“I Am Actually Scared of Everyone”: Older Adults’ Experiences of Social Isolation during COVID-19: A Qualitative Systematic Review

: The emergence of the coronavirus COVID-19 in December 2019 in Wuhan, China, affected all facets of people’s lives worldwide. As a result of the severity of the pandemic, governments worldwide adopted several policies and containment measures, such as social isolation, especially for vulnerable populations, including older adults. This study aimed to explore these older adults’ experiences of social isolation during COVID-19. A systematic review method based on the PRISMA protocol was used, and five databases (EMBASE, PsycINFO, PsycEXTRA, CINAHL, and Medline) were comprehensively searched. Studies were limited to those published between 2020 and 2023. Thirteen qualitative studies met the inclusion criteria and were analysed thematically. A thematic analysis identified the following five major themes: intense feeling of loneliness due to social isolation; use of social media as a coping mechanism during social isolation; anxiety during social isolation; fear during social isolation; and financial security during social isolation. This review provides useful information on how to mitigate the effects of social isolation on the elderly population during future public health crises


Introduction
The emergence of the coronavirus (COVID- 19) in December 2019 in Wuhan, China, affected all facets of people's lives worldwide [1].Additionally, due to its contagious nature and the alarming rate at which the disease spread globally, the World Health Organisation pronounced COVID-19 a global pandemic in March 2020 [1].Governments globally implemented multiple policies and measures to address the severity of the pandemic, including implementing lockdowns, implementing social distancing, enhancing sanitation protocols, and imposing restrictions on schools and public gatherings [2].Such actions were necessitated by the ever-increasing number of infected persons and deaths that resulted from the disease.
According to the WHO [1], the number of excess deaths that resulted directly from COVID-19 or from associated reasons between 2020 and 2021 was 14.9 million globally.The uncertainties of the future, high mortality rates, surging infection rates because of the virus and containment measures, and the lockdown caused widespread anxiety and fear across all population age groups [1].In the same vein, the elderly population was disproportionately impacted by the illness, and it is probable that their mortality rates following infections were higher [2].The elderly population was an at-risk group because of their possible immunocompromised state of health, underlying medical conditions, and other age-related factors [2,3].According to Pedrosa and Bitencourt [3], elderly persons needed special care, necessitating more stringent social isolation and quarantine measures to limit their exposure to the disease.
Apart from the elderly population, the impact of COVID-19 on other vulnerable groups such as students and families has been described, highlighting the widespread and global impacts of the pandemic [4,5].These vulnerable groups include children, adolescents, students, people with low income, people with disabilities, people with health problems, people with mental illness, migrant workers, refugees, prisoners, sex workers, victims of domestic violence, people from ethnic minority backgrounds, and people from sexual and gender minorities [4][5][6][7].Regardless of the countries or locations across the world, the negative impacts were widespread and included but were not limited to mental distress and illness, loss of jobs, loss of income, prolonged loneliness, social isolation, widening inequality, food insecurity, and disruptions in accessing health services and social support services [7][8][9].
In addition, the prohibitions on hospital visits during the COVID-19 pandemic had a significant impact on hospitalised elderly individuals, as it limited the time they could spend with their loved ones [10].These visitation restrictions were implemented to prioritise the health and safety of both patients and visitors [10].However, the elderly were disproportionately affected by the pandemic, not only due to the increased risk of contracting the disease but also because of the social isolation measures put in place to curb its spread [3].The absence of regular visits from family and friends deprived elderly patients of crucial emotional support, further exacerbating the challenges they faced during their hospital stays [11,12].
Additionally, different factors that led to the fear of COVID-19 included misinformation about the virus, and this played a role in the exacerbation of fear, hysteria, etc. [13,14].Among the elderly, social isolation raised the risk of mental and physical health problems such as depression, self-harm, anxiety, and hypertension [15].Recent studies demonstrated how social isolation is a factor in the onset of post-traumatic symptoms and that real and perceived social support operates as buffers against the detrimental effects of trauma on the mind among the elderly, particularly during the pandemic, e.g., [6,9].When compared to the pre-pandemic period [15,16], studies have shown that despite the fact that social isolation is common among older adults, it rose significantly during the pandemic [16,17].
Review studies on social isolation in older adults during COVID-19 have mainly focused on the prevalence of social isolation [18] and the impacts of social isolation [19,20], while studies that explore older adults' experiences of social isolation during the pandemic are extremely scarce.This systematic review aims to examine how older people perceived and coped with social isolation during the pandemic.This review explores their perspectives, emotions, changes in daily routines, and coping strategies in response to social isolation caused by COVID-19.This study seeks to synthesise the existing literature to provide a clearer picture of the experiences of isolated older adults.This understanding is essential for identifying potential intervention strategies that can be implemented to support and mitigate the effects of social isolation on the elderly population during future public health crises.This study will address this research question: what were the experiences of older adults regarding social isolation during the COVID-19 pandemic?

