key: cord-0690750-wwrmhelf authors: Lee, Ester Pei Xuan; Man, Ryan Eyn Kidd; Gan, Tau Liang Alfred; Fenwick, Eva K.; Aravindhan, Amudha; Ho, Kam Chun; Sung, Sharon Cohan; Wong, Tien Yin; Ho, Cyrus Su Hui; Gupta, Preeti; Lamoureux, Ecosse L. title: The longitudinal psychological, physical activity, and financial impact of a COVID‐19 lockdown on older adults in Singapore: The PIONEER‐COVID population‐based study date: 2021-11-12 journal: Int J Geriatr Psychiatry DOI: 10.1002/gps.5645 sha: 4962457dfe2e553a0b5635a99280ffe70443c7da doc_id: 690750 cord_uid: wwrmhelf BACKGROUND: Several countries have implemented ‘lockdown’ measures to curb the spread of the coronavirus disease 2019 (COVID‐19). AIMS: To examine the psychological, physical activity (PA), and financial impact of a 2‐month COVID‐19 lockdown on older adults aged ≥60 years in Singapore, and to identify factors associated with adverse lockdown‐related outcomes. METHOD: We interviewed 496 community‐dwelling adults (mean age [standard deviation]: 73.8 [7.6] years; 54.8% female) during the lockdown who had previously participated in a population‐based epidemiological study. Validated questionnaires were utilised to assess loneliness and depressive symptoms at both timepoints, while inhouse questionnaires were used to assess PA and financial difficulty during lockdown. Multivariable regression models determined the lockdown‐related change in loneliness and depression scores, and the factors associated with adverse outcomes. RESULTS: Loneliness increased significantly during the lockdown period (p < 0.001) while depressive symptoms decreased (p = 0.022). Decreased PA, greater financial problems, male gender, Indian ethnicity, living alone, having a greater body mass index and perceived susceptibility to COVID‐19 were all associated with worsening loneliness scores. A total of 36.9% and 19.6% participants reported decreased PA and had financial problems during the lockdown, respectively. Unemployment was associated with decreased PA, while self‐employed individuals, cleaners, retail workers and smokers had greater odds of experiencing financial difficulty. CONCLUSION: Despite a decrease in depressive symptoms, our population of older Asians reported a significant increase in loneliness and decreased PA, with one‐fifth experiencing financial problems during lockdown. Our data suggest that more targeted public health efforts are needed to reduce repercussions of future lockdowns. cases. 3 While social distancing measures and travel restrictions remained in place after the lockdown ended, these are being gradually reduced over time. 3 Nonetheless, psychological consequences, including loneliness and depression, from the implementation of these stringent lockdown measures have been reported globally. 4 For instance, reports showed significantly greater rates of both depression and anxiety during the initial week of a government-mandated partial lockdown in Vietnam. 5, 6 In particular, older adults (i.e., those aged ≥65 years) have been identified as a vulnerable group necessitating high-quality mental health outcomes research on the impact of such strict preventative measures during COVID-19. 7 Due to the established deleterious impact of loneliness and depression on numerous health outcomes such as mental health and overall well-being, many research groups have attempted to document the cross-sectional and longitudinal mental health changes in this older population during the COVID-19 pandemic. [8] [9] [10] However, the absence of comparative pre-COVID-19 baseline information makes assessing the true impact of lockdown periods difficult. Findings relating to the impact of lockdown on depression have also been inconsistent. 11, 12 Furthermore, our understanding of how physical activity (PA) and financial situations have been affected by COVID-19 lockdowns is also limited. Yamada and colleagues, for example, found a decrease in PA in older adults during a COVID-19 lockdown in Japan, 13 which is problematic as reduced PA may also be associated with detrimental physical and mental health. 