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

Assisted-living Case Study

Beth and William Moser, a married couple of 60 years, had been living in an assisted-living facility for 3 years. Beth was 83 years old with advanced Alzheimer disease and comorbidities that included obesity, diabetes, arthritis, hypertension, deep vein thrombosis, and peripheral vascular disease. William, her husband, was 88 years old, with a history of atrial fibrillation, anxiety, depression, and hearing loss. Beth required significant assistance from her husband with toileting, bathing, and dressing. She had experienced frequent falls over the last 5 years, with progression over the last 3 months. Their 3 daughters alternated daily visits to assist with care needs, housekeeping, and care of their cat. Occasionally, the daughters took the couple out on car rides, to restaurants or to their house for family gatherings.

Pandemic Challenges to Assisted Living

During the COVID-19 pandemic, visitation at the facility was no longer allowed, and if residents left the premises for any reason, they were to be quarantined to their room for 14 days upon return. William was a very sociable person and found their living quarters very small and confining. He enjoyed daily exercise class, bingo, and conversations/meals with the other residents, which were still allowed during the pandemic-imposed restrictions.

During this time, Beth developed a deep vein thrombosis and became incontinent most of the time. She experienced more confusion; was often awake and up at night packing to go home, asking for her parents; and frequently experienced crying episodes. Beth became very distressed and angry with care staff when they directed her in activities she was not interested in doing. Confused and not understanding why her daughters were unable to visit, Beth became increasingly argumentative with William. His lack of clear understanding of Alzheimer symptomatic progression led him to believe that his wife was intentionally antagonizing him. After much discussion via phone with the family and their care provider, William agreed to a hospice referral for Beth. Unfortunately, hospice visits were limited secondary to COVID-19 restrictions. Any form of respite care off-campus would force room isolation for both Beth and William for 14 days upon her return. Isolation did occur once when another client in the facility was diagnosed with COVID-19, leading William to become increasingly agitated, anxious, and depressed himself.

Additional challenges experienced during the pandemic included cerumen impaction in William's ears, which made communication via phone calls with family and providers very difficult. The couple did not own a computer and therefore was unable to do video telehealth. Family visits through the window were arranged but William would forget or have difficulty getting Beth organized and moved to the window. Their small room became increasingly in a state of disarray, adding to the agitation of William. He became less patient with his wife and experienced overwhelming depression. William began exhibiting nocturnal confusion, leading him to use the call light to summon care staff more often, as well as frequently phone his daughters during the night. Neither Beth nor William was sleeping well, and both were feeling very fatigued and isolated. They were unable to experience the full scope and benefit of hospice services, social work, or spiritual care due to the COVID-19 visiting restrictions imposed at the assisted-living facility.

The family became very anxious about meeting their parent's care needs because they could not personally visit them. Neither Beth nor William understood the scope of the pandemic and imposed its associated restrictions. William was unable to communicate well and would often state, "Things are bad," but not be able to clearly articulate why. After 3 months of isolation, the assisted-care facility began to allow one daughter to visit her parent's room daily. William's depression and confusion lessened considerably with the light housekeeping, removal of cerumen from William's ears, and personal care for both Beth and William that their daughters were able to provide as they had prior to the COVID-19 pandemic.

Beth was eventually moved into memory care as her care needs became too complex for the assisted-living arrangement and William was unable to take care of her alone. Now, Beth is having difficulty adjusting as she cannot have visitors. She is confused with "window" visits and has become more confused since moving. William also became lonelier. Even though there was some relief and decreased care burden, he is now living alone and is anxious about his wife whom he cannot visit. To address his loneliness, the family moved William from assisted living to his daughter's home, believing that the risks from social isolation outweighed risks from him contracting COVID-19 in the home setting.

Recurring Themes of Social Isolation in Case Studies. Although these patients received care in 3 separate locations, the impact of COVID-19 restrictions and social isolation on each patient is evident. While the influence on the individual may have been somewhat expected, the consequences with the family and the delivery of care were not anticipated.

Individual Challenges. In all cases, these patients were removed from their advocates, resulting in a loss of autonomy and independence and an altered support system. National guidelines regarding restrictions in number of patient visitors in all settings and the shift to virtual visits were barriers to the delivery of personalized health care. Because of changes in health care policies, patients often received less-than-optimal care. Finally, limiting or changing the environment or community of any person may precipitate social isolation and induce loneliness, and the potential impact on an older adult is disquieting. The patient may be at higher risk of negative outcomes when their advocates are removed, their environment or support structure is changed, or their autonomy is taken away. The true degree of influence on patient outcomes is unknown.