Materials and Methods
This systematic review was conducted in accordance with the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" guidelines [21].The PEO framework [22] was used and considered interactions between the person/people (older adults/elderly persons), the exposure/environment (COVID-19 context), and the outcome (experience of social isolation).Five databases (EMBASE, PsycINFO, PsycEXTRA, CINAHL, and Medline) were comprehensively searched using a combination of free-text terms to obtain relevant articles published between 2020 and 2023.The following keywords were used to guide the search strategy: older adults/elderly/geriatric/geriatrics/aging/senior/seniors/ older people; isolation/social isolation/loneliness; and COVID-19/coronavirus/pandemic.Boolean operators "AND" and "OR" were used to combine these terms across the selected databases.The initial searches yielded 334 results, which were reduced to 13 following a review of the titles, abstracts, and full texts (Figure 1).The inclusion criteria were peerreviewed scholarly publications related to COVID-19 that were published between January 2020 and 2023, qualitative studies that focused on the experiences of older adults in social isolation due to COVID-19, and studies published in the English language.Studies were excluded if they did not directly examine the experience of social isolation in older adults throughout the COVID-19 pandemic, if they were mainly quantitative, and if they were published in a language other than English.A total number of 61 studies were excluded after reviewing the titles and abstracts because they did not focus on older adults' experiences of social isolation during COVID-19, while 111 papers were not included because of "insufficient or irrelevant" data."Insufficient or irrelevant" data referred to information that was not sufficient or relevant for drawing reasonable conclusions on older adults' experiences of social isolation during COVID-19.The 13 studies that met the inclusion criteria above were selected for this systematic review.The selected 13 studies were downloaded and imported using End-Note software, and relevant data were extracted from them by copying and pasting relevant sections into Microsoft Word (Table 1).The included studies were evaluated using the Critical Appraisal Skills Programme [23] standards (Table 2).All the results of the included studies were analysed using thematic analysis [24] by identifying the common themes across them.The thematic analysis in this review followed the steps highlighted by [25].The findings/results of all the included studies were subjected to initial first-level coding up to the sentence level.All the similar initial codes were then collapsed into second-level descriptive codes, and the descriptive codes were collapsed into similar themes.A review of all the themes resulted in the identification of major themes among the included studies.It is crucial for older adults to maintain the availability of options, places to visit, social interactions, and a variety of activities both inside their homes and in the communities around them.

Phenomenological Approach Interviews
Participants reported feeling restricted in their daily life activities, as well as emotional instability because of loneliness and anxiety.
There is the need for the development of strategies to deal with the impact of social isolation on older persons.

Phenomenological Approach Interviews
Older adults adapted their mindset and proactively took steps, such as life skills and acquiring technology skills to stay socially connected, to preserve their resilience during the COVID-19 pandemic.
It is crucial to adopt the strategies learned from the resilience displayed by older adults in order to provide support to those who may be at a risk of declining resilience in future pandemics or similar situations.

