Social Isolation and Loneliness in Older Adults Opportunities for the Health Care System (2020) / Chapter Skim
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9 Interventions
9 Interventions
Pages 171-220
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From page 171... ...
Given the complexity of the terminology used in relation to social isolation and loneliness, a reminder of key definitions is provided in Box 9-1. LARGE-SCALE REVIEWS OF INTERVENTIONS Several studies and projects have examined interventions intended to ameliorate social isolation or loneliness specifically, or their associated health impacts; these interventions have generally not been limited to health care providers or settings (see Table 9-1)
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Social support: the actual or perceived availability of resources (e.g., informa tional, tangible, emotional) from others, typically one's social network.
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Social isolation 30 • Educational and social activity group interventions • Need for better study design (2005) and loneliness that target specific groups were most effective • Need to draw on qualitative, observational, in older adults • Most effective interventions involve active and multilevel evaluations to determine the participation of older adults transferability of evidence • Unclear if home visits, befriending, or one-on-one interventions are effective • Substantial differences in target groups, measurement tools, and outcome measures Dickens et al.
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• Methodological flaws are common: different • Research needed on cognitively impaired older groupings of age, small sample sizes, qualitative adults analyses -- • Use of technology is effective • Educational programs focused on social networks maintenance and enhancement appear to be effective Gardiner et al. Social isolation 38 • Group interventions are not necessarily more • Need better understanding for the mechanisms (2018)
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From page 175... ...
Tables 9-2 through 9-5 describe the interventions evaluated in this review, categorized by target population, intervention level, intervention type, and the rigor of the evaluation in order to give a sense of the breadth of these interventions. Retrum found that the most effective interventions included • Specific targeting of socially isolated individuals; • A multi-systemic approach; • Active participation of the older adults; and • Having a sound theoretical basis.2 Furthermore, Retrum noted3 the following persistent challenges to the evaluation of interventions for social isolation and loneliness: • A limited number of studies quantifying the impact of interventions; • A shortage of randomized controlled trials (RCTs)
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. TABLE 9-3 Intervention Level Catalog Totals One-on-One Group Community Literature Review Interventions 92 27 41 24 Unpublished Interventions 48 31 13 3 SOURCES: Retrum, 2017; American Public Health Association (APHA)
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The researchers noted several challenges overall with the evidence base, including differences in constructs and measures, the overall poor quality of the studies (based on their quality assessments of study design) , short follow-up periods, a lack of measurement of health care utilization or potential harms, and a failure to control for confounders.
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. The expert panel recognized the lack of a robust evidence base for the effectiveness of these approaches and suggested that these approaches warranted further study.
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Direct interventions are those that explicitly target social isolation, loneliness, or related social concepts. Direct interventions can fall into one of several categories: changing cognition, social skills training and psychoeducation, supported socialization, and wider community groups that create a broader sense of social integration (Mann et al., 2017)
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In her comments to this committee in 2018, Helen Stokes-Lampard, the chair of the Royal College of General Practitioners in the United Kingdom, described social prescribing as "a fancy name for what good doctors have always done, which is navigate our patients towards other resources outside of the health care sector that can help them."4 Communitybased organizations have long used this approach. For the purposes of this report, social prescribing will refer to the steps that health care providers can take to link patients with existing social services programs.
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Community-based groups such as social welfare systems, community organizations, religious groups, and government groups may be natural partners for the health care system when it comes to addressing social isolation and loneliness. Because social prescribing is tailored to existing voluntary and community-sector-led programs, it is believed to result in better social and clinical outcomes for people with chronic conditions and their caretakers, a more cost-efficient way to use health and social care5 resources, and a wider and more diverse and responsive local provider base (Dayson and Bashir, 2014)
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. Another example of a social prescribing system was piloted in Rotherham, United Kingdom, from 2012 to 2014, with the aim of increasing the capacity of general practitioners to meet the non-clinical needs of patients with longterm conditions.