Family Challenges. In each of the presented scenarios, the most significant issue affecting the family was impaired communication. This was observed as a miscommunication between the family and health care team as well as the inability of the patient to communicate with their family/support network. This alteration in communication led to frustration and increased stress. Each case scenario also highlighted the removal of or limited access to resources. The lack of social work, chaplaincy, health aides, and even home hospice present challenges for both the patient and the family and may contribute to social isolation.

Health Care Challenges. Health care providers always aim to provide the best care; however, in each of these cases, the health care delivery was altered because of the changes imposed as a result of the COVID-19 pandemic. Some examples include having all family meetings held over the phone, bedside nurses providing sole support, and having all patient medical visits by video/phone. The loss or alteration in advocacy and limited access to previously available resources required the providers to be creative in meeting care needs. The sudden integration of technology and transition of virtual care delivery caused an extraordinary burden for providers, further challenging the delivery of quality health care. The loss of patient-centered, holistic, and personalized care left patients, families, and providers feeling as though there were missed opportunities for better interactions and treatment.

Opportunities for Intervention. Examination of these cases allows the identification of opportunities for interventions to improve care delivery to patients and families by providers in response to the changing health care climate given the ongoing and evolving pandemic. The following opportunities were identified in the previously mentioned scenarios as interventions that could potentially limit the negative impact of social isolation on health (Table).

Patient-centered Opportunities

All adults, but especially in the geriatric population, benefit from daily structure or routine, often creating a sense of purpose. Patients need a reason to get up in the morning. Scheduled phone calls, facilitation of social connections, a specific time for exercise or getting outside, and new skill development have offered patients opportunities to feel more connected to the outside world.[14] With the availability of technology in the form of devices and applications, patients have the ability to interact with those beyond their home or environment despite the restrictions on visitors. Telehealth or video visits with the provider allow the patient to maintain their relationship with their provider during the pandemic.[1,15] Likewise, video chats may be easily accessible to individuals and allow for visual stimulation with a decreased sense of social isolation. Video chats may need to be facilitated by staff for patients who are unable to maneuver technical devices. Throughout the pandemic, communities have displayed creativity in order to decrease the social isolation of individuals. Acknowledgement or recognition of milestones or special events has the potential to increase feelings of connectedness. Examples include having parades in front of houses to celebrate birthdays or special events, online religious services, opening windows and blinds to let daylight in, and visits with family through the windows/screened porches. Encouraging patients to continue engagement in activities that were previously important to them also decreases feelings of social isolation.

Family-centered Opportunities

Families can also benefit from some of the previously listed interventions. Video chatting, scheduled phone calls, and engagement in online/application supported games (eg, HouseParty, Quiz Up, and Words With Friends). Ensuring that family members continue to be involved with care as they were prior to pandemic visitation restrictions is essential to decreasing the risk of social isolation.[12,14] Family involvement in health care visits can be accomplished with video conferencing or group calling.[1] Unfortunately, technology glitches, simultaneous use of the electronic medical record, and limited available bandwidth may challenge family involvement in telehealth visits. Ultimately, ensuring ongoing communication between patients and their families, allowing extra visit time for families to voice their questions or concerns, and encouraging intergenerational exchanges can limit the risk of social isolation and promote social cohesion.[15]

Health Care–Centered Opportunities

As many providers are discovering, medically enforced social isolation has heightened barriers to care and threatens the overall well-being of patients. This alteration in delivery of care in all settings offers opportunities to be creative with patient interactions and the services offered. Continuing to connect with patients on a regular basis, scheduling follow-up with shorter intervals, and frequent discussion of quality of life allow providers to assess the patient's risk of social isolation and potentially avoid poor health outcomes.[10,12] As telehealth visits may also induce feelings of social isolation, patient and family education of risk and concerning symptoms can encourage self-monitoring for changes in mental health and other risk factors.[10,12,15] Connecting patients with online services such as synchronous/asynchronous religious activities, virtual physical therapy, and contact-free pet therapy can offer an additional layer of social cohesion and support.[15] Finally, encouraging autonomy whenever possible allows the patient to feel valued and maintain a sense of control when so many things are in flux.