Phenomenological Approach Interviews
Isolation of older adults from society due to COVID-19 caused loneliness, anxiety, and financial instability.
It is crucial to challenge age-related stereotypes, critically evaluate media consumption's impact on emotional well-being, promote prosocial behaviours and communal coping within the community, establish accessible mental health support systems, and develop social programming that enhances telecommunication access for individuals of all ages.

Phenomenological Approach Interviews
The elderly population in Uganda encountered many consequences such as feelings of loneliness and anxiety due to the limits imposed and the presence of the virus.
Mental health services should be made more accessible and readily available to ensure that older adults can receive the necessary support and care they may require.The study recommended the passage of an aging bill that would improve the life of older adults during future

Results
The thematic analysis performed identified five major themes: intense feeling of loneliness due to social isolation, use of social media as a coping mechanism during social isolation, anxiety during social isolation, fear during social isolation, and financial security during social isolation.

Intense Feeling of Loneliness Due to Social Isolation
Ten studies [25,26,28,30,32,[34][35][36][37] identified loneliness as a major consequence of social isolation during the COVID-19 pandemic.The frustration and sense of confinement experienced by individuals due to social isolation measures was evident: "I can't leave the house . . .but it's complicated because when you're home because you don't want to leave, it's one thing, but when you're there because you have to be and you can't leave, the meaning changes. . .I can't go to church, I can't do the groceries, I can't go on a walk, take the bus, they say taking the bus is not good".( [30], p. 2) The absence of social interaction and meaningful activities were expressed with irritation and boredom: "Previously, prior to COVID-19, I used to walk whenever I was lonely. . .I'm frightened of contracting this virus and I can no longer do that. . .I continuously think about The Lord and pray that he keeps me forever till he arrives. . . the COVID 19 pandemic has aggravated my condition. . ."I have ceased watching television due to the absence of positive information concerning this particular pandemic".( [26], p. 7) "I hate it.It frustrates me as there's absolutely nothing to do". ( [32], p. 4)

Use of Social Media as a Coping Mechanism during Social Isolation
The use of social media as a coping mechanism during social isolation was reported by eight studies (older adults during the COVID-19 pandemic); multiple studies [25,27,[29][30][31]36,37].
Participants described social media platforms as essential tools for staying connected with family and friends and providing entertainment: "Ah, Facebook is a wonderful thing to keep track of people a little bit and be able to communicate".([29], p. 9) "I am always online, as there is so many free stuffs, such as tours of museums, churches, and there is Facebook, not that I do much on that, but some of the family do, it is an enormous resource, isn't it?I am looking things up on it all the time, it makes a huge difference, and I feel really sorry for people who don't have that resource".( [27], p. 12) However, some participants expressed the limitations of distant connectivity in fulfilling their need for physical contact.The inability to physically hug loved ones was mentioned as a significant drawback of relying solely on social media for connection: ". ... ..but it's not the same as, like even my daughter, I couldn't go hug her, you know".( [29], p. 9)

Anxiety during Social Isolation
Four studies [25,30,33,35] highlighted the issue of anxiety during the pandemic.These findings indicate that older adults experienced significant anxiety during social isolation caused by the COVID-19 pandemic.The profound disruptions and unrecognizable familiar routines contributed to feelings of uncertainty and anxiety.
"I never expected to live something like this [the pandemic] into my life. . .I seem to live in another world. . .In certain moments it looks like if I was on another planet, I seem to dream because I say to myself: 'can it be possible a thing like this?Sometimes I don't know if it is reality or fantasy".( [33], p. 12) This response highlights the disorienting and surreal experience of living through the pandemic.Another participant shared their worries about their family's safety, stating: "It scares me to think about my kids out there. . .I know I can stay in the house, and stay in my room away from people, but my family can't. . .they have to work. . .they have to go to school. . .I worry about it a lot".( [35], p. 8) This expression reflects the anxiety and fear experienced by individuals regarding the well-being of their loved ones during the pandemic.

