Physical Inactivity in Long-Term Care During COVID-19

Introduction and Literature Review Methodology

Engaging in physical activity benefits both physical wellbeing and mental health. It supports the prevention of physical and psychological problems and improves overall quality of life. This integrative literature review investigates the impact of physical inactivity in long-term care settings during the COVID-19 pandemic, based on the context of residents at the Edmonton General Continuing Care Center (EGCCC) in Edmonton, Alberta, Canada.

Ten sources — including scholarly articles, books, and evidence-based papers — were used to produce a comprehensive overview of past studies related to the topic. The inclusion criteria for the literature review encompassed the following:

Articles were extracted from CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Google. Articles were required to have been published within the last five years. Articles needed to address long-term care settings, physical inactivity, and pandemics such as COVID-19. Sources that included evidence from the Canadian context were given additional consideration.

The exclusion criteria were as follows: articles more than five years old were excluded, and no databases or search engines other than those specified above were used.

The research was conducted using a set of keywords entered into the database to extract the most relevant articles. Keywords included: impact of physical inactivity, impact of physical activity, effect of physical activity, effects of physical inactivity, effects of physical inactivity in long-term care settings, effects of physical inactivity in long-term care settings during the pandemic, and impact of physical inactivity in long-term care settings during the COVID-19 pandemic.

Impact of Physical Inactivity Worldwide Due to COVID-19

An article titled "Saving Lives Through Life-Threatening Measures? The COVID-19 Paradox of Infection Prevention in Long-Term Care Facilities" describes a conflicting situation faced by older populations who are highly vulnerable to COVID-19. These individuals were confined to their residences while simultaneously being forced to reduce physical activity, creating greater long-term risks to their mental and physical health (Thiel et al., 2021). A major strength of this article is its set of recommendations for long-term care facilities on how to increase physical activity opportunities for older residents. A notable weakness, however, is the absence of a study design, methodology, sample selection, and data collection method — limiting its standing as primary empirical research.

A second article, "COVID-19 Pandemic-Induced Physical Inactivity: The Necessity of Updating the Global Action Plan on Physical Activity 2018–2030," reported that the World Health Organization (WHO) updated its Global Action Plan on Physical Activity 2018–2030 (GAPPA) in 2017 (Amini et al., 2021). The findings indicated that because older people are at high risk of COVID-19 infection, they should not be required to travel to external centers for physical activity. Instead, updated GAPPA guidelines recommend suitably tailored programs delivered at home or in community venues, including long-term care settings. A major strength of this article is its detailed account of GAPPA and its updates regarding COVID-19 and similar pandemics through 2030. Major weaknesses include the lack of a proper research study design, sample size, age data, data collection process, and methodology; however, the article draws on useful secondary sources and may be considered secondary research.

Impact of Physical Inactivity on Older Adults

An article titled "The Importance of Physical Activity to Care for Frail Older Adults During the COVID-19 Pandemic" presents key findings related to physical inactivity in this population (Aubertin-Leheudre & Rolland, 2020). This descriptive article narrates observations about how COVID-19 affected the physical activity and physical functioning of frail older adults in long-term care settings. When governments imposed social distancing measures and complete lockdowns, the number of daily walking steps taken by older adults decreased significantly. Similar observations were recorded in long-term hospitalization settings, where older adults spent approximately 90% of their time sitting or lying down — a pattern that severely and adversely affects muscle strength and mass, thereby increasing frailty.

A major strength of the article is its presentation of programs, activities, and exercises through which frail older adults could increase their physical activity, including the use of technology, illustrated with pictures and web links. A major weakness is the absence of a study design, sample size, and data collection method; however, the article can be considered secondary research given its use of internet articles and web-based sources in its reference list.

Conclusion and Summary Table

The following table summarizes all ten sources reviewed in this integrative literature review, including each study's title, purpose, design, sample, data collection method, key findings, major strengths, and major weaknesses.

Amini et al., 2021 — COVID-19 Pandemic-Induced Physical Inactivity: The Necessity of Updating the Global Action Plan on Physical Activity 2018–2030. Purpose: To review GAPPA and its updated goals for physical activity designed by WHO in 2017 so that the effects of lifestyle changes and physical activeness could be revised. Design: N/A. Sample: N/A. Method: N/A. Findings: Older people should not be required to travel to external centers for physical activity; GAPPA updates recommend suitably tailored programs at home or in community venues, including long-term care settings. Strength: Detailed account of GAPPA and its updates regarding COVID-19 and similar pandemics through 2030. Weakness: Lack of study design, sample size, age data, data collection process, and methodology; uses secondary research.

