key: cord-0692901-ypjxu266
authors: Heid, Allison R; Cartwright, Francine; Wilson-Genderson, Maureen; Pruchno, Rachel
title: Challenges Experienced by Older People During the Initial Months of the COVID-19 Pandemic
date: 2020-09-21
journal: Gerontologist
DOI: 10.1093/geront/gnaa138
sha: bfb148569afabc8a59134aa272c39fd9eccdbc48
doc_id: 692901
cord_uid: ypjxu266

BACKGROUND AND OBJECTIVES: The Coronavirus-2019 (COVID-19) pandemic has created unique stressors for older people to manage. Informed by the Stress Process Model and the Transactional Model of Stress and Coping, we examined the extent to which older people are adhering to physical distancing mandates and the pandemic-related experiences that older people find most challenging. RESEARCH DESIGN AND METHODS: From May 4 to May 17, 2020, a web-based questionnaire focused on the COVID-19 pandemic was completed by 1,272 people (aged 64+) who were part of an on-going research panel in New Jersey recruited in 2006. Frequencies for endorsement of physical distancing behaviors were tabulated and open-ended responses to the biggest challenge of the pandemic were systematically coded and classified using content analysis. RESULTS: More than 70% of participants reported adhering to physical distancing behaviors. Experiences appraised as most difficult by participants fell into eight domains: Social Relationships, Activity Restrictions, Psychological, Health, Financial, Global Environment, Death, and Home Care. The most frequently appraised challenges were constraints on social interactions (42.4%) and restrictions on activity (30.9%). DISCUSSION AND IMPLICATIONS: In the initial weeks of the pandemic, the majority of older adults reported adhering to COVID-19 physical distancing mandates and identified a range of challenging experiences. Results highlight the factors having the greatest impact on older adults, informing quantitative modeling for testing the impact of the pandemic on health and well-being outcomes and identifying how intervention efforts may be targeted to maximize the quality of life of older adults.

worship, hospitals, and doctors" offices were closed for in-person functioning except for critical-need visits. At the beginning of May 2020, people were advised to wear personal protective equipment, such as a mask, indoors and for in-person encounters when maintaining 6-feet distance from others was not possible.

People 65+ and those with serious underlying medical conditions are particularly vulnerable to the disease (CDC, 2020; Garnier-Crussard, Forestier, Gilbert, & Krolak-Salmon, 2020; Zainab et al., 2020) . As such, it is especially important that older people maintain physical distance. Editorials in both professional journals and the popular media have suggested that older people will face physical health consequences, financial challenges, isolation, and psychological distress as a result of the pandemic (Armitage & Nellums, 2020; Brooke & Jackson, 2020; Graham, 2020; Ory & Smith, 2020; Sewell, 2020; Sheffler, Joiner, & Sachs-Ericsson, 2020 ). Yet, scientific evidence reporting the experiences of older adults to date is limited. In order to understand the impact of the pandemic on older people and develop effective interventions, it is critical to understand how older people are responding to physical distancing mandates and to identify difficulties and frustrations experienced by A c c e p t e d M a n u s c r i p t older people. While older adults may also be experiencing positive effects of the pandemic, the purposes of this manuscript, informed by the Stress Process Model (Pearlin, Mullan, Semple, & Skaff, 1990 ) and the Transactional Model of Stress and Coping (Lazarus, 1993) , are to: (1) describe the extent to which older people are following guidelines regarding physical distancing and (2) identify the pandemic stressors that older people find most challenging.

The spread of COVID-19 has resulted in mandates to maintain physical distance. Physical distancing is believed to be the most effective approach for containing the virus (Flaxman et al., 2020; Hsiang et al., 2020; Lewnard & Lo, 2020) . However, questions have been raised about the short and long-term consequences that physical distancing might have on mental health and well-being, especially for older people (Galea et al., 2020) . Even before the pandemic began, a report from The National Academies of Sciences, Engineering, and Medicine (2020) concluded that social isolation (having minimal social contact) has effects on morbidity and mortality comparable to or greater than those of smoking, obesity, and physical inactivity (Holt-Lunstad et al., 2017) . For some older adults, adherence to physical and social distancing mandates may result in an increase in social isolation and such negative outcomes (Cudjoe & Kotwal, 2020) . For others, who are able to remain physically distant but find creative ways to stay socially connected, they may be able to sustain their health and well-being, as being socially connected is associated with better health and a greater likelihood of survival (Holt-Lunstad et al., 2010; Uchino, 2009a; Uchino, 2009b; Uchino, Carlisle, Birmingham, & Vaughn, 2011) .

