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

Discussion

Public health professionals are in a unique position to reach those individuals at highest risk of social isolation. The few interventions reported in the literature have shown little effectiveness; however, small regular group meetings with an education focus were among the most effective interventions for decreasing social isolation (Cattan et al., 2005). Given the paucity of effective interventions, assessment and prevention of social isolation should be the focus of the plan of care for public health professionals. As the number of older adults continues to increase, so will the number of those affected by social isolation. Therefore, assessment of social isolation, which has been demonstrated both to be associated with and to lead to numerous negative health outcomes, needs more attention from public health professionals. A specific understanding of risk factors and associated variables of social isolation provides public health professionals with important areas to inquire about during their assessment of older adults. Assessment of older adult communities, such as conducting a needs assessment, is an important aspect of health surveillance by public health professionals. Public health professionals must assess those who make up their communities in a holistic manner, focusing not only on physical factors, but also on psychosocial factors, particularly social isolation.

The literature suggests that social isolation is not simply a condition that leads to health co-morbidities, but rather it is part of a cascade of complex psychosocial factors that interact together to cause negative health outcomes in older adults. The cascade of negative health outcomes in older adults begins to interact with the various factors outlined in this review article, such as living alone (Havens et al., 2004; Iliffe et al., 2007), declining cognition (Havens et al., 2004; Iliffe et al., 2007), and difficulty with activities of daily living (Havens et al., 2004; Iliffe et al., 2007; Wenger & Burholt 2004). Physical factors, in conjunction with subjective factors, such as lack of sense of belonging and feeling deficient in the quality of social relationships, are important attributes of social isolation. Any comprehensive holistic assessment of this condition performed by public health professionals must consider these key attributes. One way to assess for these attributes is to use appropriate measures, such as the LSNS-6. To assess for key attributes of social isolation that are not covered by this measure, specific questions regarding negative health exchanges and subject components should be asked. Assessment of these important areas will open the channels of communication between public health professionals and the communities they serve with the goal of assessing social isolation with the goal of mitigation and secondary prevention.

Implications for Assessment of Social Isolation in Primary Care Setting

Due to the psychosocial nature of social isolation, there is a unique opportunity to complete a social health assessment in conjunction with other common assessments, which may help to offset the additional time needed during a visiting nurse visit. For example, a public health professional could inquire about family and friends and ask other pertinent questions while obtaining routine objective health measures such as vital signs. By asking about family, friends, and neighbors, as well as about feelings of social isolation, public health professionals have the opportunity to increase the clinical bond and to collect important information.

Another opportunity to obtain information related to social isolation is to print out an instrument (i.e., the LSNS-6) and leave it with the client. This can be done while the public health professional is performing other functions. When time permits, for example, during a follow-up visit, the public health professional can return to review and answer questions about it. Having the client answer questions related to the instrument may also promote communication and reflection about specific problems. This information about family and friends could also be an important factor of discharge planning when considering social network members available for caregiving or transportation assistance. Information with dual purposes may be seen as a priority for busy public health professionals.

Identification of clients who are at high risk for social isolation will allow case managers to work with nursing staff to develop care plans aimed at preventing social isolation in these clients. Those clients who are deemed to be socially isolated could benefit from interventions to return to a state of social integration, and future visits could focus on prevention of future occurrences of social isolation.

Directions for the Future

Public health professionals value the preventive benefits of a thorough holistic assessment, which should include an assessment for social isolation in older adults. It is difficult enough for public health professionals to manage the client/case load without adding extra assessments, which are seen to be of little benefit to their clients. Therefore, public health professionals must be completely confident that adding extra assessments is worth the time it takes to complete them in terms of the benefit to their clients. Based on the evidence from the literature reviewed herein, the hope is that public health professionals will see that the benefits of identifying social isolation in their older clients outweigh the cost of time of assessment. This quick assessment could be a part of the discharge planning from hospitals or part of the admission planning for community health nurses. Additionally, public health professionals involved with community outreach programs have an opportunity to assess community members, especially the elderly, for social isolation. Aside from including common risk factors for social isolation, this assessment would include a rapid screening tool such as the LSNS-6, with additional follow-up questions regarding subjective attributes.

Hospitals and community health agencies that incorporate a social isolation assessment into their plans of care will benefit from a healthier population of older adults. Through assessment and identification, at-risk older adults can be referred to community resources aimed at mitigating social isolation.

Hospitals and community health agencies that make identification of social isolation a priority can demonstrate how identification leads to referrals for interventions. If these interventions lead to prevention of numerous negative and costly health problems, such as depression and falls, insurance companies are likely to reimburse for this assessment. The eventual goal is to develop effective interventions that lessen social isolation; however, the first important step it to assess and identify those at risk for this condition.

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