Advertisement

Aging and the COVID-19 pandemic: The inter-related roles of biology, physical wellbeing, social norms and global health systems

  • Author Footnotes
    1 Denotes equal contribution.
    Cristina Baena
    Footnotes
    1 Denotes equal contribution.
    Affiliations
    School of Medicine, Pontificia Universidade Católica do Paraná, Brazil
    Search for articles by this author
  • Author Footnotes
    1 Denotes equal contribution.
    Taufique Joarder
    Footnotes
    1 Denotes equal contribution.
    Affiliations
    Public Health Foundation, Bangladesh
    Search for articles by this author
  • Nasar U. Ahmed
    Affiliations
    Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
    Search for articles by this author
  • Rajiv Chowdhury
    Correspondence
    Corresponding author at: Department of Global Health, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA.
    Affiliations
    The Center for Non-communicable disease Research (CNCR), Dhaka, Bangladesh

    Department of Global Health, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
    Search for articles by this author
  • Author Footnotes
    1 Denotes equal contribution.

      Highlights

      • Coronavirus disease 2019 (COVID-19) has had a devastating and disproportionate impact on the elderly populations in terms of excess hospitalizations and deaths.
      • The detrimental impact goes beyond higher clinical risk, which could be explained by several underlying biological pathways.
      • These impacts also include widening of the existing global health disparities, and enhancement of social and economic vulnerabilities among older adults.
      • As the global population continues to age, elderly-focused health services should be integrated into the global health systems and global strategies.
      • Such reforms are particularly warranted in low- and middle-income settings with historically underfunded public health infrastructure and insufficient elderly care.

      Abstract

      The coronavirus disease 2019 (COVID-19) pandemic has had a devastating and disproportionate impact on the elderly population. As the virus has swept through the world, already vulnerable elderly populations worldwide have faced a far greater burden of deaths and severe disease, crippling isolation, widespread societal stigma, and wide-ranging practical difficulties in maintaining access to basic health care and social services – all of which have had significant detrimental effects on their mental and physical wellbeing. In this paper, we present an overview of aging and COVID-19 from the interrelated perspectives of underlying biological mechanisms, physical manifestations, societal aspects, and health services related to the excess risk observed among the elderly population. We conclude that to tackle future pandemics in an efficient manner, it is essential to reform national health systems and response strategies from an age perspective. As the global population continues to age, elderly-focused health services should be integrated into the global health systems and global strategies, especially in low- and middle-income countries with historically underfunded public health infrastructure and insufficient gerontological care.

      Keywords

      1. Introduction

      Age plays a crucial role in affecting population health and the coronavirus disease 2019 (COVID-19) pandemic was no exception. The pandemic, for instance, had a particularly devastating impact on elderly populations, making them the most vulnerable population group and producing the worst disease outcome estimates compared to any other age group. As the virus swept through the world, elderly populations bore an enormous burden of hospitalizations, severe health complications, and excess deaths [
      • CDC
      Risk for COVID-19 infection, hospitalization, and death by age group.
      ]. Currently, the COVID-19 infection incidence rates remain fairly similar among all adult age groups worldwide. However, compared to the 18–29 year reference age group, hospitalization rates are 5 and 10 times higher in the 65–74 year and 85+ year age groups, respectively. In similar comparisons of case fatality rates, people in the 65–74 year and 85+ year age groups are 65 and 340 times more likely to die due to COVID-19, respectively [
      • CDC
      Risk for COVID-19 infection, hospitalization, and death by age group.
      ], highlighting the disproportionately high impact on the elderly populations.
      These enormous increases in disease severity, hospitalizations, and an astronomical rise in the mortality rates among elderly populations, observed during the COVID-19 pandemic globally, warrant urgent attention of the scientific community to: 1) better characterize the underlying biological, social, and structural pathways that may have caused this respiratory pathogen to enact such extraordinary adverse clinical impacts on the elderly, and 2) use these insights in informing preventative and healthcare strategies. These assessments are also critical given the increasing trend of life expectancy globally: over 727.6 million people aged over 65 years and almost 146 million over 80 years in 2020, with these numbers expected to double by 2050, and gradually reaching 2.5 billion by 2100 [
      • D. of E
      • S. Affairs
      World Population Prospects 2019.
      ]. Such unprecedented and accelerated growth in human population is likely to have tremendous detrimental impacts on the global disease burden and global healthcare systems (some of these phenomena have already been observed during the current pandemic).
      In this respect, we present a broad overview of COVID-19 and aging from the interrelated perspectives of underlying biological mechanisms, physical manifestations, societal aspects, and health services with a particular focus on the elderly population.