Physical distancing mandates have the potential to fundamentally change the way older adults interact with other people and may have long-term impacts on their health and well-being. However, in order to understand these effects, it is important to have systematic empirical evidence regarding the behaviors of older adults. If physical distancing mandates have not changed the behaviors of older adults (i.e., increasing physical distancing behaviors), they may be more likely to contract COVID-19 and experience serious physical health outcomes. On the other hand, if older adults adhere to advice A c c e p t e d M a n u s c r i p t regarding physical distancing behaviors, they may experience threats to their well-being. As such, it is important to examine not only whether older people are engaging in physical distancing behaviors, but also to examine the ripple effects that physical distancing has on their lives to understand the full impact of the pandemic on short-and long-term outcomes.

The Stress Process Model (Pearlin et al., 1990) although most commonly applied in the caregiving context (Aneshensel, Pearlin, Mullan, Zarit, & Whitlatch, 1995) , can be applied here in tandem with the Transactional Model of Stress and Coping (Lazarus, 1993; Lazarus & Folkman, 1984) to understand the life course impact of a stressor, such as the COVID-19 pandemic, on older adults" well-being (Pearlin, 2010) . These theories jointly propose that a primary objective stressor affects the person through its influence on the secondary stressors a given individual experiences and appraises as challenging.

In the context of the global stressor of the COVID-19 pandemic, physical distancing mandates that require people to remain at home is defined here as an objective stressor. Thus, in order to understand the impact of the pandemic on older adults" physical and psychological well-being, it is important to first learn the extent to which older people are adhering to physical distancing mandates.

Second, to maximize understanding of the mechanisms through which the pandemic impacts older adults, it is important to identify the secondary stressors older adults experience as challenging. For example, consider two individuals -Person A and Person B. Person A typically works from home and is content with limited social contact. This person may not experience changes in lifestyle due to physical distancing mandates, and therefore not experience negative psychological effects. However, Person B typically interacts with friends daily and grandchildren weekly, and regularly engages in volunteer and other leisure activities throughout the week. For Person B, the loss of physical contact with others and activity may be experienced as stressful and upsetting. This response may then carry implications for his psychological well-being. In the context of the COVID-19 pandemic it is critical, therefore, to identify the specific difficulties individuals experience as consequences of the pandemic.

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While it is likely that many older people will identify a variety of challenges, it is also likely that some older people will not experience challenges. As hypothesized by Matthieu and Ivanoff (2006) in response to September 11 th events, it is through knowing the factors that elicit negative responses that we can then predict impacts on health outcomes in response to a global stressor or disaster. Further, by knowing the specific mechanisms of impact, we can target coping-based interventions that will address current needs of older adults.

Quantitative analyses can be used to estimate the proportion of a sample experiencing a particular phenomenon (i.e., the proportion engaging in physical distancing behaviors), while qualitative analyses can provide a greater depth of understanding of the individual experience (i.e., what the individual views as stressful). The combination of quantitative and qualitative approaches can provide a rich descriptive understanding of a phenomenon. Specifically, quantitative questions can provide systematic descriptive statistics to reference, while the analysis of open-ended data can help to build a ground-up perspective of the individual"s lived experiences, by reducing researcher bias. Such methodologies have been applied to more fully understand the impact of stressors on older adults when providing caregiving (Gaugler et al., 2018) , managing chronic illnesses (Jason & Reed, 2015; Heid et al., 2018; Liddy, Blazkho, & Mill, 2014) , or in response to a disaster (Heid, Schug, Cartwright, & Pruchno, 2017; Henderson, Roberto, & Kamo, 2010; King et al., 2015; Langan & Palmer, 2012; Miller & Brockie, 2015) .

The analyses that follow used a mixed-methods approach to examine the extent to which older adults reported adhering to physical distancing mandates in the initial weeks of the pandemic (March to May 2020) and identify the secondary aspects of the COVID-19 pandemic that older people identify as most challenging. This information is an important first step toward understanding whether the COVID-19 pandemic impacts physical and psychological well-being of older adults, the pathways M a n u s c r i p t by which the pandemic impacts outcomes, and how we can intervene effectively to support older adults.

