Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 https://doi.org/10.1186/s12877-022-03072-w RESEARCH ARTICLE Open Access Correlates to psychological distress in frail older community‑dwellers undergoing lockdown during the COVID‑19 pandemic Carmina Castellano‑Tejedor1,2,3*, Laura M. Pérez1,2, Luis Soto‑Bagaria1,2, Ester Risco1,2, Maria Victoria Mazo2,4, Ana Gómez5, Daniel Salvador6, Javier Yanguas7, María B. Enfedaque8, Alessandro Morandi2,9,10, Mariona Font2, Vanessa Davey2 and Marco Inzitari1,2,11,12 Abstract Background: This study identifies correlates of the lockdown’s psychological distress in frail older community-dwell‑ ers (Catalonia, Spain). Methods: Participants from a community frailty intervention program, with a comprehensive geriatric assessment within the 12-months pre-lockdown and COVID-19 free during the first pandemic wave (March–May 2020), under‑ went a phone assessment past the lockdown to assess COVID-19-related emotional distress (DME) as well as other sociodemograhic, clinical and psychosocial factors. Results: Of the 94 frail older adults (age = 82,34 ± 6,12 years; 68,1% women; 38,3% living alone), 84,9% were at risk of experiencing moderate-to-high psychological distress, according to the backward stepwise logistic regression model obtained (χ2 = 47,007, p < 0,001, Nagelkerke ­R2 = 0,528), based on the following factors: absence of depressive symptoms before lockdown (OR = 0,12, p = 0,014, 95%CI[0,023–0,647]), not carrying out leisure activities during lock‑ down (OR = 0,257, p = 0,023, 95%CI[0,079–0,832]) and currently experiencing high malaise due to COVID-19 situation (OR = 1,504, p < 0,001, 95%CI[1,241–1,822]). Discussion: These findings suggest that it is necessary to favour a prior overall health status and to empower frail older community-dwellers in the use of a broad repertoire of coping strategies in the face of adversity to foster men‑ tal health and keep at bay the potential emotional impact of the situation generated by the COVID pandemic. Keywords: COVID-19, Frailty, Ageing, Psychological distress, Lockdown Background bans, cancelled social events, and closed public services COVID-19 is transmitted between humans in close to contain COVID-19 [24, 53]. Confinement and isola- proximity. Thus, besides individual preventive hygiene tion have been proven to be highly effective in reduc- measures, physical-social distancing is crucial for ing the risk of contracting and spreading COVID-19 reducing its spread. By April 2020, most countries [12, 23, 52]. However, previous outbreaks of SARS and worldwide had introduced quarantine measures, travel MERS showed that such measures could negatively affect some individuals’ mental health, with increases in psychological distress or even psychiatric symptoms *Correspondence: ninacastej@yahoo.es linked to stress reactions such as anxiety and depres- 1 Parc Sanitari Pere Virgili, Area of Intermediate Care, REFiT BCN Research sion [9, 28]. Similar mid-to-long term effects have been Group, Gregal 0, 08030 Barcelona, Spain Full list of author information is available at the end of the article reported due to the COVID-19 situation [18]. This © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 2 of 10 potentially traumatic stressor might cause or exacer- Methods bate psychological distress [7]. High levels of psycho- Study population and design logical distress indicate impaired mental health and The study population was derived from the + ÀGIL Bar- may reflect common mental disorders, like depressive celona project, an ongoing “real-life” intervention pro- and anxiety disorders. gram to promote healthy lifestyles [42, 43] in Catalonia, Multiple factors may trigger increased psychologi- Spain. This program enrols to a longitudinal design cal distress during the pandemic. Importance has been study, non-disabled frail older adults presenting with at given to the direct effects of isolation, with restrictions least one sign of frailty (i.e., slow gait speed, weakness, on movements and sedentary lifestyles [41] and impov- memory complaints, involuntary weight loss, poor social erishment of social contacts [20]. Psychological distress support). + ÀGIL offers a multicomponent tailored- may also arise from the immediate need to adapt to intervention to slow or revert frailty and promote health- new lifestyles and change day-to-day routines [2, 15]. related quality of life. One of the main components of Also, an increased state of alert due to fear of conta- the + ÀGIL Barcelona program is physical activity medi- gion, grief, or mourning the loss of family members or ated via a 10-week physical exercise program combining friends for COVID-19 may undermine wellbeing [19]. at-home monitored sessions based on the ViviFrail plat- All these considerations apply to the general popula- form [27] with weekly group sessions (one day per week). tion, and very little information is available for older A physical activity maintenance plan is incorporated, adults, one of the most vulnerable collectives in society. taking advantage of existing resources in the commu- So far, data suggest that COVID-19 is associated with nity to boost and support participants to become more particularly unfavorable outcomes when infecting frail active. Promotion of a Mediterranean diet, health educa- older people. Unfortunately, the impact of the COVID- tion, and optimization of pharmacological therapies are 19 pandemic on this population may extend beyond also part of the intervention. After the initial comprehen- directly related morbidity and deaths to also include a sive geriatric assessment to tailor the intervention, the negative influence on pre-existing clinical conditions geriatrician performed follow-ups at 3 and 6 months to and geriatric syndromes [13, 38]. The burden of the revise and refine the intervention as appropriate. + ÀGIL pandemic on older people is therefore likely underes- Barcelona program activity has been continuously run- timated by official statistics, which almost exclusively ning from July 2016 until March 2020 (enrolling up to focus on mortality and the number of infected per- 245 older persons). Due to the COVID-19 pandemic, the sons. During the actual COVID-19 pandemic, older face-to-face assessments were temporarily suspended, adults were specially advised to minimize social con- and phone follow-ups were carried out instead. + AGIL tact with people outside their household and remain Barcelona protocol and preliminary results have been at home wherever possible. Consequently, it increases described elsewhere [26, 42, 43]. the risk of experiencing significant psychological dis- tress in a population already vulnerable to loneliness Procedure and data collection and social isolation [9, 17, 28]. In line with earlier In May 2020, at the end of the Spanish lockdown applied reports, high levels of depressive disorders and anxi- by the Spanish Government (7 weeks, from March 14th ety were observed among older adults, often associ- to May 2nd), participants already included in the + ÀGIL ated with physical health deterioration and decreased program and waiting for follow-up evaluation were con- social support [21]. A priori, COVID-19 provides the tacted by telephone. To be included in the present study, “perfect storm” for undermining older adults´ mental participants needed to have been previously assessed health. However, specific knowledge of the psychologi- face-to-face during the 12 months before the lockdown cal impact of social distancing measures on frail older (either at the baseline, 3, and/or 6-month follow-up individuals is still scarce [1]. visit). If the participant could not attend the phone call, From this perspective, this study sought to investigate a self-identified proxy or caregiver answered the follow- the impact of lockdown on psychological symptoms up interview. The interviews lasted around 20 min and (specifically, COVID-related distress) on frail commu- were performed by two trained physiotherapist research- nity-dwelling older people who had not been diagnosed ers. Out of 117 contacted participants from the + ÀGIL with COVID-19 during the first trimester of COVID-19 Barcelona program, 107 (91.5%) accepted to answer the strict lockdown. Factors that could modulate COVID- phone survey. The remaining cases were not reached or 19-related distress such as gender increased previous did not want to answer the phone survey. Considering physical and psychosocial vulnerability and negative con- the total included respondents, four participants (3.7%) sequences derived from the pandemic (i.e., loss of a loved were excluded from final analyses due to a positive diag- one, isolation) were also investigated. nosis of SARS-COV-2 to ensure the studied sample’s Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 3 of 10 homogeneity, and nine participants (8.4%) were excluded social contact and frequency, COVID-19 diagnosis on from analyses since no data was available regarding relatives, new onset of acute clinical events, self-reported the primary outcome variable (psychological distress, fatigue, frailty-related symptoms [42, 43], cancelled assessed with the Detection of Emotional Distress Scale health visits due to the pandemic and communication [DME]); [32, 33]. with healthcare professionals, functional independence for basic activities of daily living (Barthel index [0–100 Main