Addressing Loneliness and Social Isolation in Older Adults
Am Fam Physician. 2021 Jul ;104(1):85-87.
A 75-year-old patient, H.B., is having a telemedicine visit with their family physician for follow-up of end-stage chronic obstructive pulmonary disease, osteoarthritis, and chronic fatigue syndrome. H.B. is homebound because of dyspnea, chronic pain, and limited functional status and resides with a family member who is minimally involved in H.B.'s care. For three years, H.B. has rarely left home because minimal activity sets them back functionally for weeks. The COVID-19 pandemic has worsened H.B.'s isolation because they are afraid of being exposed to the virus. H.B. has refused all in-home support, although they actively participate in online chat groups. What is the impact of social isolation and loneliness on health-related outcomes in patients, and what interventions can be used by family physicians?
Social isolation and loneliness are increasingly recognized as complex clinical and public health problems, particularly in older adults, leading to adverse mental and physical health outcomes.1 The COVID-19 pandemic has led to physical distancing policies, which have exacerbated loneliness and social isolation.2 Social isolation is an objective absence or lack of social contact with others, whereas loneliness is defined as an undesirable subjective experience of unfulfilled social contacts and/or needs.3 The terms are distinct, although they are often used interchangeably, and both have similar health implications. Social isolation and loneliness are increasingly common in older age groups. National surveys report that approximately one in four community-dwelling older adults reports social isolation,4 and 22% to 35% report feeling lonely.1 Several factors are associated with social isolation in older adults, including being unmarried, having chronic illness, and lower reported socioeconomic status.4,5
Given the high prevalence, family physicians should consider the health consequences associated with social isolation and loneliness in older adults.6 A growing body of research demonstrates a strong link between social isolation and loneliness with adverse outcomes. All-cause mortality is increased to the same extent as that for smoking or obesity. The incidence of cardiovascular disease and mental health disorders is significantly increased, and socially isolated individuals report a higher prevalence of tobacco product usage and other deleterious health behaviors.1,3,5,7 Individuals who are socially isolated and/or lonely also report higher rates of health service utilization that may be because of greater disease occurrence and/or increased outreach provided by health service agencies.1 Nevertheless, these individuals report decreased adherence with medical advice.3,8
IDENTIFYING LONELINESS AND SOCIAL ISOLATION
Family physicians recognize the importance of loneliness as a condition that affects their patients but are often limited in their ability to reliably identify affected patients.9 The U.S. Preventive Services Task Force does not have a recommendation about screening for loneliness and social isolation; however, a recent report from the National Academy of Medicine provides guidance.1 Universal screening is not currently indicated because of the paucity of evidence-based interventions; however, physicians may consider assessments using validated tools, such as the Berkman-Syme10 or UCLA Loneliness Scale.1,11 Screening may be indicated in at-risk patients, for example, in those who have experienced a challenging life event such as the loss of a loved one, those who disclose limited social networks, or those who have frequent health care use.1 When patients at risk have been identified, physicians should consider discussing the adverse health outcomes associated with social isolation and loneliness with their patients and caregivers and investigate for underlying health or functional limitations that may be contributing factors.1
There is growing interest in information technology as a platform for assessing social isolation and loneliness.1 Several technologies are being explored as tools to identify or predict patterns of social isolation, including home-based activity monitoring, tracking of online and electronic usage patterns, and wearable devices that record sleep and physical activity.1
STRATEGIES TO MITIGATE LONELINESS AND SOCIAL ISOLATION
There is currently limited evidence to support specific interventions to mitigate the health effects of social isolation and loneliness. An integrative review categorizing several strategies, such as social facilitation and psychological therapies, has highlighted activities that promote active engagement.12 Table 1 provides strategies, descriptions, and examples for patients.12 A subsequent review from the Agency for Healthcare Research and Quality corroborated the lack of quality evidence but pointed to promising interventions that promote group physical activity and strategies that connect socially isolated older adults to health services.
Referencesshow all references
1. National Academies of Sciences, Engineering, and Medicine. Social isolation and loneliness in older adults: opportunities for the health care system. 2020. Accessed April 21, 2021. https://www.nap.edu/read/25663/chapter/1...
2. Smith BJ, Lim MH. How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Res Pract. 2020;30(2):e3022008.
3. Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. Health Soc Care Community. 2017;25(3):799–812.
4. Cudjoe TKM, Roth DL, Szanton SL, et al. The epidemiology of social isolation: national health and aging trends study. J Gerontol B Psychol Sci Soc Sci. 2020;75(1):107–113.
5. Steptoe A, Shankar A, Demakakos P, et al. Social isolation, loneliness, and all-cause mortality in older men and women. Proc Natl Acad Sci USA. 2013;110(15):5797–5801.
6. Freedman A, Nicolle J. Social isolation and loneliness: the new geriatric giants: approach for primary care. Can Fam Physician. 2020;66(3):176–182.
7. Holt-Lunstad J, Smith TB, Baker M, et al. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227–237.
8. Leigh-Hunt N, Bagguley D, Bash K, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health. 2017;152:157–171.
9. Due TD, Sandholdt H, Siersma VD, et al. How well do general practitioners know their elderly patients' social relations and feelings of loneliness? BMC Fam Pract. 2018;19(1):34.
10. Berkman LF, Syme SL. Social networks, host resistance, and mortality: a nine-year follow-up of Alameda County residents. Am J Epidemiol. 1979;109(2):186–204.
11. Russell D, Peplau LA, Ferguson ML. Developing a measure of loneliness. J Pers Assess. 1978;42(3):290–294.
12. Gardiner C, Geldenhuys G, Gott M. Interventions to reduce social isolation and loneliness among older people: an integrative review. Health Soc Care Community. 2018;26(2):147–157.
13. Veazie S, Gilbert J, Winchell K, et al. Addressing social isolation to improve the health of older adults: a rapid review. AHRQ report no. 19-EHC009-E. Agency for Healthcare Research and Quality; 2019.
14. Fisher EB, Tang PY, Muchieh Coufal M, et al Peer support. In: Daaleman TP, Helton MR, eds. Chronic Illness Care: Principles and Practice. Springer International; 2018:133–146.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to email@example.com. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, associate deputy editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions