Advertisement

Factors Influencing Mobility During the COVID-19 Pandemic in Community-Dwelling Older Adults

Published:August 29, 2022DOI:https://doi.org/10.1016/j.apmr.2022.08.009

      Highlights

      • ·
        More than a quarter of older adults report the COVID-19 pandemic has negatively affected their physical activity level, highlighting the importance of finding strategies to support physical activity and mitigate mobility decline in older adults during lockdowns from infectious disease threats.
      • ·
        Physical and environmental factors such as self-reported health, pain, and neighborhood walkability are key factors associated with mobility during the pandemic. Attention should be given to those with poorer physical health and greater environmental barriers pre-COVID-19 as they may be most at risk for declining mobility during periods of lockdown.

      Abstract

      Objective

      To describe and identify factors influencing mobility among older adults during the first 5 months of the COVID-19 pandemic.

      Design

      A cross-sectional telesurvey.

      Setting

      Community dwelling older adults, situated within the first 5 months of the COVID-19 pandemic, in Hamilton, Canada.

      Participants

      A random sample of 2343 older adults were approached to be in the study, of which 247 completed the survey (N=247). Eligible participants were aged ≥65 years.

      Interventions

      Not applicable.

      Main Outcome Measures

      Mobility was measured using global rating of change items and the Late Life Function Instrument (LLFI). Multivariate linear regression models were used to examine the association between mobility and related factors based on Webber's model.

      Results

      247 older adults (29% male, mean age 78±7.3 years) completed surveys between May and August 2020. Respectively, 26%, 10%, and 9%, rated their ability to engage in physical activity, housework, and move around their home as worse compared with the start of the pandemic. The mean LLFI score was 60.9±13.4. In the model, walking volume (β=0.03 95% confidence interval 0.013, 0.047), fall history (β=-0.04, 95% confidence interval -0.08, -0.04), male sex (β=0.06, 95% confidence interval 0.02, 0.09), unpleasant neighborhood (β=-0.06, 95% confidence interval -0.11, -0.02), musculoskeletal pain (β=-0.07, 95% confidence interval -0.11, -0.03), and self-reported health (β=0.08, 95% confidence interval 0.03, 0.13) had the strongest associations with LLFI scores and explained 64% of the variance in the LLFI score.

      Conclusions

      Physical and environmental factors may help explain poorer mobility during lockdowns. Future research should examine these associations longitudinally to see if factors remain consistent over time and could be targeted for rehabilitation.

      Keywords

      List of abbreviations:

      LLFI (Late Life Function Instrument)
      The pandemic caused by the novel coronavirus, COVID-19, has had serious economic, health, and social ramifications.
      • Statistics Canada.
      COVID-19 in Canada: a one-year update on social and economic impacts.
      Since the outset, public health authorities have urged adherence to social distancing measures and, at times, implemented stay-at-home orders. For countries in the northern hemisphere, such measures have been heavily relied upon during each of the 4 surges in cases, even with the availability of vaccines (spring and summer 2020; winter 2021; spring 2021; winter 2022).
      • Aung MN
      • Yuasa M
      • Koyanagi Y
      • et al.
      Sustainable health promotion for the seniors during COVID-19 outbreak: a lesson from Tokyo.
      Those 65 years and older have a heightened susceptibility to severe illness and outcomes if they contract COVID-19,
      • Davies NG
      • Klepac P
      • Liu Y
      • et al.
      Age-dependent effects in the transmission and control of COVID-19 epidemics.
      partly because they are more likely to have multiple health conditions that can weaken the immune system. Thus, older adults may be more cautious and adhere more stringently to public health restrictions to mitigate contracting the virus.
      • González-Castro JL
      • Ubillos-Landa S
      • Puente-Martínez A
      • Gracia-Leiva M.
      Perceived vulnerability and severity predict adherence to COVID-19 protection measures: the mediating role of instrumental coping.
      Researchers and rehabilitation professionals have raised concerns about the health-related consequences of isolation
      • Sepúlveda-Loyola W
      • Rodríguez-Sánchez I
      • Pérez-Rodríguez P
      • et al.
      Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations.
      for older adults during the pandemic and the resulting decline in social and physical activities.
      • Sepúlveda-Loyola W
      • Rodríguez-Sánchez I
      • Pérez-Rodríguez P
      • et al.
      Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations.
      Government of Scotland
      Framework for supporting people through recovery and rehabilitation during and after the COVID-19 Pandemic.

      Government of Wales. Rehabilitation: a framework for continuity and recovery 2020 to 2021. 2020. Available at: https://gov.wales/rehabilitation-framework-continuity-and-recovery-2020-2021-html. Accessed September 21, 2022.

      This decline is concerning as engagement in regular social and physical activities is essential to maintaining mobility and reducing disability, especially in later life.
      • Bangsbo J
      • Blackwell J
      • Boraxbekk C-J
      • et al.
      Copenhagen Consensus statement 2019: physical activity and ageing.
      ,
      • Cunningham C
      • O'Sullivan R
      • Caserotti P
      • Tully MA.
      Consequences of physical inactivity in older adults: a systematic review of reviews and meta-analyses.
      Maintaining mobility in older adulthood is critical given its association with healthy aging, overall wellbeing, and reduced disability.
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      ,
      • Prohaska TR
      • Anderson LA
      • Hooker SP
      • Hughes SL
      • Belza B.
      Mobility and aging: transference to transportation.
      Defined as the capacity and ability to move in and across different environments,
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      mobility is linked to participation in life activities, quality of life, and social engagement.
      • Prohaska TR
      • Anderson LA
      • Hooker SP
      • Hughes SL
      • Belza B.
      Mobility and aging: transference to transportation.
      • Pantelaki E
      • Maggi E
      • Crotti D
      Mobility impact and well-being in later life: a multidisciplinary systematic review.
      • Satariano WA
      • Guralnik JM
      • Jackson RJ
      • Marottoli RA
      • Phelan EA
      • Prohaska TR.
      Mobility and aging: new directions for public health action.
      • Rosso AL
      • Taylor JA
      • Tabb LP
      • Michael YL.
      Mobility, disability, and social engagement in older adults.
      Mobility as a construct can be measured through self-report, performance-based outcomes, or via direct observation using smart technology (eg, accelerometers, smart watches). In the model proposed by Webber et al.,
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      6 factors influence mobility: financial, psychosocial, environmental, physical, cognitive, and sex/culture/biographic.
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      Many of these factors may have been affected by the public health measures and other effects resulting from the pandemic. Understanding the most relevant factors underlying mobility is critical for informing rehabilitative strategies to build resilience both during this pandemic and in the face of future infectious disease threats—an issue that is recognized as a key priority by international bodies.
      Government of Scotland
      Framework for supporting people through recovery and rehabilitation during and after the COVID-19 Pandemic.
      ,

      Government of Wales. Rehabilitation: a framework for continuity and recovery 2020 to 2021. 2020. Available at: https://gov.wales/rehabilitation-framework-continuity-and-recovery-2020-2021-html. Accessed September 21, 2022.

