Ageing in networks : living alone but connected

To the Editor: The coronavirus disease 2019 (COVID-19) pandemic and social distancing are transforming the way we interact. Before the pandemic, national studies reported 1 in 4 older adults were socially isolated and more than 40% experienced loneliness. Decades of observational studies have demonstrated the long-term negative health outcomes of social isolation and loneliness.1, 2 The COVID-19 crisis has exacerbated these challenges, with worsening social isolation and loneliness among those who live alone or are frail and even declines in the well-being of older adults with previously active or healthy social lives. Community centers for older adults have closed, nursing homes have terminated visitation, and grandparents are unable to visit their grandchildren. Initial hopes that such restrictions would be temporary are now giving way to a need to prepare for managing the unintended consequences of prolonged social distancing and the associated impact on the health and well-being of older adults. We present an approach to identify older adults most at risk during prolonged distancing and suggest strategies that could ameliorate the effects of sustained social distancing. Although the term social distancing has been widely used during the COVID-19 pandemic to describe keeping space between ourselves and others outside of our homes, public health recommendations have increasingly shifted to using the term physical distancing. Regardless of terminology, the impact on well-being among older adults is variable due to differing abilities to maintain social connections while physical distancing. Individuals who are homebound, depressed, or cognitively impaired may struggle to adapt to physical distancing because of reliance on in-person care and interaction. In contrast, many older adults may successfully adjust to this new reality with support from community organizations, friends, family, and/or neighbors. Clinicians should monitor whether or not these support systems are sustained. This is certainly not the time to overhaul clinical measures or deploy lengthy surveys. However, we suggest assessing a few focused measures of social connections in addition to common geriatric assessments to identify individuals at risk who may have increasing difficulty finding help with activities of daily living or instrumental activities of daily living, or even maintaining essential needs (ie, food, water, and shelter). Each domain can be assessed through a single question. First, older adults should be assessed for loneliness. Contrary to common practice, it is best not to ask the direct question "Do you feel lonely?" due to concerns for underreporting and stigma with self-identifying as lonely.3 Instead, individuals should be asked if they feel isolated, they lack companionship, or feel left out, as is done in several loneliness questionnaires. These responses represent an overall indicator of whether social connections are adequate and may predict risks of future psychological distress. Loneliness is frequently unrecognized because it can occur even when older adults are married or surrounded by friends or family. Second, individuals should be assessed for their perceptions of social support by asking, "How many people do you feel you can depend on or feel close to?" Prior research suggests that the perception of social support can reduce stress.4 This may be particularly important during the COVID-19 pandemic to reduce feelings of worry, anxiety, or stress. Notably, only having one person to rely on may be a red flag for increased caregiver burden in the context of prolonged physical distancing. Third, older adults should be assessed for their access to phone or video communication technologies. Notably, access to communication can be augmented by living with individuals who can support their technology use or compensate for vision or hearing impairment to help them communicate with social contacts or healthcare providers. Individuals who feel lonely, perceive low resources for social support, and cannot use alternatives to in-person communication are at increased risk during prolonged physical distancing. Exceptions to physical distancing may exist for high-risk older adults. Geriatricians and families should develop or utilize decision tools to help balance the risk and benefits of physical distancing. Current challenges are increasing our reliance on technology. For example, active and passive technologies (ie, alerts and sensors, respectively) offer unique opportunities. However, many of these solutions need further evaluation and are not available, accessible, or acceptable to many older adults and their families.5 Addressing unmet social needs requires feasible strategies that occur at the person and population level.6 Health systems are increasingly engaging in efforts to address social needs. Telemedicine can provide a safe platform to assess salient geriatric issues (ie, safety, mobility, mood, medications, appetite, or bowel function) or COVID-19 symptoms and provide an avenue