key: cord-0897848-5tf0k890
authors: Rodrigues, Natalie Grace; Han, Claudia Qin Yun; Su, Ya; Klainin‐Yobas, Piyanee; Wu, Xi Vivien
title: Psychological impacts and online interventions of social isolation amongst older adults during COVID‐19 pandemic: A scoping review
date: 2021-10-09
journal: J Adv Nurs
DOI: 10.1111/jan.15063
sha: d6acf9e93d3402a7c1f336fd9ef0396db3beda0a
doc_id: 897848
cord_uid: 5tf0k890

AIM: To summarise the psychological impacts of social isolation amongst older adults during COVID‐19 and review the benefits and limitations of online interventions used to combat social isolation. DESIGN: A scoping review was performed. DATA SOURCES: A systematic search was performed from October 2020 to January 2021 in seven electronic databases: China National Knowledge Infrastructure (CNKI), PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Cochrane Library and Web of Science. A hand search of the reference lists of included papers and WHO publications was performed. Grey literature search was carried out from Scopus, ProQuest Dissertation and Google Scholar. REVIEW METHODS: Studies were screened, appraised and extracted independently by two reviewers. Thematic analysis was used to synthesise data, which were presented in a descriptive manner and organised into categories and themes. RESULTS: Totally, 33 studies were included. Four themes and eight sub‐themes emerged: (1) negative impacts and experiences of older adults during social isolation, (2) adopting coping behaviours in the midst of COVID‐19, (3) online interventions to combat the consequences of social isolation, (4) barriers to online intervention. CONCLUSION: The COVID‐19 pandemic has taken an emotional toll on older adults’ psychological wellbeing and has highlighted the untapped strengths of older adults facing isolation. Online interventions, which could be a new normal in the COVID era, were beneficial in combating social isolation. Strategies by various stakeholders were recommended to tackle the barriers of online interventions. IMPACT: With the COVID‐19 pandemic still in progress, this review provides insights on the psychological impacts of social isolation amongst older adults. Nurses in the community and long‐term care facilities could adopt strategies and online intervention to better support the older adults, contribute to a stronger COVID‐19 response and support system, and an overall better road to recovery from this crisis.

Following a series of pneumonia cases in Wuhan, China on 31 December 2019, Chinese authorities identified the cause to be a novel coronavirus (2019-nCoV) on 7 January 2020. Since then, this virus had been declared a pandemic by the World Health Organization (WHO) due to its alarming levels of worldwide spread, severity of infection, and inaction by countries around the world (WHO, 2020) . This global health crisis required policies of social distancing and quarantine to be strictly implemented to curb the spread of infections (Conejero et al., 2020) .

Since the implementation of these measures, COVID-19 has revealed the challenges of an ageing population, including the emergence of adverse psychological effects amongst socially isolated older adults. Population ageing is a worldwide phenomenon where nearly all countries have experienced growth in the number and proportion of older adults in their populations. According to the United Nations (2019), individuals aged 65 years and above have increased over time, rising from 6% in 1990 to 9% in 2019. As the ageing population continues to live longer (Lunenfeld & Stratton, 2013) , this silent epidemic of global ageing has become increasingly apparent against the background of social distancing policies during the current COVID-19 pandemic.

One of the more overlooked and prevailing social issues of an ageing population is the rise of older adults living alone in recent decades (Reher & Requena, 2018) . They live alone either because they are widowed or have the desire for independence (Kaplan & Berkman, 2019) . Due to the mandatory period of social distancing during the COVID-19 pandemic, older adults who live alone are less likely to be exposed to the contagion (Reher et al., 2020) ; however, this could give way to long term and more serious negative effects because of reduced social contacts and support (Armitage & Nellums, 2020) . In addition, the natural concomitant effect of an ageing population has increased the number of older adults in long-term care facilities (de Medeiros et al., 2020) . These older people face the risk of loneliness due to the initial move to nursing homes, which can be a very disorienting experience in a new environment (Botek, 2020) . Social distancing inevitably reduces older adults' social contacts by restricting visiting and communal hours in long-term care facilities, which takes a toll on their emotional wellbeing and increases the loneliness they initially experienced. This is in line with the interactionist theory of loneliness as proposed by Weiss (1973) which states that loneliness is due to the combined effects of personality and situational factors (Skaff, 2007) . In this situation, older adults who experienced loneliness were either living alone at home or in long-term care facilities.

This loneliness loop is accompanied by feelings of stress, pessimism, anxiety, and low self-esteem that activates neurobiological and behavioural mechanisms that contribute to adverse health outcomes. (Hawkley & Cacioppo, 2010) . However, the degree of loneliness and psychological impacts among older adults varies, which depends on their personality, including their coping strategies or how they perceive their level of social network (Tan et al., 2021) .

Since the start of social distancing measures during COVID-19, the reliance on technology has increased more than usual Wilson, 2020) . For example, family chats have shifted to FaceTime, while WhatsApp messaging and social media platforms are now the standard medium to catch up with friends. Delivery of outpatient care has also changed, with providers moving over to telehealth (Chan et al., 2019; Mehrotra et al., 2020) , particularly for patients with chronic health conditions (Cheng et al., 2019; Chudasama et al., 2020) and pre-existing mental illness (Bojdani et al., 2020) .

