practices and most community services were dealing with acute care with regards to pandemic. However various community programs, screening services, care of chronic illnesses and preventive programs in the community were affected. It is worth mentioning that most of these services were designed for elderly care in the community, therefore there was a huge impact noted on this cohort of population when suddenly the available resources were targeted to tackle the pandemic. In the UK and all over the world family medicine/general practice constitutes a big part of elderly population who are relying on the community run programs to maintain their general physical, mental and social wellbeing. We think the data and research presented in our study is relevant to any population as it highlights the problems related to disruption in care largely dependent on community and social care services.