A Review of Social Isolation an Important but Underassessed Condition in Older Adults

Review Article Clinical Review

Social isolation and loneliness: the new geriatric giants

Approach for master care

Canadian Family Physician March 2020, 66 (3) 176-182;

Abstract

Objective To review the bug of social isolation, loneliness, and social vulnerability in older adults and the associated risks, and to assistance primary care providers identify patients at hazard and recommend effective interventions.

Sources of information PubMed and PsycINFO searches were conducted using the terms aged, social isolation, loneliness, screening, and interventions and associated key words for relevant English-language articles. References of identified manufactures were too hand searched. A separate search of the gray literature using Google was conducted to find policy documents and cognition translation materials from relevant organizations. The search covered relevant articles from the 10 years before June 2019.

Main bulletin Social isolation, loneliness, and social vulnerability are very common in older adults and are associated with considerable morbidity and bloodshed, comparable to established risk factors such as smoking, alcohol consumption, obesity, and frailty. Numerous interventions addressing loneliness and social isolation have been studied: social facilitation (including technology), exercise, psychological therapies, wellness and social services, animal therapy, befriending, and leisure and skill evolution. Nevertheless, current evidence of effectiveness is limited. A patient-centred approach is essential to the selection of interventions. The needs of underserviced and marginalized populations, including new immigrants, older adults identifying as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and related communities), Indigenous seniors, and seniors living in poverty, as well as the needs of long-term care residents and older caregivers, require further evaluation.

Conclusion Social isolation, loneliness, and social vulnerability are common problems in older adults and have important health consequences. Family physicians are uniquely positioned to identify alone and socially isolated older adults and to initiate services.

Instance description

Natasha is an 85-year-old woman whom you see for management of hypertension and osteoarthritis. Her husband died 6 months ago with advanced dementia, and she lives alone in a subsidized flat. She only goes out to buy groceries and to come across you. She immigrated from Denmark many years agone and she has 2 developed children who live far away. She does not see whatever friends, as most take died or she lost touch with them during the years she was caring for her husband. She stopped going to church several years ago. She has pain in her knees and feels like her walking is not equally potent as it used to be.

You accept a resident working with you today who takes a thorough history that includes a review of Natasha'due south symptoms and the main geriatric syndromes.

The resident makes several useful suggestions, including adjusting Natasha's medications, some express investigations, and having an occupational therapist evaluate the safety of her home and the need for a gait aid.

When you suggest to Natasha that she should book to run across yous in iv to 6 weeks, she says, "That seems long …. How nearly 2?"

In many ways, the resident has done a thorough cess of this frail adult female, taking into account several of the "geriatric giants" taught to medical learners. Yet, her agreement of Natasha's wellness fails to appreciate those factors most probable to influence her quality of life and fifty-fifty her mortality: social vulnerability, loneliness, and social isolation.

Sources of information

We searched PubMed and PsycINFO from 2008 until June 2019 using the terms aged, loneliness, social isolation, screening, and interventions and associated primal words. The search in PubMed was limited to review articles and articles in English. References of identified manufactures were likewise paw searched. Public policy documents from Canada, the Usa, and the United Kingdom (U.k.) were institute online using Google and the same search terms. Systematic reviews, meta-analyses, and policy documents were included if they focused on the effectiveness of interventions for loneliness or social isolation in older adults. This article should not be considered a formal systematic review and does not provide a quantitative synthesis of the field.

Main message

Scope of the issue.

Estimates from 2017 prove that 17% of Canada'due south population is aged 65 and older. This population, particularly those older than 75 years, is expected to more than double in the next 20 years.^ane Emerging show shows that social factors have considerable effects on bloodshed and many aspects of health in older adults.² Terms such equally social isolation, social vulnerability, and loneliness, divers in Box 1,^3,4 are becoming increasingly of import topics of discussion. Public health agencies and governments are promoting reducing loneliness and strengthening social networks as important public health goals. In 2013–2014, the National Seniors Council prepared a Wellness Canada report on the social isolation of seniors.⁵ The UK supports a Minister for Loneliness as well as the Entrada to End Loneliness, a network of organizations working to reduce loneliness in afterwards life through customs action, do, research, and policy.^six,7 The World Health Organization has also created a Global Network for Age-friendly Cities and Communities, a fundamental strategy of which is encouraging social date for older adults.^eight

Box i.

