Fear of COVID-19 Among Elderly Patients with a Chronic Physical or Mental Disease

Older age renders individuals vulnerable during public emergency crises. Considering that older adults are a highly heterogeneous and continuously growing demographic subgroup, this study aimed to assess the mental health impact of COVID-19 on two groups of older patients: a group of chronic physical disease and a group of chronic mental disease. A total of 102 patients completed the Fear of COVID-19 Scale, the Generalized Anxiety Disorder scale, the Brief Patient Health Questionnaire (PHQ-9) and several questions regarding demographic characteristics. Suicidality was assessed by the 9 th item of the PHQ-9. According to the results, older chronic disease patients showed higher levels of fear, whereas anxiety and depressive symptoms were present mainly in the group of older psychiatric patients. Suicidality was reported from a subtotal of 25.4% that was composed of 7.8% chronic disease patients and 17.6% psychiatric patients. Chronic physical disease and higher anxiety predicted more severe COVID-19-related fear. acceptance to participate. Exclusion criteria conrmed SARS-CoV-2 infection and current diagnosis of any neurocognitive disorder. Clinical interviews were held by a trained psychiatrist who acquainted patients with the study goals, the voluntary nature of participation, the right to withdraw at any moment, and the assurance that data would be kept anonymous, once submitted. Written consent was obtained from each participant before data collection. Ethical approval was obtained from (removed for blind review).


Introduction
Older adults received particular attention during the coronavirus disease 2019  pandemic. Intrinsic factors, such as the higher prevalence of chronic diseases as well as the age-related immunosenescence and frailty, rendered them more vulnerable to severe COVID-19 illness. In addition, extrinsic factors, such as limited access to healthcare facilities for COVID-19-unrelated conditions, the strict quarantine measures, as well as the possible limited acquaintance with communication technology, heightened the risk for physical and mental health deterioration (United Nations, 2020). Older age accounts for increased vulnerability to the stress imposed during public emergency crises (Hutton, 2008) as it is related to both immunosenescence and increased prevalence of chronic conditions (Clark et al., 2020), factors raising the risk for severe COVID-19 and increasing mortality. In addition, older people may be in need of more care due to other disabilities or unpropitious psychosocial conditions (Kar, 2016).
Older individuals with underlying health conditions comprise the most vulnerable age group for life-threatening complications and death from COVID-19. In particular, oncology patients being immunocompromised are exposed to greater danger of suffering from Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection, due to both the underlying malignancy and anticancer treatments (Tsamakis et al., 2020). Oncology patients are also particularly vulnerable to increased stress, due to fear of being contaminated by the virus, the agony of cancer's progression and the health insecurities resulting from the gaps related to clinical care services (Bandinelli et al., 2021).
Likewise, although cardiovascular comorbidity in COVID-19 patients increases mortality, similar fears kept heart disease patients away from seeking urgent health care, despite having symptoms . In fact, the number of patients with heart attack who were admitted for urgent care has dropped by more than 50% during the COVID-19 outbreak, according to an extensive worldwide survey by the European Society of Cardiology (Pessoa-Amorim et al., 2020). Similarly, recent research has highlighted the consequences that chronic kidney disease patients are facing from skipping hemodialysis sessions due to fear of coronavirus infection and/or di culties in transportation (Lee et al., 2020). Limited access to both primary and emergency health care for non-COVID-19-related conditions probably affected older patients to a greater extent (United Nations, 2020). On top of the alarming implications on physical health, there is also concern about the pandemic's impact on mental health. In a recent metaanalysis, chronic disease patients had a higher risk of depression and anxiety than other populations (Wu et al., 2020).
Aging is also associated with a high prevalence of cognitive and mood disorders, which have a negative impact on physical health and wellbeing (American Psychological Association, 2015). Older individuals with a mental disorder prior to the beginning of the pandemic crisis are more susceptible to stress and more vulnerable to relapse (Yao et al., 2020). The pandemic's social consequences added to the frustration in older people with mental disorders as social distancing measures and isolation may exacerbate existing mental health conditions (Grolli et al., 2021). On top of that, according to a recent survey, the COVID-19 pandemic disrupted mental health services in 130 countries while the demand for mental health care services was on the rise due to uncertainty and fear (World Health Organization, 2020).
Over 70% of the mental health services' representatives reported disruptions in mental health care for older adults with a psychiatric condition. Furthermore, psychiatric patients constitute a major challenge to the system, as they are potentially super-spreaders, struggling to properly appreciate the risks of the disease or stick to the necessary medical precautions . According to a recent study of older bipolar patients, increased depressive and anxiety symptoms were signi cantly associated with fear for the virus and loneliness (Orhan et al., 2020).
The many faces of fear during the current pandemic, e.g fear of becoming severely ill or dying, fear of transmitting the virus, fear of health deterioration due to the signi cant changes in health care delivery, fear of disconnecting with the close ones, add an additional burden to older adults . Both positive and negative behavioural consequences arise from fear such as greater adherence to protective measures and control strategies or avoiding health care settings (Harper et al., 2021) and being hesitant to return to old habits (Holeva et al., 2021a).
Considering that older adults are a continuously growing demographic subgroup of particular research interest (United Nations, 2019), and taking into account that the impact of COVID-19 on older adults may be uneven depending on sociocultural and other individual factors , this study aimed to assess fear of COVID-19 in two subgroups of older adults, i.e. a group of older patients with chronic physical disease and a group of older patients with chronic mental disease.