for counseling or discussion. Moreover, it can increase access to mental health resources for the lonely or those anxious about the uncertainty related to the duration of home confinement. However, clinicians should recognize that even among older adults capable of using this technology, this communication medium may be insufficient to meet the social needs of this population for prolonged periods. We therefore suggest clinicians take the lead on designating individuals who can visit older adults while balancing the risk of COVID-19 exposure and need for social support. Designated individuals might be people who are tested more frequently (assuming testing becomes more widespread) or who have been verified for appropriate use of personal protective equipment). In addition, connecting older adults with community resources (eg, Meals on Wheels) that have implemented precautions to mitigate viral transmission or that already existed virtually (eg, Friendship Line, Virtual Senior Center) can address certain needs. At the population level, strategies to address social isolation and loneliness is largely underfunded and understudied.1 We unfortunately cannot wait for evidence-based interventions to emerge as this crisis unfolds. However, we can learn from prior natural disasters including the Chicago heat wave of 1995 that took the lives of 465 primarily older mobility-impaired, socially isolated individuals in 1 week.7 Based on this event and existing research, we know strategies should increase awareness about social isolation and loneliness, harness enthusiasm for volunteerism, utilize health record data to target those in need, and support organizations that are meeting the needs of older adults while adapting to physical distancing. Various technologies to address social isolation and loneliness have been tested, although the evidence to support these interventions is largely "inconsistent and weak."1, 8 There is hope. A recently published randomized controlled trial of a video-conferenced behavioral activation intervention facilitated by a lay coach was able to increase social interactions and decrease loneliness among homebound older adults.9 We now have a unique opportunity to develop methods for check-ins by neighbors or to adapt programs akin to the Jersey, British Channel Islands, "Call & Check Visits," where postal workers support older adults on their delivery routes. A knock on the door or hello from a distance from a postal worker may provide an opportunity to monitor and support older adults in the community. In addition, advocating initiatives that promote community cohesion (ie, yard, porch, and balcony or terrace gatherings) could also be beneficial in that it may provide an opportunity for neighbors to monitor the well-being and functional status of older adults from a distance. Efforts akin to the UK "Campaign to End Loneliness" and AARP "Connect2Affect" are also important and can increase awareness and offer resources to support older adults during crisis. Striving for patient-centered solutions that effectively consider benefit and burden can potentially create connections that are sustained even after this crisis. Lastly, providers and policymakers should revisit the Federal Emergency Management Agency's "Whole Community Approach" and find ways for municipal leaders to exchange strategies and align needs with resources. The COVID-19 pandemic is a timely reminder of how social well-being has a powerful impact on health. Identifying older adults at risk for the immediate and unintended health consequences of physical distancing is critical. Comprehensive geriatric and social needs assessments should be a part of the medical record so that practices, health systems, and communities may seamlessly mobilize support for those in need when public health crises occur. Technology undeniably offers novel opportunities as well as nuanced challenges; it should not limit our imagination or constrain how we balance the risk and benefit of in-person interactions. Physicians and health systems in conjunction with public health and policymakers can be positioned to identify and address social needs, optimize health, and flatten the curve of this extraordinary pandemic. Addressing social isolation and loneliness under normal circumstances is challenging; nevertheless, the current constraints of physical distancing offer a unique opportunity to envision, pilot, or implement novel solutions that could have a lasting impact on the health and well-being of older adults. We are sincerely appreciative of Cynthia M. Boyd, MD, MPH, and Thomas E. Finucane, MD, for their critical review and insightful comments. Thomas K.M. Cudjoe was supported by National Institute on Aging (NIA) Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) (R03AG064253). Ashwin A. Kotwal was supported by an NIA GEMSSTAR grant (R03AG064323). The authors have declared no conflicts of interest for this article. Manuscript concept and drafting: Cudjoe and Kotwal. Critical revision of manuscript for important intellectual content: Cudjoe and Kotwal. None.

