Many studies worldwide have reported the impact of the first wave of the pandemic on the psychological and mental health of the older population. The contributions of our study are as follows: It is a national study, including more than 110,000 of the oldest of older people (majority > 80 years old) in Sweden. It also focuses on the experiences of two specific groups (i.e., those living in RCF and those receiving HCS) of anxiety and loneliness from the initial stages of the pandemic through progression and spread, between early March and end of May. No previous studies seem to have addressed the impact of the progression of the pandemic on experiences of loneliness and anxiety in this population.
The results showed that older people in both the RCF and HCS groups experienced more loneliness than anxiety and that these experiences increased in accordance with the progression of the pandemic. Both anxiety and loneliness were more prevalent among the RCF than HCS respondents. Other studies conducted on older populations (not RCF or HCS) in other countries during the same period (March − May 2020) also reported a rise in the prevalence of loneliness. For example, studies in the United States, the Netherlands, Spain and the United Kingdom found increased or high levels of loneliness during this period [11, 13, 16, 18, 33]. In contrast, studies in other countries, for example, Germany and Austria, suggest that experiences of loneliness did not increase during March − May 2020 [34, 35]. Similar variation was found in terms of anxiety, with a study in the United Kingdom reporting only a slight increase in anxiety compared to the pre-pandemic period . Studies in Spain, Canada, Austria and Israel also suggested that older people did not seem to be especially vulnerable in terms of the development of anxiety during the initial phase of the pandemic [16, 17, 36 − 40]. However, it is difficult to draw comparisons between the findings of these studies due to the different ways in which the respective countries responded to the pandemic. Most countries implemented considerably stricter regulations than Sweden did. Moreover, methodological differences, biases in survey designs and differences in the study populations, for example the age of the population, mean the findings are not directly comparable. However, the factors found to influence anxiety and loneliness in the present study were consistent with those found in previous research conducted during the same period. Females reported more anxiety and loneliness than males, which is in accordance with previous reports [37, 41 − 43]. Living alone had a significant impact on feelings of loneliness, as found in several studies [4, 43, 44]. In addition, in accordance with the literature [14, 15], persons with dementia experienced more anxiety.
Most of the independent variables included in the present study were negatively associated with experiences of anxiety and loneliness. The variable that contributed the most to anxiety in both the RCF and in HCS groups was poor self-rated health, and its effect on loneliness was also high. Of note, experiences of disrespect by staff were associated with increased anxiety and loneliness among both the RCF and HCS respondents but to a significantly higher extent in the RCF. A decrease in satisfaction due to not being treated with dignity and respect in HCS was reported already before the pandemic . As in the present study, poor-rated health and dementia were important factors. A cross-sectional study focusing on RCF found similar results . Considering the aforementioned findings in the pre-pandemic period, the findings of the present study on the impact of disrespect by staff on feelings of loneliness and anxiety during the pandemic are not surprising.
A report by the NBHW revealed a decrease in anxiety and worry among older people receiving HCS between 2019 and the first wave of the pandemic in 2020, whereas those living in RCF experienced more anxiety and worry and were lonelier in 2020 than in 2019 . We did not compare the data in 2020 with data for 2019. Instead, we analysed differences in the responses of the RCF and HCS groups to questions about anxiety and loneliness as the pandemic progressed. According to our results, although experiences of anxiety and loneliness were more common in RCF than HCS settings, loneliness and anxiety increased significantly in both settings as the pandemic progressed.
There are several possible explanations for the increased prevalence of anxiety and loneliness in RCF as the pandemic progressed. First, those living in RCF are generally frailer and have more complex health problems than those receiving HCS. Therefore, they have an elevated risk of developing severe symptoms of COVID-19, with a subsequent increase in mortality. In our study, poor self-rated health was a strong influential factor for anxiety and loneliness. According to the literature, about half of all COVID-related deaths during the first wave of the pandemic occurred in RCF [22, 47, 48], with the highest excess mortality in Sweden occurring in RCF during this period . Thus, it might not be surprising that residents in RCF are likely to experience more anxiety and loneliness than those living in their own homes. However, a previous study suggests that being isolated from the outside world could bring a sense of security to older people in RCF in terms of virus transmission and receiving support by staff in daily living . Based on the findings and previous studies, it can be assumed that experiences varied significantly due both to the progression of COVID-19 in various regions and in specific RCF. Older people living in their own homes have described experiences of fear when leaving their homes yet feeling like prisoners in their own homes . However, home-dwelling elders in Sweden were not subjected to visitor restrictions, only recommended to limit their contacts with other people as much as possible, recommendations with which they complied .