outcome variable points] [36]), the practice of physical activity (Brief Physi- Emotional distress was screened with the Detection of cal Activity Assessment Tool [BPAAT, 0–8 points] [44]), Emotional Distress Scale (DME); [32, 33], a brief ques- self-perceived quality of life, self-perceived quality of tionnaire consisting of two parts. The first one contains sleep and activities performed to stay active during the three questions addressed to the patient; self-perceived lockdown. mood and coping with the situation (numeric scale ranging from 0–10) and a multiple-selection check item Statistical analysis recording the presence or the absence of different specific Characteristics of the sample before lockdown are pre- concerns. The second part consists of clinical observation sented as mean values and standard deviation or median of external signs of emotional distress by the healthcare values and interquartile range for continuous variables as professional. The DME gives a total score from 0 to 20, applicable, and frequency and percentages for categorical consisting of the sum of the direct scores of the answers variables. According to the total DME score, the primary to the questions concerning mood assessment and how outcome variable was the categorized psychological dis- it is handled (first part), higher scores indicating higher tress considering the cut-off ≥ 9 (mild emotional distress emotional distress. According to the previously estab- vs. moderate-to-severe emotional distress) as recom- lished cut-off, the total DME score was categorized into mended by the authors’ of the instrument. Differences mild emotional distress and moderate-severe emotional among participants with mild and moderate-to-severe distress. Questions about concerns or external signs of psychological distress due to the COVID-19 pandemic emotional distress allow healthcare professionals to pro- were analyzed using the Student’s t-test or the Mann– vide more targeted care. Cronbach’s alpha for this study Whitney U-test and Chi-square test, as appropriate. was 0.83. Variables showing an association with the main outcome variable (p-value < 0,05) and those considered clinically Covariates relevant or to have a potential influence on the main Data from the last face-to-face comprehensive geriatric outcome variable were included in a backward stepwise assessment (CGA) pre-lockdown were considered covar- logistic regression model (emotional distress as dichoto- iates. These included: sociodemographic data (age, gen- mous outcome). This stepwise approach is useful because der, living alone, education level), clinical characteristics it reduces the number of predictors, reduces the multi- including Charlson Comorbidity Index [14], functional collinearity problem, and is one way to resolve the over- independence for basic activities of daily living (Barthel fitting. All analyses were performed using SPSS version index [0–100 points] [36]) and instrumental activities 20. for daily living (Lawton index [0–8 points] [30]), previ- ous diagnosis of cognitive impairment and/or dementia, Ethical aspects or positive screening (Minicog range 0–5; < 3 positive The + ÀGIL Barcelona program and study protocol were screening for cognitive impairment [6, 10]), depressive approved by the Clinical Research Ethics Committee of symptoms (Yesavage Geriatric Depression Scale [0–15 the Institut Universitari d’Investigació en Atención Pri- points] [25, 54]), physical function (Short Physical Perfor- maria Jordi Gol i Gorina (reference number 20/048-P) mance Battery [SPPB, 0–12 points] [22, 51]), practice of and Comisión de Ética en la Experimentación Animal y physical activity (Brief Physical Activity Assessment Tool Humana, Universitat Autònoma de Barcelona (reference [BPAAT, 0–8 points] [44]), frailty status (Clinical Frailty number CEEAH 5066). All procedures align with inter- Scale (CFS) [45]), self-perceived social loneliness (Lone- nal ethical regulations and those from the World Medical liness Scale [ESTE II], 0–30 points [46]) self-reported Association and the Declaration of Helsinki of 1975, with health status (EuroQol-5 Dimension [EQ-5D] [4]) and its successive amendments. Before starting the telephone self-perceived quality of sleep. interview, oral informed consent was obtained from all Data collected by semi-structured phone interview participants after receiving the study’s information and during the lockdown included: sociodemographic data the measures to guarantee their data confidentiality and (age, gender, cohabitation), support at home, social rela- protection. Previously, written informed consent was tions with family or other persons, tools to maintain obtained from