During the first months of 2020, governments in many European countries initiated containment measures with different approaches ranging from restricting population movement and increasing social distancing, to implementing voluntary or enforced isolation and quarantine measures . Self-isolation recommendations were particularly targeted to older persons and/or to individuals with chronic medical conditions, who have a higher risk of negative health outcomes resulting from SARS-CoV-2 infection. However, these measures have the potential to impact short- and long-term NCD management and progression from various perspectives, as discussed below.
Reduced physical activity levels and other lifestyle factors
One consequence of quarantine measures will be a decrease in physical activity levels in many individuals. The closure of gyms, swimming pools, and exercise clubs in addition to laws limiting access to outdoor space and free movement will inevitably reduce opportunities to exercise. This is of particular importance to NCD patients, where physical activity is essential for controlling symptoms and risk factors such as obesity, hypertension, and elevated glucose levels . Exercise is also important for reducing sarcopenia, falls, and fall-related injuries [17, 18]. Further, cardiorespiratory fitness is also associated with cognitive functioning in older persons . In situations where opportunities for aerobic exercise training are limited, alternatives such as resistance exercise training may need to be proposed as potential alternatives, as evidence suggest that it may be as effective for reducing the risk of several chronic diseases . Access to fresh food may be limited leading to changes in diet, which can affect a number of health outcomes including cognition . Nutrition, exercise, cognitive training, and management of metabolic and vascular risk factors are all important for maintaining cognitive functioning and reducing the risk of chronic diseases in older persons .
Reduced social contact and its effect on loneliness and mental health disorders
Quarantine measures will lead to reduced social contact and increased loneliness in older individuals. This may lead to a rise in mental health disorders, such as depression, and affect outcomes of patients who have existing mental health conditions. According to the EU statistics on income and living conditions, 13.4% of households in the EU in 2013 were composed of a single person aged 65 or over. Physical and social environments are related to loneliness and mental health factors in persons aged over 50, with social cohesion and social participation playing an important role . Reduced social network, isolation, and loneliness can lead to generalized anxiety and major depression disorders in older persons  and have been shown to negatively affect a range of health outcomes , including increased healthcare utilization and mortality as well as malnutrition and vitamin D deficiency , which have important implications as discussed below. Further, people with existing mental health disorders may suffer during quarantine periods due to difficulties accessing regular outpatient visits for evaluations and prescriptions and they might be more influenced by the emotional responses related to the pandemic that could lead to relapse or worsening of mental health symptoms .
Reduction in vitamin D
Home-isolation is also likely to lead to a reduced number of hours spent outdoors, which may affect vitamin D levels. Low sunlight exposure periods are associated with vitamin D concentrations . This can have relevant health consequences as low levels of vitamin D are associated with numerous NCDs  and a higher prevalence of multimorbidity . Further, evidence exists on a link between vitamin D deficiency and impaired immune function, potentially leading to autoimmunity and increased risk of infections .
Changes to routine management of NCD patients
During the SARS-CoV-2 outbreak, healthcare systems began postponing and scaling down some aspects of routine NCD management, outpatient visits, and non-urgent surgery to avoid unnecessary hospital visits, reduce the burden on hospitals, and decrease infection risk . Although there are no data available yet on this issue, it is likely that many NCD patients have decreased access to outpatient visits and one-on-one clinical advice, and, in some cases, there may be a shortage of medicines. Further, some patients may be reluctant to seek care due to fears of infection in healthcare settings. The situation is further exacerbated by the preexisting European shortage of skilled healthcare workers  and that many healthcare workers have been infected with SARS-CoV-2, which affects staffing levels. In the short-term this has important consequences for integrated care programs, which are a vital element of the care of persons with NCDs, particularly patients with multimorbidity [33, 34]. Lack of integrated support from local health units and healthcare systems, whose focus in now on managing the COVID-19 crisis, may undermine welfare, particularly hitting vulnerable groups such as the elderly and persons with frailty and NCDs. In the long-term, reduced NCD management may have devastating consequences to some individuals, particularly those with multiple or more severe conditions who require regular symptom monitoring and adjustment of complex drug regimens. In addition, the redistribution of healthcare resources to fight the SARS-CoV-2 outbreak is likely to have long term financial effects on national health systems throughout Europe, affecting patients both with non-communicable and communicable diseases. Indeed, it is also important that vaccination for other communicable diseases are not neglected as they are also of crucial importance for fighting against emerging and re-emerging infectious diseases and for maintaining better health and functioning in older individuals.
Integrated care and clinical monitoring of NCD patients are essential for maintaining medication adherence. The scaling down of outpatient visits, as mentioned above, in addition to quarantine measures that may affect access to pharmacies may have relevant clinical implications in terms of drug adherence. Further, as rapid research into the clinical management of SARS-CoV-2 infected individuals continues and the media report premature findings to the general public there may be dangerous consequences to patients who might start to self-manage their NCD medications. For example, in March 2020 reports emerged on potential adverse effects of angiotensin-converting enzyme inhibitors (ACE-i) or Angiotensin Receptor Blockers (ARB) on the risk of infection and the severity of SARS-CoV2, leading to the publication of a position statement from the European Society of Cardiology  urging physicians and patients not to discontinue antihypertensive treatment with ACEi or ARBs. Adherence to medication regimens and continuity of treatment is essential for the management of NCDs in older persons to avoid long-term negative health outcomes [36, 37], and pharmacists may need to play a role in this, hopefully with the support of computerized prescription registries.
Effects on NCD research
Many research projects on NCDs in Europe have been either halted or postponed during the COVID-19 outbreak to drain strategic resources (structural, financial, and human) from the NCD epidemic and redirect them to the COVID-19 pandemic. In addition, several clinical studies have been paused because healthcare systems are under pressure and clinical staff do not have time to complete research protocols. Many laboratory-based projects have been temporarily suspended due to infection risks to staff, with numerous universities also closing across Europe. The postponement of ongoing NCD research projects that focus on identifying risk factors and treatment options for NCDs will likely derail progress in this area by further delaying cost-effective interventions.