On May 4, 2020, just weeks after the onset of the COVID-19 pandemic, we launched the seventh wave of the ORANJ BOWL (Ongoing Research on Aging in New Jersey: Bettering Opportunities for Wellness in Life) panel. We sent e-mails with a unique Qualtrics weblink to 2,811 ORANJ BOWL participants for whom we had deliverable e-mail addresses. Details regarding recruitment of the ORANJ BOWL panel are presented in Pruchno et al. (2010) .

The analyses below are based on data from 1,272 people who completed the questionnaire between May 4 and May 17, 2020. Compared with people who did not respond, people responding during the first two weeks of data collection were more likely to be women (χ 2 = 8.53, p < .01), White (χ 2 = 68.15, p < .001), married (χ 2 = 38.94, p < .001), younger (F 1, 3057 = 72.6, p < .001), have higher income (F 1, 3057 = 155.68, p < .001 ) and education (F 1, 3054 = 112.86, p < .001 ), and they were healthier (F 1, 3044 = 29.83, p < .001) at last wave of data collection.

Demographic Characteristics. When the sample was recruited (2006) (2007) (2008) , respondents reported their age, gender (0 = man, 1 = woman), educational attainment (from 1 = less than high school to 9 = doctoral degree), income (from 1 = less than $15,000 to 6 = more than $150,000), and race (Caucasian, African American, or Other). We also assessed marital status (married, living with someone in a committed relationship, separated, divorced, widowed, or single, never married) and number of chronic medical conditions diagnosed by a health care provider (arthritis, hypertension, heart conditions, cancer, A c c e p t e d M a n u s c r i p t diabetes, osteoporosis, stroke, and breathing problems; range 0-8) using standardized questions. At Wave 7, 83.3% (N = 1059) of participants were living in New Jersey.

Physical Distancing. We operationalized physical distancing specific to COVID-19 based on CDC recommendations that people stay at least six feet from other people, not gather in groups, and avoid crowded places and mass gatherings. We measured physical distancing by asking respondents how much (not at all, some, or a lot) they had done each of the following since mid-March: Went to public places (e.g. library, sports events, work, health club, Senior Center) less often; Cancelled doctor appointments; Spent less face-to-face time with friends or relatives; Cancelled out of town trips; Changed plans to attend a holiday, birthday, wedding or other celebration; Did not go to funerals they ordinarily would have gone to; Limited the number of trips they made to the grocery or drug store; and Cancelled a surgery or medical treatment. Responses were dichotomized as 0 (did not do) or 1 (did to any extent).

Most challenging experience. To assess what older people endorsed as most challenging about the pandemic, participants were asked to "Take a moment to reflect on your overall experiences with COVID-19 since mid-March of 2020. Of all the changes taking place, what has been most difficult for you?".

We ran descriptive statistics for sample demographic characteristics and tabulated frequencies of adherence to physical distancing behaviors. Following conventional Content Analysis strategies (Hsieh & Shannon, 2005) , responses to the open-ended question noted above were reviewed using an open-coding process to produce a base coding-tree that reflected the manifest content of the responses (Graneheim & Lundman, 2004) . Comments were classified using an iterative inductive process of theme development, whereby broader codes were identified and then refined as more specific examples were provided by participants (Glaser, 1965; Marks, 2015) . Codes were developed that captured each unique idea (Graneheim & Lundman, 2004) . A codebook was used to assure consistency in application of codes across participant responses. Coding notes and descriptions were A c c e p t e d M a n u s c r i p t maintained to clearly distinguish application of each code. Data saturation in identified themes was attained, whereby no new codes were presenting upon review of new comments. Given the large sample size, percentages of respondents indicating each specific challenge were also tabulated.

The majority of participants were white ( c c e p t e d M a n u s c r i p t grandchildren. The descriptions reflected a feeling of loss associated with not being able to "hug and kiss and [seek] physical comfort" (66-year-old woman), as well as simply not being "together in person" (72-year-old woman). Other challenges to social relationships included being isolated (N = 60, 4.7%), providing caregiving support (N = 20, 1.6%), navigating relationships with a partner or spouse (N = 17, 1.3%), missing social events (N = 10, 0.8%), and having someone move into one"s home during the pandemic (N = 2, 0.2%).

