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Impact of the COVID-19 pandemic on the cognitive and motor functions of older people: a 3-year cohort study

Abstract

Objective

To analyze the impact of the COVID-19 pandemic on the cognitive and motor functions in older people.

Method

In this cohort study, 90 older persons underwent cognitive (Mini-Mental State Examination and Frontal Assessment Battery) and motor (Timed Up and Go test and International Fall Questionnaire) tests in two moments: before the first case of the COVID-19 pandemic have been identified in Brazil and after the end of the state of public health emergency. The multiple analysis of variance was applied with the Wilk’s lambda test to verify the impact of the COVID-19 pandemic on the factors “time” (pre × post-pandemic), “group” (sex, marital status and education) and “interaction” (time × group). Effect size and statistical power are reported. Significance was set at 5%.

Results

Older persons presented cognitive decline during the COVID-19 pandemic (effect size: 0.43; statistical power: 99.8%; p=0.001). The decline was similar according to sex ( p=0.864), marital status ( p=0.910) and schooling ( p=0.969). The participants also suffered a motor decline during COVID-19 pandemic (effect size: 0.74; statistical power: 99.9%; p=0.001). The decline was similar according to sex ( p=0.542) and marital status ( p=0.260). Participants with lower educational level suffered greater physical decline than persons with higher schooling (effect size: 0.38; statistical power: 97.6%; p=0.004).

Conclusion

The COVID-19 pandemic affected the cognitive and motor functions of older persons. Participants with low schooling suffered a greater decline of their physical health during the pandemic, a fact that should encourage further studies on this thematic.

Keywords
Pandemics; Covid-19; Aged; Delivery of Health Care; Public Health

Resumo

Objetivo

Analisar o impacto da pandemia da covid-19 sobre as funções cognitivas e motoras de pessoas idosas.

Método

Neste estudo coorte, 90 idosos foram submetidos a testes cognitivos (Mini Exame do Estado Mental e Bateria de Avaliação Frontal) e motores (teste Timed Up and Go e Questionário Internacional de Queda) em dois momentos: antes do primeiro caso da pandemia ser identificado no Brasil e após o fim do estado de emergência em saúde pública. O teste de análise múltipla de variâncias para medidas repetidas foi aplicado junto ao teste lambda de Wilk para verificar o impacto da covid-19 sobre os fatores “momento” (pré × pós-pandemia), “grupo” (sexo, estado civil e escolaridade) e “interação” (momento × grupo). Tamanho do efeito e poder estatístico foram reportados. Significância foi admitida em 5%.

Resultados

Pessoas idosas sofreram declínio cognitivo durante a pandemia da covid-19 (tamanho do efeito: 0,43; poder estatístico: 99,8%; p=0,001). O declínio foi semelhante segundo sexo (p=0,864), estado civil (p=0,910) e escolaridade (p=0,969). Os participantes sofreram ainda declínio das funções motoras durante a pandemia (tamanho do efeito: 0,74; poder estatístico: 99,9%; p=0,001). O declínio foi semelhante segundo sexo (p=0,542) e estado civil (p=0,260). Participantes com menor escolaridade sofreram maior declínio físico do que pessoas com maiores níveis escolares (tamanho do efeito: 0,38; poder estatístico: 97,6%; p=0,004).

Conclusão

A pandemia da covid-19 afetou as funções cognitivas e motoras de pessoas idosas. Participantes com baixa escolaridade sofreram maior impacto da pandemia sobre sua saúde física, fato que deve incentivar novos estudos a explorar essa temática.

Palavras-Chave:
Pandemias; Covid-19; Idoso; Atenção à Saúde; Saúde Pública

INTRODUCTION

Since 2020, the world has been experiencing a health crisis caused by the Sars-Cov-2 virus, responsible for COVID-19. Characterized by a high rate of transmissibility and a high risk of complications, health authorities have recommended social isolation as the best way to prevent the disease11 Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395(10242):1973-87. Disponível em: https://doi.org/10.1016/S0140-6736(20)31142-9.
https://doi.org/10.1016/S0140-6736(20)31...
. With the advent of vaccination, the rigor of social isolation has been decreasing and the use of masks has been released by many governments22 Bartsch SM, O'Shea KJ, Chin KL, Strych U, Ferguson MC, Bottazzi ME, et al. Maintaining face mask use before and after achieving different COVID-19 vaccination coverage levels: a modelling study. Lancet Public Health. 2022;7(4):e356-65. Disponível em: https://doi.org/10.1016/S2468-2667(22)00040-8.
https://doi.org/10.1016/S2468-2667(22)00...
.

In April 2022, the Brazilian government decreed the end of the state of public health emergency. The period between 2020 and 2021 was one of great turbulence in the country. Faced with conflicting disclosures from the federal government encouraging the use of drugs without scientific proof against COVID-19 and often questioning the use of masks and the importance of vaccination, the population found itself uncertain about the best path to follow33 Santos-Pinto CB, Miranda ES, Osorio-de-Castro CGS. "Kit-covid" and the Popular Pharmacy Program in Brazil. Cad Saude Publica. 2021;37(2):e00348020. Disponível em: https://doi.org/10.1590/0102-311X00348020.
https://doi.org/10.1590/0102-311X0034802...
,44 Taylor L. 'We are being ignored': Brazil's researchers blame anti-science government for devastating COVID surge. Nature. 2021;593(7857):15-6. Disponível em: https://doi.org/10.1038/d41586-021-01031-w.
https://doi.org/10.1038/d41586-021-01031...
.

By January 2023, more than 36 million Brazilians had been diagnosed with COVID-19. Of these, approximately 700,000 lost their lives to the disease. Estimates indicate that more than 100,000 older people were victims of COVID-19, impacted mainly by the physical weakness that the disease brings55 Machado CJ, Pereira CCA, Viana BM, Oliveira GL, Melo DC, Carvalho JFM, et al. Estimativas de impacto da COVID-19 na mortalidade de idosos institucionalizados no Brasil. Cien Saude Colet. 2020;25(9):3437-44. Disponível em: https://doi.org/ 10.1590/1413-81232020259.14552020.
https://doi.org/10.1590/1413-81232020259...