14 Moreover, the various COVID-19 lockdowns globally have led to widespread job furloughs and layoffs, 15 but the associated consequent financial impact has not been comprehensively documented on an individual level. Finally, many of the studies have been conducted in Western populations, with few in Asia. 12 Studies in Asia also mainly concentrated on middle-income countries such as China, 16 with few done in high-income Asian countries. This is important as there may be cultural differences in how older adults cope with and, consequently, are affected by the lockdown. To address these gaps, we examined the self-reported psychological (loneliness and depression), PA, and financial impact of the Singapore lockdown in a multi-ethnic sample of older Asian adults aged ≥60 years using data from an ongoing population-based study conducted before the lockdown and a sub-study conducted during the lockdown. We hypothesised that the lockdown would be associated with significant and substantial decrements in mental health, PA and financial outcomes in this aged population. We additionally aimed to identify the sociodemographic, clinical and psychological factors associated with these adverse lockdown-related outcomes in this population. Our findings may enable Singapore and other developed countries to be better prepared for lockdowns due to similar disease outbreaks in the future. Loneliness was measured using a three-item scale, scored on a threepoint scale from 1 (hardly ever) to 3 (often), at both timepoints. 19 Participants rated how often they felt they lacked companionship, were left out and felt isolated from others. For the PIONEER-COVID-19 study, the item stems were modified slightly so as to ensure participant responses were specific to the lockdown (e.g., ' Since the start of the lockdown, how often do you feel that you lack companionship?'). We utilised Rasch analysis 20 The Patient Health Questionnaire (PHQ)-9, 23 a nine-item scale that measures the severity of depressive symptoms, was administered at both timepoints. Items were rated on a 4-point scale indicating the frequency the participant experienced a depressive symptom over the last 2 weeks, ranging from 0 (not at all) to 3 (nearly every day). We utilised the Singapore established cut-off (PHQ-9 score ≥ 6) to indicate presence of depression in our analyses 24 and all responses were summed to produce an overall score, with higher scores indicating greater severity of depressive symptoms. An increase in PHQ-9 scores measured during the lockdown by 0.5 SD indicated a clinically important worsening of depression. 22 The Economic Hardship Questionnaire (EHQ), 25 a 12-item scale, was adapted to examine the financial impact on participants during the lockdown, with two items excluded since these activities could not be undertaken due to the lockdown measures. Participants also described their household's financial position during the lockdown from 0 (no problems) to 2 (major problems). Due to the small number of participants reporting major financial problems (n = 18), we combined 'minor' and 'major' problems in statistical analyses. Participants also indicated how their household income had changed during lockdown from 1 (increased a lot) to 5 (decreased a lot). Responses for this item were recoded as 'increased', 'no change' and 'decreased'. Lastly, eight items assessed changes in lifestyle in the participants' household due to the financial constraints associated with the lockdown. Individual item scores were used in analyses. Standardised questionnaires that formed part of the PIONEER study were used to obtain information about sociodemographic variables (age, gender, ethnicity, education, type of housing, living arrangement, occupation, income, smoking status, and alcohol usage), clinical variables (self-reported diabetes, hypertension, hyperlipidaemia, and cardiovascular disease) and lifetime history of mental disorders. Body mass index (BMI) was calculated using height and weight measurements while chronic kidney disease (CKD) was based on the glomerular filtration rate estimated from collected blood samples (eGFR < 60 ml/min/1.73 m 2 ). 26 The Brief Resilience Scale (BRS) 27 was also administered to measure resilience. The BRS comprises six items on a five-point scale from 'strongly disagree' to 'strongly agree'. Responses from all items were summed to produce an overall score, with higher scores indicating higher resilience. During the PIONEER-COVID-19 assessment, participants also responded if they had experienced any major stressful life events over the last 6 months which were not related to COVID-19 such as hospitalisation and death of family member. To measure the perception of susceptibility to COVID-19, participants were asked to rate how likely they were to contract COVID-19 in the next 3 months on a five-point scale (very unlikely, unlikely, likely, very likely, and refused to answer). Finally, the elapsed time between baseline (pre-lockdown) and follow-up (during lockdown) assessments was recorded. All statistical analyses were performed using Stata (Version 15, StataCorp). Loneliness and depression were examined using a longitudinal design. Paired T-tests and the McNemar test were used to determine if there was a significant difference between the means and prevalence rates of