However, technology is an unfamiliar territory for most of the older generation who did not grow up with the digital world. According to Anderson and Perrin (2017) , six out of ten older adults aged 65 years and above do not own a phone, indicating that most are probably disconnected from this digital age (Dennis, 2018) . Older adults are often slower than their younger counterparts in adapting to new technologies (Vaportzis et al., 2017) and begin to feel more alone when they are left out of the digital world. However, older adults' readiness to uptake technologies very much depends on different factors ranging from individual characteristics to environmental factors (Peek et al., 2014) . Besides older adult's internal motivations or learning abilities, other variables such as financial costs or digital training play a role in older adults' uptake of technology use (Knapova et al., 2020) .

Social isolation can be defined as the objective measure of physical absence of social interactions, relationships and support from family, friends or even society (Coyle & Dugan, 2012) . Loneliness is a perceived deficit between the individual's desired and actual level of social contact (Malcolm et al., 2019) . Despite the acknowledged health impacts, the prevalence rate of both loneliness and social isolation has persisted over several decades (Victor et al., 2005) , highlighting this growing and widespread phenomenon. Though these two concepts are different, they are also related as social isolation and loneliness can frequently co-occur during imposed quarantine, which can be an unfamiliar and unpleasant experience (Usher et al., 2020) . The effects of social isolation and loneliness on mental health contributes to the overall psychological impact on an individual (Oliveira et al., 2013) . The common psychological impact of older adults during social isolation include anxiety, boredom (Robb et al., 2020) , depression and suicide (Troutman-Jordan & Kazemi, 2020) .

Presently, there is a paucity of reviews on the psychological impact experienced by socially isolated older adults during this pandemic. Most of the published studies examined the clinical features and outcomes of COVID-19 in older adults. Current research mainly focused on the immediate and more pressing issues, such as the physiological presentations of COVID-19 for older adults (Gan et al., 2020; Liu et al., 2020; Neumann-Podczaska et al., 2020; Singhal et al., 2020) . In comparison, literature about long-term mental health issues of socially isolated older adults in COVID-19 is relatively limited. While it is appropriate to prioritise the urgent physiological effects of COVID-19 in the acute setting, we should not neglect the often insidious effect that social isolation has on older adults' mental health, especially those that are living in the community and long-term care facilities. Hence, this review focused on communitydwelling and long-term care for older adults. Furthermore, majority of the studies analysed the psychological effects experienced by healthcare workers or the general public in COVID-19 pandemic (Cabarkapa et al., 2020; Luo et al., 2020; Salari et al., 2020; Tan et al., 2020; Xiong et al., 2020) . However, more focus needs to be placed on older adults since they are expected to be more severely affected, physically and mentally, by COVID-19 (Kessler & Bowen, 2020) . Older adults also tend to be the main target group for lockdown restrictions due to their weaker immune systems ), yet receive limited support, in terms of avenues for them to reach out to, for health care during isolation (de Mendonca Lima et al., 2013; Newman, 2017) .

The COVID-19 pandemic is still in progress and problems that arise from social isolation will likely persist and carry on to the future. The unprecedented nature and scale of this virus may contribute to long-term mental health issues (Kathirvel, 2020) and ultimately additional stresses to health care systems, particularly the delivery of mental health services. Mental health nurses, community nurses, long-term care facilities nurses, who are usually involved in face-to-face interactions with patients might be the group most affected by the shift to remote technologies, which are likely to remain (Foye et al., 2021) . Hence it is important that we also acknowledge the experiences and challenges that these nurses go through during COVID-19.

To compare COVID-19 with previous pandemics like the 2003 SARS outbreak, it is evident to be more virulent, which may lead to more stringent quarantine measures. With the reported symptoms of depression and anxiety during SARS (Brooks et al., 2020; Liu et al., 2012) , a timely understanding of the psychological status amongst the affected older adults during COVID-19 is an urgent need. In this relatively new and emerging field, the lack of studies focusing on older adults' mental health is indicative of a knowledge gap that contributes to the rationale for conducting this scoping review (Munn et al., 2018) .

This scoping review aims to synthesis the psychological impacts of social isolation amongst older adults during COVID-19 and +reviews the benefits and barriers of online interventions used to combat social isolation.

This scoping review followed a methodological framework developed by Arksey and O'Malley (2005) and refined by Levac et al. (2010) 2013) . Duplicates were removed. Two reviewers (NR and CH) first screened the titles and abstracts independently based on the inclusion and exclusion criteria and later retrieved the full text to be assessed in detail. Disagreements in the process were discussed in the research team.

The inclusion criteria were (1) participants of any gender, aged 55 years old and above, living alone in the community or in long-term care facilities, or socially isolated, (2) participants can either be physically healthy or have any pre-existing medical conditions during the time of the study, (3) studies that state or evaluate the psychological impact experienced by the participants, (4) Interventional studies which address mental health issues in older adults during COVID-19, (5) studies that include the context of the COVID-19 pandemic in any geographical location, (6) study designs including qualitative, quantitative, mixed-method study, case study, review, commentary, discussion paper. Only studies published from January 2020 onwards were included. This scoping review considered sources of evidence from any existing literature that met the above inclusion criteria.

Included articles were only limited to English and Chinese language.

The justifications for the inclusion and exclusion criteria were provided in Supplementary File S2.

