For Older Patients, Loneliness Might Be Biggest Social Determinant of Health
Case managers can help change this
Lonely, socially isolated people are at greater risk of early death. They also are more likely to suffer from health problems and a lower quality of life.
- Social isolation can lead to poor healthcare follow-up and sicker patients.
- Case managers should assess patients for social isolation, talk with them, and find solutions that could help them become more engaged in their homes and communities.
- Technology and social media can help to combat these issues.
Loneliness and social exclusion can have a big impact on patients’ health and quality of life, and it’s a problem that is compounded by deteriorating health as people grow older.
Research shows that loneliness and social isolation, whether it is actual or only perceived, can be associated with increased risk for early death.1,2
“It’s very clear from the data that people who are more isolated, whether from aging or from loss of family members, connections, and peers, have immune systems more at risk,” says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, principal with EFS Supervision Strategies in Burke, VA.
Socially isolated patients do not function as well physically. They become sicker, and they may not follow through on health appointments, eating well, or taking their medications regularly, she says.
“Social exclusion has always been considered one of the determinants of health,” says Karen Nelson, MSW, MBA, director of social work and case management at Stanford Healthcare in Palo Alto, CA.
“Before, it was considered that people were excluded based on race, gender, or other characteristics,” she says. “Now, we find people are not excluded based on those areas of diversity, but because society has changed fundamentally in the number of social connections it offers people naturally.”
People rely more on technology and less on phone calls and in-person visits with friends and family. They have moved from communities where they participated in church and social activities to new places where they do not know anyone, Nelson explains.
“People are not connected with their neighbors in the same way, and they move frequently,” she says. “This is a problem, especially with the elderly, because people are living longer but are so far from family connections, their children, and grandchildren.”
Decades ago, people would stay in the community in which they were born. They would stay with their church family for decades, and those affiliations would give them an identity. Now they have to search actively for an identity, and social connections are not as abundant as they were, Nelson says.
“Grandparents would look forward to that family dinner every Sunday, and they had a purpose in life — even if they weren’t working. They had natural connections,” Nelson says.
With extended family weekly meals largely gone and more people living alone than ever before, social isolation is common, she adds.
“Just like we pay attention to obesity, smoking, and lack of exercise as risk factors, we need to pay attention to loneliness and social isolation as potential impacts that could impact life expectancies,” Nelson says. “Socializing is good for your health.”
While technology has contributed to social isolation, it also can enhance and enrich older adults’ lives, one study shows.3
“Older adults are not naïve. They see the benefits of technology and are really satisfied with it,” says William J. Chopik, PhD, assistant professor in the department of psychology at Michigan State University in East Lansing.
Chopik’s study asked a large sample of older adults for their opinions about technology use.
“We found a lot of older adults were using technology for social purposes, and they were having better outcomes,” he says. “They were healthier and happier. Reaching out with technology reduced loneliness, which can take a psychological and physical toll on people.”
Using technology to combat social isolation has some inherent advantages. The older people surveyed said they liked how it saves them time and gives them flexibility in communication. Nine out of 10 said they were satisfied with technology, Chopik says.
Looking at technology a different way, it increasingly is being used to identify at-risk patients, but it is not as useful in identifying social isolation, Fink-Samnick says.
“If someone is landing in a hospital, then yes, someone should be assessing them to see if they live alone. This used to be a standard question,” she says. “A lot of new electronic health records have included social determinants and psychosocial factors as part of the assessment.”
But is this better than a case manager’s in-person assessment? Probably not, Fink-Samnick notes. “Some preliminary work being done says, ‘Sorry, but a basic assessment by a case manager or nurse, talking with a patient, is just as effective in determining social determinants of health.”
Fink-Samnick, Nelson, and Chopik offer these suggestions for how case managers can help patients overcome loneliness and achieve social connections:
• Assess patients for social isolation and loneliness. Hearing and vision problems, disability, estranged family, language barriers, mental health and substance use issues, and living in a new community all can contribute to social isolation and loneliness, particularly among older adults.
Case managers can assess patients for those qualities, particularly when patients have other signs of health risks, such as frequent hospital and ED visits, Fink-Samnick says.
“Social determinants and psychosocial factors should be part of patients’ assessment and risk stratification,” Fink-Samnick says. “The challenge is there often is such reliance on electronic health records and technology, but for social determinants of health some preliminary work needs to be done.”