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Referrals were made to a variety of social service providers, and the services addressing isolation or loneliness included befriending services, group activity programs, home visits, and group therapy sessions. An analysis of the pilot found that among the patients who received social prescribing services, inpatient admissions were reduced as much as 21 percent and accident and emergency attendance were reduced by as much as 20 percent (Dayson and Bashir, 2014)
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(2007) found that lonely individuals perceive greater negativity in social interactions than do non-lonely individuals and that lonely individuals perform more poorly on tests of executive functioning than nonlonely individuals (Cacioppo and Hawkley, 2009)
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. CBT has been found effective in addressing social anxiety disorder, insomnia, and unipolar depression (Butler et al., 2006; Edinger et al., 2001; Gress et al., 2008; Heimberg, 2002; Koszycki et al., 2007)
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From page 186... ...
conducted an RCT in which smartphone-based training was used to train participants in mindfulness techniques of awareness and acceptance for 2 weeks. The study found that individuals who received mindfulness training reported a 22 percent reduction in daily loneliness compared with the control group; thus, mindfulness training may be a promising way to mitigate the subjective risk factors associated with loneliness.
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This community- ased organization b uses community health workers to link patients to services in order to address social determinants related to diabetes prevention and management, asthma, hypertension, aging in place, behavioral health, maternal health, and substance use disorder at the individual and household levels.10 (See Chapter 7 for more on the role of the health care system in addressing the social determinants of health. See later in this chapter for more on financing interventions for social isolation and loneliness through existing programs directed at the social determinants of health.)
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in addition to addressing the social determinants of health (e.g., by connecting individuals with reliable transportation or housing assistance)
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Humana's Bold Goal12 is a population health strategy that specifically addresses the social determinants of health, including loneliness and social isolation, in order to improve health status. As part of this, Humana created a Loneliness Toolkit (Humana, 2018)
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. Advocacy activities involve health care organizations partnering with social care organizations "to promote policies that facilitate the creation and redeployment of assets or resources in order to improve health outcomes and prevent emergence of unmet social needs" (p.
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Los Angeles Social Isolation and Loneliness Impact Coalition The Los Angeles Social Isolation and Loneliness Impact Coalition was created through a collaborative arrangement between the Motion Picture and Television Fund (MPTF) and the AARP Foundation with the goal of addressing the health and financial impacts of social isolation and loneliness in older adults.
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With the growth of artificial intelligence (AI) , social robots and conversational agents are often viewed as effective tools for social engagement in gerontology.
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and software (with virtual reality content specifically designed for older adults with the goal of providing reminiscence therapy elements with familiar experiences or engagement with new stimulations) Social robots/ Use of conversational agents with artificial conversational intelligence functions to engage users in dialogue agents either for general companionship or for meeting specific goals (reminders, health or safety assessment)
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Social Media Use The Pew Research Center (2018) estimates that older adults are the fastestgrowing group of individuals to adopt and use social media sites.
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Social Robots and Conversational Agents A social robot is defined as an artificial agent (often embodied with anthropomorphic or zoomorphic features) that interacts with humans by following the social norms and behaviors attached to its role (Broekens et al., 2009; Taipale et al., 2015)
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. Broader in concept than social robots, conversational agents are "systems that mimic human conversation using text or spoken language" (Laranjo et al., 2018, p.
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. Some work has examined the use of conversational agents specifically for older adults.
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. However, ECAs and social robots as well as other new technologies (e.g., voice based personal assistants such as Amazon's Alexa)
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Existing norms and legislation related to health information are being reconsidered and extended to include new devices oriented toward patients. Specific issues related to ECAs or social robots include the protection, storage, and transmission of audio and video data (Demiris et al., 2006)
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Trust developing between an individual and a device could mean that an older adult reveals more personal information than would otherwise be the case because of the perceived lower interpersonal risk of sharing and a failure to realize that in some cases this information may become accessible to third parties or other stakeholder groups. Additional informed consent concerns that are specific to social robots or ECAs include the high level of digital literacy needed to understand the mechanisms of the technology.
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. This issue may be a particular concern with social robots and ECAs, given that these technologies rely on social interactions and building relationships.
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. Infantilization of Older Adults The introduction of social robots or ECAs for older adults in some cases introduces concerns for the infantilization of these individuals (i.e., creating a behavioral pattern in which the older adult is treated in a child-like manner)
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. The resource limitations experienced by some high-risk populations can worsen inequalities in access to technologically mediated supports to address social isolation and loneliness.
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This suggests that the social determinants of health create barriers to older adults' access to technologies and that reducing these barriers could be helpful in efforts to reduce social isolation and loneliness. Adults aged 75 and older were less likely than adults aged 65–74 to use the Internet.
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For example, Older Adults Technology Services17 trains older adults in community settings in computer skills, including the use of email, the management of medical information, and the building of community networks. Underserved Populations and the Social Determinants of Health In a literature review of the impact of sociodemographic factors on the use of eHealth, Reiners et al.