all participants at baseline measures and Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 4 of 10 inclusion, as a part of the + ÀGIL Barcelona program (p = 0,011), and experienced more discomfort (p < 0,001) and its research procedures (including face-to-face or and moderate difficulties in coping with the situation cre- telephone interviews). If the participant could not pro- ated by the COVID-19 pandemic (p < 0,001), when com- vide such consent, it was obtained from a proxy. All data pared to mild or non-distressed individuals (see Table 2). were treated following the Spanish Organic Law 3/2018 A statistically significant model (χ2 = 47,007, p < 0,001, of Protection of personal data. Data confidentiality was Nagelkerke ­R2 = 0,528) was obtained, correctly classify- ensured at all times using a coding system. Data collected ing 84,9% of individuals at risk of experiencing moderate- has been exclusively used for the present study, and par- to-high psychological distress, based on the following ticipation was not economically rewarded. factors: the absence of depressive symptoms before lock- down, not carrying out any type of the leisure activi- Results ties during the lockdown, such as painting, crafts, table Out of 117 contacted participants from + ÀGIL, 107 games, urban gardening or listening to music or watching (91,5%) agreed to answer the phone survey. To ensure the TV, and expressing high malaise due to COVID situation homogeneity of the population, those previously diag- (see Table 3). nosed with SARS-COVID-19 (n = 4), or with incomplete data (n = 9), were excluded. Finally, we included in the Discussion analyses 94 participants (mean age = 82,34 ± 6,12 years; In our sample, the general psychological impact of the 68,1% women; 38,3% living alone; mean time since last lockdown in older frail, pre-disabled community-dwellers face-to-face visit = 8,2 ± 3,8 months). There were no non affected directly by COVID-19 was medium-to-high. significant differences in terms of age, gender, and time One-third of them expressed significant malaise due to since the last face-to-face assessment between those who the COVID situation (distress thermometer), and half of accepted and those who refused to participate or were the sample reached the cut-off point in the DME assess- excluded from the survey. ment tool, indicating clinically significant emotional dis- Characteristics of the sample before the lockdown due tress. This study also revealed that factors identifying to COVID-19 are displayed in Table 1. at-risk individuals to suffer moderate-to-high psychologi- During the COVID-19 lockdown, malaise directly cal impact are related to previous mental health status, related to the COVID pandemic situation was assessed current experience and intrapersonal resources to cope by means of the distress thermometer, and results were with the situation imposed by the pandemic. medium-to-high (M = 5,57 ± 3,37, range 0–10) with Our results are in line with previous research that has approximately one-third of the sample scoring ≥ 8 points pointed out that women are more prone to suffer from (n = 33, 35%). Psychological distress assessed through psychological distress during strict lockdown measures the DME assessment tool (total score) was also medium- related to health crises. This was already documented to-high (M = 8,55 ± 4,30, range 0–18), with half of the during the equine or the H1N1 influenza outbreak, and sample (n = 53, 56,4%) scoring ≥ 9 points (DME cut- preliminary evidence related to the COVID-19 pandemic off ). Higher psychological distress during the lockdown also points in this direction [11, 35]. A possible explana- was associated with the female gender (p = 0,028) and tion for this is that, regardless of age, in Western cultures, the presence of depressive symptoms (p = 0,001), with a women present a more externalizing pattern of reporting higher proportion of women and individuals experienc- feelings and emotions, their degree of emotional aware- ing depressive symptoms within the group of moder- ness is usually higher, and they tend to share more openly ate-to-severe emotional distress. Despite not reaching their experiences and the possible impact of potentially statistical significance, this group of individuals were also traumatic experiences than men [48]. Another expla- a subsample characterized by living alone, being older, nation for these results may be that the prevalence of having a cognitive impairment and displaying a frailer depression and anxiety is generally higher in women [3, and more sedentary profile. 