Rethinking social disconnection: does it always have a negative impact?

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.

Interdependent culture and older adults’ well-being: Health and psychological happiness in Japanese communities

Population aging has intensified the need for interventions that address the psychosocial health and wellbeing of older adults. Digital social prescribing (DSP), an extension of traditional social prescribing, uses digital technologies to connect individuals with non-medical community resources and may help address social isolation and loneliness in older populations. This study explored general practitioners' (GPs) perceptions of digital social prescribing as an intervention to promote psychosocial health and wellbeing among older adults in China. A qualitative exploratory design was employed in Yiwu, Zhejiang Province, China. Semi-structured interviews were conducted with 27 general practitioners working in community health centers and clinics. Participants were recruited using convenience sampling methods. The interview data were analyzed using reflexive thematic analysis. Six key themes emerged: (i) digital technology adoption, (ii) social support networks, (iii) healthcare system integration, (iv) implementation challenges, (v) cultural and contextual adaptation, and (vi) policy and practice recommendations. GPs generally perceived DSP as a feasible and valuable approach to addressing psychosocial issues such as social isolation, loneliness, and poor mental health among older adults. However, concerns have been raised regarding digital literacy, workload, infrastructure, and data security. General practitioners expressed positive attitudes toward the use of digital social prescribing to support the psychosocial wellbeing of older adults. With appropriate training, policy support, and culturally adapted implementation, DSP has the potential to address the key social determinants of health and complement existing primary care services in rapidly aging societies.

BackgroundTraditionally, family members take care of older relatives in South Asian societies, and there is a strong reciprocal filial obligation through intergenerational family relations. The changing family structure, living arrangements, and out-migration have led to subsequent changes in reciprocal family support that influence the health and well-being of older adults. This scoping review aims to (1) map the evidence and prevailing motivations for family support including financial, instrumental, and emotional support that affect the health and well-being of older adults and (2) identify the research gaps in the academic scholarship available on motivation for family support to older adults given the changing demographic and societal dynamics in the South Asian societies.MethodsWe followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) guidelines. Electronic databases PubMed, Embase, Scopus, and ProQuest were searched, and Google Scholar was used to identify grey literature. The screening of titles, abstracts, and full texts included 22 studies for analysis.ResultsThe included studies covered health indicators such as stress and/or depression, loneliness/isolation, loss of support/neglect, and level of satisfaction to illustrate well-being of older adults. The findings revealed that adult children recognised filial duties and responsibilities to provide care to older parents, whereas older parents provide cultural upbringing and care to grandchildren. Reciprocal care exchange, cultural expectations, and intergenerational transfers motivated adult children to be primary caregivers to their older parents. Intergenerational family care such as financial, instrumental, and emotional support is associated with a higher level of life satisfaction and lower level of depression and thus reported better health and well-being among older adults.ConclusionAlthough intergenerational support is still a significant factor in determining the well-being of older adults in South Asia, this study shows the complexity of intergenerational ambivalence, where caregiving responsibilities lead to both emotional stress and a sense of obligation. Additionally, out-migration of adult children and subsequent physical absence also increase psychological distress and loneliness of older adults. This emphasises the need for policies that address both the emotional and financial aspects of elder care. The Madrid International Plan of Action on Ageing (MIPAA) policies can be adopted to ensure friendly and supportive environments and emphasise the health and well-being of older adults in developing countries. MIPAA highlights the importance of policies that promote intergenerational solidarity, active ageing, and social protection for older individuals.

Despite longstanding concerns about social isolation and loneliness among older adults, research on the macro-level factors (e.g., regional characteristics) influencing these issues remain limited. Using data from 6,045 older adults (aged 59–103) drawn from the ninth wave (2022) of the Korean Longitudinal Study of Aging and the Korean Statistical Information Service, we conducted multilevel modeling to analyze the relationships between regional factors and social disconnection (i.e., social isolation and loneliness) among older adults. Additionally, we examined whether subjective health status moderates these relationships. The results revealed that social isolation and loneliness were related to different regional factors. Older adults tended to be more isolated in regions with a lower proportion of single-person households aged 65 and older. Meanwhile, they were more likely to feel lonely in regions with a higher fiscal self-reliance rate and more leisure facilities per 1,000 older adults. Subjective health status amplified the relationship between fiscal self-reliance rate and both forms of social disconnection but reversed the relationship between proportion of social welfare spending and loneliness. Although higher fiscal autonomy was associated with lower social isolation across all health groups, it was related to greater loneliness, particularly among those in poorer health. In contrast, a higher proportion of welfare spending was linked to lower loneliness among those in poor health but to higher loneliness among those in good health. These findings underscore the need to consider both regional factors and the Person-Environment Fit (P-E Fit) framework in addressing social disconnection among older adults.

