A UK survey of COVID‐19 related social support closures and their effects on older people, people with dementia, and carers

Abstract Objectives The aim of this national survey was to explore the impact of COVID‐19 public health measures on access to social support services and the effects of closures of services on the mental well‐being of older people and those affected by dementia. Methods A UK‐wide online and telephone survey was conducted with older adults, people with dementia, and carers between April and May 2020. The survey captured demographic and postcode data, social support service usage before and after COVID‐19 public health measures, current quality of life, depression, and anxiety. Multiple linear regression analysis was used to explore the relationship between social support service variations and anxiety and well‐being. Results Five hundred and sixty‐nine participants completed the survey (61 people with dementia, 285 unpaid carers, and 223 older adults). Paired samples t‐tests and X 2‐tests showed that the mean hour of weekly social support service usage and the number of people having accessed various services was significantly reduced post COVID‐19. Multiple regression analyses showed that higher variations in social support service hours significantly predicted increased levels of anxiety in people with dementia and older adults, and lower levels of mental well‐being in unpaid carers and older adults. Conclusions Being unable to access social support services due to COVID contributed to worse quality of life and anxiety in those affected by dementia and older adults across the UK. Social support services need to be enabled to continue providing support in adapted formats, especially in light of continued public health restrictions for the foreseeable future.

services which provide vital activities and care for people living with dementia (PLWD) living in their own homes. Some of these social support services are provided by the voluntary sector, whilst others are provided by the governmental social care system, with some services being subject to financial support to access, whilst others have to be paid for by the individuals themselves. Social support services are linked to improved levels of well-being 2,3 and quality of life for people with dementia. 4 Older adults experience high rates of social isolation, 5 and a third of UK older adults live alone. 6 Social support services can provide an important life line to support them live well and engage socially. Greater social engagement has been linked to lower levels of loneliness and depression, and higher quality of life. 7,8 Even prior to the pandemic, access to dementia care varied with sociodemographic characteristics such as gender, area deprivation and ethnicity. 9,10 Many PLWD living in the community have an unmet need for social company, 11 and there can be a concern that the impacts of COVID may widen existing inequalities. A recent qualitative investigation in the UK has reported that people affected by dementia have experienced distress due to reduced availability of social services during the pandemic, with feelings of loss of control, uncertainty, and higher levels of carer burden discussed. 12 However, to date no quantitative data have evidenced the impact of these service closures on mental well-being.
Preliminary findings indicate that mental health in the general UK population has declined since the onset of the pandemic and associated social changes. 13 However, to our knowledge, this is the first study of mental health and wellbeing that has specifically recruited PLWD, their family carers, and older people; and the first to explore how availability of social services for PLWD has changed with the pandemic.
This cross-sectional survey had two aims as follows: (1) to explore how social support service access by older adults and those affected by dementia changed in March 2020, at the time when COVID-related public health measures were imposed; and (2) to explore, in people who were receiving social support services prior to the pandemic, the relationship between any change in service availability and mental well-being, anxiety, and depression symptoms.
Social support is defined as community-based, non-residential care.
We hypothesised that participants would report receiving on average fewer hours of social support after COVID-19 public health measures were instigated, relative to the weeks before the shutdown; and that receiving fewer hours of social support would be associated with worse well-being, anxiety, and depression among people who are in receipt of care services.

| Sampling and procedures
We recruited older adults aged 65þ years, people with dementia, and unpaid current and former carers of PLWD via: NIHR Join Dementia Research network, a UK-based research registry for people with dementia, carers, and health volunteers interested in taking part in dementia research; social media; and third sector and social support service organisations, using mailing lists and newsletters, and direct approach by service providers via telephone or email. As potential participants were mostly approached via generic newsletters, social media announcements, and via existing and established networks with third sector organisations and service providers, methods also employed in the University College London COVID-19 social study, 14 no data on response rate is available. The survey could be completed either online or via phone with a research team member.
The decision to include former carers arose from discussions amongst the research team, which includes academics, clinicians, those affected by dementia, service providers, and third sector organisations. The rationale for this was that former carers often continue to access social support services, mostly peer support groups, after the PLWD's death in the UK.
PLWD were assumed to have capacity when taking part in the online survey. For those who completed the survey over the phone, researchers assessed mental capacity at the beginning according to the Mental Capacity Act. 15

| Survey variables
We asked participants whether they were a PLWD, a current carer, former carer, or aged 65þ years. Respondents were invited to tick all categories that applied. For the first three categories (PLWD, current carer and former carer), no participants ticked more than one of these responses. Where respondents ticked aged 65þ years and one of the other three categories, they were categorised as a PLWD, current or former carer. Thus, no participant in the older adult category had caring responsibilities.

