Older adults’ experiences during the COVID-19 pandemic: a qualitative systematic literature review

Objectives Relatively little is known about the lived experiences of older adults during the COVID-19 pandemic. We systematically review the international literature to understand the lived experiences of older adult’s experiences during the pandemic. Design and methodology This study uses a meta-ethnographical approach to investigate the included studies. The analyses were undertaken with constructivist grounded theory. Results Thirty-two studies met the inclusion criteria and only five papers were of low quality. Most, but not all studies, were from the global north. We identified three themes: desired and challenged wellbeing; coping and adaptation; and discrimination and intersectionality. Overall, the studies’ findings were varied and reflected different times during the pandemic. Studies reported the impact of mass media messaging and its mostly negative impact on older adults. Many studies highlighted the impact of the COVID-19 pandemic on participants' social connectivity and well-being including missing the proximity of loved ones and in consequence experienced an increase in anxiety, feeling of depression, or loneliness. However, many studies reported how participants adapted to the change of lifestyle including new ways of communication, and social distancing. Some studies focused on discrimination and the experiences of sexual and gender minority and ethnic minority participants. Studies found that the pandemic impacted the participants’ well-being including suicidal risk behaviour, friendship loss, and increased mental health issues. Conclusion The COVID-19 pandemic disrupted and impacted older adults’ well-being worldwide. Despite the cultural and socio-economic differences many commonalities were found. Studies described the impact of mass media reporting, social connectivity, impact of confinement on well-being, coping, and on discrimination. The authors suggest that these findings need to be acknowledged for future pandemic strategies. Additionally, policy-making processes need to include older adults to address their needs. PROSPERO record [CRD42022331714], (Derrer-Merk et al., Older adults’ lived experiences during the COVID-19 pandemic: a systematic review, 2022).


Introduction
In March 2020 the World Health Organisation declared a pandemic caused by the virus SARS-CoV2 (COVID-19) [1].At this time 118,000 cases in 114 countries were identified and 4,291 people had already lost their lives [2].By July 2022, there were over 5.7 million active cases and over 6.4 million deaths [2].Despite the effort to combat and eliminate the virus globally, new variants of the virus are still a concern.At the start of the pandemic, little was known about who would be most at risk, but emerging data suggested that both people with underlying health conditions and older people had a higher risk of becoming seriously ill [3].Thus, countries worldwide imposed health and safety measures aimed at reducing viral transmission and protecting people at higher risk of contracting the virus [4].These measures included: national lockdowns with different lengths and frequencies; targeted shopping times for older people; hygiene procedures (wearing masks, washing hands regularly, disinfecting hands); restricting or prohibiting social gatherings; working from home, school closure, and home-schooling.
Over the past decade, the World Health Organisation (WHO) has recognised the importance of risk communication within public health emergency preparedness and response, especially in the context of epidemics and pandemics.Risk communication is defined as "the real-time exchange of information, advice and opinions between experts or officials, and people who face a threat (hazard) to their survival, health or economic or social wellbeing" ( [31], p5).This includes reporting the risk and health protection measurements through media and governmental bodies.Constructing awareness and building trust in society are essential components of risk communication [32].In the context of the pandemic, the WHO noted that individual risk perception helped to prompt problem-solving activities (such as wearing face masks, social distancing, and self-isolation).However, the prolonged perception of pandemic-related uncertainty and risk could also lead to heightened feelings of distress and anxiety [31,33], see also [34][35][36][37].
This new and unprecedented disease provided the ground for researchers worldwide to investigate the COVID-19 pandemic.To date (August 2022), approximately 8072 studies have been recorded on the U.S. National Library of Medicine ClinicalTrials.gov[38] and 12002 systematic reviews have been registered at PROS-PERO, concerning COVID-19.However, to our knowledge, there is little known about qualitative research as a response to the COVID-19 pandemic and how it impacted older adults' well-being [39].In particular, little is known about how older people experienced the pandemic.Thus, our research question considers: How did older adults experience the COVID-19 pandemic worldwide?
We use a qualitative evidence synthesis (QES) recommended by Cochrane Qualitative and Implementation Methods Group to identify peer-reviewed articles [40].This provides an overview of existing research, identifies potential research gaps, and develops new cumulative knowledge concerning the COVID-19 pandemic and older adults' experiences.QES is a valuable method for its potential to contribute to research and policy [41].Flemming and Noyes [40] argue that the evidence synthesis from qualitative research provides a richer interpretation compared to single primary research.They identified an increasing demand for qualitative evidence synthesis from a wide range of "health and social professionals, policymakers, guideline developers and educationalists" (p.1).