Seven JBI appraisal tools were selected based on the study design: JBI critical appraisal tool for case report, text and opinion paper, analytical cross-sectional studies, prevalence studies, qualitative research, quasi-experimental, and Randomised Controlled Trials (Joanna Briggs Institute, 2017) . SANRA, the Scale for the Assessment of Narrative Review Articles, was used to assess the quality of the included narrative reviews (Baethge et al., 2019) . Two reviewers (NR and CH) conducted the quality appraisal independently. Disagreements were settled in discussion with the third reviewer (XVW).

In stage four, two reviewers (NR and CH) developed a data chart form based on the research questions. This draft charting table was piloted among five papers. After independently extracting the data, we compared contents before making revisions to the chart form.

The final key items of information we extracted narratively from the included articles were the following: author(s), year of publication, research aim, design and data collection, sample characteristics, intervention, outcome measures, main findings.

Finally, in the last stage, for quantitative studies, we looked at the findings and evaluated if it supported the aim of the study. For example, Gaeta and Brydges (2020) reported 56.4% of participants reporting feeling isolated and 36.0% reporting feeling lonely due to stay-at-home orders during the pandemic. These results were reviewed in the discussion and showed relevance to the sub-theme.

While qualitative data were analysed thematically and presented in a descriptive manner under the following categories: (a) results of data extraction, (b) themes related to the psychological impact faced by socially isolated older adults, interventions to tackle social isolation and its barriers. Researchers used an inductive and semantic approach to familiarise with the texts from the different studies before identifying common patterns and themes directly from the information presented.

The electronic databases search identified 2783 records, of which 1400 duplicated records were removed. A hand search of the reference lists of the included papers and on WHO publications yielded additional ten records, bringing the total to 1393 articles for review using the inclusion and exclusion criteria. After 198 full texts were retrieved and screened, we identified the final 33 papers. The flow of articles was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) as shown in Figure 1 (Tricco et al., 2018) .

The 33 articles included a range of research designs as illustrated in Figure 1 . The majority of studies were conducted in the United States (n = 13), followed by Israel (n = 4), Spain (n = 2), the United Kingdom (n = 1), Europe (n = 1), Italy (n = 1), Japan (n = 1), Netherlands (n = 1), Sweden (n = 1), France (n = 1) and Brazil (n = 1). One of the commentaries included perspectives from China, Hong Kong, Italy and Australia while one of the narrative reviews included studies from Taiwan, England, Scotland, Canada, Australia, Sweden, Netherland and the United States. The remaining four articles did not mention where the studies were conducted as it was not relevant. Most of the papers (n = 29) described older adults' experiences and feelings, specifically the adverse psychological turmoil and mental health issues they faced during social distancing measures. Eleven papers either proposed online interventions to combat social isolation amongst older adults or evaluated the benefits and barriers of those interventions. Out of the 33 articles, the sample of older adults +was predominately from community settings, while only five articles reported older adults from long-term care facilities. Six articles reported samples from a mixture of long-term care facilities and community setting. Table 1 describes the detailed characteristics of the included studies.

The overall appraisal of the articles was ranked based on the percentage of "yes" scores to the individual questions asked in each critical appraisal checklist. The risk of bias was ranked as high when the study reached up to 49% of 'yes' scores, moderate for 50 to 69% of 'yes' scores, and low for more than 70% of 'yes' scores (Melo et al., 2018 ; The Institute Joanna Briggs, 2014) (Supplementary File S3).

Out of 33 articles, 60% are of low risk. About 15% are of moderate risk, while another 24% are of high risk. For the quality appraisal, agreement between reviewers was high (average kappa score =0.86, p-value = <.00001). With COVID-19 as a relatively recent and new topic, time has been a heavily limiting factor for any experimental study to be conducted. Hence, text and opinion studies are a more common type of study design to research this emerging field. The elements of the appraisal tool for textual or opinion-based reviews focus on authenticity of the opinion, its source, and how both sides of the opinions are presented. These elements are more universal and general and are likely to be easily fulfilled, resulting in low risk (2) Intervention: Design a very short online intervention or an equivalent protocol to be performed by the caregivers, focusing on the themes of loneliness and low levels of belongingness.

(3) Prevention: Stakeholders and health policymakers should collaborate in establishing relevant and effective protocols to target risk of suicide in community dwelling older adults.

Not mentioned One of the major risk factors for suicide ideation and behaviour among older adults is social disconnection. One of the significant negative consequences of quarantine is older adults' diminished ability to benefit from mental health services. The adverse consequences of eliminating social contact with family and friends along with the negative effects of quarantine among Israel's elderly highlight the need for an intervention. We must educate policymakers and the media in ways to discuss the COVID-19 crisis in a manner that does not overtly target older adults and communicates the value of all life, young and old. Psychosocial support mechanisms (smart technologies, encouraging family and friends to have frequent phone contact with older adults, community outreach services) need to be rapidly expanded to reduce social isolation and perceived burdensomeness for older adults.

Optimism: Media may increase anxiety and fear regarding health and mortality, this coverage, in turn, has the potential to make life seem more precious, death more fearsome, and thus suicide less likely. Increased access to services through telemedicine may be another benefit resulting from the pandemic as telemedicine can provide rapid access to health and psychiatric services without exposing the healthcare workers or the patient to additional risks for infections.

