With the world in the grip of the covid-19 pandemic, unprecedented restrictions have been placed on social freedoms. The UK government has asked those aged 70 years and older to follow strict social distancing measures to reduce the transmission of, and susceptibility to, covid-19. These restrictions involve: reducing social mixing in the community, not having friends and family visiting the house, and minimising the use of public transport. Moreover, individuals with certain high-risk conditions are advised to not leave the home at all.  While undoubtedly vital to reduce the impact of covid-19 on this vulnerable group, which is more susceptible to severe disease, these interventions carry risk, particularly on physical activity profiles and on mental health. How can we mitigate this?
Social isolation is associated with increased morbidity from chronic disease and with higher all-cause mortality. Detrimental health behaviours, such as smoking and reduced physical activity may mediate over 30% of this effect. [2,3] Both subjective and accelerometer data from adults aged 50-81 indicated that social isolation is independently associated with reduced physical activity and increased sedentary time, suggesting that this may play a role in the increased risk of disease. [4,5] Current Chief Medical Officer (CMO) guidance for older adults recommends 150 minutes of moderate intensity aerobic activity, or 75 minutes of vigorous intensity activity accumulated each week, in addition to weight-bearing activities and the breaking up of sedentary time with light activity.  In adults aged over 60 years, even doses of activity below this are associated with a 22% reduction in all-cause mortality.  Additional gains are seen in functional ability and reduced risk of falls, whereas sedentary time is associated with increased indices of frailty.  One challenge during the covid-19 pandemic is therefore mitigating the adverse effects of isolation and maintaining physical activity levels in older adults to protect health when social networks and access to exercise and leisure facilities are reduced. Furthermore, the current situation is different from previous studies of social isolation given the additional impacts of fear and uncertainty, with no certain endpoints from the pandemic.
Social isolation also has significant implications for mental health in the elderly. Perceived social isolation and loneliness lead to a wide range of psychological symptoms, including depression and anxiety, and impact negatively on quality of life.  The aetiology is complex with cause and effect difficult to untangle, but at least part of the link between social isolation and depression is mediated through physical activity outside of the home. 
Enforced social isolation in the context of a pandemic may, however, be very different to that arising in normal circumstances. A recent rapid review on the psychological impact of quarantine in disease outbreaks found links to anxiety, depression and symptoms of post-traumatic stress, with some evidence that these could persist long-term.  Factors associated with negative outcomes included quarantine for over 10 days, fears relating to infection, frustration and boredom, and lack of information and supplies. However, none of the reviewed studies focused on older adults, who are particularly susceptible to the negative impacts of social isolation. The studies tended also to involve relatively short quarantine times of less than three weeks, well under the expected duration of current restriction measures.
Given the unprecedented nature of the current outbreak measures, there is a lack of evidence for the impact of measures which are currently expected to last at least 12 weeks. However, extrapolating on what we know about the negative effects of both social isolation in the elderly and short quarantine times, the impact could be considerable. Avenues for mitigation could involve web-based solutions, and smartphone-based videoconferencing for nursing home residents which can lead to reduced subjective feelings of loneliness and pain scores.  However, there will be issues with access and ease of use of technology for isolated older individuals, with 47% of over 75s never having used the internet.  We suggest a three-tiered approach. First, dedicated online, television and radio resources for older adults, providing access to mental health, physical activity and dietary advice, in addition to guidance on the use of digital tools to maintain connections with friends and family. Second, at an individual level, clinicians can help guide older adults with brief physical activity advice. Finally, community teams, supported by NHS volunteers, that are checking on their population of older adults in isolation could include a physical activity and mental health check as part of their assessment.
The response to the covid-19 outbreak has enforced social isolation on populations globally on an unprecedented scale. While these measures are critical to limit the spread of disease, attention must be paid to the potential harms, and to mitigate the impacts of social isolation on the health of the elderly.
Thomas Beaney, Academic Clinical Fellow in Primary Care, Department of Primary Care and Public Health, Imperial College London.
David Salman, Academic Clinical Fellow in Primary Care, Department of Primary Care and Public Health, Imperial College London.
Dane Vishnubala, Sport and Exercise Medicine Consultant, Hull York Medical School.
Alison H McGregor, Professor of Musculoskeletal Biodynamics, 2MSk lab, Faculty of Medicine, Department of Surgery & Cancer, Imperial College London.
Azeem Majeed, Professor of Primary Care, Department of Primary Care and Public Health, Imperial College London.
Competing interests: None declared
Funding: NIHR Applied Research Collaboration for NW London.
Acknowledgements: TB and DS are supported by National Institute for Health Research (NIHR) Academic Clinical Fellowships. TB acknowledges support from the NIHR Imperial Biomedical Research Centre (BRC) and the NIHR Applied Research Collaboration for NW London. AM is supported by the NIHR Applied Research Collaboration for NW London.
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