6 de Oliveira Lima H, da Silva LM, de Campos Vieira Abib A, Tavares LR, Santos DWCL, de Araújo ACLF, et al. Coronavirus disease-related in-hospital mortality: a cohort study in a private healthcare network in Brazil. Sci Rep. 2022;12(1):6371. Disponível em: https://doi.org/10.1038/s41598-022-10343-4.
https://doi.org/10.1038/s41598-022-10343...
-77 Vidal Bravalhieri AA, Oliveira Rodrigues N, Batiston AP, de Souza Pegorare AB, Christofoletti G. Impact of social isolation on the physical and mental health of older adults: a follow-up study at the apex of the Covid-19 pandemic. Dement Geriatr Cogn Disord. 2022;51(3):279-284. Disponível em: https://doi.org/10.1159/000525661..

Previous studies indicate how the COVID-19 pandemic affected the health of older people. Research points to effects arising from physical inactivity, social isolation and sequelae caused by the disease77 Vidal Bravalhieri AA, Oliveira Rodrigues N, Batiston AP, de Souza Pegorare AB, Christofoletti G. Impact of social isolation on the physical and mental health of older adults: a follow-up study at the apex of the Covid-19 pandemic. Dement Geriatr Cogn Disord. 2022;51(3):279-284. Disponível em: https://doi.org/10.1159/000525661.

8 Browne RAV, Macêdo GAD, Cabral LLP, Oliveira GTA, Vivas A, Fontes EB, et al. Initial impact of the COVID-19 pandemic on physical activity and sedentary behavior in hypertensive older adults: An accelerometer-based analysis. Exp Gerontol. 2020;142:111121. Disponível em: https://doi.org/10.1016/j.exger.2020.111121.
https://doi.org/10.1016/j.exger.2020.111...
-99 Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, 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(9):938-47. Disponível em: https://doi.org/10.1007/s12603-020-1469-2.
https://doi.org/10.1007/s12603-020-1469-...
. Studies also demonstrate impairment of both physical and mental health1010 Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological Implications of physical inactivity among older adults during the COVID-19 Pandemic. Gerontology. 2020;66(5):431-8. Disponível em: https://doi.org/10.1159/000509216.
https://doi.org/10.1159/000509216...

11 Creese B, Khan Z, Henley W, O'Dwyer S, Corbett A, Vasconcelos-da-Silva M, et al. Loneliness, physical activity, and mental health during COVID-19: a longitudinal analysis of depression and anxiety in adults over the age of 50 between 2015 and 2020. Int Psychogeriatr. 2021;33(5):505-14. Disponível em: https://doi.org/10.1017/S1041610220004135.
https://doi.org/10.1017/S104161022000413...
-1212 de Moura AAM, Bassoli IR, Silveira BV, Diehl A, dos Santos MA, dos Santos RA, Wagstaff C, Pillon SC. Is social isolation during the COVID-19 pandemic a risk factor for depression? Rev Bras Enferm. 2022;75(Suppl 1):e20210594. Disponível em: https://doi.org/10.1590/0034-7167-2021-0594.
https://doi.org/10.1590/0034-7167-2021-0...
. Most works, however, addressed older people during the pandemic, not assessing people's health before and after the advent of COVID-19.

The aim of this study was to investigate the physical and mental health of older people before the first case of the COVID-19 pandemic was identified in Brazil and after the end of the public health emergency decreed by the federal government.

METHOD

This research consists of an epidemiological, cohort and analytical study carried out in the municipality of Campo Grande, state of Mato Grosso do Sul. The research was approved by the Institutional Research Ethics Committee (protocol n. 4,833,758). The ethical precepts present in Resolution number 466 of the Ministry of Health and in the Declaration of Helsinki were respected. All participants signed in writing their consent to participate in this research.

The methodological procedures are reported according to the criteria defined by the Strobe initiative. The sample was selected for convenience to ensure similar age and schooling between men and women. Participants were recruited in public environments in the city in a probabilistic and stratified manner so that all regions were covered.

The selection of participants was based on the quantitative identified by sample statistical calculation. For this, the researchers used the alpha error at 5%, the statistical power at 80% and the effect size of 0.301313 Guo J, Feng XL, Wang XH, van Ijzendoorn MH. Coping with COVID-19: Exposure to COVID-19 and Negative Impact on Livelihood Predict Elevated Mental Health Problems in Chinese Adults. Int J Environ Res Public Health. 2020;17(11):3857. Disponível em: https://doi.org/10.3390/ijerph17113857.
https://doi.org/10.3390/ijerph17113857...
. The inclusion of these factors in a longitudinal design formed with two evaluation moments found a critical value in the Fisher table of 4.05 and a non-centrality parameter of 8.28. The result indicated the need for 86 older participants so that type 1 (alpha error) and type 2 (beta error) statistical errors were controlled.

To be included in this study, participants should be at least 60 years old, have no neurological or psychiatric disorders or any motor problem that would prevent them from performing the tests. Subjects who during the pandemic period came to present diseases not present in the original recruitment were excluded. Deaths, address changes, lack of contact and withdrawal from participation were reported as sample losses.

The researchers initially collected personal, social, and demographic information from the participants. These constituted the research's independent variables. The variables collected at that time were: age, sex, education level, marital status and professional occupation. Then, a series of cognitive and motor tests were applied, with the aim of comparing the impact of the pandemic on the physical and mental health of the participants. These constituted the dependent variables of the research, evaluated before the first case of COVID-19 was identified in Brazil and after the end of the state of public health emergency decreed by the federal government1414 Governo Federal. Portaria GM/MS no 913, de 22 de abril de 2022. Brasília, 2022 [citado 2023 Jan 25]. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=22/04/2022&jornal=612&pagina=1
https://pesquisa.in.gov.br/imprensa/jsp/...
. The period between assessments was three years.