      ,

      World Health Assembly agrees to launch process to develop historic global accord on pandemic prevention, preparedness and response [press release]. 2021.

      The central importance of mobility to healthy aging and the society-wide effect of COVID-19 has resulted in the need to characterize older adults’ mobility during this time of restriction. Further, it is imperative to understand how mobility has been affected by ongoing public health measures. Objective 1 of this study was to describe community-dwelling older adults’ perceived mobility changes during the early months of the COVID-19 pandemic within the vicinity of Hamilton, Ontario, Canada. Objective 2 was to identify factors associated with mobility ability during this time in order to guide the development of rehabilitative interventions for older adults living in the community.

      Methods

      Study design and sample

      A cross-sectional analysis of a longitudinal tele-survey study administered to a random sample of older adults living in Hamilton, Ontario, Canada. Details of the protocol have been published elsewhere.
      • Beauchamp MK
      • Vrkljan B
      • Kirkwood R
      • et al.
      Impact of COVID-19 on mobility and participation of older adults living in Hamilton, Ontario, Canada: a multimethod cohort design protocol.
      Briefly, participants were recruited through consecutive phone calls made to a list of random phone numbers obtained from ASDE Survey Sampler. Any individual living in the community and equal to or over the age of 65 years was eligible to participate. Exclusion criteria included those living in a care residence, those with self-identified severe and uncorrectable visual or hearing impairments, or with self-identified severe cognitive impairments. All participants provided verbal consent for participation. This study received ethics approval from Hamilton Integrated Research Ethics Board of McMaster University (2020-10814-GRA) and an ethics board at the University of Waterloo (ORE# 4229).

      Setting and context: timeline of the pandemic and public health measures

      As context for this study, it is important to note the timeline of the COVID-19 pandemic, and the associated measures put in place in Hamilton. Additional details can be found in the protocol.
      • Beauchamp MK
      • Vrkljan B
      • Kirkwood R
      • et al.
      Impact of COVID-19 on mobility and participation of older adults living in Hamilton, Ontario, Canada: a multimethod cohort design protocol.
      Briefly, on March 11, 2020, the WHO formally declared COVID-19 a pandemic.

      WHO. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020 2020. Available at:https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed

      Subsequently, on March 17, 2020, the province of Ontario in Canada was placed under a state of emergency and most retail, restaurants, and recreational facilities were closed. Limits were placed on the number of individuals allowed to gather indoors and outdoors. Baseline data were collected by survey from May 2020 to August 2020. During this time, Ontario entered Phase 1 (May 19, 2020) of reopening, which allowed some facilities to open while maintaining gathering limits. Phases 2 (June 12, 2020) and 3 (August 3, 2020) allowed outdoor services, personal care services, and relaxing of some indoor restrictions. Across all these phases, limitations remained in place on the number of individuals allowed to gather, with strict physical distancing and health and safety protocols.

      Assessment of mobility

      Self-perceived changes in mobility

      Descriptive data captured participant-perceived changes in mobility since the beginning of the pandemic and related social/physical distancing measures. Using global rating of change scales,
      • Beauchamp MK
      • Joshi D
      • McMillan J
      • et al.
      Assessment of functional mobility after COVID-19 in adults aged 50 years or older in the Canadian longitudinal study on aging.
      we determined participant perceived self-reported changes in 3 different mobility domains: ability to move around one's home, ability to complete housework, and ability to engage in physical activity. The response options were based on a Likert scale from 1-much worse to 5-much better.

      Late life function instrument

      Mobility was assessed using the Function component of the Late Life Function Instrument (LLFI).
      • Haley S.
      Late life function and disability instrument: II. Development and evaluation of the function component.
      The LLFI is composed of 32 items assessing an individual's self-reported ability to complete discrete physical tasks. These tasks are considered as part of daily routines making up one's mobility, which is consistent with leading disablement frameworks.

      WHO. International classification of functioning, disability and health. 2001.

      ,
      • Verbrugge LM
      • Jette AM.
      The disablement process.
      An example item in the instrument is as follows: how much difficulty do you have walking a mile, taking rests a necessary, with response options ranging from no difficulty (5) to cannot do (1). Item scores are summed and the total raw score is transformed to a scale from 0 to 100, with higher scores indicating better function and mobility ability. The scale also consists of 3 sub-scales, which are derived from specific items of the scale. These subscales are upper extremity function (activities using hands and arms), basic lower extremity function (activities involving standing, stooping, or walking), and advanced lower extremity function (activities requiring a greater degree of physical ability and endurance). The subscale scores are also transformed from 0 to 100. Higher scores indicate greater ability to perform sub-scale specific activities. The LLFI has been shown to have strong convergent validity with performance-based mobility measures and good test-retest reliability among community dwelling older adults.
      • Haley S.
      Late life function and disability instrument: II. Development and evaluation of the function component.
      ,
      • Beauchamp MK
      • Schmidt CT
      • Pedersen MM
      • Bean JF
      • Jette AM.
      Psychometric properties of the late-life function and disability instrument: a systematic review.

      Assessment of factors related to mobility

      To identify potentially relevant factors underlying mobility and LLFI scores during the pandemic, we used Webber's Theoretical Framework for Mobility.
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      The Framework posits that mobility is the “ability to move oneself within community environments that expand from one's home, to the neighborhood, and to regions beyond”
      • Webber SC
      • Porter MM
      • Menec VH.
      Mobility in older adults: a comprehensive framework.
      and is influenced by 6 intersecting concepts. The measures used from our survey for each construct, except cognitive factors, are reported in detail in Supplemental table S1. These are: (1) Sex and biographic factors: self-reported age, sex, height (meters), and mass (kilograms, kg). Body mass index (BMI) was calculated by dividing mass in kg by height in meters squared; (2) Financial factors: participants’ self-reported household income and education; (3) Psychosocial factors: psychosocial factors were measured using validated questionnaires: the Impact of Events Scale-Revised
      • Horowitz M
      • Wilner N
      • Alvarez W.
      Impact of event scale: a measure of subjective stress.
      ,
      • Creamer M
      • Bell R
      • Failla S.
      Psychometric properties of the impact of event scale—revised.
      examining distress caused by events; the Brief Resilience Scale
      • Cosco TD
      • Kaushal A
      • Richards M
      • Kuh D
      • Stafford M.
      Resilience measurement in later life: a systematic review and psychometric analysis.
      ,
      • Smith BW
      • Dalen J
      • Wiggins K
      • Tooley E
      • Christopher P
      • Bernard J.
      The brief resilience scale: assessing the ability to bounce back.
      examining resilience from stress; and the EuroQol 5D-5L questionnaire
      • Herdman M
      • Gudex C
      • Lloyd A
      • et al.
      Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
      ,
      • Janssen M
      • Pickard AS
      • Golicki D
      • et al.
      Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study.
      examining quality of life. In terms of social connections, participants were asked a single question from the Center for Epidemiologic Studies Depression Scale
      • Irwin M
      • Artin KH
      • Oxman MN.
      Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D).
      examining loneliness; if they had someone they could rely on for support; their pre-pandemic social contact frequency; any lost supports since the start of the pandemic; and health assistance they received in the past 12 months; (4) Environmental factors: two questions about participants’ neighborhood; the extent to which their neighborhood is safe (generally); and the extent to which they feel it is unpleasant to walk in their neighborhood; and (5) Physical factors: medical history; whether they had experienced musculoskeletal pain in the past 30 days
      • Ferreira-Valente MA
      • Pais-Ribeiro JL
      • Jensen MP.
      Validity of four pain intensity rating scales.
      ; general self-rated health; nutrition risk using the Seniors in the Community: Risk Evaluation of Eating and Nutrition Abbreviated
      • Keller H
      • Goy R
      • Kane S.
      Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II).
      ; volume of walking
      • Washburn RA
      • Smith KW
      • Jette AM
      • Janney CA.
      The physical activity scale for the elderly (PASE): development and evaluation.
      and volume of strength fitness
      • Washburn RA
      • Smith KW
      • Jette AM
      • Janney CA.
      The physical activity scale for the elderly (PASE): development and evaluation.
      ; and if they had a fall in the past year.