Second, visitor restrictions implemented in RCF likely influenced experiences of anxiety and loneliness . Moreover, some residents were unable to go outside or even leave their rooms during the pandemic . Although digital technology, such as video calls, partially replaced physical visits and social contacts , this was probably not possible for all residents. As loneliness and lack of physical contact are risk factors for both physical and mental illnesses, it is important to plan for future similar events . Digital technologies have the potential to alleviate loneliness and social isolation in older people [53,54,55]. Therefore, RCF should be equipped with a basic technology infrastructure to facilitate modern-day technologies, which can provide opportunities for social connections . In addition to possibilities for connecting family and friends, opportunities should be created to enable various activities, such as physical activities, which have been shown to be directly related to decreased anxiety symptoms in older people . As physical and cognitive impairment (e.g. dementia) are common among the oldest members of society, particularly those in RCF, they may not have the ability to use specific technologies independently. Therefore, the technologies need to be well designed and easy to use, and the staff needs skills in how to support older people. Of course, it is important to note that even if technology can enable social connectedness and activities, it cannot replace physical contact.
Third, issues pertaining to staff could have contributed to experiences of anxiety and loneliness among those in RCF. To prevent the virus spreading, the staff were required to wear protective equipment (e.g., visors, googles and mouth guards) and to minimize social interactions. According to a previous study, such measures create a distance and severely affect the mental well-being of residents . The ability of staff to adhere to routine hygiene protocols was also an issue. According to a report on RCF in Sweden, the availability of protective equipment and adherence to hygiene routines were poorer in RCF with a spread of COVID-19 . Most staff are not sufficiently trained in hygiene routines, and they often lack an appropriate education [23, 24]. Circumstances such as those mentioned above have been widely reported by the media, which might have increased the level of anxiety among older people. Headlines of failures and fatalities have been described to cause distress among both older people living in RCF and their families . Older people receiving HCS could refuse help from staff, which some did during this time , and manage with the help of relatives. In contrast, those living in RCF were dependent on staff to provide support with daily care.
Measures are needed not only to ensure better preparedness in the future for new pandemics or other severe events but also because improvements are required in general in the care of older people. As suggested by Chu et al. , administrators and health care professionals must move beyond reactionary responses and towards proactive and thoughtful consideration of how care for older people (RCF and HCS) can be best supported in the future. Staff must be adequately trained and have access to proper equipment to provide safe, good-quality care. It is imperative that RCF and HCS staff recognize the older people’s psychological and emotional needs. Previous research has demonstrated detrimental effects of isolation or loneliness on health [7,8,9,10]. Therefore, restrictions concerning, for example, opportunities to see family members, should be balanced with the public health imperative. Moreover, registered nurses specialized in geriatric care need to be more involved in everyday care in RCF and HCS to support staff in providing good-quality care to older people.
Strengths and limitations
One strength of this study is the access to a large nationwide survey, which was conducted around the time of the first wave of the COVID-19 pandemic in Sweden, and the access to relevant national register data. Therefore, the sample may be regarded as representative, which strengthens the generalizability of the study. One limitation is the use of a single item to measure loneliness and anxiety. However, the study is based on an annual survey conducted by the Swedish National Board of Health and Welfare, which do not include any additional measurements. Other limitations are the survey non-response rate, which was higher in 2020 by 3% and 10%  for RCF and HCS, respectively, and the relatively lower rate of proxy response compared to 2019. As a result, those with relatively poor self-rated health and older age might have been underrepresented in the 2020 NBHW survey. As no information about the non-response was available, it was not possible to conduct a thorough investigation into the missing data mechanism. Moreover, the dementia status was based on diagnosis and medication records, which can be a reason for that the prevalence of dementia is probably higher than reported in the study. Nor are everyone with dementia diagnosed or receive medication treatment. Another possible limitation is that the data were collected in a short period in the initial stage of the pandemic and covered just one infection wave. However, Sweden had the highest excess mortality in RCF and HCS settings during this initial stage (March-May 2020) .