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Social isolation and loneliness among older adults in the context of COVID-19: a global challenge

DOI:10.1186/s41256-020-00154-3
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Bei Wu at New York University
Bei Wu
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Abstract

We are experiencing a historical moment with an unprecedented challenge of the COVID-19 global pandemic. The outbreak of COVID-19 will have a long-term and profound impact on older adults’ health and well-being. Social isolation and loneliness are likely to be one of the most affected health outcomes. Social isolation and loneliness are major risk factors that have been linked with poor physical and mental health status. This paper discusses several approaches that may address the issues of social isolation and loneliness. These approaches include promoting social connection as public health messaging, mobilizing the resources from family members, community-based networks and resources, developing innovative technology-based interventions to improve social connections, and engaging the health care system to begin the process of developing methods to identify social isolation and loneliness in health care settings.
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C O M M E N T A R Y Open Access
Social isolation and loneliness among older
adults in the context of COVID-19: a global
challenge
Bei Wu
Abstract
We are experiencing a historical moment with an unprecedented challenge of the COVID-19 global pandemic. The
outbreak of COVID-19 will have a long-term and profound impact on older adults’health and well-being. Social
isolation and loneliness are likely to be one of the most affected health outcomes. Social isolation and loneliness
are major risk factors that have been linked with poor physical and mental health status. This paper discusses
several approaches that may address the issues of social isolation and loneliness. These approaches include
promoting social connection as public health messaging, mobilizing the resources from family members,
community-based networks and resources, developing innovative technology-based interventions to improve social
connections, and engaging the health care system to begin the process of developing methods to identify social
isolation and loneliness in health care settings.
Keywords: COVID-19, Social isolation, Aging, Public health messaging
Background
We are experiencing a historical moment with an unpre-
cedented challenge of the COVID-19 global pandemic.
As of April 21st, 89 countries with more than a third of
the global population have experienced lockdowns due
to the outbreak. Many of the businesses that are cur-
rently closed are in some of the most prosperous cities
like New York, Tokyo, and Paris. The coronavirus has
swept through many parts of the world at a devastating
and deadly speed, with over 200,000 people worldwide
having died in countries struggling with shortages of
healthcare workers, increasing sick people, and lack of
personal protective equipment. Based on the death cer-
tificates of data retrieved and coded by the CDC Na-
tional Center for Health Statistics, 78% of COVID-19
related deaths in the U.S. occurred among older adults
age 65 and over [1]. Older adults are the segment of the
population most vulnerable in this pandemic, largely due
to their weaker immune systems and higher likelihood
of having a chronic condition such as heart disease, dia-
betes, lung disease and cancer. Having any of these con-
ditions is a risk factor for suffering complications from
COVID-19. Globally, nursing home residents are af-
fected the most. They have a much higher rate of death,
and are more likely to be infected. In the UK., it is esti-
mated that close to half of COVID-19 related deaths are
now happening in care homes; in the U.S., about one-
fifth of deaths occur in nursing homes [1]. In almost
every country battling with the COVID-19 outbreak,
older adults are being told to self-quarantine and shut
themselves off from other people who might risk infect-
ing them. In long-term care facilities, one common prac-
tice is to ban visits from family members and friends to
these facilities in order to minimize the risk of spreading
the virus. While these restrictions are legitimate under
this time of crisis, they could have a significant negative
impact on older adults’mental health status, such as ex-
periencing social isolation and loneliness.