47]. During the lockdown, individuals showing a profile Most frequently reported concerns during the COVID- of moderate-to-severe psychological distress due to the 19 pandemic were those related to the health status of a COVID-19 situation tended to use coping strategies family member and close relatives, coinciding with most based on disengagement and distraction, including lei- research in this field [11, 35, 50]. In this line, family situ- sure activities such as painting, crafts, table games, urban ation concerns were associated with moderate-to-high gardening (p = 0,012), watching TV, or listening to music psychological distress. Most reports have pointed out (p = 0,029). Also, these individuals reported significantly that the general state of worries was high at the begin- lower quality of life (p = 0,033), were more likely to have ning of the pandemic and tended to decrease steadily concerns for their family wellbeing relating to COVID-19 throughout the subsequent months; with no significant Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 5 of 10 Table 1 Pre-lockdown characteristics and association with emotional distress during the COVID-19 lockdown Baseline characteristics (pre-lockdown) Included N = 94 Mild emotional distress Moderate-to-severe emotional p-value during lockdown, n = 41a distress during lockdown, n = 53a Age, mean (SD) 82,4 (6,1) 83,2 (5,9) 81,7 (6,3) 0,233 Women, % (n) 68,1 (64) 56,1 (23) 77,4 (41) 0,028 Living alone, % (n) 55,3 (52) 61,0 (25) 50,9 (27) 0,332 Education, % (n) Illiterate 8,6 (8) 12,2 (5) 5,8 (3) 0,357 Primary school 37,6 (35) 43,9 (18) 32,7 (17) Secondary school 39,8 (37) 31,7 (13) 46,2 (24) University degree 14,0 (13) 12,2 (5) 15,4 (8) Charlson Comorbidity Index, median (IQR) 2 (1–3) 1 (1–3) 2 (1–3) 0,433 Barthel ­indexb, median (IQR) 95 (90 – 100) 95 (90 – 100) 95 (90 – 95) 0,185 Lawton ­indexc, median (IQR) 5,5 (3–8) 5 (3–8) 6 (3–8) 0,576 Previous diagnosis/positive screening of cognitive 33,3 (31) 42,5 (17) 26,4 (14) 0,103 ­impairmentd, % (n) Depressive symptoms (Yesavage GDS-15)e, % (n) 21,3 (20) 4,9 (2) 34,0 (18) 0,001 Vulnerable and/or any frailty degree (CFS)f, % (n) 62,8 (59) 65,9 (27) 60,4 (32) 0,586 Sufficient physical ­activityg, % (n) 60,9 (56) 53,7 (22) 66,7 (34) 0,204 SPPB, mean (SD) 8,5 (2,9) 8,7 (3,1) 8,4 (2,8) 0,662 Gait speed, mean (SD) 0,77 (0,21) 0,79 (0.20) 0,73 (0,22) 0,244 ESTE II total, mean (SD)h 12,5 (9–15) 12,1 (4.6) 12,9 (94,8) 0,448 ESTE II–Social support, mean (SD) 3,5 (3,0) 3,1 (2,7) 3,9 (3,1) 0,185 ESTE II–Use of new technologies, mean (SD) 4,1 (1,6) 4,0 (1,5) 4,2 (1,6) 0,437 ESTE II–Self-report social participation, mean (SD) 4,9 (2,4) 5,1 (2,5) 4,7 (2,4) 0,464 Self-reported health status, % (n) Low 14,9 (14) 12,2 (5) 17,0 (9) 0,808 Normal or regular 25,5 (24) 26,8 (11) 24,5 (13) Good or Excellent 59,6 (56) 61,0 (25) 58,5 (31) Self-reported sleep quality, good–excellent, % (n) 48,9 (46) 56,1 (23) 43,4 (23) 0,222 IQR Interquartile range, SD Standard deviation Student’s t-test or the Mann–Whitney U-test were used for continuous variables as appropriate and Chi-square test for categorical a Detection of Emotional Distress Scale (DME scale): scoring range from 0–20 (≥ 9 moderate-to-severe emotional distress) b Independence for activities of daily living, Barthel index: scoring range from 0–100 c Independence for instrumental activities of daily living, Lawton index: scoring range from 0–8 d Previous diagnosis of cognitive impairment or dementia, or positive screening performed with Minicog: scoring range 0–5 points (< 3 positive screening for cognitive impairment) e Geriatric Depression Scale Yesavage (GDS-15): scoring range from 0–15 points (> 5 points: probable depression) f Clinical Frailty Scale (CFS): scoring range from 1–9 points (1–3: very fit-fit, managing well; 4–6: mild-to-moderate frailty; 7–9: severe frailty-to-terminally ill) g Brief Physical Activity Assessment Tool (BPAAT): scoring range from 0–8 (≥ 4 points: sufficient active, 0–3: insufficient active) h Social Loneliness Scale (ESTE-II): scoring range 0–30 (≥ 11 points: moderate-to-high social loneliness) effect depending on the different official announcements and/or threats. Our sample revealed a disengaged cop- and interventions [50]. Despite not having evidence in ing style to self-regulated distress generated by the pan- this sense in our study, it is also possible that women suf- demic and lockdown situations. In this sense, the most fer from a greater care burden due to the increased need distressed individuals report greater use of distrac- for care both outside and inside the home during lock- tion such as leisure activities (i.e., painting, crafts, table down (i.e., husband and/or grandchildren) [34, 37]. games, urban gardening) and watching TV or listening Faced with the experience