      Statistical analysis

      Descriptive statistics are presented as means and standard deviations (SDs) for continuous normally distributed variables and medians and interquartile range for nonparametric data. For categorical variables, frequencies and proportions are presented. For data completeness, we excluded 25 participants (9%) who had missing data for the explanatory variables.
      Multivariate linear regression assessed the association between factors from Webber's framework with mobility measured using the LLFI. Separate regression models were run for the LLFI total score for overall function and the 3 subscales (upper extremity, basic lower extremity, and advanced lower extremity). The LLFI total score for overall function was logarithmically transformed to meet the assumption of normality of the residuals. Correlations between all pairs of independent variables were assessed using Pearson or Spearman tests to detect any potential collinearity and identify variables to include in the full model. A multivariate model was constructed using backward elimination. From the full model, we manually removed variables that did not significantly contribute to the model, as indicated by P value0.05. We also examined the adjusted R2, F statistic, and changes in the regression coefficient differences between the full and reduced models to identify the most predictive combination of variables. This model building technique was repeated for each of the LLFI subscales. The variables included in the final models for each subscale were distinct. For all models, we tested for linear regression assumptions and multicollinearity. All analyses were conducted using StataIC (v.16), using a level of significance of 0.05.

      Results

      Participant characteristics

      Study staff called 2343 random phone numbers from the ASDE sample list. Of these, 312 older adults were recruited (13%), 272 completed the baseline tele-survey, with 25 participants (9%) excluded because of missing data (fig 1). Table 1 outlines participants’ characteristics. Mean age was 78.0±7.3 and 28.7% (n=71) identified as male. Almost half of the participants had completed a post-secondary degree (46.6%, n=115), and 10.9% (n=27) had less than a secondary school education. Mean number of comorbidities reported was 3.7±2.2, where cataracts (46.6%, n=115), high blood pressure (45.7%, n=113), back pain (27.1%, n=67), osteoarthritis (28.9%, n=96), and osteoporosis (17%, n=42) were the most common. The mean total physical function score of the LLFI was 60.9±13.4 (table 2). Supplemental fig S1 identifies the mean LLFI total scores by age group, comorbidity status, education, and sex.
      Table 1Select study participant characteristics
      CharacteristicN=247
      Age, y, mean (SD)78.0 (7.3)
       65-7494 (38.1)
       75-84108 (43.7)
       85+45 (18.2)
      Male sex, frequency (%)71 (28.7)
      Body mass index, frequency (%)27.2 (5.4)
       <25 kg/m282 (33.2)
       ≥25 kg/m2156 (63.2)
      Financial factors
      Education, frequency (%)
       Less than secondary school27 (10.9)
       Secondary school graduation but no post-secondary education49 (19.8)
       Some post-secondary education56 (22.7)
       Post-secondary degree/diploma115 (46.6)
      Environmental factor
      Unpleasant walking, frequency (%)
       Disagree186 (75.3)
       Agree61 (24.7)
      Physical factors
      Perceived overall health status, frequency (%)
       Good/very good/excellent197 (79.8)
       Poor/fair50 (20.2)
      Number of comorbidities, mean (SD)3.7 (2.21)
      Most common conditions, frequency (%)
       Cataracts115 (46.6)
       Osteoporosis42 (17.0)
       Osteoarthritis96 (28.9)
       Back pain67 (27.1)
       High blood pressure113 (45.7)
      Experienced musculoskeletal pain in the past month, frequency (%)159 (64.4)
      Experienced a fall in the previous 12 months, frequency (%)84 (34)
      Use a walking aid, frequency (%)77 (31.2)
      Types of health assistance received, frequency (%)
       No receipt of health assistance142 (57.5)
       Personal care44 (17.8)
       Medical care26 (10.5)
       Medical appointments18 (7.3)
       Housework, home maintenance11 (4.5)
       Transportation5 (2.0)
       Meal preparation1 (0.4)
      Frequency of physical activity (walking), frequency (%)
       0-2 days105 (42.5)
       3-7 days142 (57.5)
      Psychosocial factors
      Perceived mental health status, frequency (%)
       Poor/fair22 (8.9)
       Good/very good/excellent225 (91.1)
      Brief resilience scale score, median (IQR)3.8 (0.8)
      Fear of falling, mean (SD)3.3 (2.4)
      Abbreviations: IQR, interquartile range.
      Table 2Late life function scores
      Late Life Function ScoresN=247
      LLFI – total score, mean (SD)60.9 (13.4)
      LLFI – upper extremity, median (IQR)77.5 (19.6)
      LLFI – basic lower extremity, median (IQR)72.1 (28.0)
      LLFI – advanced lower extremity, mean (SD)47.6 (23.2)
      Mean scores by age group, mean (SD)
       65-74 (n=94)66.7 (13.4)
       75-84 (n=108)60.2 (12.7)
       ≥85 (n=45)52.6 (10.3)
      Mean scores by sex, mean (SD)
       Male64.9 (15.6)
       Female59.3 (12.1)
      Mean scores by comorbidity
       <4 (n=130)66.1 (13.5)
       ≥4 (n=117)55.2 (10.7)
      Mean scores by education level
       Less than secondary school54.5 (8.7)
       Secondary school graduation but no post-secondary education58.1 (13.6)
       Some post-secondary education59.9 (13.4)
       Post-secondary degree/diploma64.2 (13.4)
      Abbreviations: IQR, interquartile range.

      Self-reported changes in mobility since the start of the pandemic

      Participants’ perceived changes in their ability to move around the home from the beginning of the pandemic was reported as worse for 9.3% (n=23), as was their perceived ability to engage in housework (9.7%, n=24) and physical activity (26.3%, n=65) (fig 2 and Supplemental table S2). Only a small proportion of participants reported improvements in their ability to move around home (2.8%, n=7,), ability to engage in housework (1.6%, n=4), and ability to engage in physical activity (4.5%, n=11). Most participants reported no perceived change in mobility since the start of the pandemic across the 3 self-reported domains.

