A Review of Social Isolation

An Important but Underassessed Condition in Older Adults

Nicholas R. Nicholson

Disclosures

J Prim Prev. 2012;33(2-3):137-152. 

In This Article

Abstract and Introduction

Abstract

Social isolation is a major and prevalent health problem among community-dwelling older adults, leading to numerous detrimental health conditions. With a high prevalence, and an increasing number of older persons, social isolation will impact the health, well-being, and quality of life of numerous older adults now and in the foreseeable future. For this review, a series of literature searches of the CINAHL, PsycINFO, and Medline databases were conducted, using the key words "social isolation," "social networks," "older adults," "elderly," "belonging," "perceived isolation," "social engagement," "social contacts," and "social integration," for the period of 1995–2010. The results show that there is an overabundance of evidence demonstrating numerous negative health outcomes and potential risk factors related to social isolation. However, there is scarce evidence that public health professionals are assessing social isolation in older persons, despite their unique access to very socially isolated, homebound older adults. Additionally, few viable interventions were found; therefore, it is advisable to focus on the prevention of social isolation in older adults. Public health professionals can take steps toward increasing the early assessment of social isolation and referring at-risk individuals to available community resources in order to prevent social isolation or further isolation, which would serve to reduce the numerous negative health outcomes associated with this condition.

Introduction

Social isolation is a major health problem for older adults living in the community, leading to numerous detrimental health conditions. Social isolation is defined as "a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts and they are deficient in fulfilling and quality relationships" (Nicholson, 2009, p. 1346). Current estimates of the prevalence of social isolation in community-dwelling older adults indicate that it is as high as 43 %, ranging from 10 to 43 % (Nicholson, Molony, Fennie, Shellman, & McCorkle, 2010; Smith & Hirdes, 2009). Social isolation has been demonstrated to lead to numerous detrimental health effects in older adults including increased risk for all-cause mortality (Eng, Rimm, Fitzmaurice, & Kawachi, 2002), dementia (Fratiglioni, Paillard-Borg, & Winblad, 2004), increased risk for re-hospitalization (Mistry et al., 2001), and an increased number of falls (Faulkner, Cauley, Zmuda, Griffin, & Nevitt, 2003). If social isolation is detected early, future morbidity and mortality could be avoided through prevention and mitigation efforts. However, social isolation is not routinely assessed in primary care settings, and therefore often goes undetected.

The number of adults aged 65 years and older is expected to more than double within the next 25 years (He et al., 2005). By then, older adults will represent 20 % of the US population, which translates into a total of 71.5 million people (Centers for Disease Control and Prevention & The Merck Company Foundation, 2007), and this segment of the population will continue to grow quickly. Currently, the majority (90 %) of older adults live in the community (He et al., 2005). With a prevalence of over 40 %, and the sheer number of older persons projected to increase exponentially in the near future, social isolation will likely impact the health, well-being, and quality of life (Lim & Zebrack, 2006) of numerous older persons now and in the foreseeable future.

Patient care efforts should be focused on assessing and improving not only an older person's physical well-being, but also their social well-being. According to the World Health Organization (WHO), health is defined as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO, 2003). Holistic care is an important component of nursing; therefore, it is important to take the available evidence and use it in practice to improve the care of older adults. In community health settings, the opportunity for primary care including the prevention of social isolation in at-risk groups has the potential to make the biggest difference through early assessment. This practice includes administration of a risk profile. For example, when older adults are admitted to a visiting nurse service, community health nurses are tasked with addressing a specific diagnosis or diagnoses with their skilled nursing care. However, during these visits, the nurses have a unique opportunity to provide primary care prevention of social isolation.

The specific factors encompassed in this review represent the essential aspects of social isolation that were deemed most useful and practical for public health professionals in everyday situations. This important knowledge is needed for public health professionals to have a basic overview and understanding of social isolation and its assessment. An astute public health professional with knowledge of social isolation can assess and identify it early, leading to the prevention of the various adverse health outcomes associated with it. A review of the known negative health consequences of social isolation will allow public health professionals to understand the importance of assessing social isolation as a first step toward secondary prevention and mitigation.

This review of the variables associated with and specific risk factors for social isolation outlines important potential signs that public health professionals should look for during their interactions with clients. These signs could provide important insight into which older adults may be at risk for social isolation. The variables and risk factors identified in this study can be used to construct a risk profile that is useful for public health professionals to assess social isolation.

Negative health exchange is an important factor of social isolation that is typically not assessed. Older adults who are burdened with relationships that provide negative health exchanges may need special consideration during the assessment phase. In these individuals, a greater number of social relationships is not necessarily better. Rather, the overall quality of these relationships is critically important. Inquiring about these types of relationships during an interaction with clients is an important step in determining the potential impact of negative health exchanges.

Suggestions about specific assessments indicating social isolation are also presented to provide public health professionals with clinically relevant screening tools. Quick screening instruments may provide useful information regarding social isolation status given the reality of time-limited clinical interactions between public health professionals and their clients. An older adult with a positive screen for social isolation would require additional assessment to determine the severity of social isolation. Currently, there is no specific, focused assessment formula available for older adults with a positive screen for social isolation. Because of this deficit, public health professionals may want to concentrate their focused assessment on the provided specific risk factors and associated variables. By focusing on these provided risk factors, public health professionals will be able to judge the severity of social isolation in their clients and the potential immediate and long-term health risks posed by it. Time and effort for follow-up assessments should be considered when planning for the care of clients who are deemed to be socially isolated.

Public health professionals who have assessed older adults as being socially isolated may benefit from a brief review of interventions that have been shown to be effective in this population. Public health professionals should refer such clients to available resources, such as group settings in which social connections can be made, in an effort to mitigate social isolation. Additionally, public health professionals who are responsible for or are interested in developing programs for their community with the goal of reducing social isolation may find the suggestions here useful as a starting point.

The purpose of this review article is to provide public health professionals with pertinent knowledge of social isolation in older persons and to offer practical suggestions for assessing social isolation in this population in order to prevent the numerous negative health outcomes associated with this condition. This is accomplished through an extensive review of the published literature and a presentation of clinical applications for the assessment and identification of social isolation in community-based primary care settings. Public health professionals, such as visiting community health nurses, have a unique opportunity to reach the most socially isolated (homebound) clients in their homes. Clients at high risk of extreme social isolation may not otherwise be seen by health care professionals. Socially isolated older adults may lack the necessary resources or knowledge of their condition to actively seek out assessment from outpatient community-based primary care providers. Therefore, a simple, quick screening process initiated by public health professionals who are empowered with knowledge of the significance of social isolation can help identify at-risk clients. By assessing and identifying social isolation, public health professionals may be able to prevent or reverse many of the negative health outcomes associated with this condition.

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