Since January 2020 Elsevier has created a COVID-19 resource centre with
free information in English and Mandarin on the novel coronavirus COVID-
19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company's public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related
research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
The effects of fear of COVID-19, loneliness, and resilience on the quality of
life in older adults living in a nursing home
Cemile Savci, PhD
*, Ayse Cil Akinci, PhD
, Sevinc Yildirim Usenmez, MSc, RN
Furkan Keles, RN
Department of Nursing, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul, Turkey
School of Nursing, Loma Linda University, CA, USA
Darulaceze Directorate Nursing Home, Istanbul Metropolitan Municipality, Istanbul, Turkey
Received 26 July 2021
Received in revised form 17 September 2021
Accepted 17 September 2021
Available online 25 September 2021
This study aimed to evaluate the fear of COVID-19, loneliness, resilience, and quality of life levels in older
adults in a nursing home during the pandemic, and the effects of these variables and descriptive characteris-
tics on their quality of life.
Data were collected using a participant information form, the Mini Mental State Exam (MMSE), the Brief
Resilience Scale, the Fear of COVID-19 Scale (FCV-19S), the Loneliness Scale for Elderly (LSE), and the World
Health Organization Quality of Life-BREF Turkish Version (WHOQOL-BREF-TR). Regarding the WHOQOL-
BREF-TR scale, being male, history of chronic disease, MMSE score, and the changes in sleep pattern signiﬁ-
cantly affected the physical dimension (R
=0.353, p<0.01) while age, and MMSE and LSE scores signiﬁcantly
affected the psychological dimension (R
=0.364, p<0.01). Also, the MMSE, FCV-19S, and LSE scores signiﬁ-
cantly affected the social relations dimension (R
=0.234, p<0.01) while MMSE, FCV-19S, and LSE scores sig-
niﬁcantly affected the environmental dimension (R
© 2021 Elsevier Inc. All rights reserved.
Quality of life
COVID-19 spread quickly across the world following the ﬁrst out-
break in Wuhan, China in December 2019. The World Health Organi-
zation (WHO) declared the COVID-19 infectious disease a pandemic
on March 11, 2020.
Older adults are the most vulnerable age group
in terms of experiencing more severe symptoms due to physiological
causes (such as decline in immune function, malnutrition, etc.) and
comorbidities (such as hypertension, cardiovascular disease, diabe-
tes, chronic respiratory disease, and chronic kidney disease, etc.), and
having a higher risk of death from COVID-19.
In Turkey, individuals
aged 65 and over constitute 11% of the reported patient numbers and
72% of deaths.
The risk has been reported to be even higher for older
adults living in nursing homes
, where approximately two-thirds of
them are infected with COVID-19 within three weeks, and the mor-
tality rate is 33%.
The combined effects of the media’s constant focus on mortality
rates, especially the high mortality rates in older adults, and the social
isolation, quarantine, and physical distancing measures applied to
prevent the transmission of the disease can adversely affect the psy-
chological health of older adults
and can be cause vairous prob-
lems, such as fear, anxiety, and loneliness.
reported that all older adults groups experienced depression and
anxiety during the COVID-19 pandemic,
and the rate of reporting
the fear of COVID-19 increased with age.
It has been reported that
the older adults are the age group that is most affected by the fear of
COVID-19 and loneliness in all countries regardless of the levels of
COVID-19 cases and deaths.
Studies have indicated that the long-
term restrictive measures implemented around the world, including
Turkey, may lead to increased incidences of loneliness in older adults
living in nursing homes
and at home.
The restrictive measures,
fear, and loneliness could adversely affect the physical, psychological,
mental health, life style, and quality of life (QOL) of older adults.
The term psychological resilience is deﬁned as the ability to adapt
to challenging circumstances in a positive manner.
It has been
reported that the restrictions imposed on individuals aged 65 and
over during the COVID-19 pandemic, and the social difﬁculties,
fear, stress, and loneliness that the pandemic has generated may
weaken the resilience of older adults and thereby endanger their
health and QOL.
According to the WHO, QOL refers to individuals'perceptions of
their position in life and their expectations, standards, and con-
The concept of QOL in old age has become a major topic of
*Corresponding author at: Istanbul Medeniyet University, Atalar Mah., Sehit Hakan
Kurban Cad., 34862 Cevizli, Kartal/Istanbul, Turkey.
E-mail addresses: email@example.com (C. Savci), aysecilakinci@gmail.
com (A. Cil Akinci).
0197-4572/$ see front matter © 2021 Elsevier Inc. All rights reserved.
Geriatric Nursing 42 (2021) 14221428
Contents lists available at ScienceDirect
journal homepage: www.gnjournal.com
interest on account of the current rising population of older adults
and the increase in the length of life. Previous studies have shown
that demographic characteristics,
a history of chronic disease,
and sleep quality
are among the variables that affect the quality of
life of the older adults. A limited number of studies have evaluated
the quality of life of the older adults during the COVID-19 pandemic;
however, their study results have varied from study to study.
one study, half of the older adults over the age of 70 who applied to
the hospital as outpatients during the COVID-19 pandemic reported
that their QOL decreased,
while in another study, it was reported
that older adults considered their QOL to be higher compared to that
of the young during the COVID-19 pandemic.
In the literature review
conducted for the present study, there was no study found that eval-
uated the QOL and the affecting factors the QOL (such as fear of
COVID-19, loneliness, resilience, age, gender, history of chronic dis-
ease, changing sleep pattern, and mental status, etc.) of older adults
living in nursing homes during the pandemic. Determining the qual-
ity of life of nursing home older adults, one of the groups most vul-
nerable to COVID-19, and the factors that affect their quality of life
will help with planning and implementing interventions to increase
their quality of life. This study aimed to evaluate the fear of COVID-
19, loneliness, resilience, and quality of life levels in older adults in a
nursing home during the pandemic, and the effects of these variables
and descriptive characteristics (age, gender, history of chronic dis-
ease, changing sleep pattern, and mental status) on their QOL.
