COVID-19 Shines a Spotlight on the Age-Old Problem of Social Isolation

Karen Harden, DNP, AOCNS; Deborah M. Price, DNP; Heidi Mason, DNP, ACNP-BC; April Bigelow, PhD, AGPCNP-BC, ACHPN


Journal of Hospice and Palliative Nursing. 2020;22(6):435-441. 

In This Article

Literature Review


Social distancing and physical distancing are defined as intentionally creating space between people or limiting face-to-face contact for the purpose of decreasing the spread of illness.[1] Staying home, avoiding social activities, and visiting loved ones only through technology are ways social distancing is being practiced today.[1] As a developing standard of practice, hospitals, health clinics, and long-term care facilities are now significantly limiting visitors, separating and isolating residents and patients, and conducting many important life-care decisions through virtual conversations.[2] Loneliness is defined in many ways but essentially involves a lack of psychological connectedness with another "being," resulting in emotional distress and self-perceived negative feelings.[3] The literature provides a consistent position not to use loneliness and social isolation interchangeably. Although loneliness and isolation are similar concepts, they are different and require different strategies to alleviate.[3] For example, isolation denotes being alone without anyone else with you, focusing on the lack of physical presence of another human being.[4] It is possible to make a conscious decision to be alone, creating a controllable, positive situation of solitude. Conversely, loneliness is often viewed as negative and uncontrollable.[4] Ishmuhametov[5] argued that "…the main difference between the notion of 'loneliness' and 'solitude' lies in the fact that the latter is not connected with the negative emotional evaluation of a state." Whether these negative feelings are anticipated, real, or imagined, they can have the same psychological and physical impact.[5]

Impact on Physical and Mental Health

Loneliness and social isolation are risk factors for morbidity and mortality with outcomes comparable to other risk factors such as smoking, lack of exercise, obesity, and high blood pressure.[6,7] Loneliness is associated with decreased resistance to infection, cognitive decline, depression, and dementia.[6] Further complicating these factors, institutionalized adults are also at higher risk of developing infections due to close-quarter living and weakened immune systems.[8] Additionally, living alone is associated with an increased number of unplanned hospitalizations for older people.[9]

People tend to feel anxious and unsafe when their situations change, which ultimately influences their mental health.[10] In the case of mass quarantine, as with COVID-19, people may experience escalating fear and anxiety, social isolation, feelings of being trapped, and loss of control, all of which can potentially exacerbate both physical and psychological conditions.[10] Practical steps to managing mental health disorders during a pandemic include managing media consumption, understanding official communications, ensuring daily exercise, maintaining proper distancing, and preserving social connectedness.[10]

Assessment to Determine Risk During COVID-19–Related Isolation

It is clear that older adults are already at risk of poor physical and mental health outcomes related to social isolation and loneliness, and COVID-19 has exponentially increased that risk. In addition to the usual impact of social isolation and loneliness on older adults, the imposition of a quarantine may exacerbate negative feelings induced by fear of infection, frustration and boredom, inadequate supplies, misleading information, and financial burden.[11] The use of assessment skills in a holistic framework is essential to evaluate risk of changes in health in order to provide quality care during isolation.[12] Baker and Clark[12] suggest that their biopsychopharmacosocial model is a clear framework to address the risks for people in isolation. It examines four domains of health within the context of the environment including (1) biological (personal hygiene, mobility, nutrition, and chronic symptoms), (2) pharmacological (access to and compliance with medications, use of street drugs), (3) social (access to shopping, care support, availability of technology, social activities), and (4) psychological (mental health, recent losses, socioeconomic status).[12] Risks can also be considered at different levels such as (1) individual (personal characteristics that make a person vulnerable and major life changes), (2) relationship (type of social network and frequency of contact), (3) community (high crime, low income, limited services, and public transport), and (4) societal (lack of social cohesion, marginalization).[13] Thus, isolation's impact on all of the domains underscores the need to assess risks beyond the individual in an effort to identify the full scope of potential interventions.

Interventions for Well-being During Isolation

Interventions should be tailored per person and based on their distinct needs and the degree of experienced loneliness.[14] Generally, interventions should be in the form of reaching out to lonely individuals, understanding the nature of their loneliness, and supporting individuals with care and access to services.[14] This access can be in the form of one-to-one interventions, group interventions, or technology-based or service provision.[13,14] Themes for interventions may consist of (1) social facilitation interventions, (2) psychological therapies, (3) animal interventions, (4) befriending interventions, and (5) leisure/skill development.[14] Specific technology-based interventions can include telephone befriending services, virtual pets, online activities or games, and/or chat room discussions.[14] Hoffman et al[15] suggest reimagined clinical and community supports in the form of home care support, telehealth technology, and intergenerational exchanges to promote societal cohesion.

Delivery of Care During a Pandemic

The delivery of palliative care in the inpatient, clinic, home, and long-term care settings has met new challenges during the COVID-19 pandemic, leading hospital systems and palliative care teams to creatively reestablish best practices for patients and themselves.[16] Six essential components to quality palliative care, regardless of location, include integrated teamwork, management of physical symptoms, holistic care, caregivers who are competent and caring, timely care, and patient and family preparedness. These characteristics set palliative care apart from other medical specialties.[17]

Telemedicine has been an integral strategy to provide home and clinic care for patients who are sheltering in place and to connect with family members of patients who are hospitalized and not allowed to visit.[16] Telemedicine and virtual visits can be challenging when patients or families are not computer savvy or can only manage a phone conversation. Further, they require a specialized and diverse skill set not previously highlighted in provider curricula that comprised communication and assessment tools that can be readily used during virtual visits.[16]

The following case examples highlight the impact of the pandemic in 3 different locations, prompting consideration of novel and unique interventions to provide quality health care and assist in mitigating loneliness and social isolation. All patient names have been changed.