      2. Methods

      We have conducted a targeted literature review, which is meant to be an informative, rather than all-encompassing, rapid review of the literature on a given topic. Our approach, therefore, involved an in-depth, however, non-systematic literature review of the literature, and followed by an informed selection of relevant, current and high-quality articles on the relevant topics of interest to be cited.
      First, we searched PubMed electronic database to systematically identify relevant scientific publications (of interventional and observational studies) and systematic reviews, which had investigated or addressed COVID-19 health outcomes in the specific context of elderly populations globally. We applied no date or language restrictions, and used the MeSH terms and free text words (where appropriate) related to ‘adult’, ‘middle aged “aged”’, ‘coronavirus disease’, ‘post-acute COVID-19 syndrome’, ‘immune system’, ‘sex’, ‘social isolation’, ‘social stigma’, ‘mental health’, and ‘aging’. Second, To complement our review of the scientific literature, we conducted a supplementary search, based on the same search strategy and by using a benchmark search engine (the Google Search) to identify relevant media reports and regional guidelines on the topic.
      We have summarized data from studies reporting biologic, social and healthcare potential determinants of PACS in the elderly in Table 1 and Fig. 1.
      Table 1Characteristics of the main studies used in this targeted literature review.
      Author/journalMonth/year of publicationLocationStudy designStudy population/scopeAnalytical strategyKey findings
      Zhou, et al. Lancet.03/2020Wuhan, ChinaRetrospective cohort191 adult inpatients with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary HospitalUnivariable and multivariable logistic regression to explore the risk factors associated with in-hospital death.Increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95 % CI 1·03–1·17; p = 0·0043)
      Cohen et al. BMJ02/2022USARetrospective cohort87,337 adults aged ≥65 years after the acute phase of SARS-CoV-2 infection, UnitedHealth Group Clinical Research DatabasePropensity score matching with 2019 and 2020 controls11 % excess risk for persistent and new sequelae in adults aged ≥65 years after acute infection with SARS-CoV-2.
      Salimi & Hamlin. J Gerontol A Biol Sci Med Sci06/2020USANarrative reviewThe potential roles of the hallmarks of aging, coupled with host–coronavirus interactionsDescriptive mechanistic studiesOlder adults have developed more severe and critical complications, and therefore are at higher mortality risk. Both the incidence and severity of disease appear to be more prominent in men than women, which can be partially explained by both age-dependent and -independent sex dimorphism in the immune system
      Akbar & Gilroy. Science07/2020UKPerspectiveSenescent immune system and inflammagingView pointThe effective treatment of COVID-19 patients may require a combination of anti-inflammatory and antiviral regimes to complement vaccination against the virus
      Al-Aly et al. Nature06/2021USACohort5,808,018 participants from the US Veterans Affairs electronic Healthcare databaserisk of health resource use and death, and the risk of each diagnosis, medication use, and laboratory abnormalityA substantial burden of health loss that spans pulmonary and several extrapulmonary organ systems is experienced by patients who survive after the acute phase of COVID-19
      Scully et al. Nat Rev. Immunol06/2020SpainRetrospective cohort1969 individuals (age: 61, SD: 16 years, 46.4 % women) were assessed 8.4 months after dischargeAdjusted multivariate logistic regressionsFemale sex was a risk factor for the development of some long-term post-COVID symptoms including mood disorders
      Sirin et al. Int J Geriatr Psychiatry11/2021Turkey278 participants aged 65 or older.Quantitative, qualitative mixed-method study using an online questionnaireDuring the pandemic, social isolation and lockdown for elderly people make serious risk factor for their mental well-being
      Liu et al. J Geriatr Psychiatry Neurol03/2022ChinaMulticenter observational study1063 inpatients from four major tertiary psychiatric hospitals in ChinaMultiple logistic regression analysisSuicidality was common in older patients with clinically stable psychiatric disorders during the COVID-19 pandemic.
      Mustaffa et al. J Glob Health12/2020MalaysiaObservational data from e the Department of Statistics, MalaysiaNational Malaysian COVID-19 statisticsDescriptive cases, deaths and population at riskThe elderly in Malaysia, as in other parts of the world are especially susceptible to the adverse effects of COVID-19; identifying and properly addressing health-related issues are important to ensure optimal outcomes
      Fhon et al. Rev. Lat Am Enfermagem11/2020Brazil and PeruDocumentary, retrospective, descriptive and exploratory research.4220 newspaper articles identifiedThe data were collected from articles published on open-access websitesThe health systems need to reorganize for care to the global population, especially the elderly, considering their weaknesses and also the lack of prior professional training to offer care to this population.
      Zaman and Rahman.05/2020BangladeshEditorialNational databasePoint-of-view“It was as if corona patients were personifications of the unknown fear and needed to be punished.”
      Fig. 1
      Fig. 1A summary of the inter-related roles of biology, physical wellbeing, social norms and health systems in elderly.

      2.1 Possible mechanistic pathways for excess risk among the elderly

      Age played a significant role in COVID-19 moderate and severe cases of a complex pulmonary distress syndrome that could evolve into a multi-organ systemic dysfunction [
      • Zhou F.
      • Yu T.
      • Du R.
      • Fan G.
      • Liu Y.
      • Liu Z.
      • Xiang J.
      • Wang Y.
      • Song B.
      • Gu X.
      • Guan L.
      • Wei Y.
      • Li H.
      • Wu X.
      • Xu J.
      • Tu S.
      • Zhang Y.
      • Chen H.
      • Cao B.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
      ], and the disproportionally high morbidity and mortality are documented among people aged 65+ years worldwide. The more significant burden of post-COVID condition [
      • Cohen K.
      • Ren S.
      • Heath K.
      • Dasmariñas M.C.
      • Jubilo K.G.
      • Guo Y.
      • Lipsitch M.
      • Daugherty S.E.
      Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.
      ] on survivors was seen among the elderly population.
      From a biological perspective, the aging process is marked by a shift in the immune system works, which partly explains the increased morbidity and mortality of the elderly [
      • Salimi S.
      • Hamlyn J.M.
      • Le Couteur D.
      COVID-19 and crosstalk with the hallmarks of aging.
      ]. The immune senescence in older patients with COVID-19 can increase the risk for severe cases by three main mechanisms. First, an increased number of senescent cells at infection leads to a sequence of senescent secretory events [
      • Akbar A.N.
      • Gilroy D.W.
      Aging immunity may exacerbate COVID-19.
      ]. Second, older cells and tissues have a decreased damage repair capacity [
      • Nehme J.
      • Borghesan M.
      • Mackedenski S.
      • Bird T.G.
      • Demaria M.
      Cellular senescence as a potential mediator of COVID-19 severity in the elderly.
      ]. These aspects became crucial within the COVID-19 pandemics since SARS-CoV-2 is a virus that triggers an exacerbated innate immune response and depends on the organism's competence in shifting from intrinsic to an adaptive response to be effectively neutralized [
      • Pirabe A.
      • Heber S.
      • Schrottmaier W.C.
      • Schmuckenschlager A.
      • Treiber S.
      • Pereyra D.
      • Santol J.
      • Pawelka E.
      • Traugott M.
      • Schörgenhofer C.
      • Seitz T.
      • Karolyi M.
      • Jilma B.
      • Resch U.
      • Zoufaly A.
      • Assinger A.
      Age related differences in monocyte subsets and cytokine pattern during acute COVID-19-a prospective observational longitudinal study.
      ].
      Third, the process of so-called “inflammaging” where well-controlled metabolic processes in young individuals progressively and chronically generate detrimental cytokines, oxidative reactive species (ROS) upregulating the innate immune response [
      • Cunha L.L.
      • Perazzio S.F.
      • Azzi J.
      • Cravedi P.
      • Riella L.V.
      Remodeling of the immune response with aging: immunosenescence and its potential impact on COVID-19 immune response.
      ], leading to the attenuated interferon response. In young individuals, the innate immune system maintains the stress generated by the oxidative metabolism, but as aging progresses, the body's ability to sustain this eustress level reduces. Oxidative metabolism starts to chronically trigger inflammatory and innate immune responses activating IL-1β and NF-κB inflammatory pathways, described as inflammaging [
      • Zuo L.
      • Prather E.R.
      • Stetskiv M.
      • Garrison D.E.
      • Meade J.R.
      • Peace T.I.
      • Zhou T.
      Inflammaging and oxidative stress in human diseases: from molecular mechanisms to novel treatments.
      ]. COVID-19 promotes age-induced immune cell polarization and gene expression related to inflammation and cellular senescence [
      • Zheng Y.
      • Liu X.
      • Le W.
      • Xie L.
      • Li H.
      • Wen W.
      • Wang S.
      • Ma S.
      • Huang Z.
      • Ye J.
      • Shi W.
      • Ye Y.
      • Liu Z.
      • Song M.
      • Zhang W.
      • Han J.D.J.
      • Belmonte J.C.I.
      • Xiao C.
      • Qu J.
      • Wang H.
      • Liu G.H.
      • Su W.
      A human circulating immune cell landscape in aging and COVID-19.
      ]. Overall, aging appears to significantly influence the biological mechanisms through which SARs-CoV2 affects immune regulation.