Methodology
A systematic literature review requires a specific approach compared to other reviews.Although there is no consensus on how it is conducted, recent systematic literature reviews have agreed the following reporting criteria are addressed [42,43]: (a) a research question; (b) reporting database, and search strategy; (c) inclusion and exclusion criteria; (d) reporting selection methods; (e) critically appraisal tools; (f ) data analysis and synthesis.We applied these criteria in our study and began by registering the research protocol with Prospero [44].

Protocol
The study is registered at Prospero [44].This systematic literature review incorporates qualitative studies concerning older adults' experiences during the COVID-19 pandemic.

Search strategy
The primary qualitative articles were identified via a systematic search as per the qualitative-specific SPIDER approach [45].The SPIDER tool is designed to structure qualitative research questions, focusing less on interventions and more on study design, and 'samples' rather than populations, encompassing: S-Sample.This includes all articles concerning older adults aged 60 + [1].P-Phenomena of Interest.How did older adults experience the COVID-19 pandemic?D-Design.We aim to investigate qualitative studies concerning the experiences of older adults during the COVID-19 pandemic.E-Evaluation.The evaluation of studies will be evaluated with the amended Critical Appraisal Skills Programme CASP [46].R-Research type Qualitative

Information source
The following databases were searched: PsychInfo, Medline, CINAHL, Web of Science, Annual Review, Annual Review of Gerontology, and Geriatrics.A hand search was conducted on Google Scholar and additional searches examined the reference lists of the included papers.The keyword search included the following terms: (older adults or elderly) AND (COVID-19 or SARS or pandemic) AND (experiences); (older adults) AND (experience) AND (covid-19) OR (coronavirus); (older adults) AND (experience) AND (covid-19 OR coronavirus) AND (Qualitative).Additional hand search terms included e.g.senior, senior citizen, or old age.

Inclusion and exclusion criteria
Articles were included when they met the following criteria: primary research using qualitative methods related to the lived experience of older adults aged 60 + (i.e. the experiences of individuals during the COVID-19 pandemic); peer-reviewed journal articles published in English; related to the COVID-19 pandemic; empirical research; published from 2020 till August 2022.
Articles were excluded when: papers discussed health professionals' experiences; diagnostics; medical studies; interventions; day-care; home care; or carers; experiences with dementia; studies including hospitals; quantitative studies; mixed-method studies; single-case studies; people under the age of 60; grey literature; scoping reviews, and systematic reviews.We excluded clinical/care-related studies as we wanted to explore the everyday experiences of people aged 60 + .Mixed-method studies were excluded as we were interested in what was represented in solely qualitative studies.However, we acknowledge, that mixed-method studies are valuable for future systematic reviews.

Meta-ethnography
The qualitative synthesis was undertaken by using metaethnography.The authors have chosen meta-ethnography over other methodologies as it is an inductive and interpretive synthesis analysis and is uniquely "suited to developing new conceptual models and theories" ([47], p 2), see also [48].Therefore, it combines well with constructivist grounded theory methodology.Meta-ethnography also examines and identifies areas of disagreements between studies [48].This is of particular interest as the lived experiences of older adults during the COVID-19 pandemic were likely to be diverse.The method enables the researcher to synthesise the findings (e.g.themes, concepts) from primary studies, acknowledging primary data (quotes) by "using a unique translation synthesis method to transcend the findings of individual study accounts and create higher order" constructs ( [47], p. 2).The following seven steps were applied: 1. Getting started (identify area of interest).We were interested in the lived experiences of older adults worldwide.