      Factors associated with LLFI scores during the pandemic

      The final model for the LLFI function total score explained 64% of the total variance (table 3) demonstrated no collinearity concerns between the independent variables (Variance Inflation Factor<10) and met all assumptions. By magnitude of association, younger age, less fear of falling, fewer comorbidities, less assistance required, greater volume of walking, no falls, male sex, less unpleasant neighborhood for walking, lower musculoskeletal pain, and better self-reported health were positively associated with LLFI scores. Because the baseline tele-survey was conducted over 4 phases of lockdown/reopening during the initial months of the pandemic, we performed a sensitivity analysis, controlling for pandemic phase. Thirty-nine participants were between phases 0 and 1, with a mean LLFI score of 60.23 (±13.95), whereas n=208 participants were between phases 2 and 3, with a mean score of 61.03 (±13.31). Our sensitivity analysis found no association of pandemic phase with mobility. The results of this analyses have been included in Supplemental table S3.
      Table 3Multiple regression analysis for factors associated with LLFI overall function scores
      VariablesCoefficient (95% CI)%Change Mobility Scores+
      Age-0.01 (-0.011 to -0.005)
      P<.001.
      0.81% for increase in age
      Sex
       FemaleREF
       Male0.06 (0.02-0.09)
      P<.05.
      5.6% compared with REF
      Education
       Less than secondary schoolREF
       Secondary degree/diploma-0.01 (-0.08 to 0.06)1.2% compared with REF
       Some post-secondary0.01 (-0.06 to 0.08)1% compared with REF
      Post-secondary degree/diploma0.04 (-0.02 to 0.10)3.8% compared with REF
      Musculoskeletal pain
       NoREF
       Yes-0.07 (-0.11 to -0.03)
      P<.05.
      6.5% compared with REF
      Total number of comorbidities-0.02 (-0.03 to -0.08)
      P<.001.
      1.7% for increase in comorbidity
      Self-reported health
       Poor/fairREF
       Good/very good/excellent0.08 (0.03-0.13)
      P<.05.
      8.5% compared with REF
      Volume of walking0.03 (0.013-0.047)
      P<.05.
      3.1% for increase in walking
      Receive assistance-0.03 (-0.04 to -0.01)
      P<.05.
      2.7% for increase in amount of assistance
      Fall status
       NoREF
       Yes-0.04 (-0.08 to -0.04)
      P<.05.
      4.3% compared with REF
      Fear of falling-0.01 (-0.02 to -0.01)
      P<.05.
      1.3% for increase in fear of fall
      Unpleasant to walk in neighborhood
       NoREF
       Yes-0.06 (-0.11 to -0.02)
      P<.05.
      6.2% compared with REF
      Constant4.8 (4.58-5.02)
      P<.001.
      R-SquaredAdjusted R-SquaredF-Valued.f.
      Model parameters0.6407
      P<.001.
      0.620731.9713, 233
      NOTES. REF indicates the reference value; %change Mobility scores was determined using the exponential growth equation to calculate ratios, where indicates a decrease in mobility scores, indicates an increase in mobility scores.
      Abbreviations: CI, confidence interval, REF, reference value
      low asterisk P<.001.
      P<.05.
      The final models for each of the LLFI subscales are provided in table 4. For the LLFI upper extremity score, the model explained 56% (adj 0.5404) of the variance (F10,236=29.93, P<.005). Younger age, male sex, fewer comorbidities, greater volume of walking, no history of falls, less fear of falling, greater resilience, and less unpleasant neighborhood were positively associated with upper extremity LLFI scores. For the LLFI basic lower extremity score, higher scores were associated with younger age, fewer number of comorbidities, greater volume of walking, less fear of falling, greater self-rated health, and not unpleasant to walk in the neighborhood and explained 40% (adj. 0.3748) of the variance (F11,235=14.40). Last, for the LLFI advanced lower extremity score, higher scores were associated with younger age, male sex, fewer comorbidities, greater volume of walking, no use of a walking aid, less fear of falling, and less unpleasant neighborhood and explained 65% (adj 0.6311) of the variance (F10,236=43.08).
      Table 4LLFI subscale multiple regression analysis
      VariablesUpper Extremity CoefficientBasic Lower Extremity CoefficientAdvanced Lower Extremity Coefficient
      Age-0.4
      P<.001.
      (-0.6 to -0.2)
      -0.6
      P<.001.
      (-0.9 to -0.4)
      -0.7
      P<.001.
      (-1 to -0.4)
      Sex
       FemaleREFREFREF
       Male4.2
      P<.05.
      (0.8-7.6)
      2.7 (-0.7 to 6.7)5.3
      P<.05.
      (1.3-9.4)
      Education
       Less than secondary schoolREFREFREF
       Secondary degree/diploma-1.8 (-7.5 to 4.0)1.3 (-4.5 to 7.1)-0.9 (-7.7 to 5.9)
       Some post-secondary-2.5 (-8.2 to 3.1)-0.8 (-6.5 to 4.9)0.8 (-5.9 to 7.5)
       Post-secondary degree/diploma0.7 (-4.5 to 5.9)3.4 (-1.8 to 8.7)1.7 (-4.5 to 8.0)
      Total number of comorbidities-1.4
      P<.05.
      (-2.2 to -0.7)
      -1.1
      P<.05.
      (-1.9 to -0.3)
      -2.6
      P<.001.
      (-3.5 to -1.7)
      Volume of walking1.5
      P<.05.
      (0.0-3.0)
      2.8
      P<.001.
      (1.2-4.2)
      3.8
      P<.001.
      (2.1-5.6)
      Fall status
       NoREFNANA
       Yes-4.2
      P<.05.
      (-7.6 to -0.7)
      Use of a walking aid
       NoNANAREF
       Yes-17.7
      P<.05.
      (-22.5 to -13.0)
      Fear of falling-1.2
      P<.05.
      (-1.9 to -0.5)
      -1.2
      P<.05.
      (-1.9 to -0.5)
      -1.1
      P<.05.
      (-1.9 to -0.3)
      Self-rated health (0-100)NA0.3
      P<.001.
      (0.2-0.4)
      NA
      Brief resilience score2.5
      P<.05.
      (0.3-4.7)
      NANA
      Unpleasant to walk in neighborhood
       NoREFREFREF
       Yes-4.8
      P<.05.
      (-8.4 to -1.2)
      -4.6
      P<.05.
      (-8.3 to -0.9)
      -8.1
      P<.05.
      (-12.4 to -3.8)
      Constant110.7
      P<.001.
      (90.5-130.9)
      103.1
      P<.001.
      (80.8-125.42)
      115.2
      P<.05.
      (92.2-138.1)
      NOTE. REF indicates the reference value.
      Abbreviations: NA, not applicable
      low asterisk P<.001.
      P<.05.