of a potentially overwhelm- to music to mitigate their psychological impact, com- ing and traumatic situation, people put in place a series pared to those individuals experiencing mild emotional of coping strategies and more or less conscious defence distress. These results are in line with previous research mechanisms to help to overcome perceived difficulties pointing out that strategies reflecting disengagement Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 6 of 10 Table 2 Description of characteristics of the sample during the lockdown due to COVID-19 Characteristics Included N = 94 Mild emotional Distress Moderate-to-severe emotional p-value during lockdown, distress during lockdown, n = 41a n = 53a Living alone, % (n) 38,3 (36) 34,2 (14) 41,5 (22) 0,466 Who lives at home, % (n) Family 53,2 (50) 58,5 (24) 49,1 (26) 0,718 Formal caregiver 4,3 (4) 2,4 (1) 5,7 (3) Family and formal caregiver 4,3 (4) 4,9 (2) 3,8 (2) Social contact maintained by, % (n): Phone 77,0 (67) 66,7 (24) 84,3 (43) 0,154 Video-call 9,2 (8) 13,9 (5) 5,9 (3) Phone and Video-call 13,8 (12) 19,4 (7) 9,8 (5) Social contact different than family, % (n) 46,8 (44) 36,6 (15) 54,7 (29) 0,081 Frequency of social contact, % (n) Daily 84,0 (79) 82,9 (34) 84,9 (45) 0,397 Once/twice a week 11,7 (11) 9,8 (4) 13,2 (7) No contact 4,3 (4) 7,3 (3) 1,9 (1) Received support for housework, % (n) 40,4 (38) 41,5 (17) 39,6 (21) 0,857 Received help with groceries and medication, % (n) 100,0 (94) 100,0 (41,0) 100,0 (53) Activities to stay active during ­lockdownb, % (n) Housework 47,9 (45) 43,9 (18) 50,9 (27) 0,498 Leisure ­activitiesc 36,2 (34) 22,0 (9) 47,2 (25) 0,012 Music/ TV 70,2 (66) 58,5 (24) 79,3 (42) 0,029 Provide care 5,3 (5) 2,4 (1) 7,6 (5) 0,274 Reading 27,6 (26) 26,8 (11) 28,3 (15) 0,874 Social contact 10,6 (10) 14,6 (6) 7,6 (4) 0,269 Use of technology 5,3 (5) 7,3 (3) 3,8 (2) 0,448 Self-reported health status, % (n) Low 6,4 (6) 0,0 (0) 11,3 (6) 0,033 Normal or regular 66,0 (62) 63,4 (26) 67,9 (36) Good or Excellent 27,7 (26) 36,6 (15) 20,8 (11) Self-reported sleep quality, good-excellentd, % (n) 50,0 (47) 61,0 (25) 41,5 (22) 0,061 Family member got COVID-19, % (n) 8,5 (8) 2,4 (1) 13,2 (7) 0,064 Relative died due to COVID-19, % (n) 2,1 (2) 0,0 (0) 3,8 (2) 0,209 Moderate discomfort due to COVID-19 ­situatione, % 45,7 (43) 17,1 (7) 67,9 (36) < 0,001 (n) Main concern during COVID (item 2 DME), % (n) Economic situation 9,6 (9) 7,3 (3) 11,3 (6) 0,513 Family situation 30,9 (29) 17,1 (7) 41,5 (22) 0,011 Emotional 5,3 (5) 7,3 (3) 3,8 (2) 0,448 Health-related 6,4 (6) 4,9 (2) 7,6 (4) 0,600 Others (not specified) 9,6 (9) 7,3 (3) 11,3 (6) 0,513 No concerns 37,2 (35) 53,7 (22) 24,5 (13) 0,004 Moderate difficulty coping with the COVID-19 situa‑ 33,0 (31) 0,0 (0) 58,5 (31) < 0,001 tion (item 3 DME)f % (n) a Detection of Emotional Distress Scale (DME scale): scoring range from 0–20 (≥ 9 moderate-to-severe emotional distress) b Not mutually exclusive c This category includes: painting, crafts, table games, urban gardening d Self-reported sleep quality: excellent, good, regular, bad, very bad e Discomfort due to COVID-19 (distress thermometer item from the DME): scoring range from 0–10 (≥ 7 points: moderate discomfort) f Difficulty coping with COVID-19 situation (item 3 from the DME): scoring range from 0–10 (≥ 7 points: moderate difficulty coping) Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 7 of 10 Table 3 Association with moderate emotional distress during the COVID-19 lockdown. Multivariable logistic regression analysis OR Exp (B) 95%CI for Exp (B) p-value Depressive ­symptomsa (pre-lockdown) 0,121 0,023—0,647 0,014 Leisure ­activitiesb (during lockdown) 0,257 0,079—0,832 0,023 Malaise due to COVID-19 situation (during lockdown) 1,504 1,241—1,822 < 0,001 a Assessed by means of the Geriatric Depression Scale Yesavage (GDS-15) b Leisure activities as a specific type of coping to stay active during lockdown copings, such as passive reaction pattern, palliative reac- period, it seems crucial to make time for healthy habits tion, and avoidance, were associated with less perceived combined with leisure and enjoyable activities not only control and negatively associated with psychological based on disengagement (e.g., indoor physical activi- wellbeing [16]. In this sense, it is important to highlight ties such as stretching, gymnastics, yoga, hula hoop, and that all individuals reporting moderate-to-high difficul- dumbbell exercise). ties coping with the situation are within the moderate-to- Contrary to what was expected, having suffered the high distress individuals’ group, with no cases expressing loss of a loved one and living alone was not related to significant difficulties to