      2.2 Long term consequences of COVID-19 among survivors

      There is a scarcity of studies that focus on the potential burden of the post-acute COVID syndrome (PACS) in populations over 65 years of age. In a systematic review that included 45 studies reporting frequency and variety of persistent symptoms after COVID-19 infection [
      • Nasserie T.
      • Hittle M.
      • Goodman S.N.
      Assessment of the frequency and variety of persistent symptoms among patients with COVID-19: a systematic review.
      ], only two studies reported a median age above 65 years, representing 1,9 % of the included population [
      • Halpin S.J.
      • McIvor C.
      • Whyatt G.
      • Adams A.
      • Harvey O.
      • McLean L.
      • Walshaw C.
      • Kemp S.
      • Corrado J.
      • Singh R.
      • Collins T.
      • O’Connor R.J.
      • Sivan M.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      ,
      • Taboada M.
      • Moreno E.
      • Cariñena A.
      • Rey T.
      • Pita-Romero R.
      • Leal S.
      • Sanduende Y.
      • Rodríguez A.
      • Nieto C.
      • Vilas E.
      • Ochoa M.
      • Cid M.
      • Seoane-Pillado T.
      Quality of life, functional status, and persistent symptoms after intensive care of COVID-19 patients.
      ]. Both studies looked at the severe form of COVID-19 and reported fatigue, breathlessness, and psychological distress as the most prevalent persistent symptoms, with significant impacts on functionality, independence, and cognitive function. Recently, extensive American medical databases have been analyzed, and when COVID-19 adult patients were compared to contemporary, historical, and other viral lower respiratory tract illness controls, matched by age and sociodemographic factors, those infected with SARS-CoV-2 presented an excess risk of 11 % for one or more persistent symptoms that required medical attention [
      • Halpin S.J.
      • McIvor C.
      • Whyatt G.
      • Adams A.
      • Harvey O.
      • McLean L.
      • Walshaw C.
      • Kemp S.
      • Corrado J.
      • Singh R.
      • Collins T.
      • O’Connor R.J.
      • Sivan M.
      Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
      ]. Moreover, six months following the infection, an excess risk of chronic respiratory failure, cardiac rhythm disorders, acute coronary syndromes, hypercoagulability, encephalopathy, dementia, memory difficulties, stroke, kidney injury, diabetes, and anemia have been reported (potentially increasing the burden on individuals and on the health care with increased outpatient encounters, exams and hospitalizations) [
      • Cohen K.
      • Ren S.
      • Heath K.
      • Dasmariñas M.C.
      • Jubilo K.G.
      • Guo Y.
      • Lipsitch M.
      • Daugherty S.E.
      Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.
      ,
      • Al-Aly Z.
      • Xie Y.
      • Bowe B.
      High-dimensional characterization of post-acute sequelae of COVID-19.
      ]. A prospective analysis from the REACT-2 program, using linkage data from the National Health Services (NHS) in the United Kingdom showed that being over 65 years was the most significant and independent contributor to persistent symptoms identified [
      • Whitaker M.
      • Elliott J.
      • Chadeau-hyam M.
      • Riley S.
      • Darzi A.
      Persistent COVID-19 symptoms in a community study of 606,434 people in England.
      ].
      Therefore, taken together, the exact effects of cellular senescence on several physiological systems (such as immune system disbalance), coupled with respiratory system impairment, markedly decreased lung cells regenerative capacity, increased pro-fibrotic mediators, and increased vascular dysfunction, explain a significant part of the risk for developing severe COVID-19 and could also explain longer-lasting symptoms among the elderly.