      Discussion

      This is the first study to examine mobility as reflected by the function scores of the LLFI in a random sample of community-dwelling older adults during the early months of the COVID-19 pandemic. We found 26% of older adults rated their level of physical activity as worse since the start of the pandemic compared with only 4.5% who rated it as better. Physical and environmental factors, specifically, greater volume of walking, no falls in the past 12 months, male sex, pleasant walkable neighborhood, less musculoskeletal pain, and greater self-reported health had the greatest association with mobility ability. Our model explained a high portion (64%) of the variance in mobility, highlighting the importance of physical health and environmental factors for older adults’ mobility during the pandemic.
      Our findings are consistent with a systematic review of studies reporting a general trend for reduction in physical activity among older adults during the pandemic,
      • Larson EA
      • Bader-Larsen KS
      • Magkos F.
      The effect of COVID-19-related lockdowns on diet and physical activity in older adults: a systematic review.
      as well as with a recent analysis from the Canadian Longitudinal Study on Aging COVID-19 study.
      • Beauchamp MK
      • Joshi D
      • McMillan J
      • et al.
      Assessment of functional mobility after COVID-19 in adults aged 50 years or older in the Canadian longitudinal study on aging.
      We found that 26% of our participants reported a decrease in their ability to engage in physical activity since the start of the pandemic, as compared with 25.2% in the large population-based study.
      • Beauchamp MK
      • Joshi D
      • McMillan J
      • et al.
      Assessment of functional mobility after COVID-19 in adults aged 50 years or older in the Canadian longitudinal study on aging.
      This reduction likely reflects a shift from active to sedentary behaviors as numerous studies have shown that older adults are spending more time sitting during COVID-19.
      • Larson EA
      • Bader-Larsen KS
      • Magkos F.
      The effect of COVID-19-related lockdowns on diet and physical activity in older adults: a systematic review.
      • Rantanen T
      • Eronen J
      • Kauppinen M
      • et al.
      Life-space mobility and active aging as factors underlying quality of life among older people before and during COVID-19 lockdown in Finland—a longitudinal study.
      • Mishra R
      • Park C
      • York MK
      • et al.
      Decrease in mobility during the COVID-19 pandemic and its association with increase in depression among older adults: a longitudinal remote mobility monitoring using a wearable sensor.
      • Hoffman GJ
      • Malani PN
      • Solway E
      • Kirch M
      • Singer DC
      • Kullgren JT.
      Changes in activity levels, physical functioning, and fall risk during the COVID-19 pandemic.
      These findings are concerning because extended periods of reduced mobility and limited physical activity in older adults can lead to long-term mobility loss and heightened risk of adverse events over time.
      • Ross R
      • Chaput J-P
      • Giangregorio LM
      • et al.
      Canadian 24-hour movement guidelines for adults aged 18–64 years and adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep.
      ,
      • Hoffmann C
      • Wolf E.
      Older age groups and country-specific case fatality rates of COVID-19 in Europe, USA and Canada.
      During the early phases of the pandemic, there were calls to action to try to prevent activity decline,
      • Roschel H
      • Artioli GG
      • Gualano B.
      Risk of increased physical inactivity during COVID-19 outbreak in older people: a call for actions.
      spurring the development of creative physical activity programs with early promising results
      • Levinger P
      • Panisset M
      • Dunn J
      • et al.
      Exercise interveNtion outdoor proJect in the cOmmunitY for older people–results from the ENJOY Seniors Exercise Park project translation research in the community.
      ,
      • Jennings SC
      • Manning KM
      • Bettger JP
      • et al.
      Rapid transition to telehealth group exercise and functional assessments in response to COVID-19.
      is that highlighted the potential role of rehabilitation in meeting the needs of people living in the community. In addition, our study adds to the findings in the COVID-19 literature that mobility can be affected both directly and indirectly by COVID-19. For example, a large population-based study recently showed a higher risk of new onset mobility difficulty among older adults with probable or confirmed COVID-19 living in the community, even in the absence of serious illness or hospitalization. This population-based study also reported mobility declines of a similar magnitude to our study among the general population living in the community during the pandemic. Given the ongoing high burden of COVID-19 illness in the community, there is an even greater risk of further mobility decline among older adults as the pandemic continues. Recent rehabilitation frameworks highlight the need for rehabilitation experts to mitigate both direct and indirect effects of COVID-19 and to help older adults be as physically active and mobile as possible to counteract both the effects of lockdown and to promote recovery from illness.
      Government of Scotland
      Framework for supporting people through recovery and rehabilitation during and after the COVID-19 Pandemic.
      ,
      • Katsarou M-S
      • Iasonidou E
      • Osarogue A
      • et al.
      The Greek collaborative long COVID study: non-hospitalized and hospitalized patients share similar symptom patterns.
      Our study is the first, to our knowledge, to examine the factors associated with mobility using a validated and standardized self-report measure during the pandemic. Other comparable research used non-validated measures,
      • Hoffman GJ
      • Malani PN
      • Solway E
      • Kirch M
      • Singer DC
      • Kullgren JT.
      Changes in activity levels, physical functioning, and fall risk during the COVID-19 pandemic.
      or life space mobility assesments,
      • Rantanen T
      • Eronen J
      • Kauppinen M
      • et al.
      Life-space mobility and active aging as factors underlying quality of life among older people before and during COVID-19 lockdown in Finland—a longitudinal study.
      ,
      • Perracini MR
      • De Amorim JSC
      • Lima CA
      • et al.
      Impact of COVID-19 pandemic on life-space mobility of older adults living in Brazil: REMOBILIZE study.
      ,
      • Leppä H
      • Karavirta L
      • Rantalainen T
      • et al.
      Use of walking modifications, perceived walking difficulty and changes in outdoor mobility among community-dwelling older people during COVID-19 restrictions.
      which makes interpretation challenging because changes in life space mobility may be due to public health restrictions rather than declines in older adults’ capabilities.
      • Beauchamp MK
      • Schmidt CT
      • Pedersen MM
      • Bean JF
      • Jette AM.
      Psychometric properties of the late-life function and disability instrument: a systematic review.
      Physical and environmental factors such as greater volume of walking, less perceived unpleasantness of one's neighborhood, less musculoskeletal pain, and greater self-reported health were most strongly associated with mobility. Our findings were also fairly consistent across the 3 subscales: upper extremity, basic lower extremity, and advanced lower extremity function. Other longitudinal
      • Beauchamp MK
      • Joshi D
      • McMillan J
      • et al.
      Assessment of functional mobility after COVID-19 in adults aged 50 years or older in the Canadian longitudinal study on aging.
      ,
      • Leppä H
      • Karavirta L
      • Rantalainen T
      • et al.
      Use of walking modifications, perceived walking difficulty and changes in outdoor mobility among community-dwelling older people during COVID-19 restrictions.
      ,
      • Richardson DL
      • Duncan MJ
      • Clarke ND
      • Myers TD
      • Tallis J.
      The influence of COVID-19 measures in the United Kingdom on physical activity levels, perceived physical function and mood in older adults: a survey-based observational study.
      and cross-sectional
      • Hoffman GJ
      • Malani PN
      • Solway E
      • Kirch M
      • Singer DC
      • Kullgren JT.
      Changes in activity levels, physical functioning, and fall risk during the COVID-19 pandemic.
      studies comparing individuals’ mobility before and during the pandemic also found that better self-reported health, or fewer comorbidities, were linked to better mobility, highlighting the importance of physical health for sustaining one's mobility when public health restrictions are put in place. Better physical health has previously been shown to mitigate adverse events prior to COVID-19, with significantly lower rates of hospitalization, falls, and serious illness among those with higher self-rated physical health.
      • Ferrante LE
      • Pisani MA
      • Murphy TE
      • Gahbauer EA
      • Leo-Summers LS
      • Gill TM.
      Functional trajectories among older persons before and after critical illness.
      ,
      • Gill TM
      • Allore HG
      • Gahbauer EA
      • Murphy TE.
      Change in disability after hospitalization or restricted activity in older persons.
      Environmental design features (eg, walking access and uneven pavement) affect mobility.
      • Yeom HA
      • Fleury J
      • Keller C.
      Risk factors for mobility limitation in community-dwelling older adults: a social ecological perspective.
      ,
      • Keysor JJ
      • Jette AM
      • LaValley MP
      • et al.
      Community environmental factors are associated with disability in older adults with functional limitations: the MOST study.
      In the context of the restrictions put in place because of COVID-19, our results suggest older adults who rated their neighborhood environment as more pleasant to walk in had higher mobility scores. COVID-19 infection rates are closely linked to community
      • Tieskens K
      • Patil P
      • Levy JI
      • et al.
      Time-varying associations between COVID-19 case incidence and community-level sociodemographic, occupational, environmental, and mobility risk factors in Massachusetts.
      and geographic influences,
      • Mishra S
      • Ma H
      • Moloney G
      • et al.
      Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study.
      which in turn may affect older adults’ perceived walkability. Recognizing that these restrictions might have deleterious effects, 1 strategy used during COVID-19 was to regulate and create outdoor spaces to promote physical activity without compromising safety (eg, mixed land use, pedestrian, and bicycle systems, compliant with disability needs).
      • Hasson R
      • Sallis JF
      • Coleman N
      • Kaushal N
      • Nocera VG
      • Keith N.
      COVID-19: implications for physical activity, health disparities, and health equity.
      Based on our findings, there is a clear role for rehabilitation professionals to help improve participants’ function to better meet the demands of their environment.
      Government of Scotland
      Framework for supporting people through recovery and rehabilitation during and after the COVID-19 Pandemic.
      Further, future longitudinal research is needed to better understand to what extent environmental design may influence mobility in the event of restrictions and how to ameliorate any negative effect.
      Pre-pandemic research has emphasized the importance of personal and social influences on mobility (eg, socioeconomic status, mental health, and social relations).
      • Rosso AL
      • Taylor JA
      • Tabb LP
      • Michael YL.
      Mobility, disability, and social engagement in older adults.
      ,
      • Kuspinar A
      • Verschoor C
      • Beauchamp M
      • et al.
      Modifiable factors related to life-space mobility in community-dwelling older adults: results from the Canadian Longitudinal Study on Aging.
      ,
      • Miyashita T
      • Tadaka E
      • Arimoto A.
      Cross-sectional study of individual and environmental factors associated with life-space mobility among community-dwelling independent older people.
      Yet, these factors were not significant in our model, suggesting physical and environmental factors become of greater importance to mobility when public health restrictions are in place. That said, given the inequities made apparent as a result of COVID-19,
      • Mishra S
      • Ma H
      • Moloney G
      • et al.
      Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study.
      it was surprising that the socioeconomic status indicator (ie, education) was not associated with mobility.
      • Perracini MR
      • De Amorim JSC
      • Lima CA
      • et al.
      Impact of COVID-19 pandemic on life-space mobility of older adults living in Brazil: REMOBILIZE study.
      ,
      • Liu Y
      • Wang Z
      • Rader B
      • et al.
      Associations between changes in population mobility in response to the COVID-19 pandemic and socioeconomic factors at the city level in China and country level worldwide: a retrospective, observational study.
      This may be because close to half of our sample completed post-secondary education. It was surprising few mental health and social constructs were associated with mobility, as multiple studies have reported increases in depression, anxiety, loneliness, distress, and experiences of ageism since the start of the pandemic.
      • Mishra R
      • Park C
      • York MK
      • et al.
      Decrease in mobility during the COVID-19 pandemic and its association with increase in depression among older adults: a longitudinal remote mobility monitoring using a wearable sensor.
      ,
      • van Tilburg TG
      • Steinmetz S
      • Stolte E
      • van der Roest H
      • de Vries DH.
      Loneliness and mental health during the COVID-19 pandemic: a study among Dutch older adults.
      ,
      • Lebrasseur A
      • Fortin-Bédard N
      • Lettre J
      • et al.
      Impact of the COVID-19 pandemic on older adults: rapid review.
      Although these constructs have not been examined in mobility during the pandemic, multiple studies have linked reduced physical activity to increases in mental health distress,
      • Larson EA
      • Bader-Larsen KS
      • Magkos F.
      The effect of COVID-19-related lockdowns on diet and physical activity in older adults: a systematic review.
      ,
      • Mishra R
      • Park C
      • York MK
      • et al.
      Decrease in mobility during the COVID-19 pandemic and its association with increase in depression among older adults: a longitudinal remote mobility monitoring using a wearable sensor.
      ,
      • Pérez LM
      • Castellano-Tejedor C
      • Cesari M
      • et al.
      Depressive symptoms, fatigue and social relations influenced physical activity in frail older community-dwellers during the Spanish lockdown due to the Covid-19 pandemic.
      indicating there is likely a role for mental health support in mobility maintenance.