( * Callow et al., 2020 . This study included participants aged 50 years and above, but will be included because it has a moderately large sample that includes individuals from nearly every state in the United States and many provinces of Canada, and the use of well-established measures of physical activity and symptoms of anxiety and depression validated for use in older adults.; **Gorenko et al., 2020. This study included participants aged 50 years and above, but will be included because this narrative review draws upon a wide range of evidence to provide a comprehensive overview of appropriate remotely delivered interventions for older adults that target loneliness and psychological symptoms which can duly contribute to the results of this scoping review.

ratings (McArthur et al., 2015) . Since more than half of the included articles are of low risk, it gives a strong reason for the quality assessment of articles to be reliable.

Four major themes and eight sub-themes encompass the various emotional states of the older adults during social distancing measures and the different types of remote interventions available to tackle this issue and their respective barriers (Table 2) . Table 3 illustrated the evidence that supports the themes and sub-themes in the summary findings extracted from the included articles.

The majority of the studies reported that social distancing measures during the COVID-19 pandemic took an emotional toll on older adults' psychological wellbeing. Particularly for those who lived alone at home, long-term care facilities or had pre-existing mental illnesses (Emerson, 2020; Gerritson & Oude Voshaar, 2020; de Leo & Trabucchi, 2020) , their loneliness and isolation increased (Gaeta & Brydges, 2020; Hwang et al., 2020) . The commonly reported consequences of social isolation and loneliness included feelings of worry, stress, anxiety, fear, frustration, boredom (Bergman et al., 2020; Callow et al., 2020; Chen et al., 2020; Van Dyck et al., 2020; El Haj et al., 2020; Goodman-Casanova et al., 2020; Harden et al., 2020; de Maio Nascimento, 2020; Van Orden et al., 2020) and adverse outcomes such as depression, sleep disorders and suicide ideation (Callow et al., 2020; Deguchi et al., 2020; Flett & Heisel, 2020; Grossman et al., 2021; Gustavsson & Beckman, 2020; Levi-Belz & Aisenberg, 2020; Sheffler et al., 2020) .

Community-dwelling older adults who lived alone reported struggles of eating properly, sleeping well and maintaining personal hygiene during isolation, which affected their daily function and mental health (Deguchi et al., 2020; de Leo & Trabucchi, 2020) .

Similarly, residents in long-term care facilities, who complained of being isolated in their rooms and being unable to join in communal meals or activities (van Dyck et al., 2020) , described feelings of restlessness and anxiety. There are bidirectional links between physical and psychological health. Therefore, physical problems relating to eating and sleeping may lead to the development of psychological problems (such as anxiety) or the aggravation of existing mental health problems. Furthermore, there was a high chance for older adults with pre-existing mental illness, cognitive impairment or dementia to suffer from a relapse of serious mental illness or suicide tendencies during social isolation (Burlacu et al., 2020; Flint et al., 2020) .

Carr et al. (2020) reported older adults experiencing overwhelming sadness, disbelief and intense guilt during a typical bereavement process. Due to the need for social distancing measures during COVID-19, these feelings associated with bereavement are aggravated by older adults' social isolation and the lack of coping resources, including emotional support and face-to-face mourning rituals (Carr et al., 2020) . This imposed isolation also meant that the last time the bereaved saw their loved ones would likely be when they were taken to the hospital by ambulance (Wand et al., 2020) .

Being unable to be by their loved one's side during their last hours could make it harder to accept the reality of death (Goveas & Shear, 2020) . Moreover, the only viable avenue to offer support for these bereaved older adults is through remote means. It may not, however, sufficiently meet their emotional and physical needs, affecting their wellbeing (Carr et al., 2020) . During this atypical time of grieving, many factors affected the mourning milestones, which slow down the process of adapting to loss while increasing the chances of prolonged grief disorder (Goveas & Shear, 2020) . 

Bereavement process during the current atypical period associated with COVID-19 Bergman et al., 2020 ''The connection between COVID-19-related health worries and anxiety symptoms was stronger among individuals who felt older.'' Burlacu et al., 2020 ''Difficulties in receiving medical services or specific psychiatric treatments has led to mental relapses…'' Callow et al., 2020 '…older adults, particularly those with pre-existing conditions, are now undergoing physical and social isolation, which may increase the incidence and severity of anxiety and depression among this population.' Carr et al., 2020 '…COVID-related fatalities (are) particularly devastating for bereaved kin, whose grief may be compounded by their own social isolation, lack of practical and emotional support, and high-stress living situations marked by financial precarity, worries about their own or other family members' health, confinement to home, and the loss of routine and activity that once structured their days.' '…trigger pain in seeing a loved one suffer, and they may make family members feel guilty that they could not protect their loved one from the devastating situation.' Chen et al., 2020 'Participants' comments reflected that they experienced stress, anxiety, and worry due to COVID-19.' '…relationship between social disconnectedness and social isolation and symptoms of depression and anxiety'

de Leo & Trabucchi, 2020 'The negative effects of social isolation could be particularly insidious for older adults or those with pre-existing mental illness.' 'When living alone, eating properly and maintaining personal hygiene can become quite difficult, increasing the sense of demoralization and suffering from loneliness as well as risk for suicide in late life.'

de Nascimento, 2020 Older adults experienced 'emotional changes due to anxiety, generated by social seclusion and fear of the virus contamination'. '…they were experiencing sleep disorders…' Deguchi et al., 2020 '...complained of headache, dizziness, general fatigue, and depressed mood and began to have trouble performing household chores and eating meals.' '…reported loss of motivation, appetite loss, and severe insomnia.' Despite lockdown restrictions removed, '... depressive symptoms did not improve.'