Material And Methods
Participants and survey procedure The study included 102 older adults who were divided into two groups: the rst group (Chronic Disease Patients, CDP) included 50 participants undergoing treatment for a chronic physical condition (16 patients with cardiovascular disease, 21 patients with different types of cancer, and 13 patients undergoing hemodialysis due to chronic kidney disease) and the second group (Psychiatric Patients, PP) included 52 patients with a chronic psychiatric condition (18 patients with psychotic disorder and 34 with affective disorder), all recruited from the hospital's outpatient clinics.
Inclusion criteria were age over 60 years, receiving treatment for a chronic physical or mental disease, and acceptance to participate. Exclusion criteria were con rmed SARS-CoV-2 infection and current diagnosis of any neurocognitive disorder. Clinical interviews were held by a trained psychiatrist who acquainted patients with the study goals, the voluntary nature of participation, the right to withdraw at any moment, and the assurance that data would be kept anonymous, once submitted. Written consent was obtained from each participant before data collection. Ethical approval was obtained from (removed for blind review).

Measures
Sociodemographic information was obtained from medical records and a sociodemographic form. In addition, patients completed the Greek versions of the following psychometric scales: 1. The Fear of COVID-19 scale (FCV-19S, Ahorsu et al., 2020;Tsipropoulou et al., 2020) contains 7 items (e.g., item 1, "I am most afraid of coronavirus-19") assessing fear of COVID-19 on a 5-item Likert-type response scale from 1 (strongly disagree) to 5 (strongly agree). The total score ranges from a minimum of 7 to a maximum of 35 and it is obtained by summing all items. The scale is widely used and validated in many languages and different age groups (Muller et al., 2021;Voitsidis et al., 2021a). A cut-off point score of 16.5 or higher was proposed to discriminate high levels of fear from normal fear reactions . The Cronbach's alpha internal consistency coe cient of the scale in the current study was .86.
2. The Generalized Anxiety Disorder (GAD-7, Spitzer et al., 2006;Skapinakis et al., 2007) contains 7 items (e.g., item 1, "Feeling nervous, anxious or on edge") assessing anxiety symptoms on a 4-point Likert-type scale from 0 (not at all) to 3 (nearly every day). The total score ranges from a minimum of 0 to a maximum of 21 and it is obtained by summing all items. A cut-off point score of 10 or higher indicates clinically signi cant anxiety (Spitzer et al., 2006). The Cronbach's alpha internal consistency coe cient of the scale in the current study was .87.
3. The Brief Patient Health Questionnaire (PHQ-9) Depression scale (Kroenke et al., 2001;Hyphantis et al., 2011) contains 9 items (e.g., item 1, "Little interest or pleasure in doing things") assessing depressive symptoms on a 4point Likert type scale from 0 (not at all) to 3 (nearly every day). The total score ranges from a minimum of 0 to a maximum of 27, and it is obtained by summing all items. A cut-off point score of 10 or higher indicates clinically signi cant depressive symptomatology. The Cronbach's alpha internal consistency coe cient of the scale in the current study was .83.
4. The last item of PHQ-9 was used to explore suicidal thoughts (i.e. "Over the last two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?"). Previous studies have assessed the validity of item 9 by comparisons with clinical interviewing results (Razykov et al., 2013;Walker et al., 2010). The item was proved to be a strong predictor of suicidality in different age groups (Rossom et al., 2017) and it was used in the current study to explore suicidal ideation.