This preliminary work might include a basic assessment in which the case manager speaks with the patient to determine whether he or she experiences social isolation, loneliness, and other social determinants of health to address.
• Identify barriers to social connection, including behavioral and physical health issues. “A high percentage of socially isolated patients have comorbid depression [and] anxiety and need a high level of intervention,” Fink-Samnick says.
When behavioral and mental health issues affect a patient’s feelings of social isolation, case managers can look for collaborative care programs for the patient.
“Look at what they need from a global perspective,” Fink-Samnick says.
If a patient’s isolation is caused by limited mobility, a case manager can encourage the patient to ask a family member or neighbor to visit him or her regularly, Nelson says.
“As people live longer, they are less likely to be able to drive, and if they live in a community without public transportation, then they will feel more isolated,” Nelson explains. “So if people don’t visit them, then they are very cut-off.”
Hearing loss and vision problems also contribute to the problem. An older patient could be cognitively intact but still isolated from neighbors because of these physical impairments. A solution might be to encourage the patient to live in an assisted living home where there are communal meals and community activities, Nelson adds.
• Find community resources for patients. Find out what is available for patients in the community, Fink-Samnick says.
It is important for case managers to stay informed and know where there are food banks, respite care, Meals on Wheels, and other resources.
“Could they be referred to a coalition that does medication reconciliation and sends someone into the home?” Fink-Samnick asks.
In addition to agencies that visit people’s homes, there are services that can take older people to healthcare appointments.
“About 50% of healthcare organizations have contracts with Uber Health or Lyft,” Fink-Samnick says. “Some of the connections are being made by payers; they’d rather pay for transportation than have someone readmitted to the hospital.”
“There are real benefits to patients being connected with support groups, which usually are run by social workers and psychologists,” Nelson adds. “There are online support groups, and there are ones you can physically attend, and these are helpful to people experiencing social isolation.”
Case managers also can help patients connect with volunteer opportunities and with senior centers, Nelson says.
Organizations like Stanford Healthcare also provide opportunities for social engagement. “We have an exercise program here, called Strong for Life, that is held a couple of times a week and it helps people reduce loneliness, increases stimulation, and brings a connection with others,” Nelson explains.
In cases where patients truly are isolated because of depression or other mental health issues, social workers can help by working with them to address their feelings of loss, depression, and loneliness, she adds.
• Reach out to families/neighbors when appropriate. “Case managers and social workers can help families realize how they can provide meaningful support to a loved one,” Nelson says.
One strategy is to ask the patient about the people listed as contacts on his or her chart.
“You have to be respectful of people’s boundaries,” she notes. “You need to engage them in a conversation so they can identify what might feel right for them, as there’s not one solution that will solve the problem of loneliness for everyone.”
Sometimes, the people on the patient’s contact list will be good connections. They might be family members who were just unaware that the patient needed more in-person support or phone calls. The contacts might include neighbors who, with a little nudging, could stop by to see the patient weekly or daily. But this could be problematic if the patient is not comfortable with these connections.
“There’s a difference between what we think of as loneliness and what patients perceive as loneliness,” Nelson says. “A patient might have three daughters, and you can say they’re connected with the patient, but you need to know a little more about the quality of that relationship. Does the patient feel that is a supportive relationship? Know when it’s a real connection.”
• Use technology also as way to connect. Some forms of technology can be too expensive for older patients, including smartphones and desktop computers. New technology also can be hard to learn.
But when patients have access to the internet and join online chat rooms and social media accounts, their quality of life can improve, Chopik says.
Case managers can help patients tailor social media use for their benefit. For instance, if a person’s motivation for getting online is to connect with old friends or meet new people and keep track of existing relationships, social technology, like Facebook, can be useful, he says.
“I would suggest they join Facebook, see if they do enjoy it, especially if they have mobility limitations and are confined,” Chopik says. “The great thing about technology is you can reach everyone all around the world and in your community.”
- 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.
- 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.
- Chopik WJ. The benefits of social technology use among older adults are mediated by reduced loneliness. Cyberpsychol Behav Soc Netw. 2016;19(9):551-556.
Loneliness and social exclusion can have a big impact on patients’ health and quality of life, and it is a problem that is compounded by deteriorating health as people grow older.
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