*4.1. The Impact of COVID-19 Pandemic on Everyday Activities of Elderly Population*

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may potentially lead to critical complications of the COVID-19 disease, especially in older adults. Many studies showed that the virus causes worse outcomes in the elderly, particularly in those with comorbidities such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and chronic kidney disease [3,23]. Additional infection to older, ailing people suffering from many other health conditions results in a significant reduction in their quality of life and their lifespan [24]. According to our study, COVID-19 infection entails a substantial change in older people's behavior. Over 50% and nearly 80% of the surveyed group reduced their social and recreational activities, respectively. It is undoubtedly beneficial behavior for the limitation of virus transmission, but in contrast, physical activity is salutary for older people and significantly impacts the reduction of anxiety, depression, osteoporosis, sarcopenia, and metabolic syndrome [14–17,21]. The result from our analysis is in line with recent publications that have reported COVID-19-related fear, psychosocial effects, and uncertainty among the older population around the world [25–28]. For instance, in Japan, Takashima R interviewed 24 elderly participants (mean age, 78.2 ± 5.5 years) in order to examine their perceptions regarding how COVID-19 restricted their daily lives. The following points were touched: "difficulty of maintaining connections with people", "loss of activities for pleasure in life", "tightness that gradually built up", and "confusion due to the collapse of the schedule". Authors determined frequent changes in activity styles in surveyed participants, for example, reducing the number of shopping trips or shortening the time required for shopping. This result is consistent with our data showing that 162 participants limited doing shopping due to the fear of COVID-19 infection (162/500; 32.4%) [25].

Moreover, considering that interpersonal relations and social activity are particularly beneficial in seniors, reducing activity would decrease their quality of life [29–31]. Furthermore, more than 25% of participants reduced professional activity (133/500, 26.6%), which may produce substantial economic issues. Nowadays, although social distancing and isolation are beneficial to limit the number of potential cases of spreading the virus, this economic issue is still growing, especially in low-income countries and with a high percentage of COVID-19-infected inhabitants. Many businesses were shut down temporarily, leading, in consequence, to financial market turmoil, significant declines in revenue, insolvencies, and job losses in specific sectors [32]. Furthermore, because of travel bans, border closures, and quarantine measures, many workers could not move to their workplaces or carry out their jobs, leading to unbeneficial effects on their incomes [33]. Thus, government-imposed restrictions, together with the fear and anxiety of workers in different sectors about the COVID-19 infection, may lead to a further increase in the economic issue, especially in countries with low state budgets.

#### *4.2. The Most Significant Findings of the Study*

We noticed that the most significant change in surveyed seniors' behavior due to the fear of COVID-19 infection (an increase of anxiety and reduction of activity) was observed mainly in patients (1) with other comorbidities, (2) being on multi-drug therapy, (3) vaccinated against influenza, and (4) with several mental difficulties (inferred by specified and validated scales including ADL scale, IADL scale, GDS-15 scale, GAS-10 scale, LSNS-6 scale, MNA scale, and Gierveld scale). Firstly, we found that the change in senior's behavior was especially noticeable in participants suffering from coronary heart disease, COPD, and heart failure. It is already known that patients with at least one of these high-risk conditions suffer from a more severe course of COVID-19 infection and have increased mortality. For instance, according to data from the United States, approximately one-third of COVID-19-infected patients (2692, 38%) had at least one chronic disease or risk factor; the most common were cardiovascular diseases (647, 9%), chronic lung diseases (656, 9.2%), and diabetes (784, 11%) [34]. Furthermore, based on the meta-analysis including 22,148 patients from 40 studies, Liang et al. revealed the significant association between coronary heart disease and poor prognosis of COVID-19 (OR = 3.42, 95%CI [2.83, 4.13], *p* < 0.001); this correlation was affected mostly by hypertension (*p* = 0.004) [35]. Considering COPD patients, Gerayeli et al. examined the effects of this disease on COVID-19 outcomes as their primary endpoint. COPD was associated with increased odds of hospitalization (OR = 4.23, 95%CI [3.65–4.90], Intensive Care Unit (ICU) admission (OR = 1.35, 95% CI [1.02–1.78]), and mortality (OR = 2.47, 95% CI [2.18–2.79]) [36]. These introduced above results are in line with our cross-sectional study, explaining the increased fear and anxiety of COVID-19 infection in patients with cardiac and pulmonary problems. Moreover, we noticed that a significant change in behavior also exists in patients on multi-drug therapy. The reason is probably similar to mentioned before; thus, according to many studies, patients on multi-drug therapy recognize their state of health as worse compared to patients without medications or being on single-drug therapy. Fear and anxiety of COVID-19 infection in elderly patients increase, when cardiac drugs (*p* = 0.001, Figure S3B), antihypertensives (*p* = 0.009, Figure S3C), diuretics (*p* = 0.004, Figure S3D), drugs for digestive ailments (*p* = 0.037, Figure S3E) and anticoagulants (*p* < 0.001, Figure S3F) are taken simultaneously in different combinations. These findings confirm the fear of COVID-19 infection in patients with cardiac and pulmonary difficulties who take medicines as a treatment strategy.

