Changes in activity levels, physical functioning, and fall risk during pandemic

Based on the report by American Geriatrics Society

Background

Physical function worsens with older age, particularly for sedentary and socially isolated individuals, and this often leads to injuries. Through reductions in physical activity, the COVID-19 pandemic may have worsened physical function and led to higher fall-related risks.

Methods

A nationally representative online survey of 2006 U.S. adults aged 50–80 was conducted in January 2021 to assess changes in health behaviors (worsened physical activity and less daily time spent on feet), social isolation (lack of companionship and perceived isolation), physical function (mobility and physical conditioning), and falls (falls and fear of falling) since March 2020. Multivariable logistic regression was used to assess relationships among physical activity, social isolation, physical function, falls, and fear of falling.

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Results

Among respondents, 740 (36.9%) reported reduced physical activity levels, 704 (35.1%) reported reduced daily time spent on their feet since March 2020, 712 (37.1%) reported lack of companionship, and 914 (45.9%) social isolation. In multivariable models, decreased physical activity (adjusted risk ratio, ARR: 2.92, 95% CI: 2.38, 3.61), less time spent on one’s feet (ARR: 1.95, 95% CI: 1.62, 2.34), and social isolation (ARR: 1.51, 95% CI: 1.30, 1.74) were associated with greater risks of worsened physical conditioning. Decreased physical activity, time spent daily on one’s feet, and social isolation were similarly associated with worsened mobility. Worsened mobility was associated with both greater risk of falling (ARR: 1.70, 95% CI: 1.35, 2.15) and worsened fear of falling (ARR: 2.02, 95% CI: 1.30, 3.13). Worsened physical conditioning and social isolation were also associated with greater risk of worsened fear of falling.

Conclusion

The COVID-19 pandemic was associated with worsened physical functioning and fall outcomes, with the greatest effect on individuals with reduced physical activity and social isolation. Public health actions to address reduced physical activity and social isolation among older adults are needed.

Key Points

• The COVID-19 pandemic was associated with worsened physical functioning and fall outcomes.
• Poor fall outcomes reflected worsened physical functioning and reduced physical activity levels.

Why Does this Paper Matter?

Rapid deconditioning from the pandemic requires prompt policy responses.

INTRODUCTION

Sedentary behavior and social isolation increase risks of functional impairment and injury among older adults, threatening their independence and safety.^1–5 During extended periods of reduced physical activity or isolation, such disablement may accelerate, causing a progressive loss of mobility and physical conditioning, and greater need for assistance from others for daily activities.^6–9

Although disability and functional trajectories have been extensively examined,^10–13 it is less well understood how physical functioning of older adults has been affected by the COVID-19 pandemic. Some older adults may have maintained functional capacity through continued exercise, despite restrictions on physical and social engagement.¹⁴ For others, mobility and physical conditioning may have declined due to increased social isolation and sedentary behaviors, leading to higher risk for injuries such as falls.^1–5

Limited prior research has described decreases in physical activity among older adults during the COVID-19 pandemic.¹⁵ The current study adds to this literature by examining self-reported changes in physical function and fall-related injury, and whether these changes are influenced by sedentary behavior and social isolation. Specifically, it assesses whether physical activity and social isolation influenced physical functioning, and how activity levels and social isolation influenced fall injuries and the fear of falling. These findings can improve understanding of how older adults’ levels of physical disability and injury risk change under rapid shifts in opportunities for physical and social engagement.

METHODS

Data for this study came from the January 2021 National Poll on Healthy Aging (NPHA), a nationally representative survey of U.S. adults aged 50–80 (n = 2023, completion rate = 78%). Respondents were selected from the Ipsos web-enabled KnowledgePanel® in which panel participants are randomly recruited through address-based sampling, and households are provided with access to the internet and laptop computers if needed to complete surveys. The poll asked older adults about their experiences related to activities, function, and falls since March 2020 (i.e., the start of the United States coronavirus pandemic).

Our main outcomes of interest were measures capturing physical function and falls. Two indicators of physical function were assessed: worsened mobility and physical conditioning. Mobility was defined for respondents as “a person’s ability to move around on one’s own – by walking, using assistive devices such as a cane or walker, or by using transportation.” Physical conditioning was defined for respondents as “a person’s flexibility, muscle strength, endurance, and ability to do physical activity.” Respondents were asked whether, since March 2020, each of mobility and physical conditioning had changed, if at all, with three response options: improved, worsened, and no change. Binary indicators for each of worsened mobility and worsened physical conditioning were developed from respondent answers.

Additionally, two fall-related outcomes were assessed: (1) falls, defined for respondents as “where a person ends up on the ground or a lower level due to a loss of balance, slip, or trip” and (2) worsened fear of falling. For the first measure, respondents were asked, “Since March 2020, how many times have you fallen?” with response options of 0, 1, 2–3, and ≥4 times. A binary indicator was created to categorize individuals as having fallen (≥1 fall) or not fallen (0 falls). For the second measure, respondents were asked, “Are you afraid of falling?” with response options of yes, very afraid of falling; yes, somewhat afraid of falling; and no, not afraid of falling. For those who answered yes (either very or somewhat afraid of falling), an additional question was asked: “How has your fear of falling changed since March 2020?” with response options of more fearful of falling, less fearful of falling, and no change in fear of falling.

