One in five older adults is socially isolated from family or friends, according to a University of Michigan study. This not only increases their mental and physical health risks, but it also contributes to a higher rate of mortality.
But make no mistake, social isolation is more than being alone or lonely, and addressing it involves more than just getting people to planned activities. Taking a deep dive into this issue now can result in creative programming; new community partnerships; and happier, healthier residents.
Social isolation, generally defined as a state of significant or total lack of contact with others, is a risk factor for morbidity and mortality. In fact, studies say it can be as detrimental to health as smoking, obesity, and lack of exercise. Social isolation is associated with decreased infection resistance, cognitive decline, depression, and dementia, among other health issues, and it can contribute to increased emergency room visits and longer hospitalizations.
Social isolation happens for a variety of reasons. Among the most common are hearing or vision impairments, as well as incontinence, mobility issues that make it painful or difficult to ambulate, and balance problems or other issues that cause a fear of falling.
Depression or anxiety also can contribute to isolation, and people who have suffered a recent loss and are grieving also may withdraw from others. Of course, sometimes isolation is mostly physical—such as someone living alone in a rural or remote area.
It’s All About the Baseline
Assessing and addressing social isolation is challenging, in part because it’s not one-size-fits-all. One person may be content to sit in his apartment and a read a book every night, while others may thrive on activities and relationships.
The key is to get to know each resident as an individual from day one. This can start even before someone moves in, says Esmerelda Lee, executive vice president and chief operating officer of Century Park, an affiliate of Life Care Centers of America, in Cleveland, Tenn.
“For each new customer, we use a social functioning questionnaire that addresses their social behavior, their typical daily routine, prior hobbies, social life, and work history. This gives us a really good baseline,” she says.
The form involves a checklist of pastimes, crafts/hobbies, games, sports, music/arts, reading, travel, religion, learning, and other activities that people can choose from as those they have been or would be interested in. It also includes three open-ended questions:
- What keeps you from participating in past or current hobbies or interests?
- Do family members have any particular skills/interests that they might be willing to share/volunteer in the community?
- What else do you want us to know about activities you might enjoy?
“We do this early before they move in, then we add to it over time,” says Lee. “Then we monitor changes in behavior and conduct quarterly assessments based on this questionnaire.” At the same time, she notes, “we work with our associates and teams in teaching them how to look at social cues and how issues such as loss of vision or hearing might impact the whole person. We train them what to look for when they go into residents’ homes/apartments and to look for behavioral changes.”
It’s essential to ask the right questions, agrees Michael Wasserman, MD, CMD, a geriatrician and president of the California Association of Long Term Care Medicine.
“Asking if someone likes vanilla or chocolate ice cream doesn’t really address if they like ice cream,” he says. “When looking at social needs, everyone is unique, and we have to get to know each person. You have to ask the right questions and listen to the answers.”
Among the most useful questions to ask, he says, include:
- How do you like spending your day?
- How do you like interacting with others?
- How do you feel about being alone?
- How do you feel about being in a large group?
“It’s not unusual to assume we know the answers to these questions. It takes listening to find out what type of social being each person has been and what their preferences are,” says Wasserman.
There also are formal tools, such as the Warwick-Edinburgh Mental Wellbeing Scales and the Duke Social Support Index, that can be useful. Sonya Sterbenz Barsness, MSG, a Virginia-based gerontologist and president of Sonya Barsness Consulting, uses a tool called About Me, created by Karen Stobbe at In the Moment (
see form).
“This helps us understand who someone is, what makes someone happy, and how that person likes to socialize,” Barsness says.
Getting baseline information is crucial, agrees Julie Walker, director of dementia care at Affinity Living Group. “You have to go back and examine what the person’s lifestyle was like before. You can actually push them into isolation if you don’t know who they are as individuals and what and how they feel and think,” she says. “You have to determine what is comfortable for them and how to build trust and relationships.”
One creative way to get information is to have volunteers come in to conduct interviews and collect life stories, suggests Barsness. Some of these can be consolidated in a binder that new employees can use to get to know the residents.
It might be surprising how much residents appreciate these lines of questions. As Barsness recalls, “I had one person tell me, ‘People are asking me all of these medical questions, but they’re not asking me about how I want to live.’” She says that some people may be more receptive and engaged than others. “If you hit a wall, try a different strategy. For instance, if a resident has a close relationship with someone on the housekeeping staff, have that person help ask some questions. All team members can be part of this conversation.”
Beyond Questions: Stop, Look, Listen
Awareness is key, as people often attempt to fly under the radar and hide the reasons behind their isolation. As Lee says, “People often want to be private and not call attention to themselves. We train staff to note if there is any deviation from someone’s typical routine.” Lee and her team also have started an education symposium series with family members and people in the local community. They are free to the public and designed to educate people.
