Social Isolation and Loneliness:
A Physician’s Perspective “Love is the oldest medicine.”
Dr. Vivek Murthy, former US Surgeon General What is "health"?
“Health is a state of complete physical, mental, and social well being.”
The World Health Organization
“The social determinants of health dwarf the effects of the entire medical care system.”
Dr. Donald Berwick, The Institute for Health Care Improvement Social Isolation and Health
• Death - increased likelihood of death about 30% to 45%
• Risk Factor - equivalent to 3/4 pack of cigarettes per day long term
• Disease - increased risk of dementia, diabetes, heart disease, cancer, hospitalizations, falls, re-hospitalizations
• Expensive – Greater than $7 billion in medical costs per year (similar to high blood pressure, worse than arthritis) Example 1
AJ is 68 y/o male amputee. He lives alone and has no close friends or family in the area. He presented with diabetes in poor control, hypertension, and mild chronic kidney disease.
• His diabetes and hypertension were brought under excellent control.
• However, he failed to return for follow up. He also did not follow up with a referral to the nephrologist. He stated he would come in for lab tests but had issues with transportation.
• By the time he returned, his diabetes and hypertension had again elevated.
• He was found to be in chronic renal failure. He is now on home dialysis. Example 2
PR is a 75 y/o male with diabetes, hypertension, high cholesterol, obesity, COPD, fatty liver disease, and arthritis. He lives alone; his daughter lives in another state.
• Diabetes, hypertension, and cholesterol brought under control with our team. He stopped exercising after loss of access to a swimming pool. He spends most of his time on the computer.
• He did not respond to outreach for labs over a 6-12 month period.
• When he did come in, his diabetes and blood pressure were not well controlled, he had gained weight, he had developed a peripheral neuropathy, a neglected toe infection, and was at risk for a toe amputation. Who’s at risk? “All the lonely people - where do they all come from?”
• Women - Longer life expectancy 81 vs 76 years
• Older - 1/3 of older adults say they are lonely - prevalence rates as high as 43% on older adults
• Lower socio-economic status - Poverty, working class, etc.
• Marginalized groups, race (black >white), LGBTQ, etc.
• People with mental health impairments
• Alcohol and drug dependence Who’s at risk? “All the lonely people - where do they all come from?”
• People with physical disabilities (e.g., obesity, vision and hearing impairment, incontinence, insomnia, chronic illness)
• Life changing event - Retirement, loss of primary family member or friend
• Environment - Unsafe neighborhoods, lack of public transportation
• Social issues - Few relatives, shyness, no children, death of spouse What’s a doctor to do? Evidence
Preventing social isolation and loneliness among older people: a systematic review: Cattan et al.:
• 9 out of 10 effective interventions were group activities with education and support input.
• Best programs: where members were empowered to co-create and develop the program.
• Only a third of interventions were successful. What’s a doctor to do? Prevention
• System for screening all seniors: Total Health Assessment
• Incorporate “screening” as a “vital sign”
• Prevent falls - counseling, physical therapy, home assessments, exercise programs
• Provide grief counseling and support groups
• Support patients at risk What’s a doctor to do? Screening
• We now screen for many conditions: cholesterol, hypertension, cancer, smoking, alcohol, depression, obesity, exercise, food insecurity, driving safety, and more recently - social Isolation.
• In order to qualify for screening - a problem has to “SCORE” (Sneaky, Common, Ornery, Recognizable, and Effective treatment when caught early [cost and outcomes].)
• Tools for Primary Care: LSNS-R 6, Duke Social Support Index, R-UCLA, etc. What’s a doctor to do? Screening Tool Examples
• The Total Health Assessment: How often do you feel lonely or isolated from those around you?
• UCLA Screen: Loneliness: How often do you feel: (1) left out ? (2) isolated? (3) lack of companionship?
• Social Isolation: (1) number of family members within one hour travel that you can depend on or feel close to. (2) number of times in the past week that you spent with someone not living with you. (3) number of times in the past week you spent talking with friends or relatives on the phone. (4) number of times in the past week you spent with clubs or groups. What’s a doctor to do? Medical Interventions
• Treat medical conditions that impair social interactions
• Hearing aides
• Medication and interventions for incontinence
• Cataract surgery/eye care
• Weight loss programs
• Mental health treatment (therapy and medication)
• Substance abuse treatment (counseling, medications, support groups) What’s a doctor to do? Counseling/Referral
• Emphasize - the value of social connectedness
• Explore - understand what the issues are for this patient and what the barriers and opportunities are for change
• Educate – handouts may be helpful
• Encourage participation – joining a social group (Silver Sneakers, Senior Centers, etc.)
• Enlist support – social services, therapist, community resources, etc.
• Elicit buy in – collaborate on a commitment to taking the next step What is currently being done in one healthcare system?
• Kaiser Permanente:
• Screening: Total Health Assessment - all patients 65 y/o and older
• Counseling: any positive screen get’s an outreach call, counseling, and follow up
• Silver Sneakers Programs
• Risk factors assessed at each visit Where There is Hope
• Social isolation and loneliness is a societal and public health issue.
• The medical system can be on the front lines of identifying those at risk and suffering from this social/medical situation.
• Doctors, nurses, physical and mental health therapist can be enlisted to be part of a much larger team of professionals, advocates, and planners to help address this issue in a holistic manner. Where There is Hope (cont.)
• Health is not simply the absence of disease. It is the well being of the individual and the environment of which they are apart.
• It exists on a physical, mental, social, spiritual, and environmental level.
• And it includes all of us. . . .