Fear during Social Isolation
Three studies [28,30,32] highlighted the experience of older individuals who expressed fear, particularly concerning the development and impact of the virus.As a result of this fear, older adults were found to diligently adhere to recommended public health protocols, including maintaining social distancing and isolation.
"I am actually scared of everyone because you can't know who has the disease but when the situation gets better, we shall go back to normal, greet and hug each other again".( [32], p. 40) This response reflects the apprehension felt by older adults about the potential risk of contracting the virus from others.The profound impact of the pandemic on the mental well-being of older individuals, with fear stemming from the high mortality rate associated with COVID-19, was also evident: "I am depressed; people died. . .Terrible disease does not give up, it always kills, I am afraid of it".( [28], p. 4)

Financial Security during Social Isolation
The theme of financial security emerged as a significant concern among older adults during their period of social isolation due to the COVID-19 pandemic.Three studies [25,28,36] highlighted the fear and challenges faced by older individuals in terms of their financial stability during lockdown.These studies revealed that the pandemicinduced lockdown had a detrimental impact on the income of older adults, leading to a reliance on others for survival or a struggle to meet their basic needs.Insufficient pension was also a common complaint among the participants.
"We are trying to make ends meet".( [28], p. 7) "I am retired, pension is not enough".( [28], p. 7) "I just got told I'm being furloughed because the state has lost so much money, so I'm losing 20% of my salary".( [36], p. 7) These findings highlight the vulnerability of older adults during social isolation, particularly in terms of their financial security.The pandemic exacerbated existing financial challenges, leaving many older individuals struggling to make ends meet and relying on limited resources.