Aubertin-Leheudre & Rolland, 2020 — The Importance of Physical Activity to Care for Frail Older Adults During the COVID-19 Pandemic. Purpose: To narrate observations about how COVID-19 impacted the physical activity and functioning of frail older adults in long-term care. Design: N/A. Sample: N/A. Method: N/A. Findings: In long-term hospitalization settings, older adults spent approximately 90% of their time sitting or lying down, severely affecting muscle strength and mass and increasing frailty. Strength: Presentation of beneficial programs, activities, exercises, and technology-based resources with pictures and web links. Weakness: Lack of study design, sample size, age data, data collection process, and methodology; uses secondary research.

Daly et al., 2021 — Health Impacts of the Stay-at-Home Order on Community-Dwelling Older Adults and How Technologies May Help: Focus Group Study. Purpose: To investigate the impact of COVID-19 on the mental and physical health of older adults during increased social isolation under stay-at-home orders. Design: Longitudinal study. Sample: 112 participants from a long-term care facility. Method: Semi-structured interviews. Findings: Four themes identified — effects of quarantine on mental and physical health; lack of physical activity; reliance on technology to address social isolation; and coping strategies. Strength: Rigorous thematic analysis with digitally recorded group discussions and researcher-assisted manual coding. Weakness: Limited to participants with Zoom access, who were educated, of high socioeconomic status, Caucasian, and residing in Southern California.

Davies et al., 2020 — Maximizing Mobility in Older People When Isolated with COVID-19. Purpose: To provide helpful resources for supporting older adults during social isolation. Design: Synthesis of multiple studies. Sample: Amalgamation of samples from various studies, predominantly older adults. Method: Various data collection methods drawn from multiple studies. Findings: Exercise improves fall rates and functional ability in people aged over 70; recommended exercises include resistance, functional, endurance, and balance exercises; home-based exercise yielded a fivefold reduction in frailty after one year. Strength: Synthesis of numerous studies into targeted guidance for a specific population. Weakness: Geographic locations of reviewed studies are not reported.

Frahsa et al., 2020 — "I Trust in Staff's Creativity" — The Impact of COVID-19 Lockdown on Physical Activity Promotion in Nursing Homes Through the Lenses of Organizational Sociology. Purpose: To assess the impact of physical activity on older adults during COVID-19 lockdown in nursing homes. Design: Exploratory study. Sample: Eight nursing homes in the Federal State of Baden-Württemberg during lockdown. Method: Semi-structured interviews and open-ended surveys. Findings: Social distancing restrictions prevented physical therapists from entering facilities; nurses stepped in for patient-centered care and mobilization to prevent inactivity from causing mental or physical harm, while adhering to infection management regulations. Strength: Use of actual study methods and thematic analysis. Weakness: Incomplete inclusion of nursing homes in the targeted state limits the generalizability of results.

Linkov, Keenan, & Trump, 2021 — COVID-19: Systemic Risk and Resilience. Purpose: To describe risk and resilience tools and strategies for combating the mental and physical health impacts of COVID-19. Design: N/A. Sample: N/A. Method: N/A. Findings: Congregate living settings for older adults should be the most active in physically engaging older residents to reduce morbidity and psychological distress in long-term care; information is relevant to all stakeholders involved. Strength: Application of tools and strategies assessed in a comprehensive, chapter-by-chapter manner. Weakness: None that could be applied substantially.

Rootman et al., 2021 — Promoting the Health of Older Adults: The Canadian Experience. Purpose: To describe the Ottawa Charter action framework for investigating factors and issues related to the health of older adults, specifically in the context of COVID-19. Design: N/A. Sample: N/A. Method: N/A. Findings: Five health promotion action areas are identified that would be useful in contemporary times. Strength: Up-to-date profile of Canadian older adults and current trends, incorporating technological benefits. Weakness: None that could be applied substantially.

Sallis et al., 2021 — Physical Inactivity Is Associated with a Higher Risk for Severe COVID-19 Outcomes: A Study in 48,440 Adult Patients. Purpose: To analyze the relationship between physical activity levels and COVID-19 outcomes including ICU admission, hospitalization, and death. Design: Cohort study. Sample: 48,440 adult patients from an integrated healthcare system in Southern California infected with COVID-19, aged 18 years and above. Method: Chi-square (χ²) test. Findings: COVID-19 patients who were consistently physically inactive had a significantly higher risk of hospitalization and death compared with those who were physically active. Strength: Large patient sample. Weakness: Reliance on self-reported physical activity data and missing data for variables such as odds ratios for physical activity and death rates among older patients.

