key: cord-0876856-5apq11xf
authors: Freedman, Vicki A; Hu, Mengyao; Kasper, Judith D
title: Changes in older adults’ social contact during the COVID-19 pandemic
date: 2021-09-16
journal: J Gerontol B Psychol Sci Soc Sci
DOI: 10.1093/geronb/gbab166
sha: 4078b8f54693e6a4e7aa2ababddfa4b4aee58f9c
doc_id: 876856
cord_uid: 5apq11xf

OBJECTIVES: To understand changes during the COVID-19 pandemic in weekly contact with non-resident family and friends for US adults ages 70 and older in residential care and community settings. METHODS: Participants in the National Health and Aging Trends Study COVID-19 mail supplement (N=3,098) reported frequency of phone, electronic, video, and in-person contact with non-resident family and friends in a typical week before and during the pandemic. We examined less-than-weekly contact by mode for those in residential care settings and community residents with and without limitations. We estimated multinomial logit models to examine predictors of change to less-than-weekly contact (vs. maintaining weekly-or-more contact) by mode, overall and stratified by setting. RESULTS: Weekly in-person contact fell substantially (from 61% to 39%) and more so in residential care (56% to 22%), where nearly four in ten transitioned to less-than-weekly in-person contact (doubling to 8 out of 10). Weekly-or-more contact was largely stable for electronic and telephone modes across settings. Weekly-or-more video contact increased mainly for community residents without limitations. Compared to community residents without limitations, those in assisted living or nursing homes had more than five times the odds (AOR=5.3; p=.01) of changing to less-than-weekly in-person contact; those in independent living also had higher odds of changing to less-than-weekly in-person (AOR=2.6; p=.01) and video (AOR=3.4; p=.01) contact. DISCUSSION: The pandemic revealed the importance of ensuring that communication technologies to maintain social ties are available to and usable by older adults, particularly for those living in residential care settings.

Lack of social interaction has been established as a risk factor for reduced health and wellbeing, cognitive declines and mortality in later life (Holt-Lunstad et al., 2015; Kelly et al., 2017; Courtin & Knapp, 2017; Berkman et al. 2000) . Prior to the COVID-19 pandemic, about one in 4 older adults were considered socially isolated (National Academies of Sciences, Engineering, and Medicine, 2020) . During the pandemic, shut-down orders, physical distancing guidelines and prohibition of visits with older adults in long-term care settings raised concerns about the extent to which an important aspect of social contact -in-person contact with non-resident family and friends -was curtailed, particularly for those with physical and cognitive limitations (Steinman et al., 2020; Cudjoe & Katwal, 2020; Hado & Feinberg, 2020; Zimmerman et al., 2020) .

A handful of studies have investigated social contact and isolation in light of the pandemic. For instance, a study of adults ages 50 and older in the US found increased physical isolation but not digital isolation during the outbreak (Peng & Roth, 2021) . Some studies have pointed to the distinctive emotional benefits of face-to-face contact during the outbreak relative to telephone and electronic forms of communication (Fingerman et al., 2021; Litwin & Levinsky, 2021; Hu & Qian, 2021; Summerlad et al. 2021) . Others have highlighted the value of connecting with family members in long-term care facilities, especially by telephone, when face-to-face contact is limited (Monin et al. 2020) . The benefit of online communications (e.g. social networking) and video calls for mitigating loneliness or depression has also been explored (Hajek & Konig, 2021; Zhang et al., 2020; Yu et al., 2021; Zamir et al. 2018 ), but findings are mixed.

Despite these important insights, national estimates that assess the impact of the pandemic on in-person contact for older adults with physical and cognitive limitations, particularly those in residential care settings where concerns have been especially acute (Zimmerman et al., 2020) , have been lacking.

A c c e p t e d M a n u s c r i p t Moreover, differences across residential settings in the extent to which other forms of contact-e.g.

telephone, electronic methods such as text, email, or social media, or video visits-have substituted for in-person visits during the pandemic remain unexplored.

Using data from the National Health and Aging Trends Study (NHATS), we compare older adults' frequency of social contacts before and during the pandemic. We document levels and changes by mode and how these findings differ for three groups: those in residential care settings, in the community with limitations, and in the community with no limitations. We then explore the extent to which setting influenced change by mode after controlling for demographic characteristics, pre-pandemic need and opportunities for non-resident contact, and openness to technology.