The second type of most frequently described challenges were around changes in Activity Restrictions. A third of the sample reported loss of activity (N = 393, 30.9%) as challenging. More specifically, participants described their biggest challenge being restrictions in leisure activities, going out to eat, traveling, going to the gym, volunteering, engaging in self-care, or other daily activities. In addition, under the class of activity stressors, a generalized "loss of freedom of movement" (84-yearold man) was reported (N = 164, 12.9%). Furthermore, participants described being challenged by having to wear a mask when engaging in activities (N = 28, 2.2%), adjusting to the newness of schedules and activities available (N = 18, 1.4%), adapting to technology (N = 5, 0.4%), and adjusting plans to move (N = 3, 0.2%).

To a lesser extent, but equally challenging for those that reported them, participants identified Under the domain of Global Environment, participants also expressed a challenge in understanding or accepting the current political environment and response to the pandemic (N = 61, 4.8%), as well as the broader public response to the pandemic (N = 39, 3.1%). As one participant expressed, her biggest challenge has been "Listening to the politicians who think they know more than the scientists [and] hearing the whiners [that] want things to go back to "normal"" (72-year-old woman). Further for some, their biggest challenge was accepting Death, that is accepting the loss of someone in their network (N = 36, 2.8%) or loss of so many, more broadly (N = 7, 0.6%), to COVID-19 and other illnesses during the initial weeks of the pandemic. Death within the confines of physical distancing mandates often meant an inability to pay final respects in person: "My mother died from and was alone in an assisted living facility when she died" (66-year old woman). Home care stressors were also described and included the need for increased cleaning (N = 11, 0.9%), the inability to accomplish home maintenance (N = 8, 0.6%), and increased cooking (N = 3, 0.2%). As one participant stated, "It has been most difficult staying home and having to do all the cooking and cleaning" (75-year-old woman).

These analyses provide an initial understanding of the extent to which older people have been responding to directives to maintain physical distance in order to contain the spread of the COVID-19

virus and the experiences that older people find most challenging. We found that the majority of older people are staying away from public places, cancelling doctor"s appointments and medical treatments, spending less time with friends and relatives, cancelling out of town trips, and changing plans to A c c e p t e d M a n u s c r i p t attend family gatherings. We also found that most older adults (91%) reported that the COVID-19 pandemic has presented significant challenges. More specifically, we found that older people report difficulties across eight domains: Social Relationships, Activity Restrictions, Psychological, Health, Financial, Global Environment, Death, and Home care. These findings carry important implications for future research and practice.

First, these findings provide rich contextual information about the lived experiences of older adults during the COVID-19 pandemic. They provide evidence of the specific attributes of the pandemic that are impacting the lives of older adults. The descriptive information found here can inform the development of more complex predictive models of pandemic exposure on developmental outcomes such as loneliness, functional ability, or health. Specifically, our results highlight that older adults are physically distancing themselves from others and knowing the extent of physical distancing may help us to understand how COVID-19 is impacting older individuals. Future work should consider how pre-pandemic levels of social interaction have changed during the pandemic and use this report of change to predict physical and mental health outcomes.

Furthermore, findings highlight the specific secondary aspects of the experience in response to the primary physical distancing mandates that older adults identify as stressful. Older individuals in this sample reported feeling most impacted by lack of in-person contact with others and the need to change their activity routines. In predicting mental and physical health consequences of the pandemic on older individuals (i.e., loneliness, functional ability, or health), thus, it will be critical to examine the extent of and feelings associated with being separated from others (i.e., not just the engagement in specific physical distancing behaviors) and the extent of and feelings associated with having to change one"s activity patterns. Beyond these two stressors though, future quantitative models studying the impact of the pandemic must also account for other stressors including psychological stressors (i.e., worry), health stressors (i.e., contracting COVID-19), global environment stressors (i.e., political and public response), financial stressors (i.e., change in work patterns), exposure to death (i.e., in one"s network or beyond), and stressors in the home (i.e., cleaning needs).