In this study, the following questions were addressed: i) What are
the fear of COVID-19, loneliness, resilience, and QOL levels of older
adults in nursing homes during the pandemic? ii) Do fear of COVID-
19, loneliness, resilience and descriptive characteristics (age, gender,
history of chronic disease, sleep patterns, and mental health) affect
the QOL of older adults in nursing homes during the pandemic?
Materials and methods
Study design and sample
This study was designed as a descriptive and correlational study.
The study population included 440 older adults residing in a nursing
home afﬁliated with the Istanbul Darulaceze Directorate of Hospice
between April 5, 2021 and May 20, 2021. The inclusion criteria for
the study were as follows: be over 65 years old, voluntarily agree to
participate in the study, have a Standardized Mini Mental Test Score
of 24 or higher, residence within the nursing home for at least one
year, and speak and understand Turkish. Of the population of 440
older adults, 230 did not agree to voluntarily participate in the study,
47 had MMSE test scores below 24, 33 had been living in the nursing
home for less than a year, and 27 had communication problems, and
therefore these individuals were excluded from the study. The ﬁnal
sample consisted of the remaining 103 individuals who met the
inclusion criteria for the study.
The older adults residing in the institution where the study was
conducted were housed in a two-storey building that had rooms for
3, 4, 6, 7, and 8 people. A total of 28 nurses, 9 physicians, 2 physio-
therapists, 2 social workers, and 1 food engineer were working in the
nursing home at the time of the study. The in-house psychologist had
recently left the institution at the time of the study. Routine examina-
tions and treatments of the older adults living in the nursing home
were performed in-house, but in cases of emergency or when further
examination was needed, they were referred to the hospital. The
nursing home features a rehabilitation unit where the older adults
are able to socialize, spend their free time, and ply their respective
skills to produce items (knitting, carpet weaving, painting, etc.), for
which they get paid. However, during the collection of the study
data, this unit was closed as a result of the restrictive measures
imposed during the pandemic. The institution has been closed to
visitors during the pandemic, and the older adults residing in the
nursing home have been only allowed to contact their relatives by
Data collection forms
The data of the study were collected using a participant information
form, the Mini Mental State Exam (MMSE), the Brief Resilience Scale
(BRS), the Fear of COVID-19 Scale (FCV-19S), the Loneliness Scale for
Elderly (LSE), and the World Health Organization Quality of Life-BREF
Turkish Version (WHOQOL-BREF-TR). The participating older adults
were asked to respond to the questions and scale items in a manner
that best reﬂected their experiences during the pandemic.
Participant Information Form: This form consists of 11 items
related to the descriptive characteristics of the older adults, including
age, gender, marital status, educational status, economic status, pres-
ence of children, duration of stay in the institution, number of people
in the residing room, history of chronic disease, history of COVID-19,
and sleep patterns during the COVID-19 pandemic.
The Mini Mental State Exam (MMSE): MMSE, which was developed
by Folstein et al. in 1975, is a short, standardized questionnaire that can
be used to evaluate global cognition. The MMSE includes a total of 11
items arranged under ﬁve sub-dimensions, namely, orientation (10
points), recording memory (3 points), attention and accountability (5
points), recall (3 points), and language (9 points), and it is evaluated over
a total of 30 points. Scores between “24-30”indicate normal cognitive
level, scores between “21-23”indicate mild cognitive impairment, and
scores of “20”and below indicate moderate to severe cognitive
The MMSE was adapted to the educated portion of Turk-
ish society by G€
ungen et al. in 2002,
and to the uneducated portion of
Turkish society by Ertan et al. in 1999.
In this study, only those older
adults with an MMSE score of 24 and above were included in the study.
Fear of COVID-19 Scale (FCV-19S): The FCV-19S was developed by
Ahorsu et al.
to measure COVID-19-induced fear levels. Designed as a
ﬁve-point Likert-type scale, the FCV-19S has seven items, with total pos-
sible scores from the FCV-19S ranging between 7 and 35 points. High
scores indicate higher levels of COVID-19 fear. The Cronbach’s alpha
coefﬁcient of the original scale was reported to be .82, while in the Turk-
ish validity and reliability study conducted by Ladikli et al.,
cient was .80. In this study, the Cronbach’s alpha coefﬁcient was .81.
Loneliness Scale for Elderly (LSE): This 24-question scale, which was
developed by Gierveld and Kamphuis in 1985,
was revised by van Til-
burg and de Jong Gierveld in 1999.
The 3-point Likert-type scale, con-
sisting of 11 items arranged two sub-dimensions, emotional loneliness
and social loneliness, was developed to measure the loneliness levels of
adults and the elderly. The lowest and highest scores possible from the
scale are 0 and 22, respectively. The level of loneliness increases as the
scale score increases. In the Turkish validity and reliability study of the
scale performed by Akg€
ul and Ye¸silyaprak in 2015, the internal consis-
tency coefﬁcients were reported as .79 for emotional loneliness, .81 for
social loneliness and .85 for the total scale.
In this study, the Cron-
bach’s alpha internal consistency coefﬁcients were .76 for emotional
loneliness, .81 for social loneliness, and .75 for the total scale.
The Brief Resilience Scale (BRS): This scale was developed by Smith
et al. in 2008 to measure the psychological resilience of individuals. BRS
is a 5-point Likert-type, 6-item, self-report measurement tool. The total
possible scores obtainable from the scale vary between 6 and 30, with
higher scores indicating higher psychological resilience.