Deciding what was relevant to the initial interest
(defining the focus, locating relevant studies, decision to include studies, quality appraisal).We decided on the inclusion and exclusion criteria and an appropriate quality appraisal.3. Reading the studies.We used the screening process described below (title, abstract, full text) 4. Determining how the studies were related (extracting first-order constructs-participants' quotes and second-order construct-primary author interpretation, clustering the themes from the studies into new categories (Table 3). 5. Translating the studies into one another (comparing and contrasting the studies, checking commonalities or differences of each article) to organise and develop higher-order constructs by using constant comparison (Table 3).Translating is the process of finding commonalities between studies [48].6. Synthesising the translation (reciprocal and refutational synthesis, a lines of argument synthesis (interpretation of the relationship between the themesleads to key themes and constructs of higher order; creating new meaning, Tables 2, 3), 7. Expressing the synthesis (writing up the findings) [47,48].

Screening and Study Selection
A 4-stage screening protocol was followed (Fig. 1 Prisma).First, all selected studies were screened for duplicates, which were deleted.Second, all remaining studies were screened for eligibility, and non-relevant studies were excluded at the preliminary stage.These screening steps were as follows: 1. title screening; 2. abstract screening, by the first and senior authors independently; and 3. full-text screening which was undertaken for almost all papers by the first author.However, 2 papers [9,23] were assessed independently by LS, LR, and LMM to avoid a conflict of interest.The other co-authors also screened independently a portion of the papers each, to ensure that each paper had two independent screens to determine inclusion in the review [49].This avoided bias and confirmed the eligibility of the included papers (Fig. 1).
Endnote reference management was used to store the articles and aid the screening process.

Data extraction
After title and abstract screening, 39 papers were selected for reading the full article.7 papers were excluded after the full-text assessment (1 study was conducted in 2017, but published in 2021; 2 papers were not fully available in English, 2 papers did not address the research question, 1 article was based on a conference abstract only, 1 article had only one participant age 65 +).
The full-text screening included 32 studies.All the included studies, alongside the CASP template, data extraction table, the draft of this article, and translation for synthesising the findings [47,48] were available and accessible on google drive for all co-authors.All authors discussed the findings in regular meetings.

Quality appraisal
A critical appraisal tool assesses a study for its trustworthiness, methodological rigor, and biases and ensures "transparency in the assessment of primary research" ( [51], p. 5); see also [48][49][50][51][52][53].There is currently no gold standard for assessing primary qualitative studies, but different authors agreed that the amended CASPS checklist was appropriate to assess qualitative studies [46,54].Thus, we use the amended CASP appraisal tool [42].The amended CASP appraisal tool aims to improve qualitative evidence synthesis by assessing ontology and epistemology (Table 1 CASP appraisal tool).A numerical score was assigned to each question to indicate whether the criteria had been met (= 2), partially met (= 1), or not met (= 0) [54]; see also [55].The score 16 -22 are considered to be moderate and high-quality studies.The studies scored 15 and below were identified as low-quality papers.Although we focus on higher-quality papers, we did not exclude papers to avoid the exclusion of insightful and meaningful data [42,48,[52][53][54][55][56][57].The quality of the paper was considered in developing the evidence synthesis.
We followed the appraisal questions applied for each included study and answered the criteria either 'Yes' , 'Cannot tell' , or 'No' .(Table 1 CASP appraisal criteria).The tenth question asking the value of the article was answered with 'high' of importance, 'middle' , or low of importance.The new eleventh question in the CASP tool concerning ontology and epistemology was answered with yes, no, or partly (Table 1).