      2.3 The roles of sex differential and gender norms on Covid-19

      Age and societal inequities (e.g., in healthcare access and socioeconomic circumstances) among populations may influence COVID-19 outcomes [
      • Brakefield W.S.
      • Olusanya O.A.
      • White B.
      • Shaban-Nejad A.
      Social determinants and indicators of COVID-19 among marginalized communities: a scientific review and call to action for pandemic response and recovery, disaster med.
      ], and it is possible that gender norms may further widen these disparities among the elderly. Initial reports indicated that 60 % of all COVID-19 patients were men, who were also at higher risk of developing systemic inflammation, multi-organ dysfunction, and cardiac injury, with viral shedding longer than women on average [
      • Kopel J.
      • Perisetti A.
      • Roghani A.
      • Aziz M.
      • Gajendran M.
      • Goyal H.
      Racial and gender-based differences in COVID-19.
      ]. Even though increased mortality rates in men could reflect possible differences in sanitary behavior and unequal access to testing across countries [
      • Jin J.M.
      • Bai P.
      • He W.
      • Wu F.
      • Liu X.F.
      • Han D.M.
      • Liu S.
      • Yang J.K.
      Gender differences in patients with COVID-19: focus on severity and mortality.
      ], the severity and mortality rates were far worse among men than women in almost all countries globally [
      • Scully E.P.
      • Haverfield J.
      • Ursin R.L.
      • Tannenbaum C.
      • Klein S.L.
      Considering how biological sex impacts immune responses and COVID-19 outcomes.
      ]. Additionally, there may be some mechanistic explanations for the sex differences observed in disease severity and case fatality. For example, while estrogen has been known to trigger an immune response, by contrast, testosterone shows immunosuppressive functions by reducing cytokine production and higher levels of innate immune cytokines associated with acute-phase deterioration in female patients [
      • Takahashi T.
      • Ellingson M.K.
      • Wong P.
      • Israelow B.
      • Lucas C.
      • Klein J.
      • Silva J.
      • Mao T.
      • Oh J.E.
      • Tokuyama M.
      • Lu P.
      • Venkataraman A.
      • Park A.
      • Liu F.
      • Meir A.
      • Sun J.
      • Wang E.Y.
      • Casanovas-Massana A.
      • Wyllie A.L.
      • Vogels C.B.F.
      • Earnest R.
      • Lapidus S.
      • Ott I.M.
      • Moore A.J.
      • Anastasio K.
      • Askenase M.H.
      • Batsu M.
      • Beatty H.
      • Bermejo S.
      • Bickerton S.
      • Brower K.
      • Bucklin M.L.
      • Cahill S.
      • Campbell M.
      • Cao Y.
      • Courchaine E.
      • Datta R.
      • DeIuliis G.
      • Geng B.
      • Glick L.
      • Handoko R.
      • Kalinich C.
      • Khoury-Hanold W.
      • Kim D.
      • Knaggs L.
      • Kuang M.
      • Kudo E.
      • Lim J.
      • Linehan M.
      • Lu-Culligan A.
      • Malik A.A.
      • Martin A.
      • Matos I.
      • McDonald D.
      • Minasyan M.
      • Mohanty S.
      • Muenker M.C.
      • Naushad N.
      • Nelson A.
      • Nouws J.
      • Nunez-Smith M.
      • Obaid A.
      • Ott I.
      • Park H.J.
      • Peng X.
      • Petrone M.
      • Prophet S.
      • Rahming H.
      • Rice T.
      • Rose K.A.
      • Sewanan L.
      • Sharma L.
      • Shepard D.
      • Silva E.
      • Simonov M.
      • Smolgovsky M.
      • Song E.
      • Sonnert N.
      • Strong Y.
      • Todeasa C.
      • Valdez J.
      • Velazquez S.
      • Vijayakumar P.
      • Wang H.
      • Watkins A.
      • White E.B.
      • Yang Y.
      • Shaw A.
      • Fournier J.B.
      • Odio C.D.
      • Farhadian S.
      • Dela Cruz C.
      • Grubaugh N.D.
      • Schulz W.L.
      • Ring A.M.
      • Ko A.I.
      • Omer S.B.
      • Iwasaki A.
      Sex differences in immune responses that underlie COVID-19 disease outcomes.
      ]. Furthermore, ACE2 Angiotensin Converting Enzyme 2 (ACE2), a gene coded in the X chromosome, also interferes with interferon regulation by estrogens in different tissues [
      • Aksoyalp Z.Ş.
      • Nemutlu-Samur D.
      Sex-related susceptibility in coronavirus disease 2019 (COVID-19): proposed mechanisms.
      ,
      • Ferretti V.V.
      • Klersy C.
      • Bruno R.
      • Cutti S.
      • Nappi R.E.
      Men with COVID-19 die. Women survive.
      ]. Finally, SARS-CoV-2 entry in cells has shown to be enhanced by cellular transmembrane serine protease 2 (TMPRSS2), which primes the spike protein of the virus and is regulated by androgen receptor signaling [
      • Jin J.M.
      • Bai P.
      • He W.
      • Wu F.
      • Liu X.F.
      • Han D.M.
      • Liu S.
      • Yang J.K.
      Gender differences in patients with COVID-19: focus on severity and mortality.
      ]. These biological explanations also align well with previous observations that women are less susceptible to severe forms of infection than men due to their somewhat superior immune responses [
      • Ferretti V.V.
      • Klersy C.
      • Bruno R.
      • Cutti S.
      • Nappi R.E.
      Men with COVID-19 die. Women survive.
      ].
      In addition, studies looking at the post-acute sequelae of COVID-19 have reported a significantly higher sex difference for respiratory failure and acute kidney injury risk [
      • Cohen K.
      • Ren S.
      • Heath K.
      • Dasmariñas M.C.
      • Jubilo K.G.
      • Guo Y.
      • Lipsitch M.
      • Daugherty S.E.
      Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.
      ]. It is unclear to what extent the historical gaps in access to health care and generally higher prevalence of risk factors in postmenopausal women will impact long-term COVID-19 sequelae. One recent study, based on a large prospective cohort of hospitalized COVID-19 patients in Spain [
      • Fernández-De-las-peñas C.
      • Martín-Guerrero J.D.
      • Pellicer-Valero Ó.J.
      • Navarro-Pardo E.
      • Gómez-Mayordomo V.
      • Cuadrado M.L.
      • Arias-Navalón J.A.
      • Cigarán-Méndez M.
      • Hernández-Barrera V.
      • Arendt-Nielsen L.
      Female sex is a risk factor associated with long-term post-COVID related-symptoms but not with COVID-19 symptoms: the LONG-COVID-EXP-CM multicenter study.
      ], showed that female participants reported more post-COVID symptoms, including anxiety, depression, or poor sleep quality, eight months after hospital discharge than males. However, more studies would be needed to replicate these findings since systematic differences in self-reported systems can be distorted by between-individual differences (such as gender norms).