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Furthermore, the 2019 National Academies consensus study report Integrating Social Care into the Delivery of Health Care describes the negative correlation between spending on social care and total health care costs that exists across countries and across states (NASEM, 2019)
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The second is by financing interventions that target social isolation and loneliness, either directly or indirectly. Finally, financing may be considered for public health efforts to increase awareness of the health and medical impacts of social isolation and loneliness, both for reducing the stigma associated with social isolation and loneliness and for helping to identify those at risk.
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Better coverage of hearing aids and other medically needed devices (e.g., wheelchairs, low-vision technologies) could potentially do much to help reduce the prevalence of social isolation and loneliness.18 Financing Interventions Targeting Social Isolation and Loneliness Social isolation and loneliness might also be targeted by taking advantage of existing programs to assess or address the social determinants of health in general.
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Similar pilot programs are operational in other states, and Medicaid managed care plans are similarly exploring ways to improve health outcomes by addressing the social determinants of health. Medicaid waiver programs can be used as models for interventions specifically addressing social isolation and loneliness among low-income older adults and people with disabilities.
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would begin to consider similar interventions as cost savings mechanisms. Outside the United States, the National Health Service in the United Kingdom has already created a system of social prescribing to encourage doctors to "prescribe" social activities and engagement.
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REFRAMING INTERVENTION USING A PUBLIC HEALTH APPROACH Because of the variety of ways that social isolation and loneliness affect health and well-being, there is no single treatment that can prevent or cure every instance of social isolation or loneliness. Instead, addressing these issues will necessarily involve a variety of different actors and an assortment of interventions focused on different demographics, risk factors, and health impacts.
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Some examples of secondary preventions strategies are regimens of daily low-dose aspirin for individuals who have suffered from heart attack or stroke; regular mammogram screening in order to detect early breast cancer; and regimens of antiretroviral medications for individuals who have human immunodeficiency virus. In the case of social connection, secondary prevention strategies are those that attempt to target or influence existing social isolation or loneliness that is felt acutely (in other words, a temporary state of loneliness or social isolation, perhaps due to a sentinel life event)
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Secondary prevention strategies are the responsibility of community actors such as general health care practitioners and local service groups. Those responsible for tertiary prevention strategies include affected individuals and their close associates or care team, including but not limited to family and friends (Mann et al., 2017)
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• Studies of the use of the Internet and, more specifically, social media by older adults introduce mixed findings; several studies show that online tools may increase connection and decrease isolation, while others have shown no links between Internet use and perceived isolation. • The number of studies examining social robots for social isolation and loneliness has increased significantly in recent years, but there is insuf ficient evidence of their effectiveness.
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• The committee notes the following findings from the consensus study report Integrating Social Care into the Delivery of Health Care (NASEM, 2019) : • Within existing definitions of health care, state Medicaid programs and their contracted managed care plans and accountable providers are in novating with .
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Strengthening Ties to Community-Based Networks and Resources Chapters 2 through 4 of this report show that social isolation and loneliness have wide-ranging health and medical impacts and are associated with a vast array of risk factors. Like other social determinants of health, social isolation and loneliness are community-wide problems and require coordinated solutions between the health care system and community-based social service providers.
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As an example of tailored communitybased services, the 2019 National Academies consensus study report Integrating Social Care into the Delivery of Health Care cites examples of assistance and alignment as including the provision of transportation vouchers that can be used for ride-sharing services or public transit and the investment in community ride-sharing programs (NASEM, 2019)
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Also, little is known about how current trends, such as the use of social media, will affect social isolation and loneliness in future generations of older adults. In accordance with the committee's previously identified goal of developing a more robust evidence base on effective prevention, assessment, and intervention strategies for social isolation and loneliness in older adults, the committee identified three major aspects of the overall evidence base for effective clinical interventions that need to be addressed in order to determine best practices and approaches.
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, foundations, and large health plans, should fund research on effective interventions in clinical settings to identify, prevent, and mitigate the effects of social isolation and loneliness in older adults. RECOMMENDATION 9-5: Those who fund, develop, and operate programs to assess, prevent, and intervene in social isolation and loneliness should prioritize research on the following major gaps in the evidence base: • Tailored interventions based on a public health framework of primary, secondary, and tertiary prevention.
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220 SOCIAL ISOLATION AND LONELINESS IN OLDER ADULTS • Trends among current younger adults as they age (e.g., use of tech nology, economic trends) to gain knowledge that informs future ap proaches to addressing social isolation and loneliness.
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