In the Turkish
validity and reliability study of the scale performed by Do
gan in 2015,
the Cronbach'salphacoefﬁcient of the scale was .83.
In this study, the
Cronbach’s alpha coefﬁcient was .89.
World Health Organization Quality of Life-BREF Turkish Version
(WHOQOL-BREF-TR): This scale was created based on the results of
pilot studies performed in 15 centres around the world. From these
pilot studies, the 5-point Likert-type WHOQOL-BREF, consisting of 26
C. Savci et al. / Geriatric Nursing 42 (2021) 14221428 1423
questions selected from the 100-question WHOQOL-100 scale, was
developed. Physical, psychological, social, and environmental dimen-
sion scores are calculated for all items, except for the ﬁrst two general
items. The physical, psychological, social, and environmental dimen-
sion scores calculated using a formula vary between 0-100%, and the
QOL increases as the score increases.
The internal consistency coef-
ﬁcients of the scale adapted to Turkish were reported as .76, .67, .56
and .74 for the physical, psychological, social, and environmental
In this study, the internal consistency
coefﬁcients were .68, .78, .61 and .76 for the physical, psychological,
social, and environmental dimensions, respectively.
This study was conducted in accordance with the principles outlined
in the Declaration of Helsinki. Ethics committee approval (30.12.2020/47)
and institutional permission (01.04.2021/730.10-E.2127) were obtained
for the implementation of the study. The third researcher, who is a nurse
in the institution, shared the Google survey form link with the 333 older
adults in nursing homes who met the inclusion criteria by mobile phone
(e-mail or WhatsApp) in accordance with the principle of voluntary par-
ticipation. In the e-mail/ WhatsApp, participants were informed about
the purpose of the study, and those that marked the “I agree with partici-
pating in the survey”expression at the top of the Google Form were
requested to ﬁll out the form. The researcher, who works at this institu-
tion, helped 70 adults who wanted to complete the form but could not
do so on their own and verbally asked for the help of the researcher, to
partially or fully complete the form. The study was completed with 103
To analyse the data, the SPSS 22 (Statistical Package for Social Scien-
ces Inc, IL, USA) package program was used. Number, percentage, mean,
standard deviation, and minimum and maximum values were calcu-
lated in descriptive statistics for categorical and continuous variables.
Shapiro Wilks, skewness and kurtosis values were used to determine
the conformity of the data to the normal distribution, and Pearson cor-
relation coefﬁcient was used to examine the relationship between two
normally distributed quantitative variables. Multiple linear regression
analysis was performed to determine the factors associated with the
physical, psychological, social, and environmental dimensions of the
QOL. The level of signiﬁcance was considered as p<0.05.
the mean age being 73.33§6.66 years, and the MMSE scores were
between 24 and 30, with a mean score of 27.40§1.90. Further-
39.8% were primary school graduates, and 86.4% had a moderate
economic status. The duration of stay in the institution for 54.4%
of the participants was 1-5 years, only 17.5% of the participants
had children, and 90.3% of them stayed in a room with four or
more people. Of the almost half (45.6%) the participants who had
COVID-19, 79.6% had a history of chronic disease, and 81.6% of
the participants had no change in sleep patterns during the pan-
demic (Table 1).
Distribution of the mean FCV-19S, LSE, BRS, and WHOQOL-BREF-TR scores
The mean FCV-19S score of the participants was 19.13§4.28 (11-29),
the mean LSE score was 8.92§4.56 (0-20), and the mean BRS score was
18.25§1.73 (15-22). The mean scores on the physical dimension, mental
dimension, social relations dimension, and environmental dimension of
the Short Form WHOQOL-BREF-TR were 60.47§13.06 (17.86-82.14),
67.19§13.52 (33.33-100), 56.71§16.75 (8.33-100), and 66.74§11.10
(37.50-96.88), respectively (Table 2).
Characteristics of the participants (N=103).
Characteristics Mean§SD Min-Max
Age (year) 73.33§6.66 (65-94)
MMSE score 27.40§1.90 (24-30)
Characteristics n %
Male 82 79.6
Female 21 20.4
Married 5 4.9
Single (never married,
Literate 8 7.8
Primary school 41 39.8
Secondary school 23 22.3
High school 24 23.3
Undergraduate 7 6.8
Good 11 10.7
Moderate 89 86.4
Poor 3 2.9
Presence of children
Yes 18 17.5
No 85 82.5
Duration of stay in the institution
1-5 years 56 54.4
6-10 years 24 23.3
More than 11 years 23 22.3
Number of people in the shared room
Three 10 9.7
Four or more 93 90.3
History of chronic disease
Yes 82 79.6
No 21 20.4
History of COVID-19
Yes 47 45.6
No 56 54.4
Sleep patterns during the COVID-19 pandemic
No change. 84 81.6
I sleep less. 11 10.7
I sleep more. 2 1.9
I wake up frequently at night. 2 1.9
I have difﬁculty falling asleep. 4 3.9
Total 103 100
Distribution of the mean FCV-19S, LSE, BRS, and WHOQOL-BREF-TR scores.
Scales Min Max Mean§SD
Fear of COVID-19 Scale 11.00 29.00 19.13§4.28
Loneliness Scale for Elderly 0.00 20.00 8.92§4.56
The Brief Resilience Scale 15.00 22.00 18.25§1.73
Physical dimension 17.86 82.14 60.47§13.06
Mental dimension 33.33 100.00 67.19§13.52
Social relations dimension 8.33 100.00 56.71§16.75
Environmental dimension 37.50 96.88 66.74§11.10
FCV-19S: Fear of COVID-19 Scale; LSE: Loneliness Scale for Elderly; BRS: The Brief
Resilience Scale; WHOQOL-BREF (TR): World Health Organization Quality of Life BREF
Turkish Version (TR).