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
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licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Correspondence: bei.wu@nyu.edu
NYU Aging Incubator and Hartford Institute for Geriatric Nursing, 433 First
Ave, 5th Floor, New York, NY 10010, USA
Global Healt
h
Research and Polic
y
Wu Global Health Research and Policy (2020) 5:27
https://doi.org/10.1186/s41256-020-00154-3
Social isolation and loneliness in the context of
COVID-19
Social isolation is defined as the objective state of having
few social relationships or infrequent social contact with
others while loneliness is a subjective feeling of being
isolated. Social isolation and loneliness are serious yet
underestimated public health risks that affect a significant
portion of the older adult population. In the U.S., approxi-
mately one-quarter of community-dwelling older adults are
considered to be socially isolated, and 43% of them report
feeling lonely [2].TheCOVID-19pandemicisincreasing
the number of older adults who are socially isolated includ-
ing both community-dwelling older adults and nursing
home residents, as many countries have issued stay-at-
home orders and banned visits for nursing home residents.
Prior to the disease outbreak, the vast major of
community-dwelling older adults actively participated in so-
cial activities, such as attending senior centers, churches ac-
tivities, traveling, and many other social events. Community-
based long-term care services are commonly available in de-
veloped countries and some developing countries. While
family members can be primary caregivers caring for older
adults with functional and cognitive impairment,
community-based long-term care also plays an important
role for many frail older adults. These community services
and programs cover adult-day care, respite care, home-
makers, meals on wheels, and home health services. For frail
older adults living alone, meal delivery staff may be the only
person they meet on a daily basis. For nursing home resi-
dents, family visits are an important way for them to feel so-
cially connected, and family members are their link to the
outside world. However, due to the lockdown policy, all
these services and programs are no longer available. These
restrictions would certainly increase social isolation and the
feelings of loneliness of older adults. In the context of
COVID-19, social isolation may be especially detrimental to
family caregivers being that the majority are older adults
themselves and are already at increased risk of stress, anxiety
and depression [3].
Increasing evidence demonstrates that social isolation
has detrimental impact on individual’s health and well-
being. Studies, including our own [4], have found that
social isolation and loneliness are major risk factors that
have been linked with poor physical and mental health
status: increased blood pressure, heart disease, obesity,
diminished immune system functioning, depression,
anxiety, poorer cognitive functioning, increased risk of
Alzheimer’s disease, and mortality [4,5]. Social isolation
has been associated with an approximately 50% in-
creased risk of developing dementia, a 29% increased
risk of incident coronary heart disease and a 32% in-
creased risk of stroke [2]. We need to be cognizant that
the social isolation resulting from efforts to decrease the
spread of COVID-19, can at the same time increase the
risk of these negative outcomes, potentially having a pro-
found impact on their health and wellbeing.
Multiple approaches to decrease social isolation
Public health messaging: maintaining social connection
While each country has asked their citizens to keep so-
cial distancing, this message of social distancing can be
misleading. In fact, the public messaging of keeping
physical distancing and maintaining socially connected is
becoming more important than ever. Studies have
shown that social support can mediate social isolation
and improve mental health status [6,7]. It is critical to
mobilize the resources from family members,
community-based networks and resources that address
social isolation and loneliness in older adults. There is
also great potential for older adults to be volunteers to
provide much needed peer support for isolated individ-
uals. In our early work, we found that many older adults,
including the oldest old (age 85+), were actively provid-
ing support to their family, friends, and neighbors, such
as providing companionship, giving comfort, cooking
meals, and shopping for others [8]. In nursing homes,
family and staff can play an essential role in helping resi-
dents socially connect through technology, such as video
and social media.
The role of technology in addressing social isolation
It is important to develop innovative technology-based
interventions to improve social connection for this
population. Mobile technologies can be instrumental, as
they are transforming the way in which we interact with
others, find information, access resources, and deliver
services [9]. Our recent study found that 92% of the
Chinese American older adults with low income and
education had a smart device, and 72% used WeChat,
the most commonly used social media software applica-
tion in Chinese population. Anecdotal evidence and our
personal observation suggest that Chinese Americans
use social media applications such as WeChat to con-
nect people from a distance to alleviate social isolation.