El Haj et al., 2020 'Due to isolation of residents and drastic changes in their daily life and care they receive, participants reported higher depression and anxiety during than before the COVID-19 crisis.'

Emerson, 2020 'Over one-third (36.9%) of the sample reported being moderately to a great deal stressed.' 'Those living alone had much higher rates of current loneliness (59.3%) compared to those that lived with others (38.4%).' 'Younger respondents (60-70 years) were significantly more likely to report sleeping less.'

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Bereavement process during the current atypical period associated with COVID-19 Flett & Heisel, 2020 '…growing concerns about suicidal tendencies among older people, especially during the pandemic.' Flint et al., 2020 ' There is a high chance of relapse and recurrence of serious mental illness as well as suicide tendencies for older adults because provision of outpatient electroconvulsive therapy (ECT), which is an essential service is affected due to the need for social distancing.' 'Social distancing may also lead to an increased sense of isolation and loneliness…' Gaeta & Brydges, 2020 'Over half (56.4%) of participants reported feeling isolated as a result of the COVID-19 outbreak, and more than one-third (36.0%) reported feeling lonely.'

Gerritsen & Oude Voshaar, 2020

'Challenging behaviour has been reported more in nursing home patients who are normally able to go outside and have relatively much control over their daily life.'

Goodman-Casanova et al., 2020

'Participants expressed fear, frustration, and boredom, which are frequently expressed negative feelings during confinement. Living alone was found to be a risk factor for greater psychological negative impact and sleeping problems.' Gorenko et al., 2020 Goveas & Shear, 2020 'The many stresses and the need for social distancing made it more difficult for Alice to accept the reality that Charles was gone.' 'She fluctuated between numbness, overwhelming sadness, and intense guilt…' '…not having seen him (before his death) made the feeling of disbelief even stronger.' Grossman et al., 2021 'Higher level of COVID-19 related loneliness is associated with higher levels of sleep problems among older adults.' Gustavsson & Beckman, 2020 'About half of the respondents (60.8%) said they worry about their health during the COVID-19 pandemic, and half of them said they experienced negative feelings during isolation. It was more common to have sleeping problems, feelings of depression and difficulties concentrating when single.' Harden et al., 2020 'Because of quarantine and stay-at-home restrictions… Aubree expressed feelings of isolation…' 'Isolation occurred once another client was diagnosed with covid-19 or respite off-campus care, leading William to become increasingly agitated, anxious, and depressed himself.' Hwang et al., 2020 'Quarantine and social distancing…lead to elevated levels of loneliness and social isolation, which in turn produce physicaland mental health related repercussions.'

Krendl & Perry, 2020 'Older adults experienced greater depression and loneliness than they had prior to the pandemic.'

Levi-Belz & Aisenberg, 2020 'One of the major risk factors for suicide ideation and behaviour among older adults is social disconnection.' Sheffler et al., 2020 'Social distancing policies, potentially leading to social isolation… may directly contribute to increases in desire for suicide…' Shrira et al., 2020 'Loneliness due to the COVID-19 pandemic would be related to higher levels of psychiatric symptoms (i.e., anxiety, depressive, and peritraumatic distress symptoms) among older adults, especially among those feeling older.'

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Bereavement process during the current atypical period associated with COVID-19

Van Dyck et al., 2020 ''In nursing homes, residents are secluded in their rooms and no longer partake in communal meals or activities. They have extremely limited contact with support staff and are no longer able to receive visits from family members and friend.' '…feelings of restlessness and anxiety as isolation continues, and fearfulness as COVID-19 enters nursing home facilities.'

Van Orden et al., 2020 'Mr. X reported feeling lonely and isolated, and is worried he is becoming depressed…' 'Mr Y starts having difficulty sleeping at night and appears more restless and irritable during the day, sometimes yelling at staff and other residents.' 'Ms. Z reports feeling increasingly anxious and isolated.' Wand et al., 2020 'The isolation imposed by the infection meant that thousands of people who subsequently died were last seen by family when they were taken to hospital by ambulance.'

Brooke & Clark, 2020 'Participants accepted they had lived a good life and considered themselves as being blessed, lucky and fortunate…' Burlacu et al., 2020 'Religion may provide a resource that helps in the search for meaning and in overcoming loneliness.' Chen et al., 2020 'Participants themselves reported the use of social technologies to connect with family.' 'Information and technology use kept participants informed and connected.'

De Maio Nascimento, 2020 'Vast majority of the older adults felt sufficiently informed about COVID-19 news via radio, TV, conversations with family and friends and WhatsApp.'

Emerson, 2020 'Respondents also reported using email and text messages more than usual and spending more time on computers/tablet than usual.' 'Two-thirds of respondents reported using more social media than usual.' Flint et al., 2020 'Peer-support groups, such as those affiliated with Alzheimer's organizations and addiction services, have moved activities online. Mental health and caregiver organizations have expanded their online presence, with information about coping strategies, including links to web-based counselling and advice on how to make the best use of technology.' Gaeta & Brydges, 2020 'The majority reported using some form of social media to connect to others.'

