key: cord-1055638-82j2k54x authors: SAVCI, Cemile; ÇİL AKINCI, Ayşe; YILDIRIM ÜŞENMEZ, Sevinç; KELEŞ, Furkan title: The effects of fear of COVID-19, loneliness, and resilience on the quality of life in older adults living in a nursing home date: 2021-09-25 journal: Geriatr Nurs DOI: 10.1016/j.gerinurse.2021.09.012 sha: c852425794dd13a24478a473a9cd8d2a79879bc3 doc_id: 1055638 cord_uid: 82j2k54x This study aimed to evaluate the fear of COVID-19, loneliness, resilience, and quality of life levels in older adults in a nursing home during the pandemic, and the effects of these variables and descriptive characteristics on their quality of life. Data were collected using a participant information form, the Mini Mental State Exam (MMSE), the Brief Resilience Scale, the Fear of COVID-19 Scale (FCV-19S), the Loneliness Scale for Elderly (LSE), and the World Health Organization Quality of Life-BREF Turkish Version (WHOQOL-BREF-TR). Regarding the WHOQOL-BREF-TR scale, being male, history of chronic disease, MMSE score, and the changes in sleep pattern significantly affected the physical dimension (R(2)=0.353, p<0.01) while age, and MMSE and LSE scores significantly affected the psychological dimension (R(2)=0.364, p<0.01). Also, the MMSE, FCV-19S, and LSE scores significantly affected the social relations dimension (R(2)=0.234, p<0.01) while MMSE, FCV-19S, and LSE scores significantly affected the environmental dimension (R(2)=0.351, p<0.01). infectious disease a pandemic on March 11, 2020. 1 Older adults are the most vulnerable age group in terms of experiencing more severe symptoms due to physiological causes (such as decline in immune function, malnutrition, etc.) and comorbidities (such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease, etc.), and having a higher risk of death from COVID-19. [2] [3] [4] [5] In Turkey, individuals aged 65 and over constitute 11% of the reported patient numbers and 72% of deaths. 6 The risk has been reported to be even higher for older adults living in nursing homes 7 , where approximately two-thirds of them are infected with COVID-19 within three weeks, and the mortality rate is 33%. 8 The combined effects of the media's constant focus on mortality rates, especially the high mortality rates in older adults, and the social isolation, quarantine, and physical distancing measures applied to prevent the transmission of the disease can adversely affect the psychological health of older adults 9,10 and can be cause vairous problems, such as fear, anxiety, and loneliness. 2, 11, 12 Studies have reported that all older adults groups experienced depression and anxiety during the COVID-19 pandemic 13 , and the rate of reporting the fear of COVID-19 increased with age. 14 It has been reported that the older adults are the age group that is most affected by the fear of COVID-19 and loneliness in all countries regardless of the levels of COVID-19 cases and deaths. 15 Studies have indicated that the long-term restrictive 5 measures implemented around the world, including Turkey, may lead to increased incidences of loneliness in older adults living in nursing homes 16 and at home. 9 , 17 The restrictive measures, fear, and loneliness could adversely affect the physical, psychological, mental health, life style, and quality of life (QOL) of older adults. 5, [17] [18] [19] [20] The term psychological resilience is defined as the ability to adapt to challenging circumstances in a positive manner. 21 It has been reported that the restrictions imposed on individuals aged 65 and over during the COVID-19 pandemic, and the social difficulties, 22 fear, stress, and loneliness that the pandemic has generated may weaken the resilience of older adults and thereby endanger their health and QOL. 23 According to the WHO, QOL refers to individuals' perceptions of their position in life and their expectations, standards, and concerns. 24 The concept of QOL in old age has become a major topic of interest on account of the current rising population of older adults and the increase in the length of life. Previous studies have shown that demographic characteristics 25 , a history of chronic disease 26 , and sleep quality 27 The older adults residing in the institution where the study was conducted were housed in a two-storey building that had rooms for 3, 4, 6, 7, and 8 people. A total of 28 nurses, 9 physicians, 2 physiotherapists, 2 social workers, and 1 food engineer were working in the 7 nursing home at the time of the study. The in-house psychologist had recently left the institution at the time of the study. Routine examinations and treatments of the older adults living in the nursing home were performed in-house, but in cases of emergency or when further examination was needed, they were referred to the hospital. The nursing home features a rehabilitation unit where the older adults are able to socialize, spend their free time, and ply their respective skills to produce items (knitting, carpet weaving, painting, etc.), for which they get paid. However, during the collection of the study data, this unit was closed as a result of the restrictive measures imposed during the pandemic. The institution has been closed to visitors during the pandemic, and the older adults residing in the nursing home have been only allowed to contact their relatives by telephone. The data of the study were collected using a participant information form, the Mini Table 1) . The mean FCV-19S score of the participants was 19.13±4.28 (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) , the mean LSE Table 2) . (Table 3) . 