Virtual Reality (VR) holds great promise for enhancing the health, well-being, and skills of older adults. However, VR solutions must consider the age-related “digital divide;”many older adults have less experience and proficiency with a number of newer technologies, which may serve as a barrier. Older adults especially have less experience with virtual environments, an experience many younger adults have acquired through video gaming. This study compared younger and older adults’ perceptions of immersion and presence in a series of diverse virtual environments using the HTC Vive. Participants experienced a VR meditation task, “indoor" and “outdoor” navigation tasks, and a fast-paced action game. Importantly, younger and older adults reported similarly high experiences of immersion and presence within virtual environments, and contrary to expectations, older adults reported fewer symptoms of cybersickness. Results suggest VR as a promising tool to promote the health and well-being of older adults.

The older adult population in the United States is experiencing unprecedented growth and is accompanied by a parallel increase in the health challenges of these individuals. Public health has, historically, not played a large role in older adult health, but given its contributions to longevity, it makes sense for public health to now prioritize the health of this population. With the goal of public health prioritization of healthy aging, Trust for America's Health, with support from The John A. Hartford Foundation, launched an initiative to demonstrate the crucial roles public health departments can play to improve the health of older adults. An Age-Friendly Public Health Systems (AFPHS) Learning and Action Network was created to provide local health departments in Florida with training and technical assistance through in-person and virtual activities, as well as access to events, opportunities, and resources to increase expertise and capacity to address healthy aging. AFPHS Network participants attended monthly learning activities to enhance their capacity around data analysis, health equity, partnerships and collaboration, social determinants of health, and other age-friendly initiatives. Network participants are being tracked on 13 key indicators to improve the health and well-being of older adults, including data collection and dissemination; ensuring emergency preparedness plans target older adults; and targeting older adult health needs in community health assessments. Trust for America's Health's AFPHS initiative demonstrates that state and local public health departments have crucial roles to play to improve the health and well-being of older adults through data collection and analysis, collaboration with aging sector stakeholders, and adapting policies and programs to become age-friendly.

ObjectivesTo determine what effect driving cessation may have on subsequent health and well‐being in older adults.DesignSystematic review of the evidence in the research literature on the consequences of driving cessation in older adults.SettingCommunity.ParticipantsDrivers aged 55 and older.MeasurementsStudies pertinent to the health consequences of driving cessation were identified through a comprehensive search of bibliographic databases. Studies that presented quantitative data for drivers aged 55 and older; used a cross‐sectional, cohort, or case–control design; and had a comparison group of current drivers were included in the review.ResultsSixteen studies met the inclusion criteria. Driving cessation was reported to be associated with declines in general health and physical, social, and cognitive function and with greater risks of admission to long‐term care facilities and mortality. A meta‐analysis based on pooled data from five studies examining the association between driving cessation and depression revealed that driving cessation almost doubled the risk of depressive symptoms in older adults (summary odds ratio = 1.91, 95% confidence interval = 1.61–2.27).ConclusionDriving cessation in older adults appears to contribute to a variety of health problems, particularly depression. These adverse health consequences should be considered in making the decision to cease driving. Intervention programs ensuring mobility and social functions may be needed to mitigate the potential adverse effects of driving cessation on health and well‐being in older adults.

Active aging is important for promoting the health, wellbeing, and participation of older adults. This study investigated the association between active aging and mortality risk among 2 230 respondents aged 60 and older. Principal component analysis extracted a five-factor structure from 15 indicators of active aging. The mean active aging score was 55.57 and the median was 53.33. The Kaplan-Meier curve showed that individuals with active aging scores of 53.33 and above had significantly longer survival than those below the median. Cox regression analysis indicated the significance of active aging in reducing mortality risk by 2.5% after adjusting for sex, marital status, age, ethnicity, chronic diseases, and risk factors. The active aging approach comprising health, economic, and social factors is crucial in improving survival among older adults. Hence, policies and programs that promote active aging should be encouraged to enhance the health and wellbeing of older adults and their engagement in society.

