in Older Adults
OPPORTUNITIES FOR THE
HEALTH CARE SYSTEM
Committee on the Health and Medical Dimensions of
Social Isolation and Loneliness in Older Adults
Board on Health Sciences Policy
Health and Medicine Division
Board on Behavioral, Cognitive, and Sensory Sciences
Division of Behavioral and Social Sciences and Education
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
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This activity was supported by a contract between the National Academy of Sciences and the AARP Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978–0-309-67100-2
International Standard Book Number-10: 0-309-67100-0
Digital Object Identifier: https://doi.org/10.17226/25663
Library of Congress Control Number: 2020934003
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Social isolation and loneliness in older adults: Opportunities for the health care system. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663.
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COMMITTEE ON THE HEALTH AND MEDICAL DIMENSIONS OF SOCIAL ISOLATION AND LONELINESS IN OLDER ADULTS
DAN G. BLAZER II (Chair), J.P. Gibbons Professor Emeritus of Psychiatry, Duke University School of Medicine
SUSAN BEANE, Vice President and Medical Director, Healthfirst, Inc.
CYNTHIA M. BOYD, Professor, Johns Hopkins Bloomberg School of Public Health
LINDA BURNES BOLTON, Senior Vice President and Chief Health Equity Officer, Cedars-Sinai Medical Center
GEORGE DEMIRIS, Penn Integrates Knowledge University Professor, University of Pennsylvania
NANCY J. DONOVAN, Director, Division of Geriatric Psychiatry, Brigham and Women’s Hospital, Harvard Medical School
ROBERT ESPINOZA, Vice President of Policy, PHI
COLLEEN GALAMBOS, Professor and Helen Bader Endowed Chair in Applied Gerontology, University of Wisconsin–Milwaukee Helen Bader School of Social Welfare
JULIANNE HOLT-LUNSTAD, Professor, Brigham Young University
JAMES S. HOUSE, Angus Campbell Distinguished University Professor Emeritus, Survey Research University of Michigan Institute for Social Research
KATHLEEN McGARRY, Professor and Vice Chair, Department of Economics, University of California, Los Angeles
JEANNE MIRANDA, Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
LAURIE LOVETT NOVAK, Assistant Professor, Department of Biomedical Informatics, Vanderbilt University Medical Center
CARLA M. PERISSINOTTO, Associate Professor of Medicine and Associate Chief of Clinical Programs in Geriatrics, University of California, San Francisco
JULIANN G. SEBASTIAN, Dean and Professor, College of Nursing, University of Nebraska Medical Center
TRACY A. LUSTIG, Study Director
JENNIFER A. COHEN, Program Officer
CAROLINE M. CILIO, Associate Program Officer (through October 2019)
KENDALL LOGAN, Senior Program Assistant
ANDREW M. POPE, Senior Director, Board on Health Sciences Policy
MARITA G. TITLER, University of Michigan School of Nursing
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This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
LINDA FRIED, Columbia University Mailman School of Public Health
TERRY T. FULMER, The John A. Hartford Foundation
CARMEN GARCIA-PENA, National Institute of Geriatrics
LOUISE HAWKLEY, NORC at the University of Chicago
MITCHELL H. KATZ, Health + Hospitals
JAMES LUBBEN, University of California, Los Angeles
JOSÉ A. PAGÁN, New York University School of Global Public Health
MICHELLE PUTNAM, Simmons University School of Social Work
NIRAV R. SHAH, Stanford University
ROBYN STONE, LeadingAge
PAUL C. TANG, Stanford University
WINSTON WONG, Kaiser Permanente
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by BOBBIE A. BERKOWITZ, Columbia University School of Nursing and University of Washington, and NANCY FUGATE WOODS, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The study committee and the Health and Medicine Division (HMD) project staff take this opportunity to recognize and thank the many individuals who shared their time and expertise to support the committee’s work and to inform deliberations.
This study was sponsored by the AARP Foundation. We thank the AARP Foundation president, Lisa Marsh Ryerson, for her guidance and support. We also wish to recognize the important contributions of Emily Allen and Eliza Heppner, who were instrumental in helping to launch this effort.
The committee benefitted greatly from discussions with individuals who made presentations during the committee’s open sessions: Martha Bruce, James Coan, Sara Czaja, Steve Ewell, Maureen Feldman, Linda Fried, Jeanne-Marie Guise, Sachin Jain, Michael Monson, Jessica Retrum, Lucy Savitz, Bert Uchino, and Colin Walsh. The committee is very grateful to these presenters for volunteering to share their knowledge, data, and expert opinions with the committee and members of the public who attended the committee’s open sessions. Special thanks are also extended to Sara Czaja for her early interest in this effort and her ongoing support of the National Academies’ work. The staff also recognize Martha Coven, Robin Mockenhaupt, Sheila Shapiro, and Bob Wallace for providing expertise and replying to staff inquiries.
The committee is grateful for the many staff within HMD who provided support at various times throughout this project. Special thanks are extended to Rebecca Morgan, senior librarian, who compiled literature searches; Bardia Massoudkhan, the financial associate for this project; and Robert Pool, for his editorial assistance provided in preparing the final report.
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Human beings are social by nature, and high-quality social relationships are vital for health and well-being. Like many other social determinants of health, however, social isolation (an objective lack of social contact with others) and loneliness (the subjective feeling of being isolated) are significant yet underappreciated public health risks. Social isolation and loneliness are associated with poor physical and mental health outcomes, including higher rates of mortality, depression, and cognitive decline. Recent research documents the high prevalence of social isolation and loneliness among older adults. For example, data from the National Health and Aging Trends Study found that 24 percent of community-dwelling older adults are considered socially isolated, and a 2018 survey by the AARP Foundation found that more than one-third (35 percent) of adults aged 45 and older are lonely. Additionally, a 2018 study by the Kaiser Family Foundation found that 22 percent of adults in the United States say they “often or always feel lonely, feel that they lack companionship, feel left out, or feel isolated from others.”