This research investigated the effects of social isolation on frailty and health outcomes and tested whether these associations varied across different levels of frailty. We performed a multivariate analysis of the first wave of Frailty: A longitudinal study of its expressions (FRéLE) among 1643 Canadian older adults aged 65 years and over. We assessed social isolation using social participation, social networks, and support from various social ties, namely, friends, children, extended family, and partner. Frailty was associated with disability, comorbidity, depression, and cognitive decline. Less social participation was associated with limitations in instrumental activities of daily living (IADLs), depression, and cognitive decline. The absence of friends was associated with depression and cognitive impairment. Less social support from children and partner was related to comorbidity, depression, and cognitive decline. Overall, social isolation is linked to mental health rather than physical health. The associations of having no siblings, receiving less support from friends, and participating less in social activities with ADL limitations, depression, and cognitive decline were higher among frail than prefrail and robust older adults. This study corroborates the pivotal role of social connectedness, particularly the quality of relationships, on the mental health of older adults. Public health policies on social relationships are paramount to ameliorate the health status of frail older adults.

Studies show that social networking sites (SNS) are convenient for older adults to bond with friends and family without traveling and provide new opportunities for communication that can help older adults to avoid loneliness and social isolation. However, the numbers of SNS usage among older adults are fewer in less developed nations, which can be because only a small number of older adults know how to use SNS, and difficulties such as fears and insecurities while trying to use SNS. To increase the number of older adults using SNS in Malaysia, this study explored the experiences that could affect the intention to learn SNS in older adults in using SNS. Phenomenology approaches using semi-structured one-to-one interviews were used to explore the factors that could affect the intention to learn SNS among older Malaysian adults. This study employed a qualitative approach to explore the intention to learn SNS of twelve older adults aged 60 to 73, residing in different regions of Malaysia. Thematic analysis was used to identify the themes and interpret the data after the data saturation was reached. The themes that emerged from the data were the ‘perceived usefulness,’ ‘unrealistic dependency,’ and ‘ignorant.’ The results of this study can be used to come up with policies and strategies to encourage the learning of SNS among older adults. Program developers and trainers can also use the results of this study to develop modules that are more suited for older adults.

Positivity resonance describes a connection involving shared positive affect and biobehavioral synchronization (Fredrickson, 2013), which improves one’s health (Major et al., 2018; Wells et al., 2021). Positivity resonance may also increase communal strength (e.g., going out of one’s way to meet others’ needs), which improves relationships (Mattingly et al., 2011). Though older adults’ social networks are comprised largely of close relationships (Moore et al., 2016), older relative to younger adults may be more likely to engage more distant others with positivity resonance, which may explain why weak ties are predictive of healthy aging (Huxhold et al., 2020). We explored the relationship between positivity resonance and communal strength for older and younger adults across strong, weak, no tie conditions. 250 participants (125 younger adults; 125 older adults) reported their feelings of positivity resonance and communal strength after recalling recent interactions across each level of tie strength. Using multilevel regression, we found an interaction of age and tie strength on positivity resonance, F(1, 468) = 1.38, p < .05, such that older adults experienced greater positivity resonance than younger adults for weak and no tie interactions. There was also an interaction between tie strength and positivity resonance on communal strength, F(1, 600) = 8.85, p < .01. The more positivity resonance participants experienced, the more communal strength they reported. This research advances our understanding of the quality of network diversity among younger and older adults. Our findings suggest that older adults have improved relationships with acquaintances and strangers compared to younger adults.

Social isolation can influence whether older adults develop dementia. We examine the association between social isolation and incident dementia among older adults in a nationally representative sample of community dwelling older adults in the United States (U.S.). We also investigate whether this association varies by race and ethnicity. Data (N=5022) come from the National Health and Aging Trends Study, a longitudinal and nationally representative cohort of older adults in the U.S. A composite measure of social isolation was used to classify older adults as socially isolated or not socially isolated at baseline. Demographic and health factors were measured at baseline via self-report. Dementia was measured at each round of data collection. Discrete-time proportional hazard time-to-event models were used to assess the association between social isolation and incident dementia over 9 years (2011-2020). Of 5022 older adults, 1172 (23.3%) were socially isolated, and 3850 (76.7%) were not socially isolated. Adjusting for demographic and health factors, being socially isolated (vs. not socially isolated) was associated with a 1.28 (95% CI: 1.10-1.49) higher hazard of incident dementia over 9 years. There was no statistically significant difference by race and ethnicity. Social isolation among older adults is associated with greater dementia risk. Elucidating the pathway by which social isolation impacts dementia may offer meaningful insights for the development of novel solutions to prevent or ameliorate dementia across diverse racial and ethnic groups.

Life satisfaction, as an important indicator of subjective well-being, is crucial for older adults. This study aims to examine the effects of downward intergenerational financial and practical support on life satisfaction among older adults in China, while exploring the mediating role of self-esteem and the potential differences across gender. Data were collected from 507 older adults aged 60 and above in China. The findings indicate that both financial and practical support provided by older adults positively predict their life satisfaction. Mediation analysis reveals that self-esteem partially mediates the relationship between downward intergenerational support and life satisfaction. This suggests that helping their children enhances older adults’ sense of self-worth, which in turn improves their overall well-being. Gender differences were also observed: financial support had a stronger impact on life satisfaction for men, while practical support was more significant for women. These results highlight the influence of traditional gender roles and cultural expectations on the dynamics of intergenerational support in contemporary Chinese families.