Data synthesis
The data synthesis followed the seven steps of Meta-Ethnography developed by Noblit & Hare [58], starting the data synthesis at step 3, described in detail by [47].This encompasses: reading the studies; determining how the studies are related; translating the studies into one another; synthesis the translations; and expressing synthesis.This review provides a synthesis of the findings from studies related to the experiences of older adults during the COVID-19 pandemic.The qualitative analyses are based on constructivist grounded theory [59] to identify the experiences of older adults during the COVID-19 pandemic (non-clinical) populations.The analysis is inductive and iterative, uses constant comparison, and aims to develop a theory.The qualitative synthesis encompasses all text labelled as 'results' or 'findings' and uses this as raw data.The raw data includes participant's quotes; thus, the synthesis is grounded in the participant's experience [47,48,60,61].The initial coding was undertaken for each eligible article line by line.Please see Table 2 Themes per author and country.Focused coding was applied using constant comparison, which is a widely used approach in grounded theory [61].In particular, common and recurring as well as contradicting concepts within the studies were identified, clustered into categories, and overarching higher order constructs were developed [47,48,60] (Tables 2, 3, 4).

Findings
We identified twenty-seven out of thirty-two studies as moderate-high quality; they met most of the criteria (scoring 16/22 or above on the CASP; [54].Only five papers were identified as low qualitative papers scoring 15 and below [71,73,74,86,91].Please see the scores provided for each paper in Table 4.The low-quality papers did not provide sufficient details regarding the researcher's relationship with the participants, sampling and recruitment, data collection, rigor in the analysis, or epistemological or ontological reasoning.For example, Yildirim [91] used verbatim notes as data without recording or transcribing them.This article described the analytical process briefly but was missing a discussion of the applied reflexivity of using verbatim notes and its limitations [92]. This systematic review found that many studies did not mention the relationship between the authors and the participant.The CASP critical appraisal tool asks: Has the relationship between the researcher and participants been adequately considered?(reflecting on own role, potential bias).Many studies reported that the recruitment was drawn from larger studies and that the qualitative study was a sub-study.Others reported that participants contacted the researcher after advertising the study.One study Goins et al., [72] reported that students recruited family members, but did not discuss how this potential bias impacted the results.
Our review brings new insights into older adults' experiences during the pandemic worldwide.The studies were conducted on almost all continents.The majority of the articles were written in Europe followed by North America and Canada (4: USA; 3: Canada, UK; 2: Brazil, India, Netherlands, Sweden, Turkey 2; 1: Austria, China, Finland, India/Iran, Mauritius, New Zealand, Serbia, Spain, Switzerland, Uganda, UK/Ireland, UK/Colombia) (see Fig. 2).Note, as the review focuses on English language publications, we are unable to comment on qualitative research conducted in other languages see [72].
The characteristics of the included studies and the presence of analytical themes can be found in Table 4.We used the following characteristics: Author and year of publication, research aims, the country conducted, Participant's age, number of participants, analytical methodology, CASP score, and themes.
We identified three themes: desired and challenged wellbeing; coping and adaptation; discrimination and intersectionality.We will discuss the themes in turn.

Desired and challenged wellbeing
Most of the studies reported the impact of the COVID-19 pandemic on the well-being of older adults.Factors which influenced wellbeing included: risk communication and risk perception; social connectivity; confinement (at home); and means of coping and adapting.In this context, well-being refers to the evidence reported about participants' physical and mental health, and social connectivity.