Discussion
Social Isolation and the well-being of older adults during COVID-19: Loneliness due to social isolation is a major finding of this review [25,26,28,30,32,[34][35][36][37].This finding validates the previous assertion by the World Health Organisation regarding the impact of COVID-19-induced disturbance of interpersonal relationships on the psychological wellness of older individuals [38].The adverse impacts of COVID-19 on the elderly population were further intensified by the implementation of protective measures like lockdown and social isolation, leading to the development of loneliness, which can induce psychological complications [39,40].It is well established that prolonged experiences of loneliness may have detrimental effects on mental health, perhaps culminating in the development of psychological disorders [40].This sense of loneliness among older people aligns with the developing body of research about the effects of the worldwide pandemic on elderly people in many nations [41,42].Loneliness has been observed as a prevalent outcome of the COVID-19 pandemic, with this resulting in the interruption or disruption of social networks [43,44].The significance of older people participating in social networks in relation to their psychological wellness and overall well-being was rooted in the provision of the feeling of being a part of something, as well as decreasing levels of discrimination, particularly in the context of the pandemic [26].Subjective loneliness, which might result in psychological disorders, including depression and anxiousness, is often linked to being disconnected from society [45].This observed trend could partially explain the challenges faced by older adults in maintaining adherence to COVID-19-preventative measures, notwithstanding being aware of the virus and its likely ramifications [46].
To mitigate the adverse effects of loneliness upon psychological well-being, it was crucial to establish distant connections with relatives and close friends.The use of devices such as phones often fail to offer the same degrees of interpersonal interaction compared to digital platforms such as Skype [47].Moreover, it is important to acknowledge the substantial degree of hardship experienced by older individuals residing in low-and medium-income nations [48].Additionally, it is well recognized that older persons usually possess limited digital literacy skills [49].This situation serves as a prominent illustration of how a pandemic amplifies pre-existing disparities [32].Specifically, elderly individuals in low-and middle-income countries were hindered by limited proficiency in digital knowledge and a lack of financial resources to acquire smartphones and internet connectivity [32].Consequently, their ability to engage with their loved ones was severely constrained, thereby adversely affecting their mental well-being during the pandemic.
Social media and older adults during COVID-19: Another theme identified in this review is the use of social media as a coping mechanism during social isolation [25,26,28,30,32,[34][35][36][37].Some participants disclosed the constraints associated with using social media in relation to fulfilling their needs for keeping in contact with others [25,31].However, this review revealed the adaptability and willingness of older adults to adopt social media.It has been reported that there has been a consistent increase in web usage and proficiency amongst the older population [50].
There are potentially advantageous prospects for capitalising on the increasing inclination of older adults towards virtual connectivity.In addition to the expanding population's increasing familiarity with and utilisation of the web, the heightened proficiency with and usage of video calling services, which was accelerated by the pandemic, may present greater prospects for the public health sector to connect with elderly people virtually [36].Nevertheless, certain segments of the elderly population, specifically those with limited education and poorer socioeconomic backgrounds, as well as those with physical impairments, may encounter obstacles [51].These individuals also tend to interact with technologies less often compared to other groups.It is imperative to identify obstacles hindering technological literacy in this population, as a failure to do so may exacerbate pre-existing disparities in accessibility [51].
The use of technology in communication and the dissemination of knowledge can be leveraged to offer social support in online environments, fostering social connection and a sense of inclusion amongst older adults [52].Nevertheless, it is imperative to approach the heightened utilisation of social media platforms throughout the COVID-19 outbreak with prudence.This phenomenon was found to be linked to psychological disorders, specifically anxiety and depressive symptoms amongst older adults [53].This might be because of sad news and events shared on social media platforms during the COVID-19 pandemic [53].
Social Isolation and Anxiety: Although social isolation has been acknowledged as a successful technique for mitigating the spread of the coronavirus, it is important to note that the abrupt cessation of contact with others and regular activities may have culminated in the experience of a solitary existence among individuals in this demographic [30].The pandemic resulted in older people being confined to their homes, leading to an effect on their ability to maintain social contact with others, as well as access essential services related to healthcare and civic involvement [54].The prolonged period of social exclusion and loneliness experienced by this particular age group resulted in heightened levels of anxiety [55].Decreases or inhibitions in social contact with relatives and close friends, disruptions in in-person social relationships, and a sense of exclusion resulting from physical separation had detrimental effects on their psychological well-being and resulted in an increased experience of anxiety [56].
Moreover, the way COVID-19 has been depicted by media outlets (as a condition that disproportionately affects individuals of advanced age) appeared to have induced feelings of anxiety among older adults [25].The rise in media use among older persons was driven by a desire to be updated about the ever-changing coronavirus situation, including the suggested safety measures [25].However, participants additionally observed the adverse effects of access to media on their psychological health [25].Acknowledging the significance of regulating media usage, individuals who chose to minimize their media exposure experienced a positive impact on their mental well-being [25].This finding is consistent with prior studies on the intake of media related to COVID-19.Losada-Baltar and Jiménez-Gonzalo [57] found a positive correlation between the amount of time individuals spent consuming COVID-19-related information and the level of mental discomfort, namely anxiety, experienced during the period of lockdown.Additionally, a positive correlation between heightened exposure to COVID-19-related media content and elevated levels of anxiety was reported [58].This association may be partly attributed to heightened perceptions of the danger posed by the COVID-19 pandemic.The use of fear-based communication through media platforms, which were aimed at certain age groups, has the potential to elicit ageist attitudes [25].This is shown by the fact that certain elderly people reported a discrepancy between their own subjective sense of good health and their children's assessment of danger based on age [25].Consequently, older adults experienced dissatisfaction due to seeing limitations in their ability to interact with family members and perform necessary tasks during the pandemic, thus impeding their pursuit of personal autonomy [25].
Social Isolation and Fear: Reports of older adults exhibiting fear because of social isolation were also observed in this review [28,30,32].Fear plays a crucial role in shaping individuals' responses to challenging situations, and the COVID-19 pandemic was no exception [59].Older adults, being at a higher risk of severe illness and mortality from the virus, experienced heightened levels of fear [59].This fear led to various behavioural changes, including increased social distancing and isolation as older adults attempted to protect themselves from potential infection [60].The fear of contracting and spreading the virus also led to changes in older adults' social behaviours [28,30,32].In addition to physical distancing, older adults reduced their participation in social activities, such as attending community events and participating in group exercise [60].Fear might have hindered older adults' ability to seek and access social support during the pandemic [61,62].Older adults might have been reluctant to reach out for assistance due to the fear of potential exposure to the virus or burdening others with their concerns [60].This fear-based hesitancy to seek support could have exacerbated feelings of social isolation and hindered older adults' ability to cope with the challenges they faced.To address the issue of fear and social isolation among older adults, interventions that target both fear and social connectedness are needed.Prior research has shown that interventions focusing on reducing fear and anxiety through psychoeducation, cognitive behavioural therapy, and mindfulness-based approaches can be effective [59,63].
The social isolation measures implemented during the pandemic further exacerbated underlying financial issues, as older adults faced challenges in meeting their basic needs and accessing essential services [64].Financial insecurity can lead to a reduced quality of life, increased stress, and a higher risk of developing mental health disorders among older adults.Hawkley, Zheng, and Song [65] found that older adults who experienced social isolation were more likely to face financial difficulties.The authors highlighted that limited social connections can hinder older adults' ability to access financial resources, such as employment opportunities and support networks.This finding suggests a strong relationship between social isolation and financial insecurity among older adults.Shaw and Farid [66] explored the impact of social isolation on older adults during the COVID-19 pandemic.They observed that older adults who experienced social isolation were more likely to face financial challenges, including difficulties in accessing financial assistance and increased healthcare costs.This study provides empirical evidence supporting the relationship between social isolation and financial insecurity during the pandemic.The social isolation measures implemented to protect older adults from the virus inadvertently exposed them to financial challenges, further exacerbating their financial vulnerability.