loneliness and depression before and during the lockdown, respectively. Next, unadjusted and adjusted multivariable logistic regression analyses were conducted to identify factors associated with a clinical worsening of loneliness and depression. Multivariable linear regression analyses, adjusted for age, gender, and factors that were significantly associated with clinical worsening of the exposures in unadjusted analyses, were then conducted to determine the difference between the means of loneliness and depression before and during the lockdown. Sensitivity analyses were also conducted to examine whether the mean change in each psychological outcome differed between participants who completed the baseline PIONEER assessment less than a year from the lockdown assessment versus those who completed the assessment more than a year ago. Change in PA and financial impact were examined using a crosssectional design. We utilised proportions to describe participant responses to the individual PA and EHQ items. Unadjusted and adjusted logistic regression models were conducted to identify factors associated with decreased PA and having financial problems. Variables were included as covariates in multivariable linear regression models if they had a p < 0.10 in unadjusted models. Two-sided p values of <0.05 were considered statistically significant. Cohen's d was calculated as an estimated effect size. Of the 496 participants (mean age 73.8 years [SD = 7.6]), over half were female (54.8%), most were of Chinese (61.3%) ethnicity, and majority had received more than 6 years of formal education (64.1%). They were either working (34.1%) or not working (65.9%) and their monthly household income varied from less than $1000 (41.2%) to ≥$1000 (58.8%). More details of participants' characteristics are reported in Table 1. 3.1 | Impact of lockdown and associated risk factors on: The mean loneliness score was significantly higher during lockdown than pre-lockdown (−3.02 vs. −3.78; p < 0.001). This increase remained even after multivariable adjustments (age, gender, ethnicity, living alone, BMI, hypertension, perception of susceptibility, pre-lockdown loneliness score, change in PA, and household's financial position; adjusted mean difference = 0.76, p < 0.001, medium effect size [0.56]). Our sensitivity analyses found that although participants who completed the baseline assessment more than a year ago experienced a larger mean change in loneliness score than those who completed the baseline assessment less than a year ago, the between-group difference was not statistically significant (0. Table S1 . In multivariable models (Table 2) Similarly, the prevalence of depression during the lockdown (2.22%) was also significantly lower than pre-lockdown (4.84%; p = 0.024). The proportion of participants who experienced a clinically important worsening of depressive symptoms was 11.3% (n = 56). Factors associated with clinically important worsening of depression in unadjusted analyses are reported in Table S1 . In adjusted models, having CKD (OR adj = 2.48, p = 0.026) and reporting financial problems (OR adj = 2.41, p = 0.015) increased the odds of having a clinically important worsening of depressive symptoms. In our sample, 36.9% of participants reported a decrease in PA, 53.4% reported no change, and 9.7% had increased in their PA since the lockdown. Factors associated with decreased PA in unadjusted analyses are reported in Table S2 . In multivariable models adjusted for age, gender, and occupation (Table 3) , participants who were not working (unemployed, homemaker, or retired) were more likely to report a decrease in PA compared to those with production, technical, or mechanical jobs (OR adj = 2.22, p = 0.033). smokers (β adj = 2.00, p = 0.036) were more likely to report having financial problems (Table 3) . Model included age, gender, ethnicity, chronic kidney disease, perception of susceptibility, pre-lockdown depression score and household's financial position. *p < 0.05. **p < 0.01. ***p < 0.001. the COVID-19 lockdown from pre-COVID-19 times, such as among older adults in the Netherlands. 10 This increase in loneliness could be a result of reduced social contact due to bans on household visitation, even amongst family members, coupled with an embargo on all forms of social gathering, closure of community centres and places of worship. 