Risk perception and risk communication
Politicians and media transmitted messages about the response to the pandemic to the public worldwide.These included mortality and morbidity reports, and details of health and safety regulations like social distancing, shielding-self-isolation, or wearing masks [34][35][36][37].As this risk communication is crucial to combat the spread of the virus, it is also important to understand how people perceived the reporting during the pandemic.
Seven studies reported on how the mass media impacted participants' well-being [23,67,68,70,72,81,85].Sangrar et al. [68] investigated how older adults responded to COVID-19 messaging: "My reaction was to try to make sure that I listen to everything and [I] made sure I was aware of all the suggestions and the precautions that were being expressed by various agencies …".(p.4).Other studies reported the negative impact on participants' well-being of constant messaging and as a consequence stopped watching the news to maintain emotional well-being [3,67,68,70,72,81,85].Derrer-Merk et al. [23] reported one participant said that "At first, watching the news every day is depressing and getting more and more depressing by the day, so I've had to stop watching it for my own peace of mind" (p.13).In addition, news reporting impacted participants' risk perception.For example, "Sometimes we are scared to hear the huge coverage of COVID-19 news, in particular the repeated message 'older is risky' , although the message is useful." ([81], p5).
The impact of COVID-19 on social networks highlighted the diverse experiences of participants.Some participants reported that the size of social contact was reduced: "We have been quite isolated during this corona time" ?( [80], p. 3).Whilst other participants reported that the network was stable except that the method of contact was different: "These friends and relatives, they visited and called as often as before, but of course, we needed to use the telephone when it was not possible to meet" ([77], p. 5).Many participants in this study did not want to expand their social network see also [9,[77][78][79].Hafford-Letchfield et al. [76] reported that established social networks and relationships were beneficial for the participants: "Covid has affected our relationship (with partner), we spend some really positive close time together and support each other a lot" (p. 7).
On the other hand, other studies reported decreases of, and gaps in, social connectedness: "I couldn't do a lot of things that I've been doing for years.That was playing competitive badminton three times a week, I couldn't do that.I couldn't get up early and go volunteer in Seattle" [9,67,75].A loss of social connection with children and grandchildren was often mentioned: "We cannot see our grandchildren up close and personal because, well because they [the parents] don't want us, they don't want to risk our being with the kids … it's been an emotional loss exacerbated by the COVID thing" ([68] p.10); see also [9,67,78].On the contrary, Chemen & Gopalla [66] note that those older adults who were living with other family members reported that they were more valued: "Last night my daughter-in-law thanked me for helping with my granddaughter" (p.4).Despite reports of social disconnectedness, some studies highlighted the importance of support from family members and how support changed during the COVID-19 pandemic [9,62,81,83,90].Yang et al. [90] argued that social support was essential during the Lockdown in China: "N6 said: 'I asked my son-in-law to take me to the hospital" (p.4810).Mahapatra et al. [81] found, in an Indian study, that the complex interplay of support on different levels (individual, family, and community) helped participants to adapt to the new situation.For example, this participant reported that: "The local police are very helpful.When I rang them for something and asked them to find out about it, they responded immediately" (p.5).