Strengths and Limitations
One of the notable strengths of this systematic review is its rigorous methodology.This review followed the PRISMA protocol, which ensured a comprehensive and systematic approach to conducting the review.Additionally, this review employed an exhaustive search strategy, using five highly recognized databases (EMBASE, PsycINFO, PsycEXTRA, CI-NAHL, and Medline).This means that a wide range of relevant literature studies was included, minimizing the risk of missing important studies.The included studies were evaluated using the standards of the Critical Appraisal Skills Programme (CASP), indicating a high level of quality and standards.This rigorous evaluation process enhanced the reliability and trustworthiness of the findings.A major limitation of this review is that the included studies were limited to those published in the English language.By excluding studies in other languages, there was a possibility of omitting relevant research that could contribute to the overall findings.This limitation may limit the generalisability of this review's conclusions in non-English-speaking countries.

Relevance for Clinical Practice
This review presents useful information on the negative impacts of social isolation amongst the elderly population.It will help governments, policymakers, and healthcare professionals to mitigate the negative effects of social isolation on the elderly population during future public health crises.Governments, policymakers and healthcare professionals need to design protective measures that have minimal negative impacts on the elderly population when dealing with future public health crises.

Conclusions
The arrival of COVID-19 in December 2019 affected all people's lives worldwide.As a result of the severity of the pandemic, governments worldwide adopted several policies and containment measures especially for vulnerable populations, including older adults.Using a systematic review method, this study explored older adults' experiences of social isolation during COVID-19.Five databases (EMBASE, PsycINFO, PsycEXTRA, CINAHL, and Medline) were comprehensively searched, and studies were limited to those published between 2020 and 2023.Thirteen qualitative studies met the inclusion criteria and were analysed thematically.Thematic analysis identified five major themes: intense feelings of loneliness due to social isolation; use of social media as a coping mechanism during social isolation; anxiety during social isolation; fear during social isolation; and financial security during social isolation.Prolonged experiences of loneliness had detrimental effects on the mental health of older adults.The use of social media had good potential benefits, but it also had negative consequences, such as increased anxiety and depression.The prolonged period of social exclusion and loneliness resulted in heightened levels of anxiety.Older adults experienced heightened levels of fear, which led to various behavioural changes.Social isolation measures inadvertently exposed older adults to financial challenges.

Table 1 .
Characteristics of included studies.

Table 1 .
Characteristics of included studies.
Authors and Dates Country Sample Size Research Design and Data Collection Method Key Findings Recommendations [26] Ghana 15 (≥60) Phenomenological Approach Interviews Participants noted that COVID-19 preventive measures, such as stay-at-home orders and lock-