Data analysis
All statistical analyses were performed using SPSS 26.0 (IBM Corp), with p < .05 as the level of statistical signi cance. Data were presented as mean values (M), standard deviations (SD), numbers and percentages. One-way analysis of variance was used to ascertain the presence of FCV-19S differences among type of disease. To analyze the differences in levels of fear, anxiety, depression and suicidality, independent sample t-tests were used to compare the mean scores between the two groups. Effect sizes are reported as Cohen's d. Finally, to identify signi cant predictors of fear, a three stage hierarchical regression was conducted with FCV-19S as the dependent variable.

Sociodemographic data
A total of 102 patients [47 females (46.07%) and 55 males (53.93%)] met the study inclusion criteria and were included in the study. Most of the participants completed 12 years of education or less, were married and retired. A signi cant percentage, mostly derived from the mental disease group, lived on a disability pension (Table 1).   The participants with Cancer disease had the highest FCV-19S score and the 34 participants with Affective Disorder the lowest. The effect of type of disease was signi cant [F(4,97) = 3.13, p = .018]. Patients with Cardiovascular disease, Kidney disease and Psychotic disorder have also exceeded the cut-off score of 16.5, showing high levels of Fear of COVID-19 (Table 4). Note. FCV-19S, Fear of COVID-19 Scale; GAD-7, Generalized Anxiety Disorder 7-item scale; PHQ-9, Brief Patient Health Questionnaire Depression scale

Discussion
This study explored fear of COVID-19, anxiety, depressive symptoms and suicidality in two speci c older subpopulations, that is, in older adults with chronic physical or mental disease, both conditions that may contribute to additional risk for mental health deterioration during the pandemic.
Both groups presented elevated fear of COVID-19 according to the proposed cut-off score . High fear of COVID-19 among older adults is reported by several studies using the same measurement scale Yadav et al., 2021;Parlapani et al., 2020). In a different study among 315 older adults in Turkey the mean FCV-19S score was somewhat below indicating mild fear reactions (Gokseven et al., 2021). Using the COVID-19 Fear Inventory, Han and his colleagues found highest fear levels among the oldest-old probably due to the higher health risks posed to this age group (Han et al., 2021). Increased fear of COVID-19 has been linked with higher anxiety and depression (Voitsidis et al., 2021b).

Patients with chronic physical diseases
Patients with chronic diseases reported signi cantly higher levels of fear than those with mental diseases. This result is in line with recent research (Al-Rahimi et al., 2021;Kohler et al., 2021) among immunocompromised patients during the COVID-19 outbreak reporting that they were more likely to experience high levels of fear of COVID-19. In the current study cancer patients presented more fearful than other patients probably due to their state of immunosuppression or disruptions in treatment (Guven et al., 2020). In a study of cancer patients, two months after the beginning of the pandemic lockdown in Poland, FCV-19S mean was 18.50 (SD = 7.44), also indicating high levels of fear (Sigorski et al., 2021). Contrary to this result, in a different study, although reporting high mean scores in FCV-19S cancer patients did not differ from healthy controls who also reported elevated fear of COVID-19 (Musche et al., 2020).
Participants with chronic physical disease reported mild anxiety and depressive symptoms. Only a 10% of the participants in this group reported anxiety symptoms and another 11% reported depressive symptomatology. This result is in line with a recent study among participants with chronic conditions (i.e. cancer, diabetes, obesity, and heart conditions), with a percentage of 14% presenting high levels of anxiety and 19% reporting depressive symptomatology (Budu et al. 2021). In a comprehensive literature search of research articles assessing the mental health impact of COVID-19 on older adults it was shown that older adults were less distressed than younger ones, but they are exhibiting more severe anxiety and depressive symptoms during the pandemic than before .