Theme 2: Adopting coping behaviours in the midst of COVID-19

Self-help or external support for social isolation Cherishing life and accepting death Gorenko et al., 2020 'Regular contact from family, friends, and healthcare workers can be a means to assess for increased distress, burden, health changes in older adults under self-isolation.'

Gustavsson & Beckman, 2020 'A vast majority of the participants perceived the general information about the current COVID-19 pandemic as sufficient (92.2%).

Krendl & Perry, 2020 '…older adults reported spending much more time using social media to reconnect with people they cared about.' Sheffler et al., 2020 'Psychosocial support mechanisms… such as community outreach services using online strategies need to be rapidly expanded to reduce social isolation and perceived burdensomeness for older adults.'

Media 'has the potential to make life seem more precious, death more fearsome, and thus suicide less likely.'

Online home-based physical activity programmes Banskota et al., 2020 Telemedicine may provide a temporary solution for older adults who have elective appointments for their chronic health conditions. 'Medisafe, along with its real-time missed medication alerts and frequent check- 

Older adults' attitude towards online social support and virtual exercise programme Carriedo et al., 2020 'Individuals with poor mental health symptoms and resilience could have been less prompted to exercise.' Chu et al., 2020 'While technological 3.4.2 | Adopting coping behaviours in the midst of COVID-19

To cope with the isolation they were experiencing, some older adults relied on text messages and emails, while others used social media and video calls to talk to their loved ones (Emerson, 2020; Gaeta & Brydges, 2020; Krendl & Perry, 2020) . These social technologies also allowed appropriate stakeholders to regularly check in on older adults under isolation, conduct online activities or assess any subtle emotional health changes (Flint et al., 2020; Gorenko et al., 2020; Sheffler et al., 2020) . On the other hand, a few older adults turned to various religious or spiritual practices (Burlacu et al., 2020) such as meditating, listening to inspirational programmes, or reading uplifting literature to manage their emotions during the isolation instead.

During this pandemic, some older adults have reported positive views, including feeling blessed and fortunate to have lived a long life (Brooke & Clark, 2020) , and cherishing life and accepting death (Sheffler et al., 2020) . Sheffler et al. (2020) reported that watching the media in confinement might have instead made life seem more precious and death more fearsome (Sheffler, 2020) . Furthermore, people may come together unexpectedly in the wake of a crisis, increasing one another's sense of belonging and reducing their rates of suicide. Brooke and Clark (2020) also found that older adults with higher social support levels are associated with higher perceived life satisfaction, contributing to greater appreciation of life and reduced death anxiety.

Telemedicine applications have provided temporary solutions to facilitate the care of older adults with chronic health conditions during lockdown (Banskota et al., 2020; Burlacu et al., 2020) . Specifically, in Canada, Flint et al. (2020) reported that the country's welldeveloped telemedicine infrastructure successfully supported the transition to virtual care of outpatients almost overnight. These medical apps also helped deliver virtual psychiatric assessments and treatments for older adults with mental health issues (Gerritsen & Oude Voshaar, 2020) , improved medication adherence and support from healthcare professionals (Banskota et al., 2020) . 

One of the barriers was the inaccessibility to digital devices, particularly in long-term care facilities where the number of computers and tablets were limited Van Dyck et al., 2020; Flint et al., 2020; Gorenko et al., 2020; de Maio Nascimento, 2020) . Gorenko et al. (2020) reported that in long-term care facilities, chances of older adults being able to video call their family depended on the staff's commitment and attitudes towards technology. Furthermore, older adults' geographical location or socioeconomic status affected their accessibility to the internet (Burlacu et al., 2020; Gorenko et al., 2020; Levi-Belz & Aisenberg, 2020) .

Additionally, most articles reported older adults' limited skills and unfamiliarity with technology Gorenko et al., 2020; Hwang et al., 2020; de Leo & Trabucchi, 2020; de Maio Nascimento, 2020) which impacted their uptake and adherence to online interventions. Some also expressed having difficulties in using the devices due to their poor eyesight and hearing (Van Dyck et al., 2020; Moore & Hancock, 2020) .

Older adults were not interested in learning how to use new technology (de Maio Nascimento, 2020) because they either perceived it to be difficult or were wary of their safety and privacy online (Gorenko et al., 2020; Moore & Hancock, 2020) . Moore and Hancock (2020) pointed out that older adults were easily targeted by fraud or misinformation, contributing to their scepticism towards technology.

Some also felt that digital technologies were not an essential part of their lives, hence they did not bother learning about these devices (Moore & Hancock, 2020) . About online interventions which promoted physical activity, there might be added inertia for those older adults with poor resilience and mental health to follow through with these online exercise videos (Carriedo et al., 2020) .

This scoping review provided a summary related to the experiences and emotions of older adults who were socially isolated during the Meng et al., 2020; Mukhtar, 2020) , which further confirmed this issue was prevalent and worrisome.

