social determinants of health

Social Determinants of Health, Part 4: All the Lonely People

by Dr. Randall Williams, MD

The Beatles were onto something with their song “Eleanor Rigby”. The loneliness of Eleanor Rigby and Father McKenzie strike a chord with us because we humans are social creatures—it’s woven into our DNA. From our hunter-gatherer ancestors who moved in clans to the complex, fast-moving communities we live in today, we are all dependent on one another for survival. Unfortunately, as recently as a generation ago, this social connectedness began to erode, especially driven by realities of modern society that include:

  • An aging demographic and longer life expectancy;
  • Movement from rural and urban communities to suburbs, increasing commute times, and leading to the phenomenon of virtual workplaces;
  • Erosion of social institutions such as churches and synagogues;
  • Outmigration of families away from their geographic origins as affluence and opportunity increased;
  • The dramatic increase in dependence on technology for communication, collaboration and work.

Although there are many adverse effects of social isolation, this article will focus on isolation and loneliness as social determinants of health (SDHs). Organizations who understand how social isolation affects patient populations, and how to address it, will be one step closer to succeeding with value-based care.

Defining Social Isolation and Loneliness

Social isolation is the near or total lack of interaction with others on a regular or consistent basis.

Social isolation is a chronic problem, as distinct from loneliness, which is a temporary feeling of disconnection from others. Social isolation can be self-imposed, or circumstantial. But in either instance, there is a common pattern that includes being home for extended periods (days to weeks) without intimate or meaningful contact with others, leading to feelings of loneliness, anxiety and even fear about interaction with others, and lowered self-esteem.

While social isolation can begin early in life, and might be caused by emotional or psychological conditions, it is also very prevalent in certain life situations, such as the elderly, recently displaced, unemployed, retired, or widowed. This phenomenon is increasing rapidly in our modern society. In fact, according to research from Duke University, a startling 40% of adults say they are lonely. And the prevalence of social isolation and loneliness has doubled in over the past 20 years. Today, 25% of Americans report that they have no meaningful social support and no one that they can confide in, according to Psychology Today.

Clearly, the phenomenon of social isolation is a problem of modern society, one that is accelerating in prevalence, despite, if not because of, our increased reliance on technologies and our “abundant society”.

Dangers of Social Isolation and Loneliness

Social isolation is a remarkably important health risk factor.  In fact, social isolation carries the same degree of health risk as smoking cigarettes, and doubles that of obesity. Social isolation is a huge risk factor for major depression, which itself has also doubled in prevalence in the past decade. There is evidence that social isolation is a risk factor for substance abuse and addiction.

Social isolation has been studied in humans and also in well controlled animal models, all the way from fruit flies to mice. Consistently, these studies have found that social isolation leads to increased inflammatory activation, impaired immune function, and heightened activation of the autonomic nervous system. The pattern is one of an always activated “fight or flight” state of being. This harmful biologic state resulting from social isolation has also been shown to increase levels of arthritis, Type II Diabetes and heart disease. Studies of elderly individuals show that those who lack regular social interactions are twice as likely to die prematurely.

Are there predictors of social isolation and loneliness?

Here are a few established risk factors for social isolation and loneliness that you may encounter in your efforts to manage populations:

  • Aging, dementia and frailty.

Individuals who are older, especially those who are also suffering from physical limitations in mobility or memory loss, often have extreme difficulty maintaining social connections. Often these individuals lack regular and/or intimate interactions with others, especially when living alone or outside of a caring community, such as a retirement community.

  • Recent loss of a spouse and/ or remote or absent offspring.

This challenge is also more prevalent in the aging population. The problem of social isolation is compounded if the individual lives alone.

  • Unemployment or recent retirement.

Individuals that have lost their work environment as a social connection point may struggle to replace valued personal interactions. In addition, the stigma of a job loss may compound the challenge.

  • Mobility challenges involving safe transportation.

Often due to physical disability, individuals who have special transportation needs may find it particularly hard to stay socially connected. This problem can also be compounded when there are associated emotional or learning disabilities, and where the safety of the environment is also a concern.

  • Social anxiety or substance abuse issues.

Sometimes it is difficult to know which is cause and which is effect, but social isolation goes hand in glove with issues of anxiety and substance abuse.  Often a vicious cycle can be the result, where anxiety leads to social isolation, which leads to worsening anxiety and self-medication with alcohol or drugs.

What should healthcare teams know and do about social isolation and loneliness?

As care providers take on increasing responsibility for the health and healthcare outcomes of populations, a new view of social isolation and loneliness often emerge. The socially isolated patient may be more likely to “seek” the attention of care providers through frequent ER visits, and lengthy clinic or telephone conversations with staff about many issues that appear at first blush to be non-health care related. Front office staff often bear the brunt of these demands, taking valuable time to “listen”.

The challenge is that clinical staff are often shielded from information about patients that would raise a flag about social isolation issues. And since socially isolated persons are often uncomfortable with social interactions, the very things they need to help go uncommunicated.

One way to solve this challenge is for care providers to screen and identify social situation challenges as part of every clinical assessment and encounter. Simple questions like, “Do you experience a feeling of loneliness?” or, “When is the last time you shared a meal with someone you know well?” are a good place to start.

At Pharos, our experiences in helping support population health efforts has led to a few insights worth sharing:

  • Every individual, regardless of situation or clinical status, wants to know that they are cared about;
  • Care providers need to view themselves as the first line of awareness that social isolation is occurring in their patients;
  • Often, having “visibility” into the social and living situation of a population can be a challenge to accountable care organizations, as this visibility extends beyond the usual view and scope of the normal clinical encounter;
  • “Frequent fliers” are often socially isolated and turning to the healthcare system for social interaction;
  • Forward thinking ACOs are recognizing the challenges of social isolation and loneliness and proactively interacting with their populations to both screen for and to forge ongoing meaningful interactions with their at-risk populations.

We recently visited our client, Community Health Network, an MSSP ACO located in the Twin Cities. During our conversation with Dr. Tim Hernandez, Medical Director for the ACO, the topic of social isolation came up. Watch the video clip to hear Dr. Hernandez talk about patient engagement and loneliness as a social determinant of health.

Image credit: Dedicated to all the lonely people by Beverley Goodwin at Flickr

Dr. Randall Williams, MDSocial Determinants of Health, Part 4: All the Lonely People

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