The analysis of cognitive functions involved the Mini Mental State Examination (MMSE)1515 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. Disponível em: https://doi.org/10.1016/0022-3956(75)90026-6.
https://doi.org/10.1016/0022-3956(75)900...
and the Frontal Assessment Battery (FAB)1616 Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology. 2000;55(11):1621-6. Disponível em: https://doi.org/10.1212/wnl.55.11.1621.
https://doi.org/10.1212/wnl.55.11.1621...
. The MMSE was used to assess the participants' general cognitive aspects, such as temporal and spatial orientation, word registration, attention, calculation, immediate and delayed memory, language and visuoconstructive praxis. The test ranges from 0 to 30 points, and the lower the score, the greater the risk of the person having cognitive impairment1515 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. Disponível em: https://doi.org/10.1016/0022-3956(75)90026-6.
https://doi.org/10.1016/0022-3956(75)900...
.

The FAB was included because it assesses participants' prefrontal executive functions. The instrument assesses the following executive skills: conceptualization, mental flexibility, motor programming, task conflicts, inhibitory control and environmental autonomy. The instrument score ranges from 0 to 18 points, with lower scores indicating a higher risk of cognitive impairment1616 Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology. 2000;55(11):1621-6. Disponível em: https://doi.org/10.1212/wnl.55.11.1621.
https://doi.org/10.1212/wnl.55.11.1621...
. Both in the MMSE and in the FAB, schooling was taken into account in the analysis of scores, given the impact it has on cognitive tests1717 Christofoletti G, Oliani MM, Stella F, Gobbi S, Gobbi LTB. The influence of schooling on cognitive screening test in the elderly. Dement Neuropsychol. 2007;1(1):46-51. Disponível em: https://doi.org/10.1590/S1980-57642008DN10100008..

The physical health of the participants was analyzed using the Timed Up and Go test (TUG)1818 Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8. Disponível em: https://doi.org/10.1111/j.1532-5415.1991.tb01616.x.
https://doi.org/10.1111/j.1532-5415.1991...
and the Falls Efficacy Scale – International (FES-I)1919 Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005;34(6):614-9. Disponível em: https://doi.org/10.1093/ageing/afi196.
https://doi.org/10.1093/ageing/afi196...
instrument. The TUG is a validated mobility test for the older population. The test measures the time and number of steps required for a person to get up from a chair, walk three meters, return and sit down in the chair. In the present study, the TUG was applied with and without dual-task distractors, given the impact that aging has on people's simultaneous functional activities2020 Hennah C, Ellis G, Doumas M. Dual task walking in healthy aging: Effects of narrow and wide walking paths. PLoS One. 2021;16(12):e0261647. Disponível em: https://doi.org/10.1371/journal.pone.0261647.
https://doi.org/10.1371/journal.pone.026...
. Thus, the participants performed the test in a conventional way and also taking a glass of water (dual-task with motor distractor) or saying the names of animals (dual-task with cognitive distractor). The order of the tests among the participants was randomized so as not to cause a learning effect on the results.

The FES-I scale was applied to analyze the participants' concern about falls. The instrument measures both domestic activities and social and physical tasks performed outdoors. In this instrument, higher scores indicate greater insecurity and risk of falls.

In this research, the researchers listed the following statistical hypotheses: Null hypothesis (H0) - The COVID-19 pandemic did not affect the cognitive and motor functions of older people; Alternative hypothesis (HA) - The COVID-19 pandemic affected the cognitive and motor functions of older people.

Statistical analysis involved the characterization of results in mean and standard deviation (for continuous variables) and in relative and absolute frequency (for categorical variables). The researchers applied multiple analysis of variance tests for repeated measures associated with the Wilk lambda test to verify the physical and cognitive scores of participants before the COVID-19 pandemic and after the public health emergency.

Univariate analyzes were applied by dividing participants into groups according to social and demographic factors. With this, it was possible to compare the effects of the “group” factors (gender, marital status, education and professional occupation), under the variable “moment” (pre-pandemic situation × post public health emergency state) and in the interaction “group × moment”. Effect size and statistical power were reported. Significance was assumed at 5%.

RESULTS

One hundred and ten participants were originally recruited for this research. Given the eligibility criteria and follow-up period, the sample was reduced to 90 participants, 65 women and 25 men. Sample losses did not compromise the minimum number of subjects delimited by the previous sample calculation.

The participants were all from the municipality of Campo Grande, state of Mato Grosso do Sul, living with their families. Table 1 demonstrates the socio-demographic characteristics of the participants.

Table 1
General characteristics of the participants (N=90). Campo Grande, MS, Brazil 2022.

Analyzing the impact of the COVID-19 pandemic on participants' cognition, a decline in cognitive functions was observed in the pre-pandemic × post public health emergency comparison. The inferential analysis identified that the impact of COVID-19 on the cognition of the older people had an effect size of 43%, under a statistical power of 99.8% and significance of 1%. The greatest decline occurred in the Frontal Assessment Battery, responsible for measuring prefrontal executive functions. Table 2 details the cognitive scores of the participants in the two evaluated moments.

Table 2
Participants' cognitive scores, Campo Grande, MS, Brazil 2022.

By including the sex factor in the statistical model, it is observed that the cognitive values were similar between men and women (p=0.703). Cognitive decline during the pandemic occurred in both sexes (p=0.001) and at the same intensity (p=0.864).

Regarding marital status, cognitive values were similar among single, married, divorced and widowed individuals (p=0.285). There was cognitive decline in all groups (p=0.001) and at the same intensity (p=0.910).

Regarding schooling, participants with elementary education had lower cognitive scores on the MMSE and FAB than people with higher education (p=0.005). Cognitive decline occurred in participants of all educational levels (p=0.001) and at the same intensity (p=0.969).

Professional occupation did not interfere with cognitive decline. Professionally active participants had the same cognitive performance as retired or homemaker participants (p=0.956). With the follow-up period, cognitive decline occurred in all groups (p=0.001) and at the same intensity (p=0.308). Figure 1 shows participants' cognitive scores according to gender, marital status, education and professional occupation.

Figure 1
Cognitive scores of participants according to gender, marital status, education and professional occupation, Campo Grande, MS, Brazil, 2022.