Patients with chronic mental health diseases
In the current study patients with a pre-existing mental health condition showed elevated levels of fear of COVID-19 and high anxiety and depressive symptoms. Some reports have highlighted the psychological consequences of COVID-19 on patients with a mental health disorder, reporting relapses, fear of transmitting the virus, or symptoms centered around the pandemic (Grover et al., 2021). At the beginning of the pandemic's lockdown, individuals with pre-existing mental health conditions reported increased levels of anxiety and depressive symptomatology (Fancourt et al., 2021). A longitudinal study that assessed symptoms of patients with mental health conditions, both before and during the COVID-19 pandemic, reported that for those with severe or chronic mental health disorders, the COVID-19 pandemic did not exacerbate their pre-existing symptoms, but individuals with less severe mental health conditions experienced increased levels of worry, anxiety and depressive symptomatology (Pan et al., 2021). In a multisite comparative effectiveness study of 73 older adults (age > 60) with pre-existing diagnosis of depression, no changes were found in regard to symptoms of clinical depression, anxiety, or suicidal thoughts compared to symptoms assessed before the pandemic (Hamm et al., 2020). Finally, compared to those with no mental disorder, respondents with a mood disorder were more likely to express concern for access to appropriate medical care, and were less likely to be concerned about dying of COVID-19 themselves (Van Rheenen et al., 2020).
Concerning suicidal ideation, only a small percentage of respondents reported suicidal thoughts mainly from the mental disease group. This result is in line with a web study that investigated the prevalence of suicidal ideation in the community during restriction measures in Greece. According the results, out of 5,116 adults a subtotal of 5.20% reported suicidal thoughts (Papadopoulou et al., 2021).

Gender
No differences were found between males and females regarding FCV-19S. Several studies measuring fear of COVID-19 in older adults reported signi cantly higher scores in females (Caycho-Rodríguez et al., 2021;Lin et al., 2021;Pierce et al., 2021), but this result may re ect the over-representation of females in their samples or the wide age range explored.
Taken together, the pandemic probably disproportionately affected older adults across different countries depending on case fatality rates, availability of healthcare resources, and sociocultural factors. Although there was evidence that the prevalence of mental health symptoms may have increased in older adults , several studies indicated that older adults were able to tolerate the stress imposed by the pandemic, possibly due to previous experiences with traumatic events. As such, they proved to be adaptable to the new circumstances and resilient against psychological distress (Fuller & Huseth-Zosel, 2020;Röhr et al., 2020).
Older adults are considered to be a vulnerable population during public health crises, but the 21st century is a century related with progress in healthcare provision, medical and communication technology. The COVID-19 vaccine was timely developed and, in several countries, including Greece, older adults were the rst to receive it showing high levels of vaccine acceptance (Holeva et al., 2021b). In addition, although there was evidence that older adults among the general population may express higher levels of COVID-19-related fear and worry (Max eld & Pituch, 2020), they may be resilient against the psychological strain imposed by the pandemic (Bruine de Bruin, 2021;López et al., 2020).

Limitations
Although most research on the impact of the COVID-19 pandemic on mental health is based on online studies and convenience samples, this study based its ndings on clinical interviews. Qualitative data derived from these interviews will be presented separately, to further describe how outcomes of the fear of COVID-19 on mental health could differ between population groups. However, limitations need to be addressed as the data were driven from a cross-sectional study design, reporting results from self-completed questionnaires, therefore jeopardizing the opportunity to report causal conclusions and being prone to social convenience biases.

Conclusions
Fear of COVID-19 seems to trouble older adults, especially those with a chronic physical disease, as they try to address the challenges imposed from the global medical crisis. At the beginning of the pandemic there were voices predicting an increase in mental health disorders, such as anxiety depression, and suicidality. Despite these predictions, in Greece the "mental health pandemic" with increased suicidality rates is not yet veri ed. That does not mean that researchers' predictions should be taken lightly since the pandemic is still ongoing and severe consequences may become apparent in a later time.