Furthermore, our study revealed a substantial issue in the field of vaccination against influenza in the surveyed seniors' population. Only 62 (12.4%) and 51 (10.2%) of participants were vaccinated against influenza in 2019 and 2020, respectively. The reason for such behavior in 104 (20.8%) cases was the lack of vaccines in pharmacies, but in a substantial number of patients (*n* = 164, 32.8%), it was the fear of possible vaccinationrelated complications. Moreover, we also found that only in 81 (16.2%) cases, the GP advised on vaccination, which was probably the most stressful finding. Vaccination against

influenza is especially beneficial in an older population and reduces influenza-related and comorbidities-related mortality [37,38]. In turn, due to the observed reduction of influenza cases during the COVID-19, the question arises if prior influenza vaccination may affect COVID-19 susceptibility and severity. To date, few studies have evaluated the effects of influenza on COVID-19. However, their results have been mostly conflicting. Massoudi et al. examined the role of the influenza vaccine in 261 healthcare workers, including 180 with a history of COVID-19 and 181 healthy controls. In the univariate analysis, the odds ratio of being vaccinated was 0.04 (95%CI [0.01–0.14]). The authors concluded that the influenza vaccine might have a protective effect in COVID-19 [39]. Furthermore, Zannetini et al. showed an inverse association of a greater influenza vaccination coverage in the elderly and mortality from COVID-19, suggesting a protective effect of the influenza vaccine [40]. Moreover, in patients who had received an influenza vaccination, there was a significant reduction in the odds of testing positive for COVID-19 (OR = 0.82, 95%CI [0.73–0.92], *p* < 0.01). In addition, influenza vaccinated patients were less likely to require hospitalization (OR = 0.58), mechanical ventilation (OR = 0.45) and had a shorter hospital stay (OR = 0.76). This result leads to the conclusion that the influenza vaccine is assumed to reduce the COVID-19 disease burden [41]. By contrast, in Italy, independently, Belingeri et al. and Pedote et al. found no evidence of a relationship between the influenza vaccine and either a COVID-19 diagnosis or a positive SARS-CoV-2 serology test in a group of healthcare workers and COVID-19 infected patients, respectively. Nevertheless, despite different evidence from independent studies, influenza vaccination must be promoted as a central public health measure because reducing the hospital burden can greatly benefit the management of COVID-19 patients [42,43]. It was not only information about vaccines but also routes of transmission, and updates on the number of infected cases and location (e.g., real-time, online tracking map) were associated with lower levels of anxiety [44]. It seems reasonable that educating the population leads to increased awareness about potential ways of protecting against the virus and eliminating COVID-19 cases. In this regard, the general public and social media seem to have a tremendous impact on people's awareness by promoting healthy behaviors and improving coping management strategies. This effect is seen mostly in seniors who tend to stay at home and watch media (radio, television, newspapers) more often than people of other ages. Therefore, we believe that the continuous process of education in influenza vaccination, routes of SARS-CoV-2 transmission, and protective strategies against the virus are crucial to maintain good health in the older population and reduce complications and the necessity of hospitalizations.

With the backdrop of high COVID-19 cases and the constantly evolving situation locally and globally, examining the psychological and mental health impacts, COVID-19 brings to individuals is imperative. One psychological response commonly reported is fear toward COVID-19 [45]. To date, several studies revealed a worsening of physical function after COVID-19 infection. This observation occurred mainly in COVID-19 infected older patients, especially those with dementia and psychiatric disorders, who were more likely to be burdened by the adverse effects of loneliness (i.e., perceived lack of meaningful relationships) and social isolation (i.e., lack of social interactions). The noticeable burden of disease resulting from physical and psychological sequelae of COVID-19 is one of the most important factors increasing the fear of COVID-19 infection. For instance, Zhu et al. conducted a multi-center retrospective cohort study in order to estimate the anxiety of COVID-19 survivors at discharge from hospital and analyze relative risk by exposures. Including a total of 432 survivors with laboratory-confirmed SARS-CoV-2 infection, they found a high prevalence of anxiety, accounting for 36.81% (95% CI [32.39–41.46]). Older age and severe disease course both independently increased the relative risk of IADL limitations and ADL dependence [46]. Furthermore, because one of the most common psychological reactions are symptoms of depression and anxiety, Han et al. examined the association between psychological factors and fear of COVID-19 among communitydwelling older adults during a COVID-19 lockdown in Singapore. The COVID-19 Fear Inventory scale, GDS-15 scale, and GAI-SF scale (Geriatric Anxiety Inventory—Short Form) revealed a strong interrelation between the fear of COVID-19 and affective symptoms suggesting the significant effect COVID-19 has on psychological well-being and mental health. Older age was associated with greater fear of COVID-19 [45]. However, due to the higher risks of cardiac and pulmonary problems in elderly patients (observed, for example, in our study), it is not surprising that higher fear levels were found in this subgroup of older adults.

Our study demonstrated that 10% of participants canceled planned hospitalization due to the fear of COVID-19 infection (50/500, 10%). Considering that hospitalized persons are more prone to COVID-19 infection, it could be paradoxically beneficial if the disease that would be the cause of hospitalization is not life-threatening at the moment. The most stressful finding was that over 5% of the surveyed population resigned to report to the Emergency room due to the sudden deterioration of health (32/500, 6.4%), despite, in many cases, the cause of health aggravation could be more dangerous than potential COVID-19 infection. Such behavior could produce an enormous number of complications, which would increase significant mortality in the older population. For instance, Vani et al. indicated that some patients suffering from breast cancer refused surgical treatment due to fear of COVID-19 contagion even at the risk of survival [47]. In likelihood, this behavior reported in Vani et al.'s study, as well as in our data, results from the fear that health care systems may be overrun and that adequate medical care will not be available for all COVID-19 infected and with other health difficulties [48].