Analyzing the impact of the COVID-19 pandemic on the physical health of the participants, a decline in scores was observed in the comparison pre-pandemic × post state of public health emergency. Inferential analysis identified that the impact of COVID-19 on the physical health of older people had an effect size of 74%, under a statistical power of 99.9% and significance of 1%. Table 3 shows the values of the TUG and FES-I tests. Univariate analyzes indicate that the impact of the pandemic was mainly on the number of steps taken in the TUG test and in the FES-I falls questionnaire (p<0.05).

Table 3
Values of the physical functions of the participants, Campo Grande, MS, Brazil, 2022.

By including the sex factor in the statistical model, it is observed that the results of the physical tests were similar between men and women (p=0.168). Motor decline occurred in both genders (p=0.001) and at the same intensity (p=0.542).

Regarding marital status, the motor results were similar among single, married, divorced and widowed individuals (p=0.470). There was motor decline in all groups (p=0.001) and at the same intensity (p=0.260).

Regarding schooling, participants with primary education had worse motor performance than people with secondary and higher education (p=0.001). The decline in motor functions occurred in people of all educational levels (p=0.001), but at different intensities. That is, people with lower levels of education showed greater motor decline during the pandemic than people with higher levels of education (p=0.004).

Professional occupation did not interfere with the physical health of the participants. Active professionals had the same performance in the TUG and FES-I as retired or homemaker participants (p=0.144). With the follow-up period, motor decline occurred in all groups (p=0.001) and at the same intensity (p=0.808). Figure 2 shows the participants' physical test scores according to sex, marital status, education and professional occupation.

Figure 2
Physical scores of participants according to gender, marital status, education and professional occupation, Campo Grande, MS, Brazil, 2022.

Including the variable “age” as a dependent factor in multivariate tests, it was observed that this variable did not interfere with cognitive aspects (p=0.104). Differently, age interfered with the physical health of older people. That is, older participants had worse motor responses than younger participants (p=0.001). Under a longitudinal analysis, it was found that the COVID-19 pandemic caused greater physical decline in older seniors than in younger seniors (effect size for “age × moment” interaction: 0.78; statistical power: 99.9%; p=0.001).

DISCUSSION

The aging process generates several changes in the body. These alterations involve motor and cognitive decline, which tend to affect the independence and health of the older person2121 McGrath R, Vincent BM, Hackney KJ, Al Snih S, Graham J, Thomas L, et al. Weakness and cognitive impairment are independently and jointly associated with functional decline in aging Americans. Aging Clin Exp Res. 2020;32(9):1723-30. Disponível em: https://doi.org/10.1007/s40520-019-01351-y.
https://doi.org/10.1007/s40520-019-01351...
,2222 Felippe LA, de Oliveiar RT, Garcia M, Silva-Hamu TCD, Santos SMS, Christofoletti G. Funções executivas, atividades da vida diária e habilidade motora de idosos com doenças neurodegenerativas. J Bras Psiquatr. 2014;63(1):39-47. Disponível em: https://doi.org/10.1590/0047-2085000000006.
https://doi.org/10.1590/0047-20850000000...
. The present study was developed during the COVID-19 pandemic to verify how much the pandemic intensified the physical and cognitive losses natural to aging.

The results indicated a direct impact of the pandemic on the participants' cognitive functions. Physical decline, in contrast, has been affected by both the pandemic and aging. Gender, marital status and professional occupation had little impact on the results. Low education was a risk factor for physical decline during the pandemic. Understanding these factors is essential for providing public health policies that guarantee access to health and quality of life for the older population2323 Pan A, Liu L, Wang C, Guo H, Hao X, Wang Q, et al. Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China. JAMA. 2020;323(19):1915-1923. Disponível em: https://doi.org/10.1001/jama.2020.6130.
https://doi.org/10.1001/jama.2020.6130...
.

The assessment of cognitive functions involved the MMSE and the FAB. These instruments were chosen because they analyze both general cognitive aspects (such as temporal-spatial orientation, word registration, attention, calculation and memory) and prefrontal executive functions (known for requiring great brain connectivity and processing complexity)2424 Grundy JG, Barker RM, Anderson JAE, Shedden JM. The relation between brain signal complexity and task difficulty on an executive function task. Neuroimage. 2019;198:104-13. Disponível em: https://doi.org/10.1016/j.neuroimage.2019.05.045.
https://doi.org/10.1016/j.neuroimage.201...
. Thus, the inclusion of both instruments allowed a complete analysis of the participants' cognitive functions.

Table 2 details the pre-pandemic and post-state public health emergency MMSE and FAB values. Comparisons show a decline in participants' scores on both instruments during the pandemic. Even though there has been a decline in cognitive functions, the initial and final assessments show normal scores according to the cutoff scores of both instruments2525 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. Disponível em: https://doi.org/10.1590/s0004-282x2003000500014.
https://doi.org/10.1590/s0004-282x200300...
,2626 Beato R, Amaral-Carvalho V, Guimarães HC, Tumas V, Souza CP, Oliveira GN, et al. Frontal assessment battery in a Brazilian sample of healthy controls: normative data. Arq Neuropsiquiatr. 2012;70(4):278-80. Disponível em: https://doi.org/10.1590/s0004-282x2012005000009.
https://doi.org/10.1590/s0004-282x201200...
. That is, cognitive decline occurred, but it was not indicative of dementia.

The inclusion of the age factor in the statistical model indicated that cognitive decline occurred exclusively due to the impact of the pandemic and little was due to physiological changes due to aging. This result is confirmed by medium- and long-term follow-up cohort studies, which indicate a longer time to justify cognitive decline caused by age2727 Jia F, Li Y, Li M, Cao F. Subjective Cognitive Decline, Cognitive Reserve Indicators, and the Incidence of Dementia. J Am Med Dir Assoc. 2021;22(7):1449-1455. Disponível em: https://doi.org/10.1016/j.jamda.2020.08.005.
https://doi.org/10.1016/j.jamda.2020.08....
,2828 Herrmann FR, Montandon ML, Garibotto V, Rodriguez C, Haller S, Giannakopoulos P. Determinants of cognitive trajectories in normal aging: A longitudinal PET-MRI study in a community-based cohort. Curr Alzheimer Res. 2021;18(6):482-91. Disponível em: https://doi.org/10.2174/1567205018666210930111806.
https://doi.org/10.2174/1567205018666210...
.