Definitions

Social isolation is commonly defined as having a low quantity and quality of contact with others. It is objective and can be measured using observations of an individual's social network.^three

Loneliness is the feeling of isolation regardless of objective social network size.³ Loneliness is often viewed as the subjective counterpart to social isolation.

Social vulnerability tin can help explain how social circumstances relate to health and refers to the degree to which one's social state of affairs leaves ane susceptible to further social or health-related insults.^four Andrew et al operationalized this concept past constructing a Social Vulnerability Index, which includes self-report variables such as socioeconomic status, relationships, social supports, literacy, and living state of affairs, factors previously identified in the Canadian Written report of Health and Aging.^four

Studies take shown, however, that family physicians take trouble identifying their lonely patients.⁹ A Dutch written report constitute that, while family doctors best-selling the importance of patients' feelings of loneliness in their daily practice, they had difficulty responding to these feelings and faced a lack of therapeutic options.^x

The prevalence of social isolation ranges from 6% to 43% in older community-dwelling adults, and x% to 50% report feeling solitary.^3,5,eleven

Importance of the problem.

While intrinsic factors such as genetics, medical conditions, and frailty contribute to health, in that location is growing recognition of the effects of social determinants of wellness—the weather in which people are born, alive, and age. Loneliness and social isolation were shown in a meta-analysis to exist associated with a heightened risk of mortality of 26% and 29%, respectively.¹² This increased bloodshed risk is in the same category as smoking 15 cigarettes a day and having an booze use disorder. In addition, the health risks of loneliness surpassed those associated with obesity.¹² The media has disseminated this finding with the catchy headline "loneliness is the new smoking." Some other recent meta-analysis suggested that the adventure of developing dementia for those with high levels of loneliness was 1.58 times greater than for those with a social network.¹³ There is skilful show that individuals who are lone or socially isolated take an increased risk of physical and mental health problems, likewise as increased health services apply (Table one).^{iii–v,11–19}

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Table 1.

Adverse outcomes associated with loneliness and social isolation

Conversely, increased social appointment has been associated with decreased disability and lower mortality.^19,xx In Holt-Lunstad and colleagues' meta-analysis, individuals with stronger social relationships had a l% increased survival likelihood.¹² Social connections take been shown to amend adherence to medical regimens²¹ and to decrease hospitalization time.²

Risk factors.

Many variables have been found to be associated with an increased risk of loneliness, social isolation, and social vulnerability (Table 2).^1,3,4,22

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Table 2.

Risk factors for social isolation, loneliness and social vulnerability

Identifying and reaching patients who are isolated or lonely.

Family physicians and other main care providers are well placed to identify patients who are isolated or lonely, as these providers might be the only point of social contact for many patients.^7,23–25 In the United kingdom, three out of four GPs say they come across between 1 and 5 people a twenty-four hours who accept come in mainly because they are lonely.⁷ It has been suggested that, just as physicians screen for risk factors such every bit smoking, nutrition, and do, in that location might be a role for principal care physicians to identify patients who are isolated, alone, or socially vulnerable and to recommend evidence-based interventions that could strengthen social connections.^25,26

The National Seniors Council report confirmed that a "reactive" approach is currently in place to accost the needs of socially isolated individuals, many of whom are non identified or supported until after a crunch.^v Validated scales to assess older adults at hazard of social isolation and loneliness, who might benefit from intervention, include the Lubben Social Network Scale^27,28 and the Three-detail Loneliness Calibration (Table 3).²⁹ Single-item screening questions are too bachelor, such as "How often practice you feel lonely (hardly always or never, some of the time, often)?"^eleven,30 Unmarried-item questions have been less extensively studied but are commonly used in research and might exist more practical in clinical practice.^11,xxx–32

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Table 3.