Impact of confinement on well being
Most articles highlighted the impact of confinement on older adults' well-being [9, 62, 63, 65, 67, 69, 70, 72, 75, 77-79, 81-83, 85, 89, 90].Some studies found that participants maintained emotional well-being during the pandemic and it did not change their lifestyle [79,80,82,83,89,92]: "Actually, I used this crisis period to clean my house.Bookcases are completely cleaned and I discarded old books.Well, we have actually been very busy with those kind of jobs.So, we were not bored at all" ([79], p. 5).In McKinlay et al. [82]'s study, nearly half of the participants found that having a sense of purpose helped to maintain their wellbeing: "You have to have a purpose you see.I think mental resilience is all about having a sense of purpose" (p. 6).However, at the same time, the majority of the articles (12 out of 18) highlighted the negative impact of confinement and social distancing.Participants talked of increased depressive feelings and anxiety.Many of the studies reported the negative impact of loneliness as a result of confinement on participants' well-being including [69,70,72,78,79,90,93]. Falvo et al. [67] reported that many participants experienced loneliness: "What sense does it make when you are not even able to see a family member?I mean, it is the Not all studies found a negative impact on loneliness.For example, a "loner advantage" was found by Xie et al. ( [82], p. 386).In this study participants found benefits in already being alone "It's just a part of who I am, and I think that helps-if you can be alone, it really is an asset when you have to be alone" ( [82], p. 386).
Bundy et al. [80] investigated loneliness from already lonely older adults and found that many participants did not attribute the loneliness to the pandemic: "It's not been a whole lot, because I was already sitting around the house a whole lot anyway ( …).It's basically the same, pretty well … I'd pretty well be like this anyway with COVID or without COVID" (p.873) (see also [83]).
A study from Serbia investigated how the curfew was perceived 15 months afterward.Some participants were calm: "I realized that … well … it was simply necessary.For that reason, we accepted it as a measure that is for the common good" ([70], p.634).Others were shocked: "Above all, it was a huge surprise and sort of a shock, a complete shock because I have never, ever seen it in my life and I felt horrible, because I thought that something even worse is coming, that I even could not fathom" ([70], p. 634).
The lockdowns brought not only mental health issues to the fore but impacted the physical health of participants.Some reported they were fearful of the COVID-19 pandemic: "...For a little while I was afraid to leave, to go outside.I didn't know if you got it from the air" ( [75].p. 6).Another study reported: "It's been important for me to walk heartily so that I get a bit sweaty and that I breathe properly so that I fill my lungs-so that I can be prepared-and be as strong as possible, in case I should catch that coronavirus" ([77], p. 9); see also [70,78,82,85].
A variety of coping processes were reported including: acceptance; behavioural adaptation; emotional regulation; creating new routines; or using new technology.Kremers et al. [79] reported: "We are very realistic about the situation and we all have to go through it.Better days will come" (p.e71).Behavioural adaptation was reported: "Because I'm asthmatic, I was wearing the disposable masks, I really had trouble breathing.But I was determined to find a mask I could wear" ( [68], p. 14).New routines with protective hygiene helped some participants at the beginning of the pandemic to cope with the health threat: "I am washing my hands all the time, my hands are raw from washing them all the time, I don't think I need to wash them as much as I do but I do it just in case, I don't have anybody coming in, so there is nobody contaminating me, but I keep washing" ([69], p. 4391); see also [72].Verhage et al. [87] reported strategies of coping including self-enhancing comparisons, distraction, and temporary acceptance: "There are so many people in worse circumstances …" (p.e294).Other studies reported how participants used a new technology: "I have recently learned to use WhatsApp, where I can make video phone calls." ( [88], p. 163); see also [89].
Prigent et al. [84], conducted in a New Zealand study, found that ageism was reciprocal.Younger people spoke against older adults: "why don't you do everyone a favour and drop dead you f******g b**** it's all because of ones like you that people are losing jobs" (p.11).On the other hand, older adults spoke against the younger generation: "Shame to see the much younger generations often flout the rules and generally risk the gains made by the team.Sheer arrogance on their part and no sanctions applied" (p.11).Although one study reported benevolent ageism [23] most studies found hostile ageism [23,63,67,70,76,84].One study from Canada exploring 15 older adult's Chinese immigrants' experiences reported racism as people around them thought they would bring the virus into the country.The negative impact on existing friendships was told by a Chinese man aged 69 "I can tell some people are blatantly despising us.I can feel it.When I talked with my Caucasian friends verbally, they would indirectly blame us for the problem.Eventually, many of our friendships ended because of this issue" ([88], p161).In addition, this study reported ageism when participants in nursing homes felt neglected by the Canadian government.
Two papers reported experiences of sexual and gender minorities (SGM) (e.g.transgender, queer, lesbian or gay) and found additional burdens during the pandemic [63,76].People experienced marginalisation, stereotypes, and discrimination, as well as financial crisis: "I have faced this throughout life.Now people look at me in a way as if I am responsible for the virus." ([63], p. 6).The consequence of marginalisation and ignorance of people with different gender identities was also noted by Hafford-Letchfield et al. [76]: "People have been moved out of their accommodation into hotels with people they don't know …. a gay man committed suicide, community members know of several that have attempted suicide.
They are feeling pretty marginalised and vulnerable and you see what people are writing on the chat pages" (p.4).The intersection of ageism, racism, and heterosexism and its negative impact on people's well-being during the pandemic reflects additional burden and stressors for older adults.