The inclusion of social and demographic variables aimed to complement the data analysis and investigate the impact of the pandemic and these variables on people's lives. Figure 1 demonstrates that cognitive decline was similar between men and women, people in different marital situations and with different professional occupations. That is, these aspects had little impact on the decline of cognitive functions in older people.

By including social and demographic factors as independent variables, the researchers intended to strengthen the originality of this study. So far, research that has analyzed the impact of COVID-19 on mental and cognitive health has barely addressed the interference of social and demographic factors2929 Flor LS, Friedman J, Spencer CN, Cagney J, Arrieta A, Herbert ME, et al. Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021. Lancet. 2022;399(10344):2381-2397. Disponível em: https://doi.org/10.1016/S0140-6736(22)00008-3.
https://doi.org/10.1016/S0140-6736(22)00...
.

In a study carried out with 365 people, Peng et al.3030 Peng J, Wu WH, Doolan G, Choudhury N, Mehta P, Khatun A, et al. Marital Status and Gender Differences as Key Determinants of COVID-19 Impact on Wellbeing, Job Satisfaction and Resilience in Health Care Workers and Staff Working in Academia in the UK During the First Wave of the Pandemic. Front Public Health. 2022;10:928107. Disponível em: https://doi.org/10.3389/fpubh.2022.928107.
https://doi.org/10.3389/fpubh.2022.92810...
identified that COVID-19 had a greater impact on the health and well-being of women than men. Married people had greater resilience during COVID-19 than single people. This result differs from that found in the present study, which observed similar responses according to gender, marital status and professional occupation. The divergent findings between studies may have occurred due to the age difference of the sample, where people aged over 60 years were approached here and the sample by Peng et al.3030 Peng J, Wu WH, Doolan G, Choudhury N, Mehta P, Khatun A, et al. Marital Status and Gender Differences as Key Determinants of COVID-19 Impact on Wellbeing, Job Satisfaction and Resilience in Health Care Workers and Staff Working in Academia in the UK During the First Wave of the Pandemic. Front Public Health. 2022;10:928107. Disponível em: https://doi.org/10.3389/fpubh.2022.928107.
https://doi.org/10.3389/fpubh.2022.92810...
involved mainly adults. Differences between studies should serve as incentives for further research exploring the impact of COVID-19 on people of different age groups, gender, marital status and professional occupations.

The level of education, on the other hand, significantly interfered in the cognitive results of the participants. People with low levels of education had lower scores on cognitive tests than people with higher levels of education (figure 1). This result was expected because the cognitive instruments have different cutoff scores according to the participants' education level2525 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. Disponível em: https://doi.org/10.1590/s0004-282x2003000500014.
https://doi.org/10.1590/s0004-282x200300...
,2626 Beato R, Amaral-Carvalho V, Guimarães HC, Tumas V, Souza CP, Oliveira GN, et al. Frontal assessment battery in a Brazilian sample of healthy controls: normative data. Arq Neuropsiquiatr. 2012;70(4):278-80. Disponível em: https://doi.org/10.1590/s0004-282x2012005000009.
https://doi.org/10.1590/s0004-282x201200...
. That is, people with low literacy tend to have lower scores on cognitive instruments than people with higher levels of education.

Even though people with low education had lower initial and final values than people with higher educational levels, the longitudinal analysis showed that the difference in values was similar between groups. That is, the impact of the COVID-19 pandemic on cognitive functions was similar across different educational levels. On the one hand, this result surprised researchers, as a person's greater literacy tends to serve as a cognitive reserve mechanism and decrease cognitive decline3131 Davis M, O Connell T, Johnson S, Cline S, Merikle E, Martenyi F, et al. Estimating Alzheimer's disease progression rates from normal cognition through mild cognitive impairment and stages of dementia. Curr Alzheimer Res. 2018;15(8):777-88. Disponível em: https://doi.org/10.2174/1567205015666180119092427.
https://doi.org/10.2174/1567205015666180...
. On the other hand, the follow-up period may have been short and not sensitive to verify greater cognitive decline in one group compared to the other.

Participants' physical health was assessed using the TUG test and the FES-I scale. The researchers chose to include both instruments due to their potential to assess mobility and balance problems, so common during aging3232 Cruz-Jimenez M. Normal changes in gait and mobility problems in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):713-25. Disponível em: https://doi.org/10.1016/j.pmr.2017.06.005.
https://doi.org/10.1016/j.pmr.2017.06.00...
. In addition, the TUG was evaluated with and without a dual-task distractor as a way to bring the mobility activity closer to the reality of the older person. As previous studies have shown motor decline in older people during the COVID-1977 Vidal Bravalhieri AA, Oliveira Rodrigues N, Batiston AP, de Souza Pegorare AB, Christofoletti G. Impact of social isolation on the physical and mental health of older adults: a follow-up study at the apex of the Covid-19 pandemic. Dement Geriatr Cogn Disord. 2022;51(3):279-284. Disponível em: https://doi.org/10.1159/000525661.

8 Browne RAV, Macêdo GAD, Cabral LLP, Oliveira GTA, Vivas A, Fontes EB, et al. Initial impact of the COVID-19 pandemic on physical activity and sedentary behavior in hypertensive older adults: An accelerometer-based analysis. Exp Gerontol. 2020;142:111121. Disponível em: https://doi.org/10.1016/j.exger.2020.111121.
https://doi.org/10.1016/j.exger.2020.111...