      2.4 Social stigma, social isolation, and mental health

      The sufferings of the older adults started with the start of the endemic, deteriorated with the intensification of the non-pharmacological social distancing measures such as strict generalized lockdowns, and stayed even when the pandemic started to recede. The elderly became victims of infodemic and negative news overdose. A mixed-methods study from Turkey revealed that the average time the elderly spent following news regarding COVID-19 on TV or social media was 2.74 h/day. It increased the odds of generalized anxiety disorder by a factor of 1.188 [
      • Sirin H.
      • Ahmadi A.A.
      • Ketrez G.
      • Ozbeyaz C.
      • Dikmen A.U.
      • Ozkan S.
      Assessment of anxiety in elderly population during the COVID-19 pandemic and the impact of compulsory home-stay in the central districts of Ankara, Turkey: a quantitative, qualitative mixed method study.
      ]. The news of their being at higher risk of getting infected was interpreted differently by their family members. Some thought the elderly were the source of infection or a potential conduit for the virus to enter the household. Such misperceptions caused severe stigma against the elderly worldwide.
      For instance, in Bangladesh, some family members deserted their elderly family members in the jungle [
      • Zaman S.
      • Sumon R.
      Fear and Stigma in the Context of Corona Epidemic in Bangladesh, Prothom Alo.
      ], whereas the elderly suffered domestic violence in parts of South America [
      • Calleja-Agius J.
      • Calleja N.
      Domestic violence among the elderly during the COVID-19 pandemic.
      ]. For a long time since the onset of the pandemic, however, these issues remained largely ignored in the mainstream academic discussion regarding the impact of the pandemic. Additionally, as the global health systems were almost exclusively unprepared to deal with widespread social stigma [
      • Van Daalen K.R.
      • Cobain M.
      • Franco O.H.
      • Chowdhury R.
      Stigma: the social virus spreading faster than COVID-19.
      ], or the consequent violence against the elderly, there was hardly any timely remedy to these problems. When the generalized lockdown started, many elderly people suddenly found themselves in a far more isolated circumstance than what they were already experiencing. Overwhelming evidence soon emerged from numerous studies based on middle and high-income countries worldwide indicating a deterioration of mental health, physical health, quality of life, and general wellbeing among the elderly amidst strict lockdown [
      • Sirin H.
      • Ahmadi A.A.
      • Ketrez G.
      • Ozbeyaz C.
      • Dikmen A.U.
      • Ozkan S.
      Assessment of anxiety in elderly population during the COVID-19 pandemic and the impact of compulsory home-stay in the central districts of Ankara, Turkey: a quantitative, qualitative mixed method study.
      ,
      • Llorente-Barroso C.
      • Kolotouchkina O.
      • Mañas-Viniegra L.
      The enabling role of ict to mitigate the negative effects of emotional and social loneliness of the elderly during covid-19 pandemic.
      ]. The inability of the immediate family members to visit led to alienation and psychological breakdown [
      • Sirin H.
      • Ahmadi A.A.
      • Ketrez G.
      • Ozbeyaz C.
      • Dikmen A.U.
      • Ozkan S.
      Assessment of anxiety in elderly population during the COVID-19 pandemic and the impact of compulsory home-stay in the central districts of Ankara, Turkey: a quantitative, qualitative mixed method study.
      ,
      • Zaman S.
      • Sumon R.
      Fear and Stigma in the Context of Corona Epidemic in Bangladesh, Prothom Alo.
      ,
      • Llorente-Barroso C.
      • Kolotouchkina O.
      • Mañas-Viniegra L.
      The enabling role of ict to mitigate the negative effects of emotional and social loneliness of the elderly during covid-19 pandemic.
      ], and in some cases, suicide [
      • Syrioti S.
      Letter to the editor.
      ,
      • Liu R.
      • Xu X.
      • Zou S.
      • Li Y.
      • Wang H.
      • Yan X.
      • Du X.
      • Zhang L.
      • Zhang Q.
      • Li W.
      • Cheung T.
      • Ungvari G.S.
      • Ng C.H.
      • Xiang Y.T.
      Prevalence of suicidality and its association with quality of life in older patients with clinically stable psychiatric disorders in China during the COVID-19 pandemic.
      ].

      2.5 Physical wellbeing

      The isolation that ensued following generalized lockdown also impacted the physical well-being of the elderly. A systematic review of 14 cross-sectional and 11 cohort studies revealed that COVID-19 movement restrictions reduced physical activity due to increased sitting time, increased equivalent metabolic tasks, decreased steps, and reduced exercise frequency and duration [
      • Oliveira M.R.
      • Sudati I.P.
      • Konzen V.D.M.
      • de Campos A.C.
      • Wibelinger L.M.
      • Correa C.
      • Miguel F.M.
      • Silva R.N.
      • Borghi-Silva A.
      Covid-19 and the impact on the physical activity level of elderly people: a systematic review.
      ]; these may eventually result in reduced musculoskeletal strength and endurance and cardiorespiratory capacity. Increased sedentary behavior is also associated with high blood pressure, and cardiovascular and metabolic diseases [
      • Chowdhury R.
      • van Daalen K.R.
      • Franco O.H.
      Cardiometabolic health: key in reducing adverse COVID-19 outcomes.
      ], among others. Several other studies from the Netherlands [
      • Pérez-Ros P.
      • Martínez-Arnau F.M.
      • Orti-Lucas R.M.
      • Tarazona-Santabalbina F.J.
      A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults.
      ], France [
      • Chambonniere C.
      • Lambert C.
      • Tardieu M.
      • Fillon A.
      • Genin P.
      • Larras B.
      • Melsens P.
      • Baker J.S.
      • Pereira B.
      • Tremblay A.
      • Thivel D.
      • Duclos M.
      Physical activity and sedentary behavior of elderly populations during confinement: results from the FRENCH COVID-19 ONAPS survey.
      ], Turkey [
      • Sirin H.
      • Ahmadi A.A.
      • Ketrez G.
      • Ozbeyaz C.
      • Dikmen A.U.
      • Ozkan S.
      Assessment of anxiety in elderly population during the COVID-19 pandemic and the impact of compulsory home-stay in the central districts of Ankara, Turkey: a quantitative, qualitative mixed method study.
      ], China [
      • Wang Y.
      • Zhang Y.
      • Bennell K.
      • White D.K.
      • Wei J.
      • Wu Z.
      • He H.
      • Liu S.
      • Luo X.
      • Hu S.
      • Zeng C.
      • Lei G.
      Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
      ], and Japan [
      • Yamada M.
      • Kimura Y.
      • Ishiyama D.
      • Otobe Y.
      • Suzuki M.
      • Koyama S.
      • Kikuchi T.
      • Kusumi H.
      • Arai H.
      The influence of the COVID-19 pandemic on physical activity and new incidence of frailty among initially non-frail older adults in Japan: a follow-up online survey.
      ] also reported a sharp decline in physical activity among the elderly during the COVID-19 confinement. The elderly are prone to developing sarcopenia, cardiometabolic disorders, and other comorbidities [
      • Roschel H.
      • Artioli G.G.
      • Gualano B.
      Risk of increased physical inactivity during COVID-19 outbreak in older people: a call for actions.
      ]. All of these may lead to functional decline, culminating in limitations in daily life and an increased risk of falls [
      • Pérez-Ros P.
      • Martínez-Arnau F.M.
      • Orti-Lucas R.M.
      • Tarazona-Santabalbina F.J.
      A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults.
      ].
      In addition to adverse health consequences of isolation and physical inactivity, an inability to access essential health care owing to service disruption further worsened the overall health condition of the elderly. Community-bound elderly patients suffering from NCDs in China, for example, faced difficulty in collecting medicines essential to control their conditions [
      • Wu X.
      • Gong N.
      • Meng Y.
      • Zhu M.
      • Zou W.
      • Cheng Y.
      • Zhang M.
      Risk perception trajectory of elderly chronic disease patients in the community under COVID-19: a qualitative research.
      ]. Elderly patients from Argentina reported significant schedule difficulties in accessing routine consultations for chronic illnesses, palliative care, and mental health conditions [
      • Loza C.A.
      • Baez G.
      • Valverdi R.
      • Pisula P.
      • Salas Apaza J.
      • Discacciati V.
      • Granero M.
      • Pizzorno X.S.
      • Franco J.V.A.
      A qualitative study on the elderly and accessibility to health services during the COVID-19 lockdown in Buenos Aires, Argentina - part 2.
      ]. Similar reports of service disruptions emerged from Asia [
      • Mustaffa N.
      • Lee S.-Y.
      • Mohd Nawi S.N.
      • Che Rahim M.J.
      • Chee Y.C.
      • Muhd Besari A.
      • Lee Y.Y.
      COVID-19 in the elderly: a malaysian perspective.
      ], the Americas, and Europe [
      • Fhon J.R.S.
      • Silva L.M.
      • Leitón-Espinoza Z.E.
      • Matiello F.B.
      • Araujo J.S.
      • Rodrigues R.A.P.
      Hospital care for elderly COVID-19 patients.
      ]. Additionally, as the pandemic progressed, many who survived the disease eventually fell victim to PACS [
      • Cohen K.
      • Ren S.
      • Heath K.
      • Dasmariñas M.C.
      • Jubilo K.G.
      • Guo Y.
      • Lipsitch M.
      • Daugherty S.E.
      Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.
      ], creating further challenges for already struggling global health systems, especially in low- and middle-income countries (LMICs) settings.