1424 C. Savci et al. / Geriatric Nursing 42 (2021) 14221428
Correlation between Age, MMSE, FCV-19S, LSE, BRS, and short form
There was a weak, negative correlation between age and the
mean scores on the mental dimension and environmental dimension
of the Short Form WHOQOL-BREF-TR (p<0.05) and a positive correla-
tion between the MMSE and the mean scores on all dimensions of
the Short Form WHOQOL-BREF-TR (p<0.01). A positive, weak corre-
lation was found between FCV-19S and the mean scores on the envi-
ronmental dimension of the Short Form WHOQOL-BREF-TR (p<0.05)
and a weak, negative correlation between the mean total score of the
LSE and the mean scores on all dimensions of the Short Form WHO-
QOL-BREF-TR (p<0.05). There was no statistically signiﬁcant correla-
tion between the BRS and Short Form WHOQOL-BREF-TR dimensions
The factors affecting quality of life
Being male (b: -.045), history of chronic disease (b: -.236), MMSE
score (b: .387), and changes in sleep pattern (b: -.198) signiﬁcantly
affected scores on the physical dimension of the QOL scale (R
p<0.01). Age (b: -.215), MMSE score (b: .354) and LSE score (b: -.234)
signiﬁcantly affected scores on the mental dimension (R
p<0.01). MMSE score (b: .277), FCV-19S score (b: .231), and LSE score
(b: -.264) signiﬁcantly affected scores on the social relations dimen-
sion. Finally, MMSE score (b: .296), FCV-19S score (b: .319) and LSE
score (b: -.336) signiﬁcantly affected scores on the environmental
=0.351, p <0.01) (Table 4).
The mean FCV-19S score of the older adults residing in a nursing
home in Turkey during the COVID-19 pandemic was 19.13§4.28,
which means that their fear was moderate considering the minimum
and maximum values that the scale can take. In a study conducted in
Greece at the beginning of the COVID-19 pandemic, the FCV-19S
score of older adults was reported to be 18.48§5.32.
study conducted in Turkey in June 2020, it was reported that individ-
uals over the age of 65 had a moderate level of fear of COVID-19.
The results of both studies are similar to the results of the present
study. The moderate level of fear experienced by the older adults in
the present study could be attributed to the facts that the data for
this study were collected in the latter stages of the pandemic, that
the older adults in the nursing home had information about COVID-
19, that vaccination studies had started, and that approximately half
of them had had COVID-19.
In this study, the older adults had a mean LSE score of 8.92§4.56,
indicating, based on the minimum and maximum values that the
scale can take, that the older adults’level of loneliness was low. Pre-
vious studies conducted in Turkey before the onset of COVID-19
reported that the level of loneliness of older adults in nursing homes
while studies on this subject conducted during the pan-
demic reported that the loneliness levels of older adults was moder-
ate in Turkey,
low in Greece,
and moderate in Australia.
conducted in the USA reported that 26% of individuals aged 60 and
over experienced loneliness.
Although all these results support to
some degree the results obtained from the present study, contrary to
Correlation between Age and the mean MMSE, FCV-19S, LSE, BRS, and Short Form WHOQOL-BREF-TR scores.
Physical dimension Mental dimension Social relations dimension Environmental dimension
Age r -.095 -.354** -.150 -.234*
p .339 .000 .130 .017
MMSE r .469*** .432*** .328** .365***
p<.001 <.001 .001 <0.001
FCV-19S r -.109 .118 .173 .221*
p .274 .236 .081 .025
LSE r -.233*-.312** -.223*-.354***
p .018 .001 .024 <0.001
BRS r .117 .133 -.067 .103
p .239 .179 .499 .302
** ***p<0.001, **p<0.01
*p<0.05, MMSE: The Mini Mental State Exam; FCV-19S: Fear of COVID-19 Scale; LSE: Loneliness Scale for Elderly; BRS: The Brief Resilience Scale; WHOQOL-BREF-TR: World
Health Organization Quality of Life BREF - TR.
Multiple linear regression analysis of the factors that affect quality of life.
Physical dimension bMental dimension bSocial relations dimension bEnvironmental dimension b
Age -.055**** -.215*** -.006**** -.076****
Gender -.045*** .030**** .026**** -.027****
History of chronic disease -.236** -.149**** -.134**** -.126****
MMSE .387*.354*.277** .296**
FCV-19S -.013**** .140**** .231*** .319**
Change in sleep pattern -.198*** .041**** -.103**** -.112****
LSE -.155**** -.234*** -.264*** -.336**
BRS -.015**** .090**** -.145**** .031****
R .594 .603 .484 .593
.353 .364 .234 .351
.298 .310 .169 .296
F 6.407* 6.727* 3.599** 6.358*
p<.001 <.001 .001 <.001
**** p>0.05, Codes are as follows: 0=Female, 1=Male for sex; 0= no change, 1= there is a change for sleep pattern, 0=no, 1=yes for chronic disease.
C. Savci et al. / Geriatric Nursing 42 (2021) 14221428 1425
the present study’s results, one study reported that 57% of people
over 70 years of age who were hospitalized during the COVID-19
pandemic experienced loneliness.
On the dates during which the
study was conducted, the institution was completely closed to visi-
tors within the scope of the restrictive measures applied to nursing
homes. Moreover, the psychologist had recently left the institution,
and the rehabilitation centre, which plays a key role in the ability of
the older adults living in the nursing home to socialize, was closed.