9 Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, 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(9):938-47. Disponível em: https://doi.org/10.1007/s12603-020-1469-2.
https://doi.org/10.1007/s12603-020-1469-...
-1010 Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological Implications of physical inactivity among older adults during the COVID-19 Pandemic. Gerontology. 2020;66(5):431-8. Disponível em: https://doi.org/10.1159/000509216.
https://doi.org/10.1159/000509216...
pandemic, the use of these instruments proved to be adequate to verify the participants' mobility and fear of falls during this period.

Table 3 details the pre-pandemic and post-state public health emergency physical test values. The analyzes prove the negative impact of the COVID-19 pandemic on the physical health of the older people, where the participants, in the end, needed to perform the activity with a greater number of steps than in the initial assessment. Carrying out the activity with a greater number of steps may demonstrate an insecurity of the older person, who needed short steps and larger support bases to perform the walk test. This finding is in line with the result of the FES-I, where, in the final assessment, the participants presented results consistent with greater fear of falls than in the initial assessment.

The inclusion of the age factor in the statistical model indicated that the physical decline of the participants was impacted by both the COVID-19 pandemic and the age of the participant. That is, the pre-pandemic and post-public health emergency follow-up period was sufficient to culminate in the physical decline of older people, whose decline was influenced by the age of the person and was intensified by the pandemic.

For this issue, the authors believe that social isolation, so important to prevent hospitalizations and deaths at a time when vaccination against COVID-19 was not yet available3333 da Silva RA, de Souza Ferreira LP, Leite JMRS, Tiraboshi FA, Valente TM, de Paiva Roda VM, et al. Statistical Modeling of Deaths from COVID-19 Influenced by Social Isolation in Latin American Countries. Am J Trop Med Hyg. 2022;106(5):1486-90. Disponível em: https://doi.org/10.4269/ajtmh.21-0217.
https://doi.org/10.4269/ajtmh.21-0217...
, may have intensified the physical decline of the participants. During social isolation, older people were restricted to the domestic environment and physical inactivity may have contributed to the subjects' motor decline3434 Shur NF, Creedon L, Skirrow S, Atherton PJ, MacDonald IA, Lund J, et al. Age-related changes in muscle architecture and metabolism in humans: The likely contribution of physical inactivity to age-related functional decline. Ageing Res Rev. 2021;68:101344. Disponível em: https://doi.org/10.1016/j.arr.2021.101344.
https://doi.org/10.1016/j.arr.2021.10134...
.

Similar to what was found in the analyzes of cognitive functions, gender, marital status and professional occupation had little effect on the physical decline of the participants. That is, the decline was similar between men and women, people in different marital situations and with different professional occupations. Schooling, however, was a risk factor for physical decline. Statistical analysis indicated that people with a lower level of education have worse physical values than people with a higher level of education. In addition, people with less education experienced greater physical decline during the COVID-19 pandemic than people with more education.

For this question, Oehlschlaeger et al. 3535 Oehlschlaeger MHK, Pinheiro RT, Horta B, Gelatti C, San’Tana P. Prevalence of sedentarism and its associated factors among urban adolescents. Rev Saude Publica. 2004;38(2):157-63. Disponível em: https://doi.org/10.1590/s0034-89102004000200002.
https://doi.org/10.1590/s0034-8910200400...
reported that people with lower educational levels tend to be more sedentary than people with higher educational levels. As a sedentary lifestyle has a direct impact on the physical health of older people77 Vidal Bravalhieri AA, Oliveira Rodrigues N, Batiston AP, de Souza Pegorare AB, Christofoletti G. Impact of social isolation on the physical and mental health of older adults: a follow-up study at the apex of the Covid-19 pandemic. Dement Geriatr Cogn Disord. 2022;51(3):279-284. Disponível em: https://doi.org/10.1159/000525661.,3434 Shur NF, Creedon L, Skirrow S, Atherton PJ, MacDonald IA, Lund J, et al. Age-related changes in muscle architecture and metabolism in humans: The likely contribution of physical inactivity to age-related functional decline. Ageing Res Rev. 2021;68:101344. Disponível em: https://doi.org/10.1016/j.arr.2021.101344.
https://doi.org/10.1016/j.arr.2021.10134...
, the authors believe that low education may be linked to a lower level of physical activity in this group, affecting the motor variables of the study.

Although this study found important results on the impact of COVID-19 on the health of older people, it has some limitations that should be taken into account by readers. The main limitation refers to the effect size of the impact of the pandemic, which was between 0.43 for cognitive variables and 0.74 for physical variables.

The effect size may have been influenced by the cognitive and physical tests chosen by the researchers. The inclusion of other tests could prove an even greater impact of COVID-19 on the lives of older people. That is, the researchers focused the analysis of mental health on cognitive aspects, not including other important aspects such as depression, anxiety level, mood and stress. The inclusion of other aspects could enhance the impact of COVID-19 on the mental health of older people and increase the size of the effect identified in this study.

Similarly, physical tests focused on mobility analysis and fear of falling. The inclusion of other factors, such as muscle strength, agility, flexibility and functional capacity could also enhance the proof of the impact of COVID-19 on the physical health of the older person.

CONCLUSION

This study identified the impact of the COVID-19 pandemic on the health of the older population, taking into account social and demographic peculiarities. Gender, marital status and professional occupation had little impact on the results. Low education was a risk factor for physical decline.

While cognitive decline was affected solely by the pandemic, physical decline was due to the association between the impact of the pandemic and the age of the participant.

The results of this study should be taken into account by professionals in the area of geriatrics and gerontology, and by health managers, with a view to proposing new health policies that guarantee health to the older population.

ACKNOWLEDGMENTS

We are grateful for the logistical support provided by the graduate programs “Health and Development” (Faculty of Medicine), “Movement Sciences” and “Family Health” (Integrated Institute of Health) at the Federal University of Mato Grosso do Sul.

  • Funding: Pró-Reitoria de Pesquisa e Pós-graduação da Universidade Federal de Mato Grosso do Sul e Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES – código 001).