| Demographic variables
These included age, gender, ethnicity, and for people with dementia, dementia subtype if known. Postcode data were collected to generate an Index of Multiple Deprivation (IMD) quintile. The IMD is an index of neighbourhood deprivation generating one deprivation score for income, employment, education, health, crime, barriers to housing and services, and living environment. Quintile '1' indicates the least disadvantaged neighbourhoods, with quintile '5' indicating the most disadvantaged neighbourhoods.

| Service receipt
We developed a brief questionnaire based on consultations with people affected by dementia and clinicians as part of a previous ongoing study. We asked all participants to state types and levels of social support service access, which were recorded in hours per GIEBEL ET AL. week, including paid carers, support groups, social activities in the community, respite, day care centres, meal deliveries, befriending and accompanying services, and others, pre-(T1) and post-(T2) COVID-19 (measured as in a typical week before and since the UK lockdown on the 23rd of March). From this data, we calculated a variable of variations in social support service usage, by calculating the difference in total weekly hours between T2 and T1.

| Psychological measures
Participants were asked to complete the following validated scales: The Short Warwick-Edinburgh Mental Well-Being Scale

| Data analysis
We used SPSS 25 to analyse data. We used standard summary statistics to describe the data. A paired samples t-test was used to compare the mean in hours of social support service usage before and since COVID. A Chi-square test was used to compare the number of people having used no social support services at T1 and T2. To assess caseness of anxiety and depression, the cut off score for the GAD-7 and the PHQ-9 were employed to categorise participants into those with ('1') and without ('0') anxiety and depression. For each group (PLWD, unpaid carers and older adults), multiple regression analyses were employed where variations in hours of social support service usage were found to be significantly correlated with the continuous measures of SWEMWBS, GAD-7, and PHQ-9, via previously conducted bivariate correlation analysis. Dummy variables were created for IMD quintiles, with Quintile 5 (most disadvantaged) as the reference category. We included age, gender, living situation, years of education, and IMD quintiles in regression analyses as covariates, whilst checking for multi-collinearity.
Participants with complete missing data on the PHQ-9, GAD-7, and SWEMWBS were removed from the total sample. There were no cases with only one or two items missing on the scale, but instead the entire questionnaire was incomplete.

| Demographic characteristics
Six hundred sixty people participated in the survey, of which 25 were duplicates and 66 had large numbers of missing data, resulting in 569 participant cases included in this study (61 PLWD; 219 current carers; 66 former carers; 223 older adults). The majority of participants completed the survey online (93.5%).
The majority of participants were female (68%) and from a White ethnic background (97%) lived with other(s) (74%) and were retired (71%), with more participants living in less disadvantaged as opposed to more disadvantaged neighbourhoods, as measured by the IMD score. Most PLWD lived with and carers (had) cared for someone living with Alzheimer's disease dementia (41%), followed by mixed (23%) and vascular dementia (14%). PLWD and carers were on average 70 (þ/À 10) and 61 (þ/À 13) years of age, respectively, with the group of older adults interviewed who did not identify as living with dementia or being a carer for a person with dementia, having an average age of 72 (þ/À 6). Participants had on average 16 (þ/À 4) years of education. Table 1 shows all demographic characteristics of the sample by group.

| Social support service usage at T1 and T2
Mean weekly hours of accessing social support services was 12.0 (SD ¼ 28.5; Skewness ¼ 4.5; Kurtosis ¼ 21.0) at T1 and 6.6 (SD ¼ 29.5; p < .001). Two hundred and fifty-one participants reported having received >0 h at T1 (31 PLWD, 156 current carers, 20 former carers, 44 older adults). Of those, the variation in mean number of hours between T1 and T2 was 9.0 (þ/À 23.4), ranging from À 162 to þ168, with some participants experiencing fewer hours at T2, and others more hours. 1 Figure 1 shows social support service usage at T1 and T2 by group. Engaging in social activities in the community, such as singing and dancing groups, was accessed the most at T1, followed by accessing peer support groups and receiving paid carers in the home,

| Mental well-being
The group with the highest proportion scoring above the cut off for both anxiety (33%) and depression (48%) were those living with dementia. In contrast, far fewer older adults achieved caseness (5% anxiety and 5% depression). Amongst carers, proportions of anxiety and depression were higher amongst current (28%, 20%) than former carers (14%, 11%). Figure 2 summarises these findings.