Such factors could have negatively impacted the QOL of the older
adults in the nursing home. According to a study, in nursing homes,
sharing a room with three to ﬁve friends and having the opportunity
to engage in daily conversations with roommates support social
Phone calls and video calls involving discussion of posi-
tive topics to make up for the absence of physical visits for older
adults in nursing homes has been reported to be a good form of social
support to eliminate the feeling of loneliness.
The fact that the older
adults included in this study stayed in the same room with at least
three people, had social interaction with the personnel who provide
health care, food, and cleaning services in the nursing home, and had
opportunities to communicate with their families and loved ones
with the help of technological tools may have contributed to their
low levels of loneliness.
In this study, the mean BRS score was 18.25§1.73, indicating,
based on the minimum and maximum values that the scale can take,
that the resilience of the older adults was moderate. Similar to the
results obtained from the present study, one study reported that the
mean BRS score was 19.41§2.67 in individuals over the age of 65 dur-
ing the COVID-19 process.
Psychological resilience refers to an indi-
vidual's ability to successfully overcome adverse conditions and
adapt to a new situation.
While loneliness, negative feelings, and
mental illness negatively affect resilience,
networking, and positive feelings positively affect resilience.
moderate level of psychological resilience seen in this study corre-
sponded with the older adults’mean MMSE scores of 24 and above,
their moderate fear of COVID-19 and low levels of loneliness, and the
negative circumstances they faced during the pandemic, such as sep-
aration from loved ones.
In this study, the QOL of the older adults in the nursing home was
slightly above average according to their scores on the physical
dimension, mental dimension, social relations dimension, and envi-
ronmental dimension of the Short Form WHOQOL-BREF-TR. While
the dimensions of the QOL most affected by the pandemic were the
social relations and physical dimensions, the least affected were the
mental dimension and the environmental dimension. In three studies
conducted with older adults living in nursing homes before the pan-
demic in Turkey
and in a study conducted with older adults dur-
ing the pandemic in Australia, it was reported that the older adults
had an above average score on the QOL scale, with the highest scores
being in the environmental and physical dimensions and the lowest
score being in the social relations dimension.
According to the
results of the present study, the older adults’social QOL was least
affected by the pandemic, while their mental and environmental QOL
were most affected. The social relations dimension of the scale, which
was a factor used to evaluate the QOL in this study, addresses rela-
tions with other people, sexual life, and satisfaction with the support
of friends. In evaluating the frequency of the responses to these spe-
ciﬁc areas, it was determined that the relations with other people
and the level of satisfaction with the support of friends were high,
whereas satisfaction with sexual life was low. These results were
attributed to the fact that 95.1% of the older adults living in the nurs-
ing home were single. In this study, the physical dimension was the
second most affected area of QOL during the COVID-19 pandemic.
The physical dimension of the scale addresses the ability to maintain
daily life and the level of satisfaction with this ability. The curfews
and prolonged lockdowns applied to older adults during the
pandemic likely affected their daily life and contributed to their
decrease in the quality of physical life. According to the results of the
study, the older adults’mental and environmental QOL scores after
COVID-19 were at the highest level. The mental dimension of the
scale addresses physical and mental satisfaction with life and self-sat-
isfaction in general. Under the environmental dimension of the scale,
satisfaction with the opportunities offered in the living environment,
the feeling of safety in this environment, and the opportunities to
meet physical, intellectual, and mental needs are addressed in gen-
eral. The activities and care services provided in the nursing home
where the study was conducted and the sharing of a room with at
least three people or living with peers likely contributed to meeting
the physical, intellectual, and mental needs of the older adults in the
study, and therefore, their mental and environmental dimension
scores were high.
In the study, while being male, having a history of chronic disease,
and experiencing a change in sleep patterns negatively affected the
physical dimension of the QOL, high MMSE score had a positive effect
on this dimension. Contrary to the present study’s results, other stud-
ies have reported no indication of there being a relationship between
gender and physical health in older adults during the pandemic
of men having better physical health than that of women.
results from the present study could be attributed to the fact that the
majority of the participating older adults were male. In a study con-
ducted in a nursing home before the pandemic, it was reported that
the physical QOL of those without chronic diseases was higher, which
supports the present study’s results.
The mean MMSE score of
above 24 obtained by the older adults in the present study indicates
that they easily understood and complied with the information and
measures related to COVID-19, which positively affected their physi-
cal QOL. Older people need fewer hours of sleep. However, they do
need sufﬁcient sleep for physiological and psychological functions
and to keep their quality of life at optimum levels.
In a study con-
ducted at an adult day care centre before the pandemic, it was found
that the older adults with sleep disorders were inadequately able to
maintain their physical functions and had physical and emotional
Based on this, it could be argued that the lack of
change in sleep patterns of the older adults in this study during the
pandemic helped to sustain their physical ability and satisfaction
with their daily lives in the nursing home.
In the study, age and LSE score negatively affected the mental
dimension of the QOL, while MMSE score positively affected it. The
low mental QOL was believed to be due to the difﬁculties that the
decrease in physical and mental functions attending old age create in
adapting to an adverse situation like the pandemic. In one study, it
was reported that loneliness negatively affected mental health,
another study, it was reported that loneliness predicted the mental
health dimension of QOL.
Accordingly, practices aimed at reducing
loneliness and protecting and improving mental functions of older
adults in nursing homes would be useful for keeping their mental
health at a high level.