REFERÊNCIAS

  • 1
    Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395(10242):1973-87. Disponível em: https://doi.org/10.1016/S0140-6736(20)31142-9.
    » https://doi.org/10.1016/S0140-6736(20)31142-9
  • 2
    Bartsch SM, O'Shea KJ, Chin KL, Strych U, Ferguson MC, Bottazzi ME, et al. Maintaining face mask use before and after achieving different COVID-19 vaccination coverage levels: a modelling study. Lancet Public Health. 2022;7(4):e356-65. Disponível em: https://doi.org/10.1016/S2468-2667(22)00040-8.
    » https://doi.org/10.1016/S2468-2667(22)00040-8
  • 3
    Santos-Pinto CB, Miranda ES, Osorio-de-Castro CGS. "Kit-covid" and the Popular Pharmacy Program in Brazil. Cad Saude Publica. 2021;37(2):e00348020. Disponível em: https://doi.org/10.1590/0102-311X00348020.
    » https://doi.org/10.1590/0102-311X00348020
  • 4
    Taylor L. 'We are being ignored': Brazil's researchers blame anti-science government for devastating COVID surge. Nature. 2021;593(7857):15-6. Disponível em: https://doi.org/10.1038/d41586-021-01031-w.
    » https://doi.org/10.1038/d41586-021-01031-w
  • 5
    Machado CJ, Pereira CCA, Viana BM, Oliveira GL, Melo DC, Carvalho JFM, et al. Estimativas de impacto da COVID-19 na mortalidade de idosos institucionalizados no Brasil. Cien Saude Colet. 2020;25(9):3437-44. Disponível em: https://doi.org/ 10.1590/1413-81232020259.14552020.
    » https://doi.org/10.1590/1413-81232020259.14552020
  • 6
    de Oliveira Lima H, da Silva LM, de Campos Vieira Abib A, Tavares LR, Santos DWCL, de Araújo ACLF, et al. Coronavirus disease-related in-hospital mortality: a cohort study in a private healthcare network in Brazil. Sci Rep. 2022;12(1):6371. Disponível em: https://doi.org/10.1038/s41598-022-10343-4.
    » https://doi.org/10.1038/s41598-022-10343-4
  • 7
    Vidal Bravalhieri AA, Oliveira Rodrigues N, Batiston AP, de Souza Pegorare AB, Christofoletti G. Impact of social isolation on the physical and mental health of older adults: a follow-up study at the apex of the Covid-19 pandemic. Dement Geriatr Cogn Disord. 2022;51(3):279-284. Disponível em: https://doi.org/10.1159/000525661.
  • 8
    Browne RAV, Macêdo GAD, Cabral LLP, Oliveira GTA, Vivas A, Fontes EB, et al. Initial impact of the COVID-19 pandemic on physical activity and sedentary behavior in hypertensive older adults: An accelerometer-based analysis. Exp Gerontol. 2020;142:111121. Disponível em: https://doi.org/10.1016/j.exger.2020.111121.
    » https://doi.org/10.1016/j.exger.2020.111121
  • 9
    Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, 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(9):938-47. Disponível em: https://doi.org/10.1007/s12603-020-1469-2.
    » https://doi.org/10.1007/s12603-020-1469-2
  • 10
    Damiot A, Pinto AJ, Turner JE, Gualano B. Immunological Implications of physical inactivity among older adults during the COVID-19 Pandemic. Gerontology. 2020;66(5):431-8. Disponível em: https://doi.org/10.1159/000509216.
    » https://doi.org/10.1159/000509216
  • 11
    Creese B, Khan Z, Henley W, O'Dwyer S, Corbett A, Vasconcelos-da-Silva M, et al. Loneliness, physical activity, and mental health during COVID-19: a longitudinal analysis of depression and anxiety in adults over the age of 50 between 2015 and 2020. Int Psychogeriatr. 2021;33(5):505-14. Disponível em: https://doi.org/10.1017/S1041610220004135.
    » https://doi.org/10.1017/S1041610220004135
  • 12
    de Moura AAM, Bassoli IR, Silveira BV, Diehl A, dos Santos MA, dos Santos RA, Wagstaff C, Pillon SC. Is social isolation during the COVID-19 pandemic a risk factor for depression? Rev Bras Enferm. 2022;75(Suppl 1):e20210594. Disponível em: https://doi.org/10.1590/0034-7167-2021-0594.
    » https://doi.org/10.1590/0034-7167-2021-0594
  • 13
    Guo J, Feng XL, Wang XH, van Ijzendoorn MH. Coping with COVID-19: Exposure to COVID-19 and Negative Impact on Livelihood Predict Elevated Mental Health Problems in Chinese Adults. Int J Environ Res Public Health. 2020;17(11):3857. Disponível em: https://doi.org/10.3390/ijerph17113857.
    » https://doi.org/10.3390/ijerph17113857
  • 14
    Governo Federal. Portaria GM/MS no 913, de 22 de abril de 2022. Brasília, 2022 [citado 2023 Jan 25]. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=22/04/2022&jornal=612&pagina=1
    » https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=22/04/2022&jornal=612&pagina=1
  • 15
    Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98. Disponível em: https://doi.org/10.1016/0022-3956(75)90026-6.
    » https://doi.org/10.1016/0022-3956(75)90026-6
  • 16
    Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology. 2000;55(11):1621-6. Disponível em: https://doi.org/10.1212/wnl.55.11.1621.
    » https://doi.org/10.1212/wnl.55.11.1621
  • 17
    Christofoletti G, Oliani MM, Stella F, Gobbi S, Gobbi LTB. The influence of schooling on cognitive screening test in the elderly. Dement Neuropsychol. 2007;1(1):46-51. Disponível em: https://doi.org/10.1590/S1980-57642008DN10100008.
  • 18
    Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8. Disponível em: https://doi.org/10.1111/j.1532-5415.1991.tb01616.x.
    » https://doi.org/10.1111/j.1532-5415.1991.tb01616.x
  • 19
    Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005;34(6):614-9. Disponível em: https://doi.org/10.1093/ageing/afi196.
    » https://doi.org/10.1093/ageing/afi196