      3. Conclusion and recommendations

      COVID-19 pandemic has demonstrated that the detrimental impact of a novel virus on elderly populations could go beyond a higher clinical risk of severe disease manifestation and hospitalization. As the world now seeks to return to normalcy, the elderly population, however, remains the ones left behind, especially in resource-limited LMIC settings where the healthcare services and social safety net are historically poor. COVID-19 pandemic may have significantly worsened the pre-existing health disparities among older adults, including access to essential preventive and curative services, and may further enhance social and economic vulnerabilities. For example, given the “new norm,” many activities have turned online, and such a rapid transition has been difficult for the elderly worldwide, who are often unfamiliar with many emerging technologies. Evidently, such lack of familiarity with the new technologies has discouraged teleconsultation, including a sense of dissatisfaction owing to the virtual nature of clinical consultations. Therefore, besides developing innovative interventions to tackle these issues, further implementation research should be conducted to assess the gaps and challenges in access, adoption, and sustainability of these measures in elderly populations. Furthermore, to tackle future pandemics efficiently, it is essential to reform national health systems with an age perspective. As the global population continues to age, elderly-focused health services should also be integrated into the global health systems and global strategies, especially in the low and middle-income countries with historically underfunded public health infrastructure and insufficient gerontological care.

      Contributors

      Cristina Baena contributed to conducting the systematic review and manuscript preparation.
      Taufique Joarder contributed to conducting the systematic review and manuscript preparation.
      Nasar U Ahmed contributed to manuscript preparation.
      Rajiv Chowdhury contributed to overall conceptualization, supervision, and manuscript preparation.

      Funding

      No funding from an external source was received for the preparation of this review.

      Provenance and peer review

      This article was commissioned and was externally peer reviewed.

      Declaration of competing interest

      The authors declare that they have no competing interest.