Thiel et al., 2021 — Saving Lives Through Life-Threatening Measures? The COVID-19 Paradox of Infection Prevention in Long-Term Care Facilities. Purpose: To describe the conflicting situation faced by older adults who are highly vulnerable to COVID-19 and must be confined to their residences, which simultaneously reduces their physical activity and increases their long-term mental and physical health risks. Design: N/A. Sample: N/A. Method: N/A. Findings: The physical and mental strain experienced by the target population is documented so that protective measures can be developed. Strength: The authors post practical recommendations for long-term care facilities to increase physical activities for older residents. Weakness: Absence of study design, methodology, sample selection, and data collection method for primary research.

World Health Organization, 2020 — Guidance on COVID-19 for the Care of Older People and People Living in Long-Term Care Facilities, Other Non-Acute Care Facilities, and Home Care. Purpose: To provide an evidence-based standard procedure for caring for older adults at home or in long-term care facilities. Design: N/A. Sample: N/A. Method: N/A. Findings: Older adults should remain as physically active as possible in daily activities, practice regular hygiene, maintain social distancing, drink adequate water, eat nutritious meals, engage in hobbies, rely on lighter tasks according to physical capacity, avoid stress and anxiety, and stay connected with friends and family through information technology. Strength: Widely researched statistics related to deaths and physical decline in older adults across religious and ethnic backgrounds, with guidelines tailored to specific categories of age-related illness such as dementia. Weakness: None that could be applied substantially.

Amini, H., Habibi, S., Islamoglu, A. H., Isanejad, E., Uz, C., & Daniyari, H. (2021). COVID-19 pandemic-induced physical inactivity: The necessity of updating the Global Action Plan on Physical Activity 2018–2030. Environmental Health and Preventive Medicine, 26. https://doi.org/10.1186/s12199-021-00955-z

Aubertin-Leheudre, M., & Rolland, Y. (2020). The importance of physical activity to care for frail older adults during the COVID-19 pandemic. Journal of the American Medical Directors Association, 21(7), 973–976. https://doi.org/10.1016/j.jamda.2020.04.022

Daly, J. R., Depp, C., Graham, S. A., Jeste, D. V., Kim, H., Lee, E. E., & Nebeker, C. (2021). Health impacts of the stay-at-home order on community-dwelling older adults and how technologies may help: Focus group study. JMIR Aging, 4(1). https://doi.org/10.2196/25779

Davies, J. H. N., Frost, R., Bussey, J., & Park, S. (2020). Maximizing mobility in older people when isolated with Covid 19. The Centre for Evidence-Based Medicine. https://www.cebm.net/covid-19/maximising-mobility-in-the-older-people-when-isolated-with-covid-19/

Frahsa, A., Altmeier, D., John, J. M., Gropper, H., Granz, H., Pomiersky, R., Haigis, D., Eschweiler, G. W., Nieb, A. M., Sudeck, G., & Thiel, A. (2020). "I trust in staff's creativity" — The impact of COVID-19 lockdown on physical activity promotion in nursing homes through the lenses of organizational sociology. Frontiers in Sports and Active Living, 2. https://doi.org/10.3389/fspor.2020.589214

Linkov, I., Keenan, J. M., & Trump, B. D. (2021). COVID-19: Systemic risk and resilience. Springer Nature.

Rootman, I., Edwards, P., Levasseur, M., & Grunberg, F. (2021). Promoting the health of older adults: The Canadian experience. Canadian Scholars' Press.

Sallis, R., Young, D. R., Tartof, S. Y., Sallis, J. F., Sall, J., Li, Q., Smith, G. N., & Cohen, D. A. (2021). Physical inactivity is associated with a higher risk of severe COVID-19 outcomes: A study in 48,440 adult patients. British Journal of Sports Medicine, 55, 1099–1105. http://dx.doi.org/10.1136/bjsports-2021-104080

Thiel, A., Altmeier, D., Frahsa, A., Eschweiler, G. W., Nieb, A., & Sudeck, G. (2021). Saving lives through life-threatening measures? The COVID-19 paradox of infection prevention in long-term care facilities. European Review of Aging and Physical Activity, 18(11). https://doi.org/10.1186/s11556-021-00265-x

World Health Organization. (2020, July 23). Guidance on COVID-19 for the care of older people and people living in long-term care facilities, other non-acute care facilities, and home care. https://apps.who.int/iris/rest/bitstreams/1316982/retrieve