      Limitations

      While our findings are important, there are a few limitations. First, the original study survey design was not based on Webber's Mobility Framework. To that end, measures of cognition were not included. Given some of the concerns around cognitive decline during the COVID-19 pandemic,
      • De Pue S
      • Gillebert C
      • Dierckx E
      • Vanderhasselt M-A
      • De Raedt R
      • Van den Bussche E.
      The impact of the COVID-19 pandemic on wellbeing and cognitive functioning of older adults.
      this may have been overlooked as an important factor. As well, we measured mobility using the self-report LLFI, which focuses on the ability to perform discrete physical tasks and may not have included all relevant aspects of mobility (eg, use of public transportation or driving), nor captured actual mobility performance in daily life (eg, accelerometry).
      • Zijlstra W
      • Giannouli E.
      Mobility in community-dwelling older adults; what are its determinants?.
      Second, given the symptoms of COVID-19, it is possible that contracting COVID-19 may have affected participants’ mobility levels to some extent; however, only 1 participant reported a positive test at baseline. A larger sample size would be needed to examine this further. Third, while we contacted a random sample for inclusion in this study, we had a low participation rate likely indicative of volunteer bias; and, all participants answered the phone, indicating they were able to complete this instrumental activity of daily living. Further, we excluded 25 participants from the analysis because of missing data. We made this decision after verifying there were no substantial differences in baseline data between those who had missing data and those who did not. Finally, given that this was a cross-sectional analysis, we cannot make any predictions or causal inferences. Rather, our findings can be used as a starting point for examining future ways to maintain older adults’ physical function mobility as we begin to move forward in the COVID-19 era.