In this study, the MMSE score and FCV-19S score positively
affected the scores on the social relations dimension of the QOL,
while the LSE score had a negative effect. The participating older
adults’MMSE scores of 24 and above suggest that they had positive
relations with others. In one of the more surprising results, the older
adults with a high fear of COVID-19 had high scores in the social rela-
tions dimension, which could be attributed to the sense of safety that
these older adults felt as a result of the measures taken in the nursing
home and to their physical, social, intellectual and mental needs
being met in the nursing home. It was reported in one study that
loneliness negatively affected the social health of older adults during
the pandemic, which supports the results of the present study.
study conducted in a nursing home before the pandemic in Turkey,
the mean social relations dimension score obtained by older adults
1426 C. Savci et al. / Geriatric Nursing 42 (2021) 14221428
on the QOL was reported to be lower in those who were experiencing
These results point to the importance of evaluating indi-
viduals who have a high level of loneliness, as indicated by low social
QOL, and taking measures to reduce the level of loneliness in order to
increase social QOL.
In this study, the MMSE score and the FCV-19S score posi-
tively affected the environmental dimension of the QOL, whereas
MMSE score of 24 and above suggests that they were adept at
making lifestyle changes and adapting to the environment. The
older adults who had a high fear of COVID-19 also had a high
score in the environmental dimension, which was surprising. This
high environmental QOL of the older adults who had a fear of
COVID-19 could be attributed to the feeling of safety they had
due to the COVID-19-related restrictions and measures imple-
mented in the nursing home environment. Contrary to the pres-
ent study’s results, it was reported in one study that loneliness
was not associated with environmental health.
Limitations and strengths of the study
This study has a single-center design and is limited by its small
sample size. The participants includes older adults who are able to ﬁll
out the Google survey form link (sufﬁcient cognitive levels, speak
and understand Turkish) and, therefore, the results cannot be gener-
alized to the overall of older adults in a nursing home during the pan-
demic. However, this study is the ﬁrst to evaluate the fear of COVID-
19, loneliness, resilience, and QOL levels in older adults in a nursing
home during the pandemic, and the effects of these variables and
descriptive characteristics on their QOL. The results of the study,
therefore, will ﬁll the gap in the research on this topic.
In this study, COVID-19 fear levels were moderate, loneliness lev-
els were low, resilience levels were moderate, and all dimensions of
QOL in the older adults living in the nursing home during the pan-
demic were slightly above the moderate level. The social relations
and physical dimensions had the most impact on QOL, while the
mental and environmental dimensions had the least. Being male,
having a history of chronic disease, and experiencing a change in
sleep patterns negatively affected the physical dimension of the QOL,
while mental status had a positive effect on it. Age and loneliness
negatively affected the mental dimension of QOL, whereas mental
status had a positive effect, and lastly, mental status and fear of
COVID-19 had positive effects on the social relations and environ-
mental dimensions of QOL, while loneliness had a negative effect.
Based on these results, it is recommended that initiative be
applied to protect the mental status, provide regular sleep patterns,
and reduce loneliness levels in order to increase the QOL of older
adults in nursing homes during the pandemic. It is further recom-
mended that older adults living in nursing homes be provided with
various means of communication, like the telephone, e-mail, and
video chat and mobile applications, to prevent loneliness and
increase QOL. Lastly, due to the positive effect that a high level of fear
was shown to have on the social relations and environmental dimen-
sions of the QOL, it is recommended that fear should be considered as
a protective health factor as opposed to viewing it in the traditional
way as a factor that negatively affects health.
The authors declared that this study has received no ﬁnancial
Research has not been published in Turkey or abroad, in Turkish
or any other language, or has not been sent to a journal for publica-
tion. It has not been previously communicated at a congress.
This study was designed and conceptualized by CS, ACA, SYU, FK.
Analysis of research data was done by CS, ACA and CS, ACA, SYU, FK con-
tributed in data gathering and interpretation, agreeing on the design
and scrutinizing the technical content and write ups of the full manu-
script. CS, ACA, SYU, FK after ﬁnal review of the revised version of the
manuscript agreed and approved to be submitted for publication.
This study was conducted in accordance with the principles out-
lined in the Declaration of Helsinki. Ethics committee approval
(30.12.2020/47) and institutional permission (01.04.2021/730.10-
E.2127) were obtained for the implementation of the study.
Declaration of Competing Interest
The authors declare that there is no conﬂict of interest.
The authors would like to thank all participating in this study.
1. WHO. Novel Coronavirus (2019-nCoV) Situation Report 51. 2020. Geneva.
2. Altin Z. Covid-19 pandemisinde yaslilar (Elderly people in Covid-19 outbreak).
Tepecik Egit ve Arast Hast Dergisi. 2020;30(Ek sayı):49–57. https://doi.org/10.5222/
3. Wilson N, Kvalsvig A, Barnard LT, Baker MG. Case-fatality risk estimates for COVID-
19 calculated by using a lag time for fatality. Emerg Infect Dis. 2020;26(6):1339–
4. Morley JE, Vellas B. COVID-19 and older adults (Editorial). J Nutr Health Aging.
5. Girdhar R, Srivastava V, Sethi S. Managing mental health issues among elderly dur-
ing COVID-19 pandemic. J Geriatr Care Res. 2020;7(1):32–35.
6. Ministry of Health COVID-19 WeeklyStatus Report 12/10/2020 18/Oct/2020Turkey.
Access date, 01 July 2021, https://covid19.saglik.gov.tr/Eklenti/39168/0/ covid-19-haf-
7. Fallon A, Dukelow T, Kennelly SP, O’Neill D. COVID-19 in nursing homes. QJM.
8. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG, et al. Epide-
miology of Covid-19 in a long-term care facility in King County, Washington. N
Engl J Med. 2020;382(21):2005–2011. https://doi.org/10.1056/NEJMoa2005412.
9. Whitehead BR, Torossian E. Older adults’experience of the COVID-19 pandemic: a
mixed-methods analysis of stresses and joys. Gerontologist. 2021;61(1):36–47.