While the science of social relationships and their consequences on health and well-being has been documented for decades, the topics of social isolation and loneliness have recently garnered increased attention in the mass media. For example, in the past few years, articles in The New York Times featured headlines such as “How Social Isolation Is Killing Us” and “The Surprising Effects of Loneliness on Health.”
In particular, the AARP Foundation has played a key role in bringing attention to the health and medical impacts of social isolation and loneliness. In this context, the AARP Foundation came to the National Academies of Sciences, Engineering, and Medicine for an examination of the health and medical dimensions
of social isolation and loneliness and for recommendations on the role of the health care system in helping to reduce the incidence and adverse health impacts of social isolation and loneliness among older adults in clinical settings. This exploration is notable in that relatively few stakeholders have paid attention to the particular role that health care professionals and providers can play.
During this broad-based review of the issues of social isolation and loneliness, the committee identified several overarching challenges. Most prominently is the multiplicity of terms for different aspects of social relationships (such as social isolation, social support, loneliness, and social networks, among others). Furthermore, the terms social isolation and loneliness are often conflated, but they represent distinct concepts, each with their own measures. As a result, the literature base on the health and medical impacts of social isolation and loneliness, as well as potential interventions, are confounded by this confusion of terminology. In the report, the committee sought to carefully report the evidence accurately in terms of the specific aspects of social isolation and loneliness that were actually targeted and measured.
This report presents a comprehensive review of the impacts of social isolation and loneliness on mortality and morbidity, the risk factors for social isolation and loneliness, the mechanisms by which social isolation and loneliness impact health, the factors that affect those mechanisms, and the ways in which researchers measure social isolation and loneliness and their resultant impacts on health. Furthermore, the committee discusses the role of the health care system in addressing these issues, the ways in which we can better educate and train our health care workforce, and which interventions (particularly for the clinical setting) show the most promise. Finally, the committee discusses general principles of dissemination and implementation that will be important for translating research into practice, especially as the evidence base for effective interventions continues to flourish.
Overall, this committee comes to the firm conclusion that the health care system is well poised to develop and evaluate methods and processes to identify social isolation and loneliness among older adults in clinical settings. In fact, the committee notes that a single interaction with the health care system may represent the only opportunity to identify those individuals who are the most isolated and lonely. However, we emphasize that the health care system cannot solve the problems of social isolation and loneliness alone; rather, the goals and recommendations presented in this report represent a vision for how the health care system can help as part of a larger global effort to combat the adverse health impacts of social isolation and loneliness among adults aged 50 and older in the United States.
As chair of the committee I would like to recognize and thank each committee member for his/her contributions to the report. Our committee was most engaged with, even passionate, about the topic yet throughout our discussions and drafting of the report the committee maintained the highest level of critical
thinking and reliance on the evidence available to us. The entire committee owes a special thanks to Tracy Lustig, Jennifer Cohen, Caroline Cilio, and Kendall Logan. We could not have asked for a more dedicated and thoughtful staff from the National Academies. Finally I offer thanks to Andy Pope, the senior director of the Board on Health Sciences Policy at the National Academies and to the AARP Foundation for supporting this exciting and meaningful exploration.
Dan G. Blazer II, Chair
Committee on the Health and Medical Dimensions of Social Isolation and Loneliness in Older Adults
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Relevant National Academies Reports
Overview of the Committee’s Report
2 EVALUATING THE EVIDENCE FOR THE IMPACTS OF SOCIAL ISOLATION, LONELINESS, AND OTHER ASPECTS OF SOCIAL CONNECTION ON MORTALITY
A History of Understanding the Contributors to Human Health
Discovering Social Connections as a Determinant of Health and Longevity
The Current State of the Evidence on Impacts of Social Isolation, Loneliness, and Social Support on Mortality
A Further Note on Social Isolation, and Social Connection More Generally, as a Potential Causal Risk for Mortality
3 HEALTH IMPACTS OF SOCIAL ISOLATION AND LONELINESS ON MORBIDITY AND QUALITY OF LIFE
Impact on Health-Related Behaviors
Impact on Quality-of-Life Outcomes
Next Steps and Recommendations
4 RISK AND PROTECTIVE FACTORS FOR SOCIAL ISOLATION AND LONELINESS
Psychological, Psychiatric, and Cognitive Factors
Mediators: Behavioral, Psychological, and Biological Mechanisms
Moderating Factors Influencing Mortality and Health Outcomes
6 ASSESSMENT OF SOCIAL ISOLATION AND LONELINESS IN RESEARCH
Measurement of Social Isolation and Loneliness
Measuring Impact for Social Isolation and Loneliness
Identification of Individuals and Populations at Risk
7 ROLE OF THE HEALTH CARE SYSTEM
Health Care Access and Utilization
Social Determinants of Health and the Health Care System
Clinical Assessment of Social Isolation and Loneliness
Technology as Infrastructure for Coordination and Intervention
Framework for the Role of Education in Catalyzing Change
National Standards and Policy Priorities
Current Education and Training of the Health Care Workforce
Next Steps and Recommendations
Large-Scale Reviews of Interventions
Types of Interventions Relevant to the Health Care System
Coalitions and Partnerships to Address Social Isolation and Loneliness
Ethical and Practical Considerations for Intervention
Reframing Intervention Using a Public Health Approach
Next Steps and Recommendations
10 DISSEMINATION AND IMPLEMENTATION
Overview of Implementation Strategies
Addressing the Characteristics of the Topic
Addressing Users of the Evidence-Based Information
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