      Conclusions

      In conclusion, during the first 5 months of the pandemic a quarter of older adults reported a decrease in their ability to engage in physical activity, with 10% reporting decreases in other mobility domains. Our findings contribute to the reports emerging on the condition of older adults during COVID-19 and show that physical and environmental factors are especially important for mobility during periods of lockdown. Future longitudinal analyses will be needed to determine if these factors remain consistent.

      Acknowledgments

      We would like to thank Tara Noble, Anna Bhatti, Ruth Chen, Stephanie Civiero, Natalie Constantin, Cassandra D'Amore, Vincenza Gruppuso, Vishal Mokashi, Cindy Wei, and Nicholas Dietrich for their support with data collection.

      Appendix. Supplementary materials

      References

        • Statistics Canada.
        COVID-19 in Canada: a one-year update on social and economic impacts.
        • Aung MN
        • Yuasa M
        • Koyanagi Y
        • et al.
        Sustainable health promotion for the seniors during COVID-19 outbreak: a lesson from Tokyo.
        J Infect Dev Ctries. 2020; 14: 328-331
        • Davies NG
        • Klepac P
        • Liu Y
        • et al.
        Age-dependent effects in the transmission and control of COVID-19 epidemics.
        Nat Med. 2020; 26: 1205-1211
        • González-Castro JL
        • Ubillos-Landa S
        • Puente-Martínez A
        • Gracia-Leiva M.
        Perceived vulnerability and severity predict adherence to COVID-19 protection measures: the mediating role of instrumental coping.
        Front Psychol. 2021; 12674032
        • Sepúlveda-Loyola W
        • Rodríguez-Sánchez I
        • Pérez-Rodríguez P
        • et al.
        Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations.
        J Nutr Health Aging. 2020; 24: 938-947
        • Government of Scotland
        Framework for supporting people through recovery and rehabilitation during and after the COVID-19 Pandemic.
        Cabinet Secretary for Health and Social Care, 2020 (Care CSfHaS, editor. 2020)
      1. Government of Wales. Rehabilitation: a framework for continuity and recovery 2020 to 2021. 2020. Available at: https://gov.wales/rehabilitation-framework-continuity-and-recovery-2020-2021-html. Accessed September 21, 2022.

        • Bangsbo J
        • Blackwell J
        • Boraxbekk C-J
        • et al.
        Copenhagen Consensus statement 2019: physical activity and ageing.
        Br J Sports Med. 2019; 53: 856-858
        • Cunningham C
        • O'Sullivan R
        • Caserotti P
        • Tully MA.
        Consequences of physical inactivity in older adults: a systematic review of reviews and meta-analyses.
        Scand J Med Sci Sports. 2020; 30: 816-827
        • Webber SC
        • Porter MM
        • Menec VH.
        Mobility in older adults: a comprehensive framework.
        Gerontologist. 2010; 50: 443-450
        • Prohaska TR
        • Anderson LA
        • Hooker SP
        • Hughes SL
        • Belza B.
        Mobility and aging: transference to transportation.
        J Aging Res. 2011; 2011392751
        • Pantelaki E
        • Maggi E
        • Crotti D
        Mobility impact and well-being in later life: a multidisciplinary systematic review.
        Res Transp Econ. 2020 Oct 10; ([Epub ahead of print])
        • Satariano WA
        • Guralnik JM
        • Jackson RJ
        • Marottoli RA
        • Phelan EA
        • Prohaska TR.
        Mobility and aging: new directions for public health action.
        Am J Public Health. 2012; 102: 1508-1515
        • Rosso AL
        • Taylor JA
        • Tabb LP
        • Michael YL.
        Mobility, disability, and social engagement in older adults.
        J Aging Health. 2013; 25: 617-637
      2. World Health Assembly agrees to launch process to develop historic global accord on pandemic prevention, preparedness and response [press release]. 2021.

        • Beauchamp MK
        • Vrkljan B
        • Kirkwood R
        • et al.
        Impact of COVID-19 on mobility and participation of older adults living in Hamilton, Ontario, Canada: a multimethod cohort design protocol.
        BMJ Open. 2021; 11e053758
      3. WHO. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020 2020. Available at:https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed

        • Beauchamp MK
        • Joshi D
        • McMillan J
        • et al.
        Assessment of functional mobility after COVID-19 in adults aged 50 years or older in the Canadian longitudinal study on aging.
        JAMA Netw Open. 2022; 5e2146168
        • Haley S.
        Late life function and disability instrument: II. Development and evaluation of the function component.
        J Gerontol. 2002; 57: M217-M222
      4. WHO. International classification of functioning, disability and health. 2001.