cope in the mild-distressed indi- higher odds of suffering from psychological distress. This viduals’ group. might be due to the low prevalence of grieving individ- A strong relationship between self-perceived general uals in our sample and the long time they were already health status and mental health has been noted in several living alone before the COVID-19 pandemic. Also, there studies [5]. When analysing differences in self-reported were no significant differences in the means or frequency health of the participants, a higher percentage of indi- of social contact between individuals that experienced viduals reporting low health status was observed among moderate to severe emotional distress and individuals those in the moderate-to-high distress group. These dif- whose emotional distress was only mild. Studies have ferences reached statistical significance when they were shown that older adults [49], as well as younger adults reassessed during confinement. (between 18–35 years of age) [29], reported high levels Our study reveals several factors that could serve to of loneliness after social distancing measures were imple- identify and characterize this sample of at-risk indi- mented. However, some research suggests that older viduals to suffer moderate-to-high distress due to the adults may be more resilient to the negative effects on COVID-19 situation. Among frail community older mental health [40] and younger adults might be at greater adults not diagnosed with COVID during the first tri- risk for heightened loneliness during the pandemic [8]. In mester of strict lockdown, those not carrying out any our study, perhaps due to the low variability in the age leisure activities during the lockdown, and not having range included in the study sample, these associations experienced depressive symptoms before this period but could not be found. expressing current significant malaise due to COVID-19 In light of these results, our findings suggest that it is situation are those at higher risk of moderate-to-high necessary to favour a prior overall health status and, at psychological impact. the same time, to empower individuals in the use of a As some research has demonstrated, there is a clear broad repertoire of coping strategies in the face of adver- interplay between physical activities and psychological sity to foster mental health and make it easier to keep factors in the general population and, specifically, among concerns at bay. older adults [39]. Evidence has shown that regular physi- This study has different limitations. Data were mainly cal activities help develop self-efficacy and bring changes collected through self-report measures and semi-struc- in the perception of one’s health and happiness, thereby tured interviews by phone, which presents a possible reducing depression and increasing and broadening bias in the responses and the one-sided view of the par- coping resources. These associations seem relevant for ticipants’ psychological conditions. More objective, unbi- those with previous psychopathological symptoms and/ ased measures are recommended in similar future studies or diagnosis [7] but also, for individuals who have not addressing the older adults’ mental health. However, we faced severe situations throughout their lives and, there- consider this research has implemented the best possible fore, might not have a vast repertoire of coping strategies methodology to address the study objectives in such spe- or might have low self-efficacy to deal with the possible cific complex circumstances imposed by the COVID-19. impact that a serious situation can imply, such as that Also, we used a small convenience sample of individu- generated by the COVID-19. Due to restrictions on out- als already recruited for a previous project, and creating side activities during the social distancing and quarantine study subsamples to carry out different analyses, makes Castellano‑Tejedor et al. BMC Geriatrics (2022) 22:516 Page 8 of 10 it difficult to generalize these results to different popu- listed authors have seen the final version and approved it. The author(s) read and approved the final manuscript. lations within the same age group and therefore, could limit the statistical power. Funding Despite these limitations, this work has different Research project partially supported by Subvencions de L’institut de Cultura de Barcelona per a Projectes de Recerca i Innovació del Pla Barcelona Ciència strengths. First of all, it provides information about a “real 2019 (ID 19S01576-006). world” cohort of very well-characterized patients since they are part of a larger project, + AGIL BCN [42, 43]. Availability of data and materials