Living arrangements played a part in older adults' mental status during the pandemic. Before the lockdown, older adults who lived alone had avenues for interactions with the community such as participating in activities at the senior centres (Wu, 2020) or having volunteers, family or friends visit their homes. Some frequently spent their time walking or staying around their neighbourhood or public places (Wong, 2020) . However, the quarantine did not allow them to live as they used to, which resulted in overwhelming psychological effects. Most long-term care facilities have not only suspended group activities and communal dining but also restricted visitors. This is particularly burdensome for residents with cognitive impairment and dementia whose family members wish to continue their caregiving activities (Yamamoto-Mitani et al., 2002) . Continuous family involvement may benefit older adults in long-term care facilities as it increases their social contact and improves their psychological functioning (Cohen et al., 2013) . However, the lockdown took away their social interaction with the outsiders, increasing their isolation. Recent systematic reviews evidenced that psychosocial interventions could improve older adults' cognition, psychological and mental health, and social support (Chow et al., 2020; Tam et al., 2021) .

Older adults who have experienced past pandemics of comparable psychological effects (Lahav, 2020) would be more vulnerable to psychiatric symptoms during the COVID-19 pandemic. Specifically, the traumatic experiences of the SARS outbreak in 2003 predisposed much fear and anxiety in emotionally unstable older people during COVID-19 (Wand et al., 2020) . This is because older adults who were isolated during SARS exhibited long-term mental health issues like post-traumatic stress disorder (PTSD) (Hong et al., 2009; Tzeng et al., 2020) . What the older adults experienced during SARS was likely carried over when similar quarantine and social distancing measures were implemented in COVID-19, worsening their psychiatric symptoms (Taylor, 2020) .

This review reported the challenges of bereavement in the age of COVID-19 with social distancing measures in place. Weir (2020) stated that the act of saying goodbye to a loved one in fact starts well before the funeral or memorial. For most, the remaining days and hours of a loved one become especially precious to have meaningful conversations and interactions before saying their last goodbyes.

These final moments tend to give the mourners closure, softening the blow of loss (Dutta et al., 2020) . However, with strict isolation measures in most hospitals, most people could not be by their loved one's side for the final farewell (Wallace et al., 2020) . It was hard to hold physical memorials and funerals, hence mourners were not able to physically gather for emotional support and comfort (Fernández & González-González, 2020) . Furthermore, ageing and isolation take a heavy toll on an older person's emotional wellbeing (American Psychological Association & Silk, 2012; Sanjiv, 2020) , which possibly makes them easily frustrated and helpless when they experience this ambiguous loss without any form of closure or strong emotional support.

This review revealed that older adults turning to various religious or spiritual practices as coping strategies during isolation. According to Kaplan and Berkman (2019) , many older people reported that religion was the most important factor enabling them to cope with external factors. Especially during such a trying time like COVID-19, many might feel despondent and powerless, hence engagement with religious practices and staying connected with God gave older adults a sense of security and strength to manage their emotions (Koenig, 2020; Kowalczyk et al., 2020) . Furthermore, older adults, who would have probably encountered more frequent reminders of their mortality during COVID-19, relied on their close relationship with God for hope, peace and a purpose in life, contributing to their fearless attitude towards death (Malone & Dadswell, 2018) .

Spirituality promotes better coping abilities (Kim & Goldstein, 2017) and lowers death anxiety amongst older adults (Taghiabadi et al., 2017) . Nevertheless, some older adults reported feeling grateful and blessed to have lived a long life (Brooke & Clark, 2020) . This could be due to the social class of the sample included in the article. These participants were of a higher social class and lived quite comfortably. With no external financial stressors or unnecessary worries, it would be more likely that their social needs were met and they could count themselves as 'fortunate' (Scott et al., 2011) . This contributed to a better quality of life for them, higher life satisfaction and a more positive outlook in life (Fortuin et al., 2018) . Notably, low-income countries lack the economic and human capital to develop specialist services, which includes mental health care (Prince et al., 2007) . Conversely, high-income countries have strengthened their research and services for older adults who require support for their mental health (Yasamy et al., n.d.) . The ongoing pandemic may affect long-term wellbeing and global inequalities would put older adults in developing countries further behind in terms of receiving help for mental health (United Nations, 2020).

This crisis has motivated some older adults to learn and expand their use of social technology to stay connected with family and friends to cope with the loneliness they faced during the isolation (Poon & Holder, 2020) . These online social networking platforms helped overcome obstacles of social distancing by allowing older adults to stay in contact with family and friends (Khosravi et al., 2016) . Besides facilitating increased communication, internetconnected devices empowered older adults to carry out tasks such as ordering food online or making an appointment with their doctor.

These functional features promoted independent living amongst older adults, ultimately increasing their resilience and coping abilities during isolation (Berkowsky et al., 2018) .

Healthcare professionals such as nurses and psychiatrists or social services have also learnt to tap on these online strategies to foster greater connections with older adults (Kassler, 2020) and support their mental health (Goswami et al., 2010) . Even though there have been concerns from long-term care facilities nurses who feel that they were not adequately prepared for taking care of older adults' psychological problems due to the lack of focus in this area during their schooling and training years (Kuo et al., 2019) , more attention has been paid to mental health care in recent years. Literature has shown that efforts have been made to improve nurses' knowledge and attitudes towards mental health in older adults (Muhsin et al., 2020; Puentes et al., 2010) and efforts in community nurses to empower older adults on self-care has proven beneficial during the pandemic (Yi et al., 2020) . These nurses and other healthcare providers are a source of external emotional support that can help older adults cope emotionally during isolation (Peng et al., 2019) , hence it becomes important for them to adapt when necessary and develop their mental health care competence to ensure there is continuity of remote mental health care for older adults in this COVID era. However, it is undeniable that these remote interventions cannot fully replace interpersonal intimacy which older adults receive through physical human touch and interactions with others (Bush, 2001) .