We used data from the COVID-19 Supplement to the National Health and Aging Trends Study (NHATS) linked to the 2019 NHATS interview. NHATS is a nationally representative study of Medicare enrollees ages 65 and older. Annual interviews have taken place in participants' homes from 2011 through 2019 (Kasper & Freedman, 2021) . In 2020, NHATS participants who completed a phone interview (response rate 96%) were eligible for a supplemental mail study (response rate 82%) about participants' experiences during the pandemic (Freedman and Hu, 2021) . All NHATS participants in 2020 were ages 70 or older. Nearly 90% of 3,257 COVID-19 booklets returned were completed during July and August 2020. We omitted 158 cases (<5%) that did not complete the social interaction items and one case with no 2019 NHATS interview, leaving N=3,098 for analysis.

Outcomes. In the COVID-19 supplement, respondents were asked for the period before and during the outbreak: in a typical week, how often did you have contact with family and friends not living with you by: 1) phone calls 2) emails, texts, or social media messages 3) video calls and 4) in person visits. Answers included: at least daily, a few times a week, about once a week, less than once a week, A c c e p t e d M a n u s c r i p t and never. We examined distributions by mode (Appendix Table A1 ) and then collapsed answer categories into weekly-or-more vs less-than-weekly contact for each mode. We created an indicator for each mode of whether frequency changed (e.g., to weekly-or-more or less-than-weekly contact) or remained the same before and during (e.g. less-than-weekly or weekly-or-more contact).

Comparison groups. We created three comparison groups ("settings") based on 2019 measures: those who lived in residential care, in the community with physical or cognitive limitations, and in the community with no limitations. These groups enable comparisons by residential setting, taking into account care needs. Physical limitation was defined as receiving any help with four self-care (bathing, dressing, eating or toileting) or three mobility-related (getting out of bed, getting around inside, getting outside) activities or with five household activities (laundry, making meals, shopping, banking, or managing medications) for health or functioning reasons (see Freedman & Spillman, 2014 for details).

Cognitive limitation was defined as having probable dementia based on reported diagnosis, informant reports of two or more memory-related problems, or cognitive tests scores 1.5 SD below the mean on two or more domains reflecting memory, orientation, or executive functioning (see Kasper, Freedman and Spillman, 2013) .

Control variables. Control variables were drawn from the 2019 NHATS interview. Participants' characteristics included age, gender, and race/ethnicity (non-Hispanic white vs. other groups). For those in residential care, we differentiated independent living from assisted living or nursing home settings.

We represented need and opportunities for non-resident contact by whether the participant lived alone, had at least one non-resident daughter or social network member (i.e., someone they talked with about important things) and the size of the non-resident network (i.e., sum of non-resident adult children, stepchildren, siblings, and social network members and in a small number of cases a nonresident spouse or partner). Openness to technology was represented by whether the participant had a college M a n u s c r i p t education and (for models predicting in-person, telephone and video contact outcomes) by whether the participant emailed or texted most or some days or if they visited social networking sites.

Methods. We reported p-values for X 2 tests for differences across settings in contact frequency before and during the pandemic and in changes in contact frequency. We tested for differences across setting in covariates with t-tests and X 2 tests (for continuous and categorical variables, respectively).

Finally, we estimated a series of multinomial logit models for all settings combined (and by setting; see Appendix) predicting change in contact by mode, with the omitted category maintaining weekly-or-more contact before and during the pandemic. We reported β-coefficients and associated p-values and in the text adjusted odds ratios (AOR=exp(β)) to facilitate interpretation.

All estimates used weights taking into account differential probabilities of selection and response to NHATS and the COVID-19 supplement. Standard errors were adjusted to reflect the complex design of NHATS.

Among adults 70 and older, 60.5% had weekly-or more in-person contact before the pandemic; this figure dropped to 39.0% during the pandemic (top panel, Table 1 ). Weekly-or-more contact was substantial and largely stable for telephone (89.2%-86.6%) and electronic methods (64.8%-62.5%) whereas weekly video communication increased (from 21.4% to 26.0%). Altogether, one in four (25.0%) older adults experienced changes to less-than-weekly in-person contact. Although changes in phone or electronic contact were relatively uncommon, 8.1% increased to weekly-or-more contact by video.

With respect to setting differences, four points are noteworthy (bottom panel, Table 1 ). First, community residents with no limitations were most likely to have weekly-or-more in-person, phone and electronic contact before the pandemic. Second, for those in residential care settings, weekly-or-more A c c e p t e d M a n u s c r i p t in-person contact declined substantially (55.8% to 21.7%) and more than for those in the community.