28 Most of the factors independently associated with a clinically important worsening of loneliness identified in our study, including being of Indian ethnicity, living alone, having a higher BMI, greater perceived susceptibility to COVID-19, reduced PA during lockdown, experiencing financial problems, and having a worse Consistent with other studies, 13 we found one in three participants had reduced their PA during the lockdown. In particular, individuals who were unemployed, homemakers, or retired were more likely to report a decrease in PA compared to production, technical, or mechanical workers. A possible explanation is that technical and mechanical workers might be more likely to work in essential services such as maintenance and repair services which were exempted from the lockdown. In contrast, as all senior-centric PA activities and sport and recreation facilities were cancelled or closed during the lockdown, 32 those who usually access these sites were unable to engage in their usual PA. 34 Our findings suggest more public health efforts are needed to encourage unemployed/retired older adults to stay active during future lockdowns, such as broadcasting simple home exercises on media channels frequented by this population. Lastly, one in five of our participants experienced financial problems during the lockdown, with 28.6% reporting a decrease in household income. Despite government financial subsidies ranging between S$600-S1200 given to all Singaporeans aged 21 and above during the lockdown, 35 this figure was higher than another study which reported that 19.7% of households had a decrease in income during the lockdown among individuals aged 65 and above living in New Zealand. 36 As 92.2% of our participants were part of a larger household compared to only 50% of older adults in New Zealand, 37 it is likely that our sample had more household members who were financially impacted by the lockdown; especially since adults aged 64 and below are more likely experience income loss. 36 We also found that self-employed individuals, cleaners, service and sales workers and smokers were more likely to have financial problems, a result that is supported by previous studies. 36 Our finding could be related to the forced suspension of non-essential services during the lockdown, which are the sole source of income for most self-employed individuals. Additional financial support should therefore be considered for older adults who are self-employed, cleaners, or those working in the service sectors when similar lockdown measures are undertaken in the future. Strengths of our study include its prospective design to assess psychological outcomes, a study population drawn from the community, and detailed information on a variety of potential confounders. We also utilised Rasch analysis to increase the validity and test-retest reliability of the loneliness scale. Our study limitations include paucity of Malay participants (n = 48) in our sample, which may have limited the generalisability of our results since Singapore is a multi-ethnic country comprising of Chinese (75.9%), Malays (15.0%), Indians (7.5%) and other ethnic groups (1.6%). 38 Second, our pre-lockdown data for depressive symptoms and loneliness were collected over 19 months which could have introduced variability in the results; however, sensitivity analyses found no significant differences in these outcomes between participants who completed the baseline PIONEER assessment less than a year from the lockdown assessment versus those who completed the assessment more than a year ago. Third, our study mainly used selfreported questionnaires to measure psychiatric symptoms and did not establish clinical diagnoses, notwithstanding that the gold standard for establishing psychiatric diagnosis involves conducting a structured clinical interview and functional neuroimaging. [39] [40] [41] Olszewska-Guizzo and colleagues found decreased brain haemodynamics during the COVID-19 pandemic which is associated with depressive symptoms. 42 As such, future research is required to assess a subset of participants, using functional neuroimaging and clinical diagnosis, for associated lockdown depression, may be 8 - warranted. Lastly, as mentioned previously, our data collection was undertaken towards the tail end of the lockdown. This meant that our findings could not capture the psychological, PA, and financial impact of the initial part of the lockdown. As such, future research should consider examining the change in outcomes across various phases of a lockdown. In conclusion, in our population of older Asian individuals, we found that a government-mandated lockdown resulted in a significant increase in loneliness and a decrease in PA, although they were less impacted financially, with only one in five reporting some degree of financial difficulty. 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The data that support the findings of this study are available from the corresponding author, Ecosse L. Lamoureux, upon reasonable request.