Objectives: Characterized by infrequent contact, low emotional intensity, and limited intimacy, weak ties are found to be associated with better subjective well-being and other health outcomes. Drawing on the theory of weak ties and the convoy model of social relations, this paper aims to examine the association between weak ties and cognitive function among older adults in China.Methods: We used multilevel growth modeling to analyze panel data for adults aged 60 years and over (N = 2,650) selected from the China Health and Retirement Longitudinal Study (CHARLS, 2011–2015). Weak ties were measured based on the frequency of social activity participation and the number of social activities.Results: Weekly or irregular social activity participation in at least one social activity was significantly associated with better mental status and memory. The number of participated social activities was also significantly and positively associated with mental status and memory. After controlling for age, gender, marital status, educational attainment, geographic residence, household expenditures, and health conditions (i.e., depressive symptoms and self-reported health), we found that participation in a greater number of social activities protected memory from declining by 4% for every 2 years (p < 0.001).Conclusion: These findings suggest that social interactions with peripheral members of a diverse social network may help prevent cognitive decline for older Chinese adults. Greater attention on weak ties might yield practical implications for non-pharmacological dementia prevention and health promotion for the general older population.

Social Connections for Seniors During COVID-19: An Online Psychoeducation and Peer Support Program

To clarify whether the combination of diabetes mellitus (DM) and social isolation is associated with loneliness among community-dwelling older adults. Data of community-dwelling older adults aged 60 years and older without initial long-term care needs from the Japanese National Center for Geriatrics and Gerontology Study of Geriatric Syndromes were analyzed. Loneliness was measured using the University of California Los Angeles Loneliness Scale. Social isolation was assessed based on four categories: lack of conversation, lack of passive support, lack of support provided to others, and lack of social participation. DM status was determined by assessing patients' medical histories. Modified Poisson regression models were employed to assess relationships between DM, social isolation, and loneliness, including interactions according to sex. Data from 5876 participants (54.2% women) aged 68-77 years were included. The prevalence rates of loneliness, social isolation, and DM were 35.9%, 46.5%, and 13.1%, respectively. Among women, DM and social isolation were associated with loneliness (DM, prevalence ratio [PR]: 1.35, 95% confidence interval [CI]: 1.02-1.78; social isolation, PR: 1.98, 95% CI: 1.33-2.94). Among men, only social isolation was associated with loneliness (PR: 1.41, 95% CI: 1.09-1.84). No interaction was observed between DM and social isolation for either sex. Social isolation was associated with loneliness in men and women. DM was associated in women but not in men. The findings of this study may help develop strategies to maintain the mental health of older adults.

Diabetes is among the leading causes of morbidity and mortality in the United States, particularly in older adults. Prior research has demonstrated that social isolation is associated with worse diabetes outcomes, but the specific relationship between distinct living situations and healthcare utilization among older diabetic adults remains underexamined. This study aims to determine whether living situations, including living alone, living with a partner, or living with other adult(s), are associated with varying rates of hospitalizations, emergency department visits, and urgent care visits among older adults with diabetes. Data from the 2021 and 2022 National Health Interview Survey (NHIS) was analyzed via descriptive statistics, logistic regression, and zero-inflated negative binomial regression to investigate the relationship between the living situation and health outcomes as measured by overnight hospitalizations, number of urgent care visits, and emergency department visits of adults with diabetes over the age of 65. After adjusting for age, sex, race and ethnicity, education level, and comorbidities, participants living with a partner had significantly higher odds of visiting the emergency room when compared to individuals living alone. No significant differences were observed in urgent care visit frequency or hospitalization rates across living situations. This contrasts with the expectation that social isolation may drive increased healthcare utilization, suggesting that partners may encourage care-seeking behavior or results could reflect underlying differences in health status and access to outpatient care. Understanding factors contributing to increased ED visits is crucial for developing preventative measures to reduce the disease burden and financial burden associated with diabetes.