Of course, it also is important to educate residents. For instance, they may not realize that Medicare covers an annual wellness check, says Kevin O’Neil, MD, CMD, chief medical officer of Affinity Living Group. They also may be afraid that acknowledging a vision, hearing, mobility, or other issue may lead to a loss of independence.
“They need to know that there is much we can do to help them and keep them active and engaged, even if they have a deficit or disability,” he says.
At the same time, some attending physicians may not be as familiar with inappropriate drugs in this population that can contribute to social withdrawal and isolation, so it is important to educate them. This includes tracking the use of antipsychotics and medications that may contribute to loss of balance, dizziness, diarrhea, or other problems. Then the facility’s medical director can identify and reach out to practitioners who are prescribing these medications.
A large part of addressing isolation is observation, watching for changes, and addressing them promptly, and all staff members play a role in this. However, the detective work doesn’t stop there.
Since vision and hearing problems often lead to social isolation, Lee says, “We host quarterly screenings. We have food and entertainment, and we partner with a local audiologist and ophthalmologist for a health fest.” Making this a fun event takes the pressure off, and most residents participate. The results can be powerful.
“We had one resident who had been very active at Bingo, coming out several times a week. Her attendance went down, then she stopped coming altogether. She wouldn’t tell us what was happening. She came to the health fest, and we discovered that she had a chronic ear infection that was affecting her hearing.” After treatment and follow-up with a specialist, her hearing returned to normal. “Now she is back to Bingo several times a week and doing well,” says Lee.
O’Neil agrees that sensory deficits and cognitive decline can cause people to start isolating themselves. Caregivers play a crucial role here, O’Neil says. They are perfectly positioned to recognize early changes in behavior, such as an avid reader who no longer picks up a book or a music lover who stops going to weekly concerts.
“If residents are dealing with a physical problem that causes them to be socially isolated, we need to recognize it as early as possible,” he says. “Then we need a care plan working with the family and interdisciplinary team to address the issue and get people more engaged.”
Seek Golden Opportunities
“There’s no silver bullet to address social isolation,” says Wasserman, and just getting someone involved in a program, class, or activity isn’t enough.
“It all comes down to purpose. Socialization is a proxy for purpose,” he says. Of course, purpose is individualized. Some people prefer activities they can do on their own time and their own schedule, such as making political calls for candidates. Other people may prefer working with others toward a mutual goal. For instance, there are initiatives where people raise and find homes for dogs, care for orphaned kittens, and prepare and serve meals for people who are homeless or homebound in the community at large.
In identifying activities that can increase socialization for an individual, it is essential to focus on that person’s abilities, rather than their disabilities. As Wasserman says, “Someone with dementia can help make a salad. It doesn’t have to look pretty or perfect. If we treat them like they are helpless, they start to act like it. If they don’t have a reason to get out of bed, they won’t.”
- Some other activities that can feed people’s sense of purpose include:
- Environmental volunteerism programs that let residents work with marine labs, or botanical or community gardens, can be appealing to those with a green thumb.
- Multilingual residents can teach a language to staff members, school children, or others.
- A resident who was a professional artist can teach painting or drawing classes.
- Interested, willing, able residents may welcome an opportunity to participate in research studies or projects. Vivian Miller, PhD, MSSA, LSW, assistant professor in social work in the Department of Human Services at Bowling Green State University, says, “I interviewed 190 residents in 11 facilities for a research project, and lots of them really enjoyed it because they want to make a difference and help. One resident, who was bedridden, told me later that if she could get out of bed, the first thing she would do is come to my graduation.”
Going Intergenerational
Intergenerational programs can be powerful. “We’ve been increasing volunteerism to bridge the generational gap,” says Walker. These efforts include residents “adopting” a third-grade class and being pen pals for young people in Czechoslovakia. “We give residents opportunities that they haven’t been exposed to before or remind them of happy experiences in their past,” she says.
Biologist, Author, and Educator
William Haseltine points to Swan’s Market Cohousing, an urban community building in California that houses residents of all ages, including older adults. The building features common meals, monthly parties, and a neighbors-helping-neighbors philosophy.
“There is so much that younger and older people can do for each other, and these relationships are mutually beneficial,” says Haseltine. Expect to see more of such efforts, he says.
In his book, “Aging Well,” Haseltine writes, “In the United States and internationally, there is a continuing focus on community supports and inclusive societies that allow older adults to remain active and engaged. This focus includes age-friendly cities, inclusive housing, and employment opportunities.”