  • 20
    Hennah C, Ellis G, Doumas M. Dual task walking in healthy aging: Effects of narrow and wide walking paths. PLoS One. 2021;16(12):e0261647. Disponível em: https://doi.org/10.1371/journal.pone.0261647.
    » https://doi.org/10.1371/journal.pone.0261647
  • 21
    McGrath R, Vincent BM, Hackney KJ, Al Snih S, Graham J, Thomas L, et al. Weakness and cognitive impairment are independently and jointly associated with functional decline in aging Americans. Aging Clin Exp Res. 2020;32(9):1723-30. Disponível em: https://doi.org/10.1007/s40520-019-01351-y.
    » https://doi.org/10.1007/s40520-019-01351-y
  • 22
    Felippe LA, de Oliveiar RT, Garcia M, Silva-Hamu TCD, Santos SMS, Christofoletti G. Funções executivas, atividades da vida diária e habilidade motora de idosos com doenças neurodegenerativas. J Bras Psiquatr. 2014;63(1):39-47. Disponível em: https://doi.org/10.1590/0047-2085000000006.
    » https://doi.org/10.1590/0047-2085000000006
  • 23
    Pan A, Liu L, Wang C, Guo H, Hao X, Wang Q, et al. Association of Public Health Interventions With the Epidemiology of the COVID-19 Outbreak in Wuhan, China. JAMA. 2020;323(19):1915-1923. Disponível em: https://doi.org/10.1001/jama.2020.6130.
    » https://doi.org/10.1001/jama.2020.6130
  • 24
    Grundy JG, Barker RM, Anderson JAE, Shedden JM. The relation between brain signal complexity and task difficulty on an executive function task. Neuroimage. 2019;198:104-13. Disponível em: https://doi.org/10.1016/j.neuroimage.2019.05.045.
    » https://doi.org/10.1016/j.neuroimage.2019.05.045
  • 25
    Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. Disponível em: https://doi.org/10.1590/s0004-282x2003000500014.
    » https://doi.org/10.1590/s0004-282x2003000500014
  • 26
    Beato R, Amaral-Carvalho V, Guimarães HC, Tumas V, Souza CP, Oliveira GN, et al. Frontal assessment battery in a Brazilian sample of healthy controls: normative data. Arq Neuropsiquiatr. 2012;70(4):278-80. Disponível em: https://doi.org/10.1590/s0004-282x2012005000009.
    » https://doi.org/10.1590/s0004-282x2012005000009
  • 27
    Jia F, Li Y, Li M, Cao F. Subjective Cognitive Decline, Cognitive Reserve Indicators, and the Incidence of Dementia. J Am Med Dir Assoc. 2021;22(7):1449-1455. Disponível em: https://doi.org/10.1016/j.jamda.2020.08.005.
    » https://doi.org/10.1016/j.jamda.2020.08.005
  • 28
    Herrmann FR, Montandon ML, Garibotto V, Rodriguez C, Haller S, Giannakopoulos P. Determinants of cognitive trajectories in normal aging: A longitudinal PET-MRI study in a community-based cohort. Curr Alzheimer Res. 2021;18(6):482-91. Disponível em: https://doi.org/10.2174/1567205018666210930111806.
    » https://doi.org/10.2174/1567205018666210930111806
  • 29
    Flor LS, Friedman J, Spencer CN, Cagney J, Arrieta A, Herbert ME, et al. Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021. Lancet. 2022;399(10344):2381-2397. Disponível em: https://doi.org/10.1016/S0140-6736(22)00008-3.
    » https://doi.org/10.1016/S0140-6736(22)00008-3
  • 30
    Peng J, Wu WH, Doolan G, Choudhury N, Mehta P, Khatun A, et al. Marital Status and Gender Differences as Key Determinants of COVID-19 Impact on Wellbeing, Job Satisfaction and Resilience in Health Care Workers and Staff Working in Academia in the UK During the First Wave of the Pandemic. Front Public Health. 2022;10:928107. Disponível em: https://doi.org/10.3389/fpubh.2022.928107.
    » https://doi.org/10.3389/fpubh.2022.928107
  • 31
    Davis M, O Connell T, Johnson S, Cline S, Merikle E, Martenyi F, et al. Estimating Alzheimer's disease progression rates from normal cognition through mild cognitive impairment and stages of dementia. Curr Alzheimer Res. 2018;15(8):777-88. Disponível em: https://doi.org/10.2174/1567205015666180119092427.
    » https://doi.org/10.2174/1567205015666180119092427
  • 32
    Cruz-Jimenez M. Normal changes in gait and mobility problems in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):713-25. Disponível em: https://doi.org/10.1016/j.pmr.2017.06.005.
    » https://doi.org/10.1016/j.pmr.2017.06.005
  • 33
    da Silva RA, de Souza Ferreira LP, Leite JMRS, Tiraboshi FA, Valente TM, de Paiva Roda VM, et al. Statistical Modeling of Deaths from COVID-19 Influenced by Social Isolation in Latin American Countries. Am J Trop Med Hyg. 2022;106(5):1486-90. Disponível em: https://doi.org/10.4269/ajtmh.21-0217.
    » https://doi.org/10.4269/ajtmh.21-0217
  • 34
    Shur NF, Creedon L, Skirrow S, Atherton PJ, MacDonald IA, Lund J, et al. Age-related changes in muscle architecture and metabolism in humans: The likely contribution of physical inactivity to age-related functional decline. Ageing Res Rev. 2021;68:101344. Disponível em: https://doi.org/10.1016/j.arr.2021.101344.
    » https://doi.org/10.1016/j.arr.2021.101344
  • 35
    Oehlschlaeger MHK, Pinheiro RT, Horta B, Gelatti C, San’Tana P. Prevalence of sedentarism and its associated factors among urban adolescents. Rev Saude Publica. 2004;38(2):157-63. Disponível em: https://doi.org/10.1590/s0034-89102004000200002.
    » https://doi.org/10.1590/s0034-89102004000200002.

Edited by

Edited by: Yan Nogueira Leite de Freitas

Publication Dates

  • Publication in this collection
    07 Apr 2022
  • Date of issue
    2022

History

  • Received
    06 Sept 2022
  • Accepted
    16 Feb 2023
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