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Our results can help inform intervention efforts. These descriptive findings suggest the need to better understand the pathways through which the primary stressor of the pandemic (physical distancing) may impact health and well-being outcomes. For example, findings indicate that physical distancing mandates are causing many to remove themselves from social encounters. Knowing that prior work has documented an association of social isolation (having minimal social contact) with morbidity and mortality (Holt-Lunstad et al., 2017) , it is important to understand the extent of social removal. It will be critical to identify if there are positive social engagement strategies older adults are invoking that can moderate the impact of physical distancing on well-being. Intervention efforts that target loss of contact may prove especially meaningful for those that are not engaging in continued social contact with others. Further, interventions that target coping strategies that directly respond to the specific stressors reported by older adults have the likelihood of minimizing negative pandemic outcomes (Matthieu & Ivanoff, 2006) . Clinical intervention efforts that focus on the specific stressors experienced by older adults may have the potential to maximize positive functioning and well-being.

While the findings of this study are critical for understanding how older adults are responding to the COVID-19 pandemic, this study is not without limitation. First, the analyses included data from people responding to an e-mail message within a two-week period. Compared with people who did not respond, these early responders were more likely to be women, White, younger, married, have higher levels of education and income, and were healthier. By nature, the sample has the capacity and tendency to stay connected using e-mail, which may not be true for more vulnerable older adults.

Until data from the full sample can be collected and analyzed, our understanding of the challenges older adults face during the pandemic is preliminary, at best. Second, our list of physical distancing behaviors may not be a complete index of behaviors individuals are engaging in due to the pandemic.

Other behaviors not assessed here may be happening more frequently. Third, for some individuals, the response to physical distancing mandates may not represent a change in their status quothey do not engage in these behaviors to begin withand future research should explore this individual response to mandates by accounting for pre-pandemic behaviors. Fourth, the findings here apply to older adults who predominantly lived in New Jersey, a state that instituted sweeping regulations to close all non-M a n u s c r i p t essential businesses, schools, and medical offices except for emergency needs as of March 22, 2020.

Additional challenges may have been present for those living in other regions. Further, the findings focus on the first 6-8 weeks of the pandemic experience, additional challenges may be present or become more important for older adults as the pandemic continues. And finally, this manuscript focuses on the narrow lens of challenges perceived by older adults during this time of adjusting to new social mandates. However, older adults may also be engaging in new positive social exchange strategies that have positive rippling effects for well-being. New creative strategies for staying engaged (i.e., use of video conferencing technology) may be able to moderate the impact of physically distancing constraints on functioning. Future research should explore this diversity in experience.

Overall, despite limitations, findings reported here highlight the lived experiences of older adults during the initial weeks of the COVID-19 pandemic. These reported experiences set the stage for how older adults are and will continue to cope with the changing nature of the social environment as a result of COVID-19. These findings are important, given projections that intermittent physical distancing may be necessary until 2022 (Kissler et al., 2020) and evidence that physical distancing is an effective way to contain the COVID-19 virus (Flaxman et al., 2020; Hsaing, et al., 2020) . Knowing what physical distancing behaviors older adults are engaging in and the aspects of the experience they identify as most challenging, informs the testing of more complex associations of the impact of the pandemic on health and well-being of older adults and intervention efforts to support older adults during this uncertain time.

A c c e p t e d M a n u s c r i p t M a n u s c r i p t M a n u s c r i p t 

Profiles in caregiving: The unexpected career

COVID-19 and the consequences of isolating the elderly

Older people and COVID-19: Isolation, risk and ageism

COVID-19 Guidance for Older Adults

Social distancing" amid a crisis in social isolation and loneliness

Estimating the effects of nonpharmaceutical interventions on COVID-19 in Europe

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The complexities of family caregiving at work: A mixed-methods study

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The authors thank all the ORANJ BOWL participants who have graciously spent time completing the questionnaires.

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Work Reference to work related challenges of not being able to work, let go, or furloughed; closing business; goals not being met (or met on expected timeline); retirement plans being altered; or other aspects of work being challenging 97 7.6% I'm a doctor -greatly increased stress in the hospital. (66-year-old woman)I have been furloughed from work. I work in an event-related marketing field which will not be coming back to normal for some time. On top of that I am just 2 years away from my target for retirement and I fear the company will not bring me back... and I"m left to try and find a job at the age of 65. (65-year-old man)

Reference to concern about financial well-being; loss of finances or future finances or own business 47 3.7% Wondering how I will be paying my bills (