Based on this review there is currently very uncertain evidence on the effectiveness of video call interventions to reduce loneliness in older adults. The review did not include any studies that reported evidence of the effectiveness of video call interventions to address social isolation in older adults. The evidence regarding the effectiveness of video calls for outcomes of symptoms of depression was very uncertain. Future research in this area needs to use more rigorous methods and more diverse and representative participants. Specifically, future studies should target older adults, who are demonstrably lonely or socially isolated, or both, across a range of settings to determine whether video call interventions are effective in a population in which these outcomes are in need of improvement.

Objectives The COVID-19 pandemic has increased depressive symptoms and disrupted activities that might typically mitigate depressive symptoms. Pandemic restrictions to social participation that supports well-being in older adults may contribute to worse mental health outcomes, but how participation relates to pandemic depressive symptoms is unclear. Methods Using longitudinal data from the nationally representative National Health and Aging Trends Study (N = 3181), we assessed whether older adults’ pandemic depressive symptoms were associated with participation in paid work, volunteering, religious services, and other organized activities during the pandemic, as well as changes in participation in these activities compared to pre-pandemic engagement. Results Of participation during the pandemic, only attending religious services predicted pandemic depression, with religious attendance associated with higher risk of mild pandemic depressive symptoms. However, for changes in participation, stopping paid work during the pandemic predicted higher risk of moderate/severe pandemic depressive levels, while stopping attending religious services predicted lower risk of mild pandemic depression. Conclusion This work demonstrates the importance of social participation for mental health and indicates what types of disruptions may reduce integration to increase older adults’ vulnerability to depressive symptoms during a global pandemic.

The impact of Home- and Community-Based Services (HCBS) on the health of older adults has been a topic of concern for geriatric health and policy development. However, the existing studies have yielded inconsistent empirical findings. This meta-analysis aimed to assess the effectiveness of HCBS on the physical and mental health of older adults. We conducted a meta-analytic examination of 26 correlations in 11 separate studies, using random-effects meta-analysis to pool the data. The findings support a positive relationship between HCBS and the health of older adults, with a highly significant positive correlation with mental health ( r = .532, 95% CI: [0.201, 0.864]) and a weak positive correlation with physical health ( r = .076, 95% CI: [−0.171, 0.324]) in older adults. The study found high correlations between HCBS and well-being and depression relief, while the correlations between HCBS and self-rated health (SRH) and physical function were moderate and weak, respectively. Furthermore, the effects did not differ across different measurements of HCBS, duration of service, or country of investigation. These findings suggest that practitioners should develop precise integration of community care services with healthcare services, providing a full spectrum of services throughout the lifecycle to enhance the health and well-being of older adults.

Social isolation mediates association between depressive symptoms and cognitive function: Evidence from China health and retirement longitudinal study.

BackgroundThe population of older adults is increasing globally and in India. Depression, anxiety, social isolation, and loneliness commonly impact their well-being. Technology is being explored to improve access to mental health resources, with digital self-help platforms emerging as a promising approach. Given WhatsApp’s wide use in India, it holds potential for delivering such support to older adults. This study explored the perspectives of urban Indian older adults on mental health and well-being needs, experiences with digital platforms, and views on a proposed WhatsApp-based self-help platform for mental health.MethodsA qualitative approach was used, involving 19 older adults (aged 55 +), with at least eight years of formal education, and fluency in English/Hindi/Kannada. Individual interviews were conducted, and participants rated potential self-help topics. The Patient Health Questionnaire (PHQ-4) documented distress levels. Data were analyzed using framework analysis.ResultsFive major themes emerged: ‘Changes with Ageing’, ‘Protective Factors for Mental Health’, ‘Interactions with Digital Platforms’, ‘Views on WhatsApp’, and ‘Additional Suggestions’. Older adults reported using digital platforms for recreation, maintaining health, and socializing. They expressed openness to a WhatsApp-based mental health self-help platform with accurate content, simple interface, integration with health services, and access to support. Over three-fourths of participants rated all proposed self-help topics as important.ConclusionThe study highlights the potential acceptability and usability of a WhatsApp-based self-help platform for urban Indian older adults, with participants emphasizing the need for credible content, simplicity, support-access, and relevant self-help content. It offers valuable insights for developing WhatsApp based platforms to support mental health and well-being of older 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.