It is time to develop more person-centered applications
with the input from older adults and their family mem-
bers. Existing evidence-based interventions for older
adults can be used as the basis for creating needed social
support via instant messaging apps or videos. In
addition, peer support via social media may enhance the
effects of evidence-based professional support, such as
information resources, health promotion and counseling,
and problem solving. On the other hand, we also need
to be aware that as with other areas of health care, eth-
ical and legal considerations especially must be explored
when the technology is used in interventions for isola-
tion and loneliness.
Wu Global Health Research and Policy (2020) 5:27 Page 2 of 3
Healthcare system’s response to social isolation
Globally, older adults have much higher usage of the
health care system compared to younger populations.
The health care system is well positioned to develop
methods to identify social isolation and loneliness in
health care settings. By identifying those at highest risk
and whether their condition is acute or chronic, health-
care providers may be able to use these findings to de-
velop appropriate clinical and public health
interventions for patients. These interventions can then
be adopted and implemented to other high-need coun-
tries/regions and populations served. Health professions
schools and direct care worker training programs should
include education and training related to social isolation
and loneliness in their teaching curricula [2]. Develop-
ment of more tele-health approaches can provide older
adults and their family with better access to healthcare
providers and facilitate screening, diagnosis, and treat-
ment of social isolation.
Conclusions
The outbreak of COVID-19 will have a long-term and
profound impact on older adults’health and well-being
globally. Social isolation and loneliness are likely to be-
come major risk factors that affect older adults’health
outcomes. Some strategies to address these issues can be
implemented in many countries. These strategies in-
clude: raising awareness of the health and medical im-
pact of social isolation and loneliness across the health
care workforce and among members of the public; de-
veloping innovative technology based interventions to
mobilize the resources from family members,
community-based networks and resources that address
social isolation and loneliness in older adults; and en-
gaging the health care system to begin the process of de-
veloping methods to identify social isolation and
loneliness in health care settings.
Acknowledgements
Not applicable.
Author’s contributions
I am the sole contributor to this article. The author(s) read and approved the
final manuscript.
Authors’information
Bei Wu, PhD., is Dean’s Professor in Global Health, Director for Research at
the Hartford Institute for Geriatrics Nursing, New York University Rory Meyers
College of Nursing. She is also an inaugural Co-Director of the NYU Aging
Incubator.
Funding
Not applicable.
Availability of data and materials
Data sharing not applicable to this article as no data-sets were generated or
analyzed during the current study.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 23 April 2020 Accepted: 13 May 2020
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The mediating roles of functional limitations and social support on the relationship between vision impairment and depressive symptoms in older adults
Article
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Vision impairment is prevalent and it is strongly associated with depressive symptoms in older adults. This study aimed to investigate the mediating roles of functional limitations and social support on the relationship between vision impairment and depressive symptoms in older adults. This study used data from a probability-based sample of 1,093 adults aged 60 and older in Shanghai, China. Structural equation models were used to examine the structural relationships among sets of variables simultaneously, including vision impairment, activities of daily living ADLs, instrumental ADLs (IADLs), friends support, family support, relatives support and depressive symptoms. The bootstrapping method and the program PRODCLIN were used to test the indirect effects of these variables. This study found that vision impairment was directly associated with a higher level of depressive symptoms, and the association was partially mediated by functional limitations (IADLs) and social support (friends support). The study demonstrates that improving social support from friends and enhancing social participation for visually impaired older adults can reduce depressive symptoms. More importantly, this study contributes to the knowledge of mediating mechanisms between vision impairment and depressive symptoms.