10. Birditt KS, Turkelson A, Fingerman KL, Polenick CA, Oya A. Age differences in stress,
life changes, and social ties during the COVID-19 pandemic: implications for psy-
chological well-being. Gerontologist. 2021;61(2):205–216. https://doi.org/
11. 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
[published online ahead of print, 2020 Aug 5]. J Gerontol B Psychol Sci Soc Sci. 2020.
12. Sarangi A, Nelson J. A descriptive study evaluating the impact of COVID-19 on
delivery of care and mental health of geriatric nursing home staff. Am J Geriatr Psy-
chiatry. 2021;29(4):121–122. https://doi.org/10.1016/j.jagp.2021.01.116.
13. Meng H, Xu Y, Dai J, Zhang Y, Liu B, Yang H. Analyze the psychological impact of
COVID-19 among the elderly population in China and make corresponding sugges-
tions. Psychiatry Res. 2020;289: 112983. https://doi.org/10.1016/j.
no M, Harris C, Drawve G, Fitzpatrick KM. Race and ethnicity, gender, and age on
perceived threats and fear of COVID-19: evidence from two national data sources.
SSM - Popul Health. 2021;13: 100717. https://doi.org/10.1016/j.
C. Savci et al. / Geriatric Nursing 42 (2021) 14221428 1427
15. Lo Coco G, Gentile A, Bosnar K, Milovanovi
c I, Bianco A, Drid P, Pi
sot S. A cross-
country examination on the fear of COVID-19 and the sense of loneliness during
the ﬁrst wave of COVID-19 outbreak. Int J Environ Res Public Health. 2021;18
16. Madden A, Leen B. Evidence summary: what is the impact of the coronavirus pan-
demic on the mental health of elderly nursing home residents? [v1. 0], 2020.
17. Macdonald B, H €
ur G. Well-being and loneliness in swiss older adults during the
COVID-19 pandemic: the role of social relationships. Gerontologist. 2021;61:240–
18. Jeste DV, Di Somma S, Lee EE, Nguyen TT, Scalcione M, Biaggi A, et al. Study of lone-
liness and wisdom in 482 middle-aged and oldest-old adults: a comparison
between people in Cilento, Italy and San Diego, USA. Aging Mental Health. 2020:1–
19. Kaelen S, van den Boogaard W, Pellecchia U, Spiers S, De Cramer C, Demaegd G,
et al. How to bring residents’psychosocial well-being to the heart of the ﬁght
against Covid-19 in Belgian nursing homes—a qualitative study. Plos One. 2021;16:
(3) e0249098. https://doi.org/10.1371/journal.pone.0249098.
20. Chakrawarty A, Ranjan P, Klanidhi KB, Kaur D, Sarkar S, Sahu A, et al. Psycho-social
and behavioral impact of COVID-19 on middle-aged and elderly individuals: a
qualitative study. J Educ Health Promot. 2021;10:269. https://doi.org/10.4103/jehp.
21. Manyena SB. The concept of resilience revisited. Disasters. 2006;30(4):434–450.
22. Set Z. Covid-19 surecinde 65 yas ve uzeri bireylerin psikolojik saglamlık duzeyleri:
cesitli degiskenler acisindan bir degerlendirme (Psychological resilience levels of
individuals aged 65 and over in the Covid-19 process: An evaluation in terms of
various variables). Electron Turk Stud. 2020;15(6):1051–1063.
23. Plagg B, Engl A, Piccoliori G, Eisendle K. Prolonged social isolation of the elderly
during COVID-19: between beneﬁt and damage. Arch Gerontol Geriatr. 2020;89:
24. WHO, 2015. World Health Organization, World Report on Ageing and Health.
Access date, 01 July 2021, http://apps.who.int/iris/bitstream/10665/186463/
25. Efklides A, Kalaitzidou M, Chankin G. Subjective quality of life in old age in Greece:
the effect of demographic factors, emotional state and adaptation to aging. Eur
Psychol. 2003;8(3):178–191. https://doi.org/10.1027/1016-9040.8.3.178.
26. Nguyen HC, Nguyen MH, Do BN, Tran CQ, Nguyen TT, Pham KM, et al. People with
suspected COVID-19 symptoms were more likely depressed and had lower health-
related quality of life: the potential beneﬁt of health literacy. J Clin Med. 2020;9
27. Tel H. Sleep quality and quality of life among the elderly people. Neurol Psychiatry
Brain Res. 2013;19(1):48–52. https://doi.org/10.1016/j.npbr.2012.10.002.
28. Folstein MF, Folstein SE, McHugh PR. Mini-mental state”: a practical method for
grading the cognitive state of patients for the clinician. J Psych Res. 1975;12
29. Gungen CD, Ertan T, Eker E, Yasar R, Engin F. Reliability and validity of The Stan-
dardized Mini Mental State Examination in the diagnosis of mild dementia in Turk-
ish population. Turkish Journal of Psychiatry. 2002;13(4):273–281. PMID:
30. Ertan T, Eker E, Gungen C. The Standardised Mini Mental State Examination for
illiterate Turkish elderly poupulation: SMMSE-E. 2nd International Symposium on
Neurophysiological and Neuropsychological Assessment of Mental and Behavioral Dis-
orders. Bursa, Turkey: 1999.
31. Ahorsu DK, Lin C-Y, Imani V, Saffari M, Grifﬁths MD, Pakpour AH. The Fear of
COVID-19 Scale: development and initial validation. Int J Mental Health Addict.
2020:1–9. [Internet]Available from; https://pubmed.ncbi.nlm.nih.gov/32226353.