        • Verbrugge LM
        • Jette AM.
        The disablement process.
        Soc Sci Med. 1994; 38: 1-14
        • Beauchamp MK
        • Schmidt CT
        • Pedersen MM
        • Bean JF
        • Jette AM.
        Psychometric properties of the late-life function and disability instrument: a systematic review.
        BMC Geriatr. 2014; 14: 1-12
        • Horowitz M
        • Wilner N
        • Alvarez W.
        Impact of event scale: a measure of subjective stress.
        Psychosom Med. 1979; 41: 209-218
        • Creamer M
        • Bell R
        • Failla S.
        Psychometric properties of the impact of event scale—revised.
        Behav Res Ther. 2003; 41: 1489-1496
        • Cosco TD
        • Kaushal A
        • Richards M
        • Kuh D
        • Stafford M.
        Resilience measurement in later life: a systematic review and psychometric analysis.
        Health Qual Life Outcomes. 2016; 14: 1-6
        • Smith BW
        • Dalen J
        • Wiggins K
        • Tooley E
        • Christopher P
        • Bernard J.
        The brief resilience scale: assessing the ability to bounce back.
        Int J Behav Med. 2008; 15: 194-200
        • Herdman M
        • Gudex C
        • Lloyd A
        • et al.
        Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
        Qual Life Res. 2011; 20: 1727-1736
        • Janssen M
        • Pickard AS
        • Golicki D
        • et al.
        Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups: a multi-country study.
        Qual Life Res. 2013; 22: 1717-1727
        • Irwin M
        • Artin KH
        • Oxman MN.
        Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D).
        Arch Intern Med. 1999; 159: 1701-1704
        • Ferreira-Valente MA
        • Pais-Ribeiro JL
        • Jensen MP.
        Validity of four pain intensity rating scales.
        Pain. 2011; 152: 2399-2404
        • Keller H
        • Goy R
        • Kane S.
        Validity and reliability of SCREEN II (Seniors in the community: risk evaluation for eating and nutrition, Version II).
        Eur J Clin Nutr. 2005; 59: 1149-1157
        • Washburn RA
        • Smith KW
        • Jette AM
        • Janney CA.
        The physical activity scale for the elderly (PASE): development and evaluation.
        J Clin Epidemiol. 1993; 46: 153-162
        • Larson EA
        • Bader-Larsen KS
        • Magkos F.
        The effect of COVID-19-related lockdowns on diet and physical activity in older adults: a systematic review.
        Aging Dis. 2021; 12: 1935-1947
        • Rantanen T
        • Eronen J
        • Kauppinen M
        • et al.
        Life-space mobility and active aging as factors underlying quality of life among older people before and during COVID-19 lockdown in Finland—a longitudinal study.
        J Gerontol A Biol Sci Med Sci. 2021; 76: e60-e67
        • Mishra R
        • Park C
        • York MK
        • et al.
        Decrease in mobility during the COVID-19 pandemic and its association with increase in depression among older adults: a longitudinal remote mobility monitoring using a wearable sensor.
        Sensors. 2021; 21: 3090
        • Hoffman GJ
        • Malani PN
        • Solway E
        • Kirch M
        • Singer DC
        • Kullgren JT.
        Changes in activity levels, physical functioning, and fall risk during the COVID-19 pandemic.
        J Am Geriatr Soc. 2021; 70: 49-59
        • Ross R
        • Chaput J-P
        • Giangregorio LM
        • et al.
        Canadian 24-hour movement guidelines for adults aged 18–64 years and adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep.
        Appl Physiol Nutr Metab. 2020; 45: S57-102
        • Hoffmann C
        • Wolf E.
        Older age groups and country-specific case fatality rates of COVID-19 in Europe, USA and Canada.
        Infection. 2021; 49: 111-116
        • Roschel H
        • Artioli GG
        • Gualano B.
        Risk of increased physical inactivity during COVID-19 outbreak in older people: a call for actions.
        J Am Geriatr Soc. 2020; 68: 1126-1128
        • Levinger P
        • Panisset M
        • Dunn J
        • et al.
        Exercise interveNtion outdoor proJect in the cOmmunitY for older people–results from the ENJOY Seniors Exercise Park project translation research in the community.
        BMC Geriatr. 2020; 20: 1-13
        • Jennings SC
        • Manning KM
        • Bettger JP
        • et al.
        Rapid transition to telehealth group exercise and functional assessments in response to COVID-19.
        Gerontol Geriatr Med. 2020; 62333721420980313
        • Katsarou M-S
        • Iasonidou E
        • Osarogue A
        • et al.
        The Greek collaborative long COVID study: non-hospitalized and hospitalized patients share similar symptom patterns.
        J Pers Med. 2022; 12: 987
        • Perracini MR
        • De Amorim JSC
        • Lima CA
        • et al.
        Impact of COVID-19 pandemic on life-space mobility of older adults living in Brazil: REMOBILIZE study.
        Front Public Health. 2021; 9: 313
        • Leppä H
        • Karavirta L
        • Rantalainen T
        • et al.
        Use of walking modifications, perceived walking difficulty and changes in outdoor mobility among community-dwelling older people during COVID-19 restrictions.
        Aging Clin Exp Res. 2021; : 1-8
        • Richardson DL
        • Duncan MJ
        • Clarke ND
        • Myers TD
        • Tallis J.
        The influence of COVID-19 measures in the United Kingdom on physical activity levels, perceived physical function and mood in older adults: a survey-based observational study.
        J Sports Sci. 2021; 39: 887-899
        • Ferrante LE
        • Pisani MA
        • Murphy TE
        • Gahbauer EA
        • Leo-Summers LS
        • Gill TM.
        Functional trajectories among older persons before and after critical illness.
        JAMA Intern Med. 2015; 175: 523-529
        • Gill TM
        • Allore HG
        • Gahbauer EA
        • Murphy TE.
        Change in disability after hospitalization or restricted activity in older persons.
        JAMA. 2010; 304: 1919-1928
        • Yeom HA
        • Fleury J
        • Keller C.
        Risk factors for mobility limitation in community-dwelling older adults: a social ecological perspective.
        Geriatr Nurs. 2008; 29: 133-140
        • Keysor JJ
        • Jette AM
        • LaValley MP
        • et al.
        Community environmental factors are associated with disability in older adults with functional limitations: the MOST study.
        J Gerontol A: Biol Sci Med Sci. 2010; 65: 393-399
        • Tieskens K
        • Patil P
        • Levy JI
        • et al.
        Time-varying associations between COVID-19 case incidence and community-level sociodemographic, occupational, environmental, and mobility risk factors in Massachusetts.
        BMC Infect Dis. 2021; 21: 686
        • Mishra S
        • Ma H
        • Moloney G
        • et al.
        Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study.
        Ann Epidemiol. 2022; 65: 84-92
        • Hasson R
        • Sallis JF
        • Coleman N
        • Kaushal N
        • Nocera VG
        • Keith N.
        COVID-19: implications for physical activity, health disparities, and health equity.
        Am J Lifestyle Med. 2021; 16: 420-433
        • Kuspinar A
        • Verschoor C
        • Beauchamp M
        • et al.
        Modifiable factors related to life-space mobility in community-dwelling older adults: results from the Canadian Longitudinal Study on Aging.
        BMC Geriatr. 2020; 20: 1-12
        • Miyashita T
        • Tadaka E
        • Arimoto A.
        Cross-sectional study of individual and environmental factors associated with life-space mobility among community-dwelling independent older people.
        Environ Health Prev Med. 2021; 26: 1-8
        • Liu Y
        • Wang Z
        • Rader B
        • et al.
        Associations between changes in population mobility in response to the COVID-19 pandemic and socioeconomic factors at the city level in China and country level worldwide: a retrospective, observational study.
        Lancet Digital Health. 2021; 3: e349-e359
        • van Tilburg TG
        • Steinmetz S
        • Stolte E
        • van der Roest H
        • de Vries DH.
        Loneliness and mental health during the COVID-19 pandemic: a study among Dutch older adults.
        J Gerontol B Psychol Sci Soc Sci. 2021; 76: e249-e255
        • Lebrasseur A
        • Fortin-Bédard N
        • Lettre J
        • et al.
        Impact of the COVID-19 pandemic on older adults: rapid review.
        JMIR Aging. 2021; 4: e26474
        • Pérez LM
        • Castellano-Tejedor C
        • Cesari M
        • et al.
        Depressive symptoms, fatigue and social relations influenced physical activity in frail older community-dwellers during the Spanish lockdown due to the Covid-19 pandemic.
        Int J Environ Res Public Health. 2021; 18: 808
        • De Pue S
        • Gillebert C
        • Dierckx E
        • Vanderhasselt M-A
        • De Raedt R
        • Van den Bussche E.
        The impact of the COVID-19 pandemic on wellbeing and cognitive functioning of older adults.
        Sci Rep. 2021; 11: 1-11
        • Zijlstra W
        • Giannouli E.
        Mobility in community-dwelling older adults; what are its determinants?.
        BMC Geriatr. 2021; 21: 228