12 The factors affecting quality of life .319) and LSE score (β: -.336) significantly affected scores on the environmental dimension (R 2 =0.351, p <0.01) ( Table 4 ). The mean FCV-19S score of the older adults residing in a nursing home in Turkey during the COVID-19 pandemic was 19.13±4.28, which means that their fear was moderate considering the minimum and maximum values that the scale can take. In a study conducted in Greece at the beginning of the COVID-19 pandemic, the FCV-19S score of older adults was reported to be 18.48±5.32. 40 In another study conducted in Turkey in June 2020, it was reported that individuals over the age of 65 had a moderate level of fear of COVID-19. 41 The results of both studies are similar to the results of the present study. The moderate level of fear experienced by the older adults in the present study could be attributed to the facts that the data for this study were collected in the latter stages of the pandemic, that the older adults in the nursing home had information about COVID-19, that vaccination studies had started, and that approximately half of them had had COVID-19. In this study, the older adults had a mean LSE score of 8.92±4.56, indicating, based on the minimum and maximum values that the scale can take, that the older adults' level of loneliness was low. Previous studies conducted in Turkey before the onset of COVID-19 13 reported that the level of loneliness of older adults in nursing homes was low, 42 while studies on this subject conducted during the pandemic reported that the loneliness levels of older adults was moderate in Turkey, 43 low in Greece, 40 and moderate in Australia 44 . A study conducted in the USA reported that 26% of individuals aged 60 and over experienced loneliness. 45 Although all these results support to some degree the results obtained from the present study, contrary to the present study's results, one study reported that 57% of people over 70 years of age who were hospitalized during the COVID-19 pandemic experienced loneliness. 46 On the dates during which the study was conducted, the institution was completely closed to visitors within the scope of the restrictive measures applied to nursing homes. Moreover, the psychologist had recently left the institution, and the rehabilitation centre, which plays a key role in the ability of the older adults living in the nursing home to socialize, was closed. Such factors could have negatively impacted the QOL of the older adults in the nursing home. According to a study, in nursing homes, sharing a room with three to five friends and having the opportunity to engage in daily conversations with roommates support social interaction. 47 Phone calls and video calls involving discussion of positive topics to make up for the absence of physical visits for older adults in nursing homes has been reported to be a good form of social support to eliminate the feeling of loneliness. 48 The fact that the older adults included in this study stayed in the same room with at least three people, had social interaction with the personnel who provide health care, food, and cleaning services in the nursing home, and had opportunities to communicate with their families and loved ones with the help of technological tools may have contributed to their low levels of loneliness. In this study, the mean BRS score was 18 process. 19 Psychological resilience refers to an individual's ability to successfully overcome adverse conditions and adapt to a new situation. 36 While loneliness, negative feelings, and mental illness negatively affect resilience, 45, 49, 50 well-being, social networking, and positive feelings positively affect resilience. 49, 50 The moderate level of psychological resilience seen in this study corresponded with the older adults' mean MMSE scores of 24 and above, their moderate fear of COVID-19 and low levels of loneliness, and the negative circumstances they faced during the pandemic, such as separation from loved ones. In this study, the QOL of the older adults in the nursing home was slightly above where the study was conducted and the sharing of a room with at least three people or living with peers likely contributed to meeting the physical, intellectual, and mental needs of the older adults in the study, and therefore, their mental and environmental dimension scores were high. In the study, while being male, having a history of chronic disease, and experiencing a change in sleep patterns negatively affected the physical dimension of the QOL, high MMSE score had a positive effect on this dimension. Contrary to the present study's results, other studies have reported no indication of there being a relationship between gender and physical health in older adults during the pandemic 44 or of men having better physical health than that of women. 