The Three-particular Loneliness Scale

Some communities accept used existing data sets pertaining to hazard factors for loneliness—for example, mapping geographic areas with more risk factors (to create "a loneliness heat map") to target services. Other communities have trained "non-traditional referral sources"—individuals with whom older adults might accept contact (eg, volunteers, shopkeepers)—an approach called "eyes on the footing."^7,33,34

Interventions.

Diverse interventions aimed at reducing loneliness and social isolation have been studied (Table four).^14,35–46 Multiple systematic reviews evaluating these interventions have come to unlike and often contradictory conclusions.^14,35–46 For example, several systematic reviews have found improved outcomes with group interventions that are educational or social, or which combine exercise with a leisure or psychosocial intervention.^35–38 Other reviews, all the same, demonstrate greater evidence for one-on-1 interventions (such as videoconferencing, Net utilize, and animal therapy).^39–42,46 The systematic reviews comment on the poor methodologic quality of the principal studies, including small sample sizes, follow-upwards not existence long plenty to see health benefits, lack of measurement of health care utilise, and lack of consistency on whether and how social isolation or loneliness are measured.^{fourteen,35–46} The review done past the Agency for Healthcare Inquiry and Quality rated fewer than half of the included studies as fair or good quality.³⁸

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Tabular array four.

Comparison of interventions to accost social isolation and loneliness

Given the poor quality of the studies, information technology is difficult to draw conclusions about which factors contribute to successful interventions. It has been suggested that the mechanism by which technology might accost social isolation is through enhancing connections to family unit and friends, gaining social support, engaging in areas of interest, and boosting self-confidence.⁴¹ Gardiner et al propose in their integrative review that the most successful interventions share the following features: adaptability to a local context and local command of the design, a community development approach (where interventions are designed and implemented past service users), and productive engagement activities (either individually or as a group) rather than passive activities.⁴³

"Social prescribing" is a new model addressing social isolation and loneliness that is being widely adopted and promoted in the UK and that is being studied in communities in Ontario.^7,47 This is a wide approach to the delivery of interventions that focuses non on what is delivered but on how services are delivered to a local community. In this model, a patient is identified within primary care and referred to a navigator who assesses their needs and connects them to advisable services (eg, caregiver respite, sensory services, recreation, transportation, food, or income supports). Individual studies of this model prove improvements in cocky-reported health measures and reductions in health service usage. Yet, a recent systematic review of social prescribing institute that the current evidence fails to provide sufficient detail to judge either success or value for money, as nearly of the studies are small and of poor quality.⁴⁵

Practical approach to loneliness and social isolation.

Given the lack of articulate guidelines as to which interventions are effective for which individuals and the diverse needs and preferences of older adults, we propose clinicians apply an individualized, patient-centred approach in addressing social isolation and loneliness (Box 2).^{7,fourteen,38,48}

Box ii.

A patient-centred approach to addressing social isolation and loneliness

A patient-centred approach addresses the following factors

Exploring. What is happening now? Facilitate the person's telling of his or her story and review the degree of loneliness or social isolation.

Scoping solutions and goals. What solutions are in that location? Help the person imagine a different future. (How would you like things to be? What would you be doing differently? What are your interests? Your strengths?)

Accept the private ready his or her ain goals—ie, not the provider's (eg, being more physically active, preventing falls, making new connections, attending meetings, playing bridge).

Activity. What needs to exist done? Assist the person construct a plan that maps out where he or she wants to become to.

Adjusted from the Campaign to Cease Loneliness.⁴⁸

Social services involvement is essential in selecting the interventions most appropriate to the context of a particular patient. Many cities accept central websites and telephone lines (eg, Canada 211) with searchable databases of services. In our own and others' experiences, creating a directory of local assets can be a valuable reference tool in the electronic medical record, bachelor in hard copy in the office or distributed on habitation visits. Customs centres and public libraries also often offering practice programs, social programs, and figurer training for older adults (Table 5).