Purpose Assistive technology (AT) is an effective tool to promote social connectedness among older adults affected by the COVID-19 pandemic; however, its role in reducing loneliness and health inequities is not well understood. The goal of this scoping review was to construct a model for how technologies may be deployed to mitigate the impact of the COVID-19 pandemic on social isolation, loneliness and health inequities for older adults. Methods PubMed, SCOPUS and PsychINFO were searched from 2010 to 2020 for the following keywords: “social isolation,” “loneliness,” “social support,” “resilience,” “technology,” “pandemic” and “health inequit*.” Articles selected for full analysis attempted to understand how technology alleviates social isolation and/or loneliness among older adults. Results Eighteen articles met the criteria for selection and data extraction. Six were review-type studies, seven were observational, three were randomized control trials, one opinion piece and one case study. ATs have been shown to reduce loneliness and social isolation, strengthen social support, and promote resilience among older adults. AT reduces loneliness both directly and indirectly, by affecting social isolation. There is insufficient evidence to determine technology’s relationship to health inequities experienced by older adults. Conclusions The model we have proposed should help advance research on the relationship between ATs and health inequities among older adults that may be aggravated by the COVID-19 pandemic. We hypothesize that AT interventions for social support and functional competence should be sequenced to reduce health disparities. Implications for rehabilitation The social distancing and quarantine measures as a result of the COVID-19 pandemic can be linked to adverse health outcomes among older adult populations. Technology is an effective tool to promote social connectedness among older adults affected by the pandemic. Assistive technology (AT) interventions for social support and functional competence should be sequenced in order to have best effects on reducing health disparities.

Loneliness and social isolation are triggers for unfavorable changes in older adults’ health and well-being. Information and communication technology (ICT) can be used by older adults to mitigate the negative effects of loneliness and social isolation. However, ICT needs to be customized to the specific needs and conditions of older adults. The aim of this study was to explore older adults’ use of a new, co-designed and research-based web platform for social interaction from the perspectives of older adults, researchers, and social services personnel. The study is an intervention study with a multimethod approach in which 20 older adults used the web platform for social interaction “the Fik@ room” for eight weeks. Quantitative and qualitative data were collected pretest, during the test, and posttest. The Fik@ room met the expectations of those older adults who completed the study. It enabled them to expand their social network and develop new friendships, but their experiences of loneliness were not reduced. The involvement of social services personnel in recruitment and support was important in facilitating older adults’ use of the Fik@ room. Our study contributes knowledge about a new, co-designed and research-based web platform, customized specifically for older adults, which is valuable in guiding the design and delivery of future web platforms for social interaction among older adults.

Background: Prior visual-world research has demonstrated that emotional priming of spoken sentence processing is rapidly modulated by age. Older and younger participants saw two photographs of a positive and of a negative event side-by-side and listened to a spoken sentence about one of these events. Older adults’ fixations to the mentioned (positive) event were enhanced when the still photograph of a previously-inspected positive-valence speaker face was (vs. wasn’t) emotionally congruent with the event/sentence. By contrast, the younger adults exhibited such an enhancement with negative stimuli only. Objective: The first aim of the current study was to assess the replicability of these findings with dynamic face stimuli (unfolding from neutral to happy or sad). A second goal was to assess a key prediction made by socio-emotional selectivity theory, viz. that the positivity effect (a preference for positive information) displayed by older adults involves cognitive effort. Method: We conducted an eye-tracking visual-world experiment. Results: Most priming and age effects, including the positivity effects, replicated. However, against our expectations, the positive gaze preference in older adults did not co-vary with a standard measure of cognitive effort - increased pupil dilation. Instead, pupil size was significantly bigger when (both younger and older) adults processed negative than positive stimuli. Conclusion: These findings are in line with previous research on the relationship between positive gaze preferences and pupil dilation. We discuss both theoretical and methodological implications of these results.

Every research participant has their own personality characteristics. For example, older adults assisted by socially assistive robots (SAR) may have their own unique characteristics and may not be representative of the general population of older adults. In this research, we compared the average personality characteristics of participants in a workshop on robotics recruited directly through posting with those of older Japanese adults to examine participant selection bias and group representativeness for future study of SARs. After a one-week recruitment period, the workshop was attended by 20 older participants (nine males and 11 females) aged between 62 and 86 years. Extroversion among workshop participants was 4.38, 0.40 higher than the average for older adults in Japan. The workshop participants' openness was 4.55, 1.09 higher than the average for the Japanese elderly. Thus, the results indicate a slight selection bias in the personal characteristics of the participants depending on the recruitment method when compared to the Japan national average for older adults. In addition, only one of 20 participants was below the cutoff on the LSNS-6 score and considered to have a tendency toward social isolation. The development and introduction of socially assistive robots is often being considered to support people in social isolation in their daily lives; however, the results of this study showed that it is difficult to recruit people who tend to be socially isolated when gathering research participants by methods such as posting. Therefore, the effectiveness of the method of recruiting participants should be carefully verified in research regarding socially assistive robots.

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.