| Multiple regression analysis on changes in social support service hours and well-being and anxiety
Of those having received >0 h at T1 (n ¼ 251), we combined current and former carers into one single carers group (n ¼ 179), to increase the power of this group for the regression model.  to reduced scores on the SWEMWBS (p < 0.05) and higher scores on the GAD-7 (p < 0.05), not the PHQ-9 (p ¼ 0.155).
Four multiple regression analyses were conducted (see Table 3 for further details). Variation in social support service hours were significantly related with anxiety in PLWD (p < 0.05), mental wellbeing in carers (p < 0.05), and mental well-being and anxiety in older adults (p < 0.05; p < 0.05), all of whom had received at least some weekly hours pre COVID. When running the multiple regression analysis for carers with current carers only, results were comparable to the model with both former and current carers merged, but variation in hours of social support service usage failed to achieve statistical significance (p > 0.05). Higher levels of variation in hours of support were related to higher levels of anxiety and lower levels of well-being. Other factors such as age, gender, years of education, living situation (alone/with others), and IMD quintiles were not found to be significantly associated.

| DISCUSSION
Our study is the first to quantify how the pandemic has impacted social support service availability, and to explore the impact of this on For carers, being unable to access previously utilised activities significantly predicted their well-being. Unpaid carers provide a large proportion of dementia care, worth over £13 billion each year in the UK. 21 While carers might not always acknowledge themselves how much care they provide, ranging from preparing a hot meal to dressing the PLWD or supporting them to use the toilet, carers can become increasingly burdened as the dementia progresses and symptoms advance with PLWD requiring more support. 22 Accessing respite care and having some time to themselves whilst the PLWD is attending a day care centre is therefore crucial to support the carer. With COVID and restrictions in place, these opportunities have suddenly been taken away from carers, leaving them likely at a loss of how to adapt the care required for the PLWD. Carers are thus likely to have to pick up increased care hours, or merely get no respite from caring for someone 24/7, which might explain the significant association with their well-being as evidenced in this study. However, former carers have also been affected, as the desire and need to access peer support after their relative has passed away stays in place for many carers.
Therefore, findings clearly highlight the need for both current and former carers to continue accessing social support. Anxiety Depression F I G U R E 2 Prevalence of anxiety and depression by group. The diagram shows the proportion of PLWD, carers, and older adults who scored 10 or above on the GAD-7 or PHQ-9 for anxiety and depression, respectively. OAs, Older adults; PLWD, People living with dementia GIEBEL ET AL.

PLWD
-7 COVID-related closures were also significantly related to lower mental well-being and higher levels of anxiety in older adults. In our sample, older adults had the highest proportion of those living alone (34%). They mostly accessed social activities in the community pre COVID, which include for example arts groups or other hobbies.
These are important for enabling social inclusion and social interactions, and the link between social engagement and well-being is well established in the literature. 23 Previous research has shown a

| CONCLUSIONS
Social support services are vital to support the mental well-being of older adults and people affected by dementia. Our research demonstrated a link between COVID-related service loss and detrimental impacts on these vulnerable groups. With public health restrictions such as social distancing likely to stay in place for some time to come, it is important to find ways to adapt these services to seeking alternative ways to re-provide support to meet the needs of those requiring social support. This can in some way achieved by providing remote support services, which is very slowly being trialled with very little evidence to date though (Cheung & Peri 27 ; Goodman-Casanova et al. 28 ). However, remote service support does not substitute face-to-face support, so that a right mix of different formats needs to be provided, in a safe environment, to enable older adults and people affected by dementia access support services throughout the pandemic. There is evidence that social support reduces the risk of care home admissions and unplanned hospital admissions. Therefore, it is important to act now and enable prepandemic levels of social support, if not better, as otherwise health care and social care services will be overburdened with

CONFLICT OF INTEREST
We declare no competing interests.

AUTHOR CONTRIBUTIONS
Clarissa Giebel conceptualised the study. Clarissa Giebel, Claudia Cooper, and Mark Gabbay developed the study analysis in consultation with the team. Daniel Pulford managed recruitment. Clarissa Giebel performed data analysis and draughted the manuscript. All coauthors interpreted the findings jointly, provided feedback on drafts of the manuscript, and approved the final draft.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request. -9