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Table 5.

Resources for social isolation and loneliness

Addressing barriers to implementing interventions

Transportation needs: Connecting older adults to reliable and affordable transportation is often a prerequisite to their remaining engaged in the customs and in supporting relationships.^3,7

Sensory loss and mobility restrictions: A 2008 review of social isolation in community-dwelling seniors found that rehabilitation for mild or moderate hearing loss was effective in improving communication disabilities and reducing loneliness.¹⁴ No studies were found that evaluated the effects of interventions for other age-related functional disabilities such as vision loss or mobility restrictions. However, the authors of the review point out that research is not necessarily needed to confirm that correcting mobility restrictions or vision loss could amend quality of life and social engagement.¹⁴

Participating in many interventions is only possible after optimizing mobility, vision, and hearing.

Income: Cost can exist a bulwark to participating in social programs. Older adults should be encouraged to submit their taxation forms, as government benefits exist for low-income seniors.⁴⁹ Programs might waive fees or use a sliding scale for low-income older adults.

Gaps in understanding and research: underserved populations.

Starting time-generation immigrants struggle to admission mainstream interventions for loneliness attributable to lack of familiarity with resources as well as language and cultural barriers. In the National Seniors Council study, this population identified challenges in finding care facilities and social programming in their linguistic communication of choice.^v The literature does non describe how seniors of different ethnicities experience loneliness and isolation. The level of social isolation experienced by older Indigenous people is not known. Nonetheless, cultural and structural factors, coupled with high rates of traumatic events over the person's life, might increase the adventure of loneliness and social isolation.⁵⁰ The Agency for Healthcare Research and Quality review notes that only 1 of the viii good-quality studies reported on the ethnicity of participants.³⁸

Older adults who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and related communities) are at a high risk of loneliness and social isolation.^50–52 A survey by the American Association of Retired Persons found that most older adults identifying equally LGBTQ+ are concerned most having enough back up from family and friends as they age.⁵¹ Many LGBTQ+ older adults limited a desire for LGBTQ+ specific services and housing.^l,51

Despite being in the company of others, older adults living in residential or long-term intendance however experience high levels of loneliness and isolation. As many every bit 44% of seniors living in long-term care in Canada have been diagnosed with depression or have symptoms of low, and these residents are more probable to be socially isolated.⁵³ Near of the research on institutionalized older adults has involved persons who were cognitively intact, and there were no systematic reviews specific to long-term care. Feelings of loneliness and isolation are common in dementia, and these patients might detect it more hard to cope with the feelings associated with these problems.⁴⁰ In addition, senior caregivers are often a socially isolated, hidden population, and farther research is needed to identify which interventions are effective in this group.^xiv

Although the association betwixt poverty and social isolation is well described, there is very little literature on the effects of poverty on the experience of loneliness and social isolation.

Case resolution

Although Natasha'southward demeanour is cheerful, it is clear that she is solitary and socially isolated. When you ask her why she stopped going to church, she says that information technology was hard to become there. When she did get, she could not hear the service or read the prayer book. She misses this, as it was an important part of her week earlier her husband got sick. She speaks to her children infrequently by telephone, as calling them has become very expensive. They have encouraged her to Skype or email them, but she does non accept a computer.

Natasha is open to having her hearing and vision tested, also as to having an occupational therapy assessment. You look upward transportation for older adults on Canada 211 and print out an application for a public transit system for those with disabilities, too as some other low-price options for older adults so that Natasha can work on getting dorsum to her church. You mention an exercise grouping as a way of improving her forcefulness and lowering her chance of falls, but Natasha is not interested. She does like the idea of learning to employ a calculator to connect with her children. You advise her to check with her local library to see if they offer computer courses. Natasha volition return to come across y'all in one month to follow up on these plans.