      References

        • CDC
        Risk for COVID-19 infection, hospitalization, and death by age group.
        Ctr. Dis. Control Prev. 2021;
        • D. of E
        • S. Affairs
        World Population Prospects 2019.
        2019
        • Zhou F.
        • Yu T.
        • Du R.
        • Fan G.
        • Liu Y.
        • Liu Z.
        • Xiang J.
        • Wang Y.
        • Song B.
        • Gu X.
        • Guan L.
        • Wei Y.
        • Li H.
        • Wu X.
        • Xu J.
        • Tu S.
        • Zhang Y.
        • Chen H.
        • Cao B.
        Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
        Lancet. 2020; 395: 1054-1062https://doi.org/10.1016/S0140-6736(20)30566-3
        • Cohen K.
        • Ren S.
        • Heath K.
        • Dasmariñas M.C.
        • Jubilo K.G.
        • Guo Y.
        • Lipsitch M.
        • Daugherty S.E.
        Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.
        BMJ. 2022; e068414https://doi.org/10.1136/bmj-2021-068414
        • Salimi S.
        • Hamlyn J.M.
        • Le Couteur D.
        COVID-19 and crosstalk with the hallmarks of aging.
        J. Gerontol. A Biol. Sci. Med. Sci. 2020; 75 (e34- e41)https://doi.org/10.1093/gerona/glaa149
        • Akbar A.N.
        • Gilroy D.W.
        Aging immunity may exacerbate COVID-19.
        Science (80-.). 2020; 369: 256-257https://doi.org/10.1126/science.abb0762
        • Nehme J.
        • Borghesan M.
        • Mackedenski S.
        • Bird T.G.
        • Demaria M.
        Cellular senescence as a potential mediator of COVID-19 severity in the elderly.
        Aging Cell. 2020; 19: 1-14https://doi.org/10.1111/acel.13237
        • Pirabe A.
        • Heber S.
        • Schrottmaier W.C.
        • Schmuckenschlager A.
        • Treiber S.
        • Pereyra D.
        • Santol J.
        • Pawelka E.
        • Traugott M.
        • Schörgenhofer C.
        • Seitz T.
        • Karolyi M.
        • Jilma B.
        • Resch U.
        • Zoufaly A.
        • Assinger A.
        Age related differences in monocyte subsets and cytokine pattern during acute COVID-19-a prospective observational longitudinal study.
        Cells. 2021; 10https://doi.org/10.3390/CELLS10123373
        • Cunha L.L.
        • Perazzio S.F.
        • Azzi J.
        • Cravedi P.
        • Riella L.V.
        Remodeling of the immune response with aging: immunosenescence and its potential impact on COVID-19 immune response.
        Front. Immunol. 2020; 11: 1748https://doi.org/10.3389/fimmu.2020.01748
        • Zuo L.
        • Prather E.R.
        • Stetskiv M.
        • Garrison D.E.
        • Meade J.R.
        • Peace T.I.
        • Zhou T.
        Inflammaging and oxidative stress in human diseases: from molecular mechanisms to novel treatments.
        Int. J. Mol. Sci. 2019; 20 (20 (2019) 4472): 4472https://doi.org/10.3390/IJMS20184472
        • Zheng Y.
        • Liu X.
        • Le W.
        • Xie L.
        • Li H.
        • Wen W.
        • Wang S.
        • Ma S.
        • Huang Z.
        • Ye J.
        • Shi W.
        • Ye Y.
        • Liu Z.
        • Song M.
        • Zhang W.
        • Han J.D.J.
        • Belmonte J.C.I.
        • Xiao C.
        • Qu J.
        • Wang H.
        • Liu G.H.
        • Su W.
        A human circulating immune cell landscape in aging and COVID-19.
        Protein Cell. 2020; 11: 740-770https://doi.org/10.1007/s13238-020-00762-2
        • Nasserie T.
        • Hittle M.
        • Goodman S.N.
        Assessment of the frequency and variety of persistent symptoms among patients with COVID-19: a systematic review.
        JAMA Netw. Open. 2021; 4https://doi.org/10.1001/jamanetworkopen.2021.11417
        • Halpin S.J.
        • McIvor C.
        • Whyatt G.
        • Adams A.
        • Harvey O.
        • McLean L.
        • Walshaw C.
        • Kemp S.
        • Corrado J.
        • Singh R.
        • Collins T.
        • O’Connor R.J.
        • Sivan M.
        Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.
        J. Med. Virol. 2021; 93: 1013-1022https://doi.org/10.1002/jmv.26368
        • Taboada M.
        • Moreno E.
        • Cariñena A.
        • Rey T.
        • Pita-Romero R.
        • Leal S.
        • Sanduende Y.
        • Rodríguez A.
        • Nieto C.
        • Vilas E.
        • Ochoa M.
        • Cid M.
        • Seoane-Pillado T.
        Quality of life, functional status, and persistent symptoms after intensive care of COVID-19 patients.
        Br. J. Anaesth. 2021; 126: e110-e113https://doi.org/10.1016/j.bja.2020.12.007
        • Al-Aly Z.
        • Xie Y.
        • Bowe B.
        High-dimensional characterization of post-acute sequelae of COVID-19.
        Nature. 2021; 594: 259-264https://doi.org/10.1038/s41586-021-03553-9
        • Whitaker M.
        • Elliott J.
        • Chadeau-hyam M.
        • Riley S.
        • Darzi A.
        Persistent COVID-19 symptoms in a community study of 606,434 people in England.
        Nat. Commun. 2021; : 1-10
        • Brakefield W.S.
        • Olusanya O.A.
        • White B.
        • Shaban-Nejad A.
        Social determinants and indicators of COVID-19 among marginalized communities: a scientific review and call to action for pandemic response and recovery, disaster med.
        Public Health Prep. 2022; : 1-28https://doi.org/10.1017/dmp.2022.104
        • Kopel J.
        • Perisetti A.
        • Roghani A.
        • Aziz M.
        • Gajendran M.
        • Goyal H.
        Racial and gender-based differences in COVID-19.
        Front. Public Health. 2020; 8: 1-8https://doi.org/10.3389/fpubh.2020.00418
        • Jin J.M.
        • Bai P.
        • He W.
        • Wu F.
        • Liu X.F.
        • Han D.M.
        • Liu S.
        • Yang J.K.
        Gender differences in patients with COVID-19: focus on severity and mortality.
        Front. Public Health. 2020; 8: 1-6https://doi.org/10.3389/fpubh.2020.00152
        • Scully E.P.
        • Haverfield J.
        • Ursin R.L.
        • Tannenbaum C.
        • Klein S.L.
        Considering how biological sex impacts immune responses and COVID-19 outcomes.
        Nat. Rev. Immunol. 2020; 20: 442-447https://doi.org/10.1038/s41577-020-0348-8
        • Takahashi T.
        • Ellingson M.K.
        • Wong P.
        • Israelow B.
        • Lucas C.
        • Klein J.
        • Silva J.
        • Mao T.
        • Oh J.E.
        • Tokuyama M.
        • Lu P.
        • Venkataraman A.
        • Park A.
        • Liu F.
        • Meir A.
        • Sun J.
        • Wang E.Y.
        • Casanovas-Massana A.
        • Wyllie A.L.
        • Vogels C.B.F.
        • Earnest R.
        • Lapidus S.
        • Ott I.M.
        • Moore A.J.
        • Anastasio K.
        • Askenase M.H.
        • Batsu M.
        • Beatty H.
        • Bermejo S.
        • Bickerton S.
        • Brower K.
        • Bucklin M.L.
        • Cahill S.
        • Campbell M.
        • Cao Y.
        • Courchaine E.
        • Datta R.
        • DeIuliis G.
        • Geng B.
        • Glick L.
        • Handoko R.
        • Kalinich C.
        • Khoury-Hanold W.
        • Kim D.
        • Knaggs L.
        • Kuang M.
        • Kudo E.
        • Lim J.
        • Linehan M.
        • Lu-Culligan A.
        • Malik A.A.
        • Martin A.
        • Matos I.
        • McDonald D.
        • Minasyan M.
        • Mohanty S.
        • Muenker M.C.
        • Naushad N.
        • Nelson A.
        • Nouws J.
        • Nunez-Smith M.
        • Obaid A.
        • Ott I.
        • Park H.J.
        • Peng X.
        • Petrone M.
        • Prophet S.
        • Rahming H.
        • Rice T.