Several measures of health behaviors and physical function (hereafter, “function”) were also assessed. Respondents were asked “Since March 2020, how often have you done moderate or more vigorous physical activity for at least 30 minutes?” Response options were as follows: every day or nearly every day, several times a week, about once a week, every 2–3 weeks, once a month or less, and never. Examples of moderate physical activities included brisk walking, housework, or mowing the lawn. Participants were then asked, “How has the amount of moderate or more vigorous physical activity you do changed since March 2020, if at all?” Respondents were also asked “How has the amount of time you spend on your feet standing or walking on a typical day changed since March 2020, if at all?” Response options for both questions were as follows: more active, less active, or no change. Two dichotomous indicators were created to categorize individuals into those with reduced versus not reduced physical activity and with reduced versus not reduced daily time spent on their feet. To assess social isolation, respondents were asked “In the past year, how often have you felt isolated from others?” Response options were as follows: hardly ever, some of the time, often. A dichotomous indicator was created to categorize individuals into those who felt frequent social isolation (some of the time or often) versus hardly ever.

Sociodemographic and health characteristics included age (continuous), gender, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Other), education (high school or less, some college, bachelor’s degree or higher), total annual household income (<$30,000, $30,000–$59,999, $60,000–$99,999, ≥$100,000), marital status (married/partnered, not married/not partnered), and health status (poor, fair, good, very good, or excellent).

In analyses, overall sociodemographic and health characteristics were first described. Next, t-tests for continuous and chi-square tests for binary or categorical variables were used to compare these measures by physical activity (hereafter, “activity”) levels, daily time spent on one’s feet, mobility, and physical conditioning (hereafter, “conditioning”).

Given conceptual and empirical understandings of disablement and injury (Figure 1), we hypothesized that reduced activity and greater social isolation would be associated with worsened function. In turn, we expected that decreased function would increase injury risk and fear of injury. To test these hypotheses, four logistic regression models were estimated. For the first and second models, logistic regression models were separately estimated, regressing each of worsened mobility and worsened conditioning on reduced activity, less daily time spent on one’s feet, and social isolation. For the third and fourth models, logistic regression models were separately estimated, regressing each of having a fall and worsened fear of falling on worsened mobility, worsened conditioning, and social isolation.

DISCUSSION

Since the start of the COVID-19 pandemic in the United States, one-third of older adults reported reduced activity levels. Declines in activity were associated with two to three-fold worsening of several self-reported measures of physical function. In turn, poorer function was associated with increases in the risk of falls and fear of falling. Social isolation was also associated with an increased risk of poorer function and worse fall-related outcomes. Together, the results suggest the pandemic was associated with changes in health and social activities among older adults, and that these changes appear to have led to physical deconditioning and increased risk of fall-related injuries.

Beyond infection rates, hospitalizations, and mortality, recent literature on the COVID-19 pandemic has observed excess mortality that likely reflects clinically under-addressed or untreated acute and long-term health issues.¹⁷ This study illustrates another concern, that of pronounced physical functioning decline among older adults, potentially associated with sustained periods of reduced physical and social activity during the pandemic. Beyond previously measured excess death and morbidity, this may presage worrisome population health disability and injury cascades in which deconditioning, functional loss, and injury created more disablement.

Observed changes could reflect common disability trends rather than effects from the pandemic. However, prior work observed that from 2019 to 2020 the proportions of adults aged 70 and older with mobility difficulties decreased only slightly, from 19.3% to 18.5%.¹⁸ Therefore, the findings are likely to reflect pandemic-related declines.

Risks for falls increase both with a history of previous falls and in the presence of fear of falling, as each can produce avoidant strategies such as using excessive caution getting around or avoidance of activity that can harm conditioning and mobility.^19–21 These behaviors could increase short-term fall risk; they could also reduce risk by limiting opportunities for falls. In either case, fall risk may increase once regular activities resume, with important implications for older adults’ health and health care costs.²² To the extent reduced activity levels mask shorter-term fall risk, and because falls are predictors for future disability, our study and others may understate the pandemic’s longer-term impacts on older adults’ functioning and safety.

Sedentary behavior and social isolation are strong predictors of morbidity and mortality, and short-term deconditioning due to these factors can lead to functional decline and injury risk.^{10, 11, 23, 24} The current findings suggest critical, if distinct, roles for these risk factors and confirm that short-term exposures to these risks (in the approximately year-long pandemic period we assessed) can be associated with sizeable impacts on conditioning and mobility. Reversing these deficits will, therefore, require interventions on a broad range of individual and environmental factors that require support from public health agencies, clinicians, and policy makers.

Conclusion

In a national survey, substantial decreases in activity levels, physical conditioning, and mobility from March 2020 to January 2021 were observed among U.S. older adults aged 50–80 years. An increase in population-wide fall risk was observed along with worsened physical functioning brought on by reduced physical activity levels. In all, the findings could imply rapid deconditioning associated with restricted physical and social activities during the pandemic and should be more closely examined and addressed through innovative clinical and policy changes that can help integrate interdisciplinary preventive care for at-risk older adults. Community interventions that facilitate physical activity, including safe areas for walking in parks and neighborhoods, and efforts to manage safety risks at home, particularly in lower-income areas, can help address threats to mobility among the most vulnerable older adults.

Full article here:

https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.17477

Authors: Geoffrey J. Hoffman PhD, Preeti N. Malani MD, MSJ, Erica Solway PhD, MSW, MPH, Matthias Kirch MS,Dianne C. Singer MPH, Jeffrey T. Kullgren MD, MS, MPH