32. Ladikli N, Bahadir E, Yumusak FN, Akkuzu H, Karaman G, Turkkan Z. Turkish reli-
ability and validity study of the Kovid-19 Fear Scale. International Journal of Social
33. De Jong-Gierveld J, Kamphuls F. The development of a Rasch-type loneliness scale. Appl
Psychol Measure. 1985;9(3):289–299. https://doi.org/10.1177/014662168500900307.
34. De Jong Gierveld J, Van Tilburg T. Manual of the Loneliness Scale 1999. Amsterdam:
Department of Social Research Methodology, Vrije Universiteit Amsterdam; 1999.
(Updated from the printed version 1801 02: 7-5-2021).
35. Akgul H, Yesilyaprak B. Adaptation of the “Loneliness Scale for the Elderly”to Turkish
culture: Validi ty and relia bility study. YaslıSorunlari ArastirmaDergisi. 2015;8(1).
36. Smith BW, Dalen J, Wiggins K, Tooley E, Christopher P, Jennifer Bernard J. The brief resil-
ience scale: Assessing the ability to bounce back. Int J Behav Med. 2008;15:194–200.
37. Dogan T. Kisa Psikolojik Saglamlik Olceginin Turkce uyarlaması: Gecerlik ve guve-
nirlik calısmasi (Adaptation of the Brief Resilience Scale into Turkish: a validity
and reliability study). J Happiness Well-Being. 2015;3(1):93–102.
38. Group The WHOQOL. Development of the World Health Organization WHOQOL-
BREF quality of life assessment. Psychol. Med. 1998;28(3):551–558.
39. Eser E, Fidaner H, Fidaner C, Eser SY, Elbi H, Goker E. WHOQOL-100 ve WHOQOL-
BREF’in psikometrik €
ozellikleri (Psychometric properties of tlte WHOQOL-100 and
WHOQOLBREF). Psikiyatri Psikoloji Psikofarmakoloji (3P) Dergisi. 1999;7(Suppl
40. Parlapani E, Holeva V, Nikopoulou VA, Sereslis K, Athanasiadou M, Godosidis
A, et al. Intolerance of uncertainty and loneliness in older adults during the
COVID-19 pandemic. Front Psychiatry. 2020;11:842. https://doi.org/10.3389/
41. Durmus M, Durar E. The relationship between spiritual well-being and fear of
COVID-19 among Turkish elders. J Relig Spiritual Aging. 2021:1–14. https://doi.org/
42. Eskimez Z, Demirci PY, Tosun Oz IK, Oztunc G, Kumas G. Loneliness and social sup-
port level of elderly people living in nursing homes. Int J Caring Sci. 2019;12
43. Aung K, Nurumal MS, Bukhari WNSW. Loneliness among elderly in nursing homes.
Int J Stud Child Women Elder Disabl. 2017;2:72–78.
44. Strutt PA, Johnco CJ, Chen J, Muir C, Maurice O, Dawes P, et al. Stress and coping in
older Australians during COVID-19: health, service utilization, grandparenting,
and technology use. Clin Gerontol. 2021:1–13. https://doi.org/10.1080/
45. Sams N, Fisher DM, Mata-Greve F, Johnson M, Pullmann MD, Raue PJ, et al. Under-
standing psychological distress and protective factors amongst older adults during
the COVID-19 pandemic. Am J Geriatr Psychiatry. 2021;29(9):881–894. https://doi.
46. Bailey L, Ward M, DiCosimo A, Baunta S, Cunningham C, Romero-Ortuno R, et al.
Physical and mental health of older people while cocooning during the COVID-19
pandemic. QJM. 2021:1–6. https://doi.org/10.1093/qjmed/hcab015.
47. Chow L. Care homes and COVID-19 in Hong Kong: how the lessons from SARS were
used to good effect. Age Ageing. 2021;50(1):21–24. https://doi.org/10.1093/age-
48. Turk A. COVID-19 pandemisi s€
urecinde yaslılara yonelik uygulamalar ve yaslilarin
psiko-sosyal durumu uzerine bir degerlendirme. Sosyal Hizmet. 2020:35–46.
49. Kaye-Kauderer H, Feingold JH, Feder A, Southwick S, Charney D. Resilience in the
age of COVID-19. BJPsych Adv. 2021;27(3):166–178. https://doi.org/10.1192/
alez R, Facal D, Martínez-Santos AE, Gandoy-Crego M. Psychologi-
cal, social and health-related challenges in Spanish older adults during the lock-
down of the COVID-19 ﬁrst wave. Front Psychiatry. 2020;11:1393. https://doi.org/
51. Baglama SS, Bakir E, Koleoglu S, Disli E, Cirak K. Huzurevinde kalan ya¸slıların
sam kalitesi: €
uk ve ila¸c kullanımının etkisi? (The life quality of elderly
nursing home residents: disability and the effect of drug use?). ACU Sa
glık Bil Derg.
52. Ilhan N, Arpaci S, Havaoglu D, Kalyoncuoglu H, Sari P. Quality of life and factors
affecting the quality of life of elderly nursing home residents. Clin Exp Health Sci.
53. Reid KJ, Martinovich Z, Finkel S, Statsinger J, Golden R, Harter K, Zee PC. Sleep: a
marker of physical and mental health in the elderly. Am J Geriatr Psychiatry.
54. Ozvurmaz S, Asgarpour H, Gunes Z. Yaslilarda uyku kalitesi ve yasam kalitesi ara-
sindaki iliski: kesitsel bir calisma (Relationship of quality of sleep and quality of
life in elderly: crosssectional study). Med Sci. 2018;13(3):72–79. https://doi.org/
1428 C. Savci et al. / Geriatric Nursing 42 (2021) 14221428