The datasets generated and/or analysed during the current study are not Therefore, a wide array of pre-and post-lockdown health- publicly available due to the sensitive nature of the personal health data col‑ realted pre-pandemic measures are available, which adds lected from a vulnerable population and privacy and confidentiality reasons, a valuable standpoint to analyze the psychological impact but might be partially available from the corresponding author on reasonable request. of the pandemic on this vulnerable and understudied sample population. Secondly and, in the same line, we believe this research adds to the existing knowledge by Declarations providing evidence on the demographic, clinical and Ethics approval and consent to participate psychographic COVID-19 related variables that might The + ÀGIL Barcelona program study protocol and all its procedures were approved by the Clinical Research Ethics Committee of the Institut Universitari influence older adults mental health. The COVID-19 d’Investigació en Atención Primaria, Jordi Gol i Gorina (reference number situation called for immediate measures that deal with 20/048-P) and Comisión de Ética en la Experimentación Animal y Humana, the profound impact of confinement, quarantine and Universitat Autònoma de Barcelona (reference number CEEAH 5066). Before starting the telephone interview, oral informed consent was obtained from all the uncertainty that the general population suffered, and participants after receiving the study’s information and the measures to guar‑ particularly, at-risk vulnerable groups. All these knowl- antee their data confidentiality and protection, this consent was registered edge could help in future heath crises. However, more and noted in the same initial consent already collected face-ti-face, at the beginning of the + AGIL program. studies with prospective longitudinal designs in this line and with this specific population are still necessary, to Consent for publication further identify the relevant protective factors for older All participants provided written informed consent for study publication. Data collected has been exclusively used for the present study. adults’ mental health and to validate and refine factors that entail the most significant risk [31]. We believe that Competing interests efforts to protect mental health are equally important as Dra. Pérez has received honoraria for teaching activities by Nestlé, unrelated with the topic of the present work. Dr. Inzitari have also received honoraria by efforts to physically prevent and treat COVID-19 or other Nestlé for presenting at scientific meetings and serving as members of expert pandemics, especially among the older adults. Analyzing, advisory boards, unrelated to the present work. proposing, and implementing practical psychological and Author details mental treatment strategies for this sample population 1 Parc Sanitari Pere Virgili, Area of Intermediate Care, REFiT BCN Research Group, must be a priority. Thus, we strongly encourage further Gregal 0, 08030 Barcelona, Spain. 2 RE-FiT Barcelona Research Group. Vall research in this matter, which is now essential to tackle d’Hebron Institute of Research and Parc Sanitari Pere Virgili, Barcelona, Spain. 3 GIES Research Group, Basic Psychology Department, Autonomous University the emotional and psychological impact associated with of Barcelona, Bellaterra, Spain. 4 Primary Healthcare Center Barceloneta, the pandemic. That will be the key to protect and ensure Atenció Primària Pere Virgili, Barcelona, Spain. 5 Primary Healthcare Center older adults mental health in similar and possible future Bordeta‑Magòria, Institut Català de La Salut, Barcelona, Spain. 6 Fundació Pri‑ vada Avismón-Catalunya, Barcelona, Spain. 7 Programa de Mayores. Fundación scenarios. “La Caixa”, Barcelona, Spain. 8 Institut Català de La Salut, ICS, Barcelona, Spain. 9 Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy. 10 Depart‑ ment of Clinical Sciences and Community Health, Università Di Milano, Abbreviations Milan, Italy. 11 Department of Medicine, Universitat Autònoma de Barcelona, BPAAT​: Brief Physical Activity Assessment Tool; CFS: Clinical Frailty Scale; CGA​: Barcelona, Spain. 12 Faculty of Health Sciences, Universitat Oberta de Catalunya Comprehensive Geriatric Assessment; DME: Detection of Emotional Distress Scale; (UOC), Barcelona, Spain. ESTE II: Self-perceived Social Loneliness Scale; EQ-5D: European Quality of Life Self- reported measure-5 dimensions; GDS-15: Geriatric Depression Scale Yesavage-15 Received: 8 August 2021 Accepted: 20 April 2022 items; SPPB: Short Physical Performance Battery. 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