Conclusion and next steps

In 1965 Professor Bernard Isaacs coined the term geriatric giants: immobility, instability, incontinence, and impaired intellect or retentivity.⁵⁴ Practitioners and medical learners are encouraged to exist vigilant for these conditions, in add-on to screening for recognized hazard factors such as smoking, alcohol use, and physical activity, and to intervene to forbid further disability, hospitalization, and mortality.

Given the abundance of literature demonstrating the powerful relationship between loneliness, social isolation, and social vulnerability and these same outcomes, chief care providers would be remiss if we did not recognize these problems in our patients and emphasize social relationship factors as critical wellness variables to our learners.

Interventions targeting loneliness and social isolation evidence hope, but more research is needed to provide firm guidance as to which interventions are effective for which populations.

Just as loneliness might be the new smoking, interventions targeting loneliness and social isolation might be the new "statin." However, addressing loneliness and social isolation is not as simple as prescribing a medication. A patient-centred approach is disquisitional, as are well-defined partnerships and coordination between those working in health care and those in the social service, government, and research sectors.⁵⁵ Social isolation and loneliness might well exist the new geriatric giants.

Acknowledgments

We thank Lorna McDougall, NP, for her thoughtful comments and careful review of the manuscript.

Notes

Editor's cardinal points

• ▸ Estimates from 2017 show that 17% of Canada's population is aged 65 and older. This population, especially those older than 75 years, is expected to more than than double in the next 20 years. Emerging prove shows that social factors—including social isolation, loneliness, and social vulnerability—are associated with considerable morbidity and mortality, comparable to established risk factors such as smoking, alcohol consumption, obesity, and frailty.

• ▸ Family physicians and other primary care providers might be the only point of social contact for many older patients. It has been suggested that, simply every bit physicians screen for other take chances factors, there might be a part for primary intendance physicians to identify patients who are isolated, solitary, or socially vulnerable and to recommend testify-based interventions that could strengthen social connections.

• ▸ Interventions targeting loneliness and social isolation show hope, but more enquiry is needed to provide firm guidance as to which interventions are effective for which populations. A patient-centred approach is critical in selecting interventions, as are well-defined partnerships and coordination between those working in health care and those in other sectors.

Footnotes

• Contributors

  Both authors contributed to the literature review, its interpretation, and preparing the manuscript for submission.

• Competing interests

  None declared

• This article is eligible for Mainpro+ certified Cocky-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

• This article has been peer reviewed.

• La traduction en français de cet article se trouve à world wide web.cfp.ca dans la table des matières du numéro de mars 2020 à la page e78.

• Copyright© the College of Family Physicians of Canada

References

1. 1.↵
2. two.↵
3. 3.↵
4. 4.↵
5. v.↵
6. 6.↵

   Minister of loneliness appointed to keep Jo Cox's piece of work. BBC News 2018 Jan 17. .

7. 7.↵
8. eight.↵
9. ix.↵
10. 10.↵
11. eleven.↵
12. 12.↵
13. 13.↵
14. fourteen.↵
15. 15.
16. 16.
17. 17.
18. 18.
19. xix.↵
20. 20.↵
21. 21.↵
22. 22.↵
23. 23.↵
24. 24.
25. 25.↵
26. 26.↵
27. 27.↵
28. 28.↵
29. 29.↵
30. 30.↵
31. 31.
32. 32.↵
33. 33.↵
34. 34.↵
35. 35.↵
36. 36.
37. 37.
38. 38.↵
39. 39.↵
40. 40.↵
41. 41.↵
42. 42.↵
43. 43.↵
44. 44.
45. 45.↵
46. 46.↵
47. 47.↵
48. 48.↵
49. 49.↵
50. fifty.↵
51. 51.↵
52. 52.↵
53. 53.↵
54. 54.↵
55. 55.↵

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Source: https://www.cfp.ca/content/66/3/176

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