{"subscriber":false,"subscribedOffers":{}} Cross-Sector Collaborations To Decrease Loneliness And Social Isolation In Older Adults | Health Affairs

Cross-Sector Collaborations To Decrease Loneliness And Social Isolation In Older Adults

Editor’s Note: This article is the fourth in an occasional series on the Health Affairs Blog responding to and reflecting on the latest findings of the University of Michigan’s National Poll on Healthy Aging. 

Loneliness—the subjective feeling of being isolated, being left out, and lacking companionship—and social isolation—an objective measure of social networks and social connection—are growing public health epidemics among older Americans. Loneliness and social isolation have enormous health consequences, frequently contributing to worsening chronic disease burden, depression and anxiety, functional and cognitive decline, and even premature death. Among Medicare beneficiaries alone, social isolation is the source of $6.7 billion in additional health care costs annually. Preventing and addressing loneliness and social isolation, therefore, are critically important goals for health care systems, communities, and national policy. To be effective, interventions must account for the complex factors contributing to loneliness and social isolation, as well as the unique features that characterize each individual’s resources and needs. 

Beyond Social Isolation—The Loneliness Paradox

To contribute to our understanding of the national epidemic of loneliness, in October 2018, the University of Michigan National Poll on Aging collected survey data from a nationally representative sample of 2,035 respondents older than age 50. The survey found that 34 percent of adults age 50–80 felt a lack of companionship, and 27 percent felt isolated from others during the past year. The poll findings are consistent with a growing body of research that suggests about 30–40 percent of US older adults feel lonely–a proportion that amounts to tens of millions of people nationwide.

Absent or inadequate social networks can increase risk for loneliness. The University of Michigan poll found that 60 percent of respondents without other adults in their household felt lonely. However, it is important to note that loneliness can also occur in the presence of seemingly robust social lives. For example, 34 percent of those in the Michigan poll who lived with two or more other adults reported that they felt lonely, and one study found that most older adults who were lonely were also partnered.

The fact that many people who feel lonely have contact with others illustrates the complexities of loneliness that go deeper than having access to social supports. Loneliness frequently is accompanied by deleterious thinking in which lonely individuals fail to take advantage of opportunities for socializing, miss opportunities for connection, or are unable to find meaning in social interactions that others might find fulfilling. Not surprisingly, interventions to mitigate loneliness that focus only on building social networks often fail to make people feel better. In contrast, a large meta-analysis of interventions to reduce loneliness found that interventions specifically targeting maladaptive thinking (for example, via teaching ways to reframe one’s thinking about social interactions, promoting positive coping, and managing social anxiety) were associated with the largest reductions in loneliness. Other interventions promoting social support, social access, and social skills training were also found effective, but to a lesser degree. 

The Limitations Of Screening At Health Care Encounters

The National Academies of Sciences, Engineering, and Medicine and the Centers for Medicare and Medicaid Services (CMS) have recognized social isolation and loneliness as important social determinants of health worthy of routine screening at health care encounters. One commonly used tool for screening is the Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool, a product of the Center for Medicare and Medicaid Innovation that evaluates social determinants of health and may eventually be used in future value-based payment models. The AHC tool asks individuals to rate how often they feel either lonely or isolated from those around them. Like many other screening tools, it does not distinguish between loneliness and social isolation, and as a consequence may not give clinicians a clear enough picture of an individual’s situation or needs.   

Similarly, some health systems and payers such as CareMore Health, UnitedHealthcare, and Kaiser Permanente are making strides linking screening for social isolation with referral to social and clinical support services. Despite these important advances, most patients suffering from loneliness and isolation go unnoticed during health care encounters, and programming to address their unique needs remains an opportunity for future development. 

Prevention Starts With Activating Individuals And Communities

Even if clinicians increase their ability to identify patients experiencing loneliness and social isolation, screening within health care settings may have limited social impact because many lonely individuals may not present for routine medical care due to functional limitations, cognitive decline, lack of transportation, and other factors. Thus, health care and public health leaders must engage in neighborhoods and communities to act upstream of health care encounters.

An important first step is to raise awareness. In particular, more older adults, caregivers, health care professionals, and communities need to understand that many lonely people are not isolated. One example of how to educate the public is an informational effort by the National Association of Area Agencies on Aging and the AARP Foundation, that includes an easy-to-read fact sheet highlighting risk factors for loneliness and social isolation, suggestions for strengthening social networks and connections (including volunteerism and community engagement), and including information on local and national resources. Among the resources is a tool that sends text message reminders to keep in touch with loved ones. While this broad effort is an important first step, the Administration for Community Living should collaborate with local area agencies on aging as well as leaders in public health and academia to develop and implement specific, evidence-based strategies that take into account the unique characteristics of vulnerable groups such as those with lower health literacy, non-English speakers, people living in rural areas, and people with low incomes.

The most effective way to reach these vulnerable groups of older adults may be to partner with organizations that already serve them and have established the cultural credibility and networks needed to jump-start services and programming. One excellent example is Meals on Wheels America. Nationally, nearly 60 percent of Meals on Wheels participants live alone and have complex health needs. While delivering meals, volunteers frequently identify older adults that are socially isolated and work with the organization to connect them to needed services, including medical care. A clinical trial published in 2015 demonstrated that daily meal delivery corresponded to major reductions in self-reported loneliness. In fact, 40 percent of participants in that trial stated that they would have little daily social contact were it not for the meal deliveries. Results were achieved primarily through increased opportunities for socialization for vulnerable older adults. Of note, nearly 30 percent of individuals receiving daily meals did not self-report reductions in loneliness as a result of the intervention, suggesting that a significant proportion of older adults who are homebound might benefit from additional interventions to improve maladaptive thinking and other contributors to loneliness. 

Aligning Priorities At The National Level

Meeting the complex needs of lonely and socially isolated older adults requires alignment of priorities and a common vision across many sectors, from grassroots efforts to state and national policy. Such alignment can be achieved through multidisciplinary, national collaboratives. The United Kingdom (UK) recently appointed a Minister for Loneliness who established the Campaign to End Loneliness—a network of more than 2,500 individuals and advocacy groups aiming to raise awareness about loneliness. Efforts range from raising individual contributions such as fundraising at marathons, to launching a social media campaign called #YouAreNotAlone, to help bring attention to the nearly one million people in the UK older than age 65 who suffer from loneliness. Other initiatives include national and international campaigns, such as those of the Marmalade Trust, a grassroots organization aiming “to find and support isolated people to reconnect with society and enjoy better lives.” The Marmalade Trust sponsored a national Loneliness Awareness Week that included more than 250 events across the UK, garnering international television coverage and reaching an estimated four million individuals in 2018. Other countries are developing similar multisectoral collaboratives, including Australia’s Coalition to End Loneliness.

In the US, the National Academies of Sciences, Engineering, and Medicine has formed an ad hoc committee evaluating social isolation and loneliness in older adults. This committee is tasked with furthering the evidence base to better understand risk factors, outcomes, and interventions to address loneliness and social isolation, especially in low-income, underserved, and vulnerable adults older than age 50. There is also the newly formed Coalition to End Social Isolation and Loneliness, a multidisciplinary effort aiming to promote awareness, stakeholder engagement, and evidence-based interventions and policies. This cross-sector collaboration and investment is going beyond just raising awareness; it will allow the further evaluation and dissemination of interventions addressing loneliness and social isolation. 

Authors’ Note

The National Poll on Healthy Aging is conducted by the University of Michigan Institute for Healthcare Policy and Innovation and sponsored by AARP and Michigan Medicine, the University of Michigan’s academic medical center.