Team members can engage people on a personal level, Barsness says. “There was a woman in one assisted living community. She kept to herself, and I was told that she couldn’t be part of things because she had dementia. I started talking to her, and I told her I was getting married. She lit up because she had been happily married, and talking about this brought happy memories,” she says. “I started a wedding planning group with other residents and asked her to join. She really enjoyed it, and we had some wonderful conversations. We need to remember that our residents still want to contribute to the world and make a difference. The wedding planning group gave this woman a sense of purpose and something to look forward to.”
Barsness also takes students from Georgetown University’s Masters in Aging and Health program to an assisted living community to meet with elders and ask them about psychological theories of aging and what growing older successfully means to them.
“We’ve had some wonderful discussions. The students enjoyed it and found it tremendously enlightening,” she says. The residents loved it too, she says. After all, “Who doesn’t want to be asked about themselves in a meaningful way? If you’re open to the answers, it’s amazing what people say.”
Elsewhere, Lee says, “One of our communities has partnered with an organization called Angels’ Wings, where residents help deliver meals to older people in their homes around the local area. “They really appreciate having another person their age come in and talk peer-to-peer with them. One woman was having trouble communicating with people, but she was able to hear and understand the resident who visited her.”
The importance of sense of purpose can’t be underestimated, says Lisa Marsh Ryerson, president of the AARP Foundation. “You need someone to be a purpose matchmaker for the community and connect residents with resources and opportunities to make a difference on their terms and according to their definitions of ‘purpose.’”
For example, she says, “Older adults volunteer as literacy tutors for children through the AARP Foundation Experience Corps program. We’ve learned that this is a meaningful connection for many people, and it improves their health outcomes.”
Failing to make such connections comes at a high cost, says Ryerson. “Social isolation adds nearly $7 billion to Medicare spending each year. If we don’t address social isolation, we are missing an opportunity to address a public health issue, and we’re losing out on the contributions older adults can make every day.”
Night and Day
Environmental issues could contribute to social isolation. For instance, residents who lived in Minnesota their whole lives may have trouble adapting to the Florida heat. At the same time, the concept of circadian lighting, electric light used to support human health by minimizing the impact of electric light on the human circadian rhythm, is showing promise.
The circadian rhythm is a 24-hour internal clock that receives signals from the eyes to determine when it’s daytime and nighttime. Affinity has begun using this type of lighting. Walker says that while they don’t have documented evidence, staff report that residents have started sleeping better, waking naturally, and increasing their socialization. Staff also felt more energy, she says.
Consider other environmental factors that can contribute to social isolation:
- Safety (residents feel like they aren’t safe when they leave their room, apartment, or home);
- Ease of navigation (how quick and easy it is to get from one place to another);
- Air quality (such as pollution or humidity);
- Noise (such as nearby construction or traffic);
- Lack of transportation or inconvenient location of grocery stores, pharmacies.
Finance is another issue that can contribute to isolation and shouldn’t be ignored. “Many older people, especially those with multiple chronic conditions, need supportive help, including efforts to address social isolation,” says Haseltine.
In “Aging Well,” Haseltine says, “The unsustainability of medical costs is an incentive for the Centers for Medicare & Medicaid [Services] to support more efficient, less costly, and better quality systems of care for the sickest people. The financial burden is also borne by people living with multiple chronic conditions through out-of-pocket costs and the high price of prescription drugs.
“To properly and sustainably meet the needs of older adults, providers must challenge fragmented and complex care and social support systems and implement coordinated person-centered care across a variety of care settings and providers,” he says.
Not all of these may be easy to solve. However, there are creative ideas out there, such as ProMedica HCR ManorCare’s Meals-to-Go program. This ensures that patients who are discharged to home from skilled nursing facilities (SNFs) have enough food to eat. It has been such a success that it will go national at all of the company’s SNFs by the end of 2020.
What Next?
Monitoring various data can help track changes that suggest an isolation problem, as well as track how well efforts to address it are working. For instance, Lee says, “Century Park team members track how many meals we’re delivering to homes/apartments and how many residents are missing meals in the dining hall.”
Walker notes, “One of our best practices is to have activities directors monitor social involvement and identify those who aren’t engaged or participating.” Elsewhere, metrics such as weight loss, malnutrition, use of antidepressants and sleep medications, and readmissions or emergency room visits can suggest increases or decreases in isolation.
When a team works together to address isolation, members can cover the waterfront and make sure that all issues, concerns, and problems—physical, emotional, mental, and spiritual—are identified and addressed promptly for each individual. The result may not mean more people at game night or weekly concerts, but it will mean that each person enjoys a healthy level of engagement that satisfies their wants and needs.
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.