Associations between loneliness and perceived social support and outcomes of mental health problems: A systematic review
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Background: The adverse effects of loneliness and of poor perceived social support on physical health and mortality are established, but no systematic synthesis is available of their relationship with the outcomes of mental health problems over time. In this systematic review, we aim to examine the evidence on whether loneliness and closely related concepts predict poor outcomes among adults with mental health problems. Methods: We searched six databases and reference lists for longitudinal quantitative studies that examined the relationship between baseline measures of loneliness and poor perceived social support and outcomes at follow up. Thirty-four eligible papers were retrieved. Due to heterogeneity among included studies in clinical populations, predictor measures and outcomes, a narrative synthesis was conducted. Results: We found substantial evidence from prospective studies that people with depression who perceive their social support as poorer have worse outcomes in terms of symptoms, recovery and social functioning. Loneliness has been investigated much less than perceived social support, but there is some evidence that greater loneliness predicts poorer depression outcome. There is also some preliminary evidence of associations between perceived social support and outcomes in schizophrenia, bipolar disorder and anxiety disorders. Conclusions: Loneliness and quality of social support in depression are potential targets for development and testing of interventions, while for other conditions further evidence is needed regarding relationships with outcomes.
Are contributory behaviors related to culture? Comparison of the oldest old in the United States and in China
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The purpose of this study is to examine the impact of culture on contributory behaviors within the context of family, friends, and neighbors among the oldest old in the United States and in China. The study was conducted in suburban areas of Boston in 1996 (n=465), and later in 1999 a replication of the study was conducted by Chinese researchers in urban areas of Shanghai, China (n=539). This study found some common factors such as objective measure of health status, assistance received from others, and group affiliation. However, many differences emerged in the study. The range of contributory behaviors toward friends is quite different between the two samples. Some of the correlates’ impact is also culturally specific, such as sibling support. These differences reflect variation in respondents’ social support as well as social structural differences. Findings from this study suggest that providing more opportunities for elders to participate in groups would facilitate their participation in volunteer activities and improve their overall well-being.
Dementia Caregiver Interventions in Chinese Population: A Systematic Review
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Aims The aim of this systematic review was to examine the characteristics and efficacy of dementia caregiving interventions among the Chinese population. Background In recent years, an increasing number of dementia caregiving interventions have been developed for Chinese older adults living in Asia that aim to reduce caregivers’ burden, depression and distress and enhance quality of life. Little is known, however, on the nature and the efficacy of these interventions. Design Systematic review with narrative summary. Data Sources We searched four databases for studies published in English between 1 January 1994 ‐ 30 December 2017. Nineteen studies reported in twenty‐three articles were included in the final analysis. Review Methods We used a set of criteria from the Cochrane Collaboration tool to assess for the risk of bias across studies. Results We found that interventions varied in length, frequency, approach and content, making comparisons across studies challenging. Caregivers’ burden, depression and distress were improved among most included studies. All studies that examined quality of life of caregivers (N=6) showed improvement. Most of the interventions showed beneficial effects on care recipients’ behavioral symptoms, agitation and depression; cognitive function, however, failed to improve. Conclusion Although the review found mixed results on intervention outcomes, the majority of interventions showed a potential to improve the health and well‐being of dementia caregivers and care recipients. This review provides suggestions for future dementia caregiving research in the Chinese population, such as inclusion of relevant theoretical frameworks and more rigorous research designs. This article is protected by copyright. All rights reserved.
Social Isolation and Cognitive Function in Appalachian Older Adults
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Investigating the relation between social isolation and cognitive function will allow us to identify components to incorporate into cognitive interventions. Data were collected from 267 Appalachian older adults (M = 78.5, range 70-94 years). Overall cognitive functioning and specific cognitive domains were assessed from data of a self-assembled neuropsychological battery of frequently used tasks. Social isolation, social disconnectedness, and perceived isolation were measured from the Lubben Social Network scale-6. Results indicated a significant positive association between all predictor variables (e.g., social isolation, social disconnectedness, and perceived isolation) and outcome variables (e.g., overall cognitive function, memory, executive functioning, attention, and language abilities). Perceived isolation accounted for nearly double the amount of variance in overall cognitive functioning than social disconnectedness (10.2% vs. 5.7%). Findings suggest that social isolation is associated with poorer overall cognitive functioning and this remains true across varied cognitive domains. © The Author(s) 2012.
A Review of Social Isolation: An Important but Underassessed Condition in Older Adults
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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.