Engagement in intimate and interpersonal social interactions is one of the core influences of an older adult's wellbeing (Lomanowska & Guitton, 2016) . Nonetheless, the relevance of these social technologies in almost every aspect of our everyday lives (Daniels et al., 2017) has made them the most appropriate solutions during social distancing measures (He et al., 2021) .

The emergence of home-based online exercises has become useful as activities can be executed in small indoor spaces to promote better functional health and strengths of lower limbs, prevention of fall, and decrease stress and anxiety in older adults (Chan et al., 2021; Chua et al., 2019; Goethals et al., 2020) . It is important to maintain these older adults' physical activity because sedentary behaviours during the quarantine could lead to the potential deterioration of chronic health conditions (Cunningham & O'Sullivan, 2020) .

Moreover, older adults with chronic diseases (National Institute on Ageing, 2017) cannot afford to neglect their regular check-ups or treatments because uncontrollable medical conditions may lead to severe consequences (Wright et al., 2020) . Therefore, telehealth has become essential during social isolation to facilitate health-related services. The use of video-conferencing enables verbal and visual interactions between patients and physicians, allowing more interactive and appropriate managements of older adults' chronic conditions (Boccalandro et al., 2019) .

However, older adults who did not grow up around technology would naturally be adverse to using technology in their daily lives, let alone shifting over to telemedicine (van Houwelingen et al., 2018) . Older adult's readiness to use technology can be affected by various factors including lack of guidance and confidence as evidenced by previous similar studies that reported the lack of access to technology and poor digital literacy amongst older adults (Fischer et al., 2014; Ma et al., 2020; Pywell et al., 2020; Vaportzis et al., 2017) . Furthermore, the more outstanding reason holding back technology use among older adults is their mindset, particularly having wider concerns about technology's impact on society (Knowles & Hanson, 2018) . This factor has affected how they adapt and live during this pandemic. Older adults worry that with the popular use of technology, online activity would threaten local brick and mortar businesses (Lee, 2020) , which may remove places that were once hang out spots with friends. They cherish face-to-face contact (Kemper & Lacal, 2004) and hence are reluctant to shift to online experiences. They also have concerns that digital technologies may make certain jobs obsolete, endangering their grandchildren's job prospects (Sherlock, 2020) .

This review summarizes the psychological impacts of older people living in the community and long-term care facilities experiencing social distancing measures and evidence of interventions.

Technological interventions provide many avenues for improving older adults' wellbeing during the COVID-19 pandemic. With telemedicine making a breakthrough in healthcare, mental health, community and long-term care nurses could reach out to older patients and provide better support. Given the barriers of online in- (Pywell et al., 2020; Robey, n.d.) . Targeted stakeholders such as technology companies or community organizations that support older adults should focus on accessibility to technology and digital literacy (Schaffel, 2018) . By providing resources like technology tutoring or loaner devices, older adults can better understand how to operate the newer social technologies to cope during the pandemic. These collaborative efforts may be useful to bridge the digital gap faced by older adults, so that nurses can maximise the use of telehealth to provide the best possible patient care for them (Duncan et al., 2020) . In the future, more research should be done in this area, so that barriers to online interventions can be overcome and more older adults can use technologies to promote their psychosocial and mental health.

One of the strengths of this scoping review is the application of framework in the methodology, which contributed to the rigour and clarity of the study. The various stages in the framework allowed researchers to carry out each stage separately and in a reflexive way.

Throughout the search process, search terms were refined and each tions, specifically in terms of physical access to social support system, or incidences of neglect or abuse from care staff (Su et al., 2021) . Another limitation is that only articles in English and Chinese were included.

This scoping review highlighted feelings of anxiety, frustration and boredom, and outcomes such as depression, sleep disorders and suicide experienced by socially isolated older adults during the COVID-19 pandemic. On the other hand, it revealed that some older adults coped well during this pandemic and felt blessed. Online interventions such as telehealth, online exercises and virtual social support, which could be a new normal in the COVID era, were beneficial in combating social isolation. Nurses in the community and long-term care facilities could adopt strategies and online intervention to better support the older adults, contribute to a stronger COVID-19 response and support system, and an overall better road to recovery from this crisis.

We would like to thank the generous support from Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore.

The authors declare no conflicts of interest.

Natalie Grace RODRIGUES was involved in study conception, design, search strategy development, database searching, study selection, data extraction, collection, analysis and writing of the manuscript. Claudia Qin Yun HAN was involved in the independent review of articles during the study selection and data extraction process and quality appraisal. Dr Ya SU and Associate Professor Piyanee KLAININ-YOBAS were involved in data analysis and critical review of the manuscript. Dr. Xi Vivien WU was involved in the study conception, design, study selection, quality assessment, data analysis and the overall critical review of the manuscript.

Piyanee Klainin-Yobas https://orcid.org/0000-0003-2581-4572

Xi Vivien Wu https://orcid.org/0000-0002-9264-3630

Xi Vivien Wu @WxvivienWu

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