Discussion
This systematic literature review is important as it provides new insights into the lived experiences of older adults during the COVID-19 pandemic, worldwide.Our study highlights that the COVID-19 pandemic brought an increase in English-written qualitative articles to the fore.We found that 32 articles met the inclusion criteria but 5 were low quality.A lack of transparency reduces the trustworthiness of the study for the reader and the scientific community.This is particularly relevant as qualitative research is often criticised for its bias or lack of rigor [94].However, their findings are additional evidence for our study.
Our aim was to explore, in a systematic literature review, the lived experiences of older adults during the COVID-19 pandemic worldwide.The evidence highlights the themes of desired and challenged wellbeing, coping and adaptation, and discrimination and intersectionality, on wellbeing.
Perceived risk communication was experienced by many participants as overwhelming and anxiety-provoking.This finding supports Anwar et al. 's [37] study from the beginning of the pandemic which found, in addition to circulating information, that mass media influenced the public's behaviour and in consequence the spread of disease.The impact can be positive but has also been revealed to be negative as well.They suggest evaluating the role of the mass media in relation to what and how it has been conveyed and perceived.The disrupted social connectivity found in our review supports earlier studies that reported the negative impact of people's well-being  at the beginning of the pandemic.This finding is important for future health crisis management, as the protective health measures such as confinement or selfisolation had a negative impact on many of the participants' emotional wellbeing including increased anxiety, feelings of depression, and loneliness during the lockdowns.As a result of our review, future protective health measures should support people's desire to maintain proximity with their loved ones and friends.However, we want to stress that our findings are mixed.
The ability of older adults to adapt and cope with the health crisis is important: many of the reported studies noted the diverse strategies used by older people to adapt to new circumstances.These included learning new technologies or changing daily routines.Politicians and the media and politicians should recognise both older adults' risk of disease and its consequences, but also their adaptability in the face of fast-changing health measures.This analysis supports studies conducted over the past decades on lifespan development, which found that people learn and adapt livelong to changing circumstances [95][96][97].
We found that discrimination against age, race, and gender identity was reported in some studies, in particular exploring participants' experiences with immigration backgrounds and sexual and gender minorities.These studies highlighted the intersection of age and gender or race and were additional stressors for older adults and support the findings from Ramirez et al. [98] This review suggests that more research should be conducted to investigate the experiences of minority groups to develop relevant policies for future health crises.
Our review was undertaken two years after the pandemic started.At the cut-off point of our search strategy, no longitudinal studies had been found.However, in December 2022 a longitudinal study conducted in the USA explored older adult's advice given to others [99].They found that fostering and maintaining well-being, having a positive life perspective, and being connected to others were coping strategies during the pandemic [100].This study supports the results of the higher order constructs of coping and adaptation in this study.Thus, more longitudinal studies are needed to enhance our understanding of the long-term consequences of the COVID-19 pandemic.The impact of the COVID-19 restrictions on older adults' lives is evident.We suggest that future strategies and policies, which aim to protect older adults, should not only focus on the physical health threat but also acknowledge older adults' needs including psychological support, social connectedness, and instrumental support.The policies regarding older adult's protections changed quickly but little is known about older adults' involvement in decision making [100].We suggest including older adults as consultants in policymaking decisions to ensure that their own self-determinism and independence are taken into consideration.
There are some limitations to this study.It did not include the lived experiences of older adults in care facilities or hospitals.The studies were undertaken during the COVID-19 pandemic and therefore data collection was not generally undertaken face-to-face.Thus, many studies included participants who had access to a phone, internet, or email, others could not be contacted.Additionally, we did not include published papers after August 2022.Even after capturing the most commonly used terms and performing additional hand searches, the search terms used might not be comprehensive.The authors found the quality of the papers to be variable, and their credibility was in question.We acknowledge that more qualitative studies might have been published in other languages than English and were not considered in this analysis.
To conclude, this systematic literature review found many similarities in the experiences of older adults during the Covid-19 pandemic despite cultural and socioeconomic differences.However, we stress to acknowledge the heterogeneity of the experiences.This study highlights that the interplay of mass media reports of the COVID-19 pandemic and the policies to protect older adults had a direct impact on older adults' well-being.The intersection of 'isms' (ageism, racism, and heterosexism) brought an additional burden for some older adults [98].These results and knowledge about the drawbacks of health-protecting measures need to be included in future policies to maintain older adults' well-being during a health crisis.

Fig. 2
Fig. 2 Numbers of publications by country

Table 3
From codes to categories and higher order constructs

Table 4
Characteristics of studies and participants and presence of analytical themes.( a Higher order constructs: Risk perception and risk communication; coping and adaptation;