51, 52 The results from the present study could be attributed to the fact that the majority of the participating older adults were male. In a study conducted in a nursing home before the pandemic, it was reported that the physical QOL of those without chronic diseases was higher, which supports the present study's results. 52 The mean MMSE score of above 24 obtained by the older adults in the present study indicates that they easily understood and complied with the information and measures related to COVID-19, which positively affected 16 their physical QOL. Older people need fewer hours of sleep. However, they do need sufficient sleep for physiological and psychological functions and to keep their quality of life at optimum levels. 53 In a study conducted at an adult day care centre before the pandemic, it was found that the older adults with sleep disorders were inadequately able to maintain their physical functions and had physical and emotional role difficulties. 54 Based on this, it could be argued that the lack of change in sleep patterns of the older adults in this study during the pandemic helped to sustain their physical ability and satisfaction with their daily lives in the nursing home. In the study, age and LSE score negatively affected the mental dimension of the QOL, while MMSE score positively affected it. The low mental QOL was believed to be due to the difficulties that the decrease in physical and mental functions attending old age create in adapting to an adverse situation like the pandemic. In one study, it was reported that loneliness negatively affected mental health, 44 in another study, it was reported that loneliness predicted the mental health dimension of QOL. 52 Accordingly, practices aimed at reducing loneliness and protecting and improving mental functions of older adults in nursing homes would be useful for keeping their mental health at a high level. In this study, the MMSE score and FCV-19S score positively affected the scores on the social relations dimension of the QOL, while the LSE score had a negative effect. The participating older adults' MMSE scores of 24 and above suggest that they had positive relations with others. In one of the more surprising results, the older adults with a high fear of COVID-19 had high scores in the social relations dimension, which could be attributed to the sense of safety that these older adults felt as a result of the measures taken in the nursing home and to their physical, social, intellectual and mental needs being met in the nursing home. It was reported in one study that loneliness negatively affected the social health of older adults during the pandemic, which supports the results of the present study. 44 In a study conducted in a nursing home before the pandemic in Turkey, the mean social relations dimension score obtained by older adults on the QOL was reported to be lower in those who were experiencing loneliness. 52 These results point to the importance of evaluating individuals who have a high level of loneliness, as indicated by low social QOL, and taking measures to reduce the level of loneliness in order to increase social QOL. In this study, the MMSE score and the FCV-19S score positively affected the environmental dimension of the QOL, whereas the LSE score had a negative effect. This study has a single-center design and is limited by its small sample size. The participants includes older adults who are able to fill out the Google survey form link (sufficient cognitive levels, speak and understand Turkish) and, therefore, the results cannot be generalized to the overall of older adults in a nursing home during the pandemic. However, this study is the first to evaluate the fear of COVID-19, loneliness, resilience, and QOL levels in older adults in a nursing home during the pandemic, and the effects of these variables and descriptive characteristics on their QOL. The results of the study, therefore, will fill the gap in the research on this topic. In this study, COVID-19 fear levels were moderate, loneliness levels were low, resilience levels were moderate, and all dimensions of QOL in the older adults living in the nursing home during the pandemic were slightly above the moderate level. Based on these results, it is recommended that initiative be applied to protect the mental status, provide regular sleep patterns, and reduce loneliness levels in order to increase the QOL of older adults in nursing homes during the pandemic. It is further recommended that older adults living in nursing homes be provided with various means of communication, like the telephone, e-mail, and video chat and mobile applications, to prevent loneliness and increase QOL. Lastly, due to the positive effect that a high level of fear was shown to have on the social relations and environmental dimensions of the QOL, it is recommended that fear should be considered as a protective health factor as opposed to viewing it in the traditional way as a factor that negatively affects health. WHO. 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(The Life Quality of Elderly Nursing Home Residents: Disability and the Effect of Drug Use?) Quality of life and factors affecting the quality of life of elderly nursing home residents Sleep: A marker of physical and mental health in the elderly Yaşlılarda uyku kalitesi ve yaşam kalitesi arasındaki ilişki: kesitsel bir çalışma