        • Rose K.A.
        • Sewanan L.
        • Sharma L.
        • Shepard D.
        • Silva E.
        • Simonov M.
        • Smolgovsky M.
        • Song E.
        • Sonnert N.
        • Strong Y.
        • Todeasa C.
        • Valdez J.
        • Velazquez S.
        • Vijayakumar P.
        • Wang H.
        • Watkins A.
        • White E.B.
        • Yang Y.
        • Shaw A.
        • Fournier J.B.
        • Odio C.D.
        • Farhadian S.
        • Dela Cruz C.
        • Grubaugh N.D.
        • Schulz W.L.
        • Ring A.M.
        • Ko A.I.
        • Omer S.B.
        • Iwasaki A.
        Sex differences in immune responses that underlie COVID-19 disease outcomes.
        Nature. 2020; 588: 315-320https://doi.org/10.1038/s41586-020-2700-3
        • Aksoyalp Z.Ş.
        • Nemutlu-Samur D.
        Sex-related susceptibility in coronavirus disease 2019 (COVID-19): proposed mechanisms.
        Eur. J. Pharmacol. 2021; 912174548https://doi.org/10.1016/j.ejphar.2021.174548
        • Ferretti V.V.
        • Klersy C.
        • Bruno R.
        • Cutti S.
        • Nappi R.E.
        Men with COVID-19 die. Women survive.
        Maturitas. 2022; 158: 34-36https://doi.org/10.1016/j.maturitas.2021.11.014
        • Fernández-De-las-peñas C.
        • Martín-Guerrero J.D.
        • Pellicer-Valero Ó.J.
        • Navarro-Pardo E.
        • Gómez-Mayordomo V.
        • Cuadrado M.L.
        • Arias-Navalón J.A.
        • Cigarán-Méndez M.
        • Hernández-Barrera V.
        • Arendt-Nielsen L.
        Female sex is a risk factor associated with long-term post-COVID related-symptoms but not with COVID-19 symptoms: the LONG-COVID-EXP-CM multicenter study.
        J. Clin. Med. 2022; 11https://doi.org/10.3390/jcm11020413
        • Sirin H.
        • Ahmadi A.A.
        • Ketrez G.
        • Ozbeyaz C.
        • Dikmen A.U.
        • Ozkan S.
        Assessment of anxiety in elderly population during the COVID-19 pandemic and the impact of compulsory home-stay in the central districts of Ankara, Turkey: a quantitative, qualitative mixed method study.
        Int. J. Geriatr. Psychiatry. 2021; 36: 1785-1794https://doi.org/10.1002/gps.5600
        • Zaman S.
        • Sumon R.
        Fear and Stigma in the Context of Corona Epidemic in Bangladesh, Prothom Alo.
        2020
        • Calleja-Agius J.
        • Calleja N.
        Domestic violence among the elderly during the COVID-19 pandemic.
        Rev. Esp. Geriatr. Gerontol. 2021; 56: 64https://doi.org/10.1016/j.regg.2020.05.002
        • Van Daalen K.R.
        • Cobain M.
        • Franco O.H.
        • Chowdhury R.
        Stigma: the social virus spreading faster than COVID-19.
        J. Epidemiol. Community Health. 2021; 75: 313-314https://doi.org/10.1136/jech-2020-214436
        • Llorente-Barroso C.
        • Kolotouchkina O.
        • Mañas-Viniegra L.
        The enabling role of ict to mitigate the negative effects of emotional and social loneliness of the elderly during covid-19 pandemic.
        Int. J. Environ. Res. Public Health. 2021; 18https://doi.org/10.3390/ijerph18083923
        • Syrioti S.
        Letter to the editor.
        Turk. Med. Student J. 2020; 7: 41-42https://doi.org/10.4274/tmsj.galenos.2020.07.01.08
        • Liu R.
        • Xu X.
        • Zou S.
        • Li Y.
        • Wang H.
        • Yan X.
        • Du X.
        • Zhang L.
        • Zhang Q.
        • Li W.
        • Cheung T.
        • Ungvari G.S.
        • Ng C.H.
        • Xiang Y.T.
        Prevalence of suicidality and its association with quality of life in older patients with clinically stable psychiatric disorders in China during the COVID-19 pandemic.
        J. Geriatr. Psychiatry Neurol. 2022; 35: 237-244https://doi.org/10.1177/08919887221078557
        • Oliveira M.R.
        • Sudati I.P.
        • Konzen V.D.M.
        • de Campos A.C.
        • Wibelinger L.M.
        • Correa C.
        • Miguel F.M.
        • Silva R.N.
        • Borghi-Silva A.
        Covid-19 and the impact on the physical activity level of elderly people: a systematic review.
        Exp. Gerontol. 2022; 159https://doi.org/10.1016/j.exger.2021.111675
        • Chowdhury R.
        • van Daalen K.R.
        • Franco O.H.
        Cardiometabolic health: key in reducing adverse COVID-19 outcomes.
        Glob. Heart. 2020; 15: 1-6https://doi.org/10.5334/GH.879
        • Pérez-Ros P.
        • Martínez-Arnau F.M.
        • Orti-Lucas R.M.
        • Tarazona-Santabalbina F.J.
        A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults.
        Braz. J. Phys. Ther. 2019; 23: 19-26https://doi.org/10.1016/j.bjpt.2018.05.005
        • Chambonniere C.
        • Lambert C.
        • Tardieu M.
        • Fillon A.
        • Genin P.
        • Larras B.
        • Melsens P.
        • Baker J.S.
        • Pereira B.
        • Tremblay A.
        • Thivel D.
        • Duclos M.
        Physical activity and sedentary behavior of elderly populations during confinement: results from the FRENCH COVID-19 ONAPS survey.
        Exp. Aging Res. 2021; 47: 401-413https://doi.org/10.1080/0361073X.2021.1908750
        • Wang Y.
        • Zhang Y.
        • Bennell K.
        • White D.K.
        • Wei J.
        • Wu Z.
        • He H.
        • Liu S.
        • Luo X.
        • Hu S.
        • Zeng C.
        • Lei G.
        Physical distancing measures and walking activity in middle-aged and older residents in Changsha, China, during the COVID-19 epidemic period: longitudinal observational study.
        J. Med. Internet Res. 2020; 22e21632https://doi.org/10.2196/21632
        • Yamada M.
        • Kimura Y.
        • Ishiyama D.
        • Otobe Y.
        • Suzuki M.
        • Koyama S.
        • Kikuchi T.
        • Kusumi H.
        • Arai H.
        The influence of the COVID-19 pandemic on physical activity and new incidence of frailty among initially non-frail older adults in Japan: a follow-up online survey.
        J. Nutr. Health Aging. 2021; 25: 751-756https://doi.org/10.1007/s12603-021-1634-2
        • Roschel H.
        • Artioli G.G.
        • Gualano B.
        Risk of increased physical inactivity during COVID-19 outbreak in older people: a call for actions.
        J. Am. Geriatr. Soc. 2020; 68: 1126-1128https://doi.org/10.1111/jgs.16550
        • Wu X.
        • Gong N.
        • Meng Y.
        • Zhu M.
        • Zou W.
        • Cheng Y.
        • Zhang M.
        Risk perception trajectory of elderly chronic disease patients in the community under COVID-19: a qualitative research.
        Geriatr. Nurs. 2021; 42: 1303-1308https://doi.org/10.1016/j.gerinurse.2021.09.004
        • Loza C.A.
        • Baez G.
        • Valverdi R.
        • Pisula P.
        • Salas Apaza J.
        • Discacciati V.
        • Granero M.
        • Pizzorno X.S.
        • Franco J.V.A.
        A qualitative study on the elderly and accessibility to health services during the COVID-19 lockdown in Buenos Aires, Argentina - part 2.
        Medwave. 2021; 21e8192https://doi.org/10.5867/medwave.2021.04.8192
        • Mustaffa N.
        • Lee S.-Y.
        • Mohd Nawi S.N.
        • Che Rahim M.J.
        • Chee Y.C.
        • Muhd Besari A.
        • Lee Y.Y.
        COVID-19 in the elderly: a malaysian perspective.
        J. Glob. Health. 2020; 10: 20370https://doi.org/10.7189/jogh.10.020370
        • Fhon J.R.S.
        • Silva L.M.
        • Leitón-Espinoza Z.E.
        • Matiello F.B.
        • Araujo J.S.
        • Rodrigues R.A.P.
        Hospital care for elderly COVID-19 patients.
        Rev. Lat. Am. Enfermagem. 2020; 28e3396https://doi.org/10.1590/1518-8345.4649.3396