That is, nearly four in ten in residential care transitioned to less-than-weekly in-person contact, resulting in a doubling to 8 out of 10. Third, phone contact also declined in residential care more than in community settings (82.3% before; 76.8% during), but the declines were not as steep as for in-person visits. Fourth, 9% of those in the community without limitations changed to weekly-or-more video communication (vs. 5%-6% for other groups).

Compared to community residents (with or without limitations), those in residential care were older on average, more likely to be female and living alone, and had smaller non-resident networks than other groups (Table 2 ). They were more likely to be college-educated but less likely to have a history of regularly using email, texting or social network sites. Those living in the community with limitations were more racially and ethnically diverse than the other groups.

In models, setting was significantly associated with change to less-than-weekly in-person and video contact (Table 3) . Compared to community residents with no limitations, those in assisted living or nursing home settings had more than five times the odds of changing to less-than-weekly in-person contact vs. maintaining weekly-or-more contact (β=1.94, p<.01; AOR=5.3). Those in independent living settings had higher odds of changing to less-than-weekly in-person (β=0.97, p<.01; AOR=2.6) and video (β=1.25, p<.05; AOR=3.4) contact.

Several additional points about covariates (Table 3 and Appendix Tables 2 and 3) are noteworthy. First, pre-pandemic family and social network measures were associated with lower odds of changing to less-than-weekly phone contact, particularly for those with limitations. Second, the chances of changing to less-than-weekly contact were higher for in-person and lower for video contact when the older adult had a history of email, texting or social networking, but this finding was limited to A c c e p t e d M a n u s c r i p t those without limitations. Finally, those who lived alone had lower odds of changing to less-than-weekly in-person contact across all settings.

We found that during the COVID-19 pandemic, across all settings, one in four older adults experienced a change to less-than-weekly in-person visits with non-resident family and friends. Video contact increased marginally, and phone and electronic contact remained substantial and largely stable.

Our findings align with one other national study examining COVID-related changes in contact, which found a significant increase in mean physical isolation scores but no difference in digital isolation for those ages 50 and older in 2020 compared to 2016 (Peng and Roth, 2021) .

We also add to the literature by identifying differences across settings. During the pandemic, weekly in-person contact fell most for those in residential care so that 8 out of 10 older adults in these settings -double the pre-pandemic level -had less-than-weekly in-person contact with non-resident family or friends. In adjusted models, the chances of changing to less-than-weekly contact were highest for those in assisted living and nursing home settings, followed by independent living settings. These findings highlight the challenges posed by the pandemic to settings that have been characterized as centered on providing opportunities for social engagement (Zimmerman et al. 2020) .

Video contact increased marginally during the pandemic mainly among those without limitations in the community. Elevated chances of changing to less-than-weekly video contact were observed in independent living settings, although the reasons for this pattern are not clear. It may be that access to shared technology or designated staff to assist with technology may have been limited during the pandemic (Zimmerman et al. 2020) .

A c c e p t e d M a n u s c r i p t This analysis has limitations. Pre-pandemic measures of contact were collected retrospectively.

Although the average recall period was only 4-5 months (to before March 2020), reports of prepandemic behaviors may have been inaccurate for some participants. Seasonal influences on contact, particularly for face-to-face visits, also cannot be ruled out. In addition, because of limited sample sizes, in stratified (supplemental) models, we combined those living in residential care and in the community with limitations. We were therefore unable to explore whether family/network and technology use had different effects in these settings. Moreover, this analysis focused on the frequency of social contacts and did not address the quality of interactions or extent of emotional support related to such contacts, nor did it explore other kinds of social participation that may have taken place during the pandemic.

Despite these limitations, this study is the first to document the extraordinary declines during the COVID-19 pandemic in face-to-face visits across residential settings for a national sample of older adults. Particularly striking are the substantial declines for in-person visits and low levels of regular video use with family and friends, especially in residential care settings. In response to the pandemic, some have suggested that clinicians should monitor not only loneliness and perceptions of social isolation among patients, but also access to phone and video communication technologies (Cudjoe & Katwal, 2020) . Our findings underscore the importance of this recommendation and the need for residential care facilities to monitor these outcomes for residents as well. Finally, although additional studies are needed to evaluate the potential of video and other technologies to mitigate loneliness and social isolation (Hajek & König, 2021) , the pandemic has made clear the need to invest in technological and personnel infrastructure -particularly in residential care settings -not only for "tele-medicine" purposes but for "tele-visits" with family and friends as a means of maintaining social ties when inperson contact is not possible.

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 M a n u s c r i p t 

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M (sd)

Nonresident network size, M(sd) = sum of spouse/partner, children, siblings, and social network members