COVID-19 isn’t just a danger to older people’s physical health

Because the risk of death from COVID-19 increases with age, family members and friends are limiting their visits to older people, whether they’re in nursing homes, assisted living facilities or just their own homes. But that new practice of social distancing — or reducing close physical proximity with others — may contribute to another deadly epidemic among older adults: social isolation and loneliness.

Even before the pandemic began, an alarming number of older Americans were so socially isolated and lonely that their health — and even their lives — are at risk, according to a new report released by the National Academies of Sciences, Engineering and Medicine in February. The AARP Foundation sponsored the study.

Social isolation and loneliness aren’t the same thing, the report emphasizes. Isolation is an objective lack of social contact, while loneliness is the subjective feeling of being lonely; you can be alone without feeling lonely. But both isolation and loneliness are associated with increases in heart disease, dementia and other health problems, the report finds. In fact, social isolation increases mortality risk on a par with such risk factors as smoking, obesity and lack of physical activity, according to a review by Julianne Holt-Lunstad, PhD, a psychology professor at Brigham Young University, and colleagues (American Psychologist, Vol. 72, No. 6, 2017).

And yet the connection between social relationships and health is often overlooked, says Holt-Lunstad, one of the three psychologists on the 15-person committee that wrote the “Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System” report.

“We have good evidence that the effect sizes of these social factors — lack of connection, social isolation and loneliness — are comparable to many of these other risk factors we take quite seriously,” she says. “But that surprises people.”

COVID-19 could make matters worse, says psychologist James S. House, PhD, a co-author of the report and a professor emeritus of survey research, public policy and sociology at the University of Michigan. “On one hand, you have to protect older people from the virus,” he says. “On the other, we’re cutting them off from one of the things that’s very important to their well-being.”

Psychologists can help mitigate the impact of social distancing, closures and other pandemic-related factors putting older people at even greater risk, say House and other experts:

• Stay in touch with patients. Reach out to patients during this crisis, says Brian Carpenter, PhD, a psychology professor at Washington University in St. Louis and president of the Society of Clinical Geropsychology, a section of APA’s Div. 12 (Society of Clinical Psychology). Let them know what your plans are for upcoming visits and how you plan to keep in touch. If your office is still open, you’ll need to make sure patients understand the risks of coming in.
• Consider telemental health options. “I wouldn’t assume that older adults are less savvy or connected, but ask about it,” says Carpenter. “If that turns out to be the case, relying on the telephone is another viable option.” Keep in mind that they’ll need to sign the appropriate consent form and that the reimbursement landscape is changing rapidly.
• Encourage older patients to keep in touch with family and friends. “I don’t like the term ‘social distancing,’” says Karen Fingerman, PhD, who co-directs the Aging and Longevity Center at the University of Texas in Austin. Psychologists should encourage older patients to ramp up other ways to stay in touch, whether through video chat apps, the telephone or even old-fashioned letters or postcards.
• Promote intergenerational connection. Encourage younger patients to check in with grandparents and other older people in their lives, whether that means running errands or just checking in, say Carpenter and Fingerman.
• Help families keep older relatives safe. Psychologists can help families come up with more effective ways to keep older adults at home. “Messages that focus on ‘We’re afraid for you’ get resistance,” says Fingerman. “Give them something important to stay home for.” That might mean encouraging older people to stay in to protect younger people with serious illnesses or to spend time writing the story of their lives for their grandchildren.

Even in the best of times, almost a quarter of noninstitutionalized Americans age 65 and older are socially isolated, meaning they have few social relationships and infrequent social contact, says the report. An even larger percentage of older people confess to feeling lonely, with 35% of people age 45 and older and 43% of those age 60 and older suffering from subjective feelings of isolation.

While anyone can feel lonely or isolated, the report emphasizes, older adults are at higher risk because of such precipitating factors as chronic illness, hearing loss and other sensory impairments, a higher likelihood of living alone and the death of friends and family members. Older people with hearing loss may be less eager to join in social events, for instance.

And certain subpopulations of older people are even more vulnerable to being isolated and lonely, the report says. Older women may face higher risks, for example. Older people with depression and anxiety are more likely to be socially isolated and lonely than their peers. Older people within the gay, lesbian and bisexual community are more likely than their heterosexual counterparts to be lonely, perhaps because of stressors such as lifetimes of discrimination. And immigrant elders are also more likely to experience both loneliness and social isolation, due to language barriers and the loss of deep relationships.

One of the report’s key points is that health-care providers are ideally positioned to identify problems and offer help since almost all older people interact with the health-care system.

Once the COVID-19 crisis has passed, that might mean psychologists making sure the older adults they come in contact with understand the importance of having a social network, says psychologist Jeanne Miranda, PhD, another one of the report’s authors and a professor of psychiatry and biobehavioral sciences at the University of California Los Angeles.

“Often, we’re the people they confide in and feel close to, so we should be helping them find the support that’s so essential to their health,” Miranda says. The report calls on APA and other organizations representing the health-care workforce to alert their members to the health impact of isolation and loneliness through their publications.

More specifically, psychologists and other health-care providers should periodically use validated tools to assess whether older patients are experiencing isolation or loneliness, the report recommends. If that assessment reveals heightened risk — perhaps the patient has lost a spouse or moved—the psychologist should start interventions designed to prevent isolation and loneliness. For both patients at risk and those who are currently isolated or lonely, psychologists should discuss the associated health risks, connect these patients with the social care they need and use evidence-based practices to address underlying causes. The report also suggests that social isolation be included as an element in electronic health records.

To be ready for such patients, the report adds, psychologists and other health-care providers should form partnerships with social service providers that serve this vulnerable population. These might include transportation providers, housing support and other community-based services that can help address isolation.

In addition to raising awareness among both health-care professionals and the public, recommendations include:

• Conducting more research to identify effective ways to assess, prevent and intervene when it comes to social isolation and loneliness among older adults.
• Translating the research that already exists into practice.
• Strengthening education and training in issues related to social isolation and loneliness in older people among the health-care workforce.
• Strengthening connections between the health-care system and community-based resources that could help with older people’s isolation and loneliness.

For Miranda, the research side is just as important as the clinical. “We do not have much science to guide us in the area of interventions for social isolation and loneliness,” she says. “We need to learn how best to intervene to prevent and treat them.”

APA has already been taking action on the issue.

For example, APA is a member of the Coalition to End Social Isolation and Loneliness, which brings together healthcare providers, patient advocates, consumer groups, health plans and other national groups.

As part of that coalition, APA helped push for the inclusion of provisions related to older adults’ loneliness and social isolation in the Supporting Older Americans Act of 2020, which reauthorizes the Older Americans Act.

Passed unanimously by both the House and Senate in March, the reauthorization establishes screening for social isolation and the coordination of supportive services and health care to address social isolation and loneliness within the act’s description of health promotion services that aging agencies can provide. The legislation also tasks the assistant secretary for aging within the U.S. Department of Health and Human Services with developing a plan to support state and local efforts to respond to social isolation, with input from aging network stakeholders and caregivers.

For more information, read the full National Academies reportopens in new window.

Holt-Lunstad shares more on loneliness on APA’s Speaking of Psychology podcast.

Learn how to protect your patients and your practice (PDF, 221KB)opens in new window. Get tips on how caregivers (PDF, 233KB)opens in new window can help older people during a disaster like coronavirus and how older people can help themselves and others. To earn continuing education credit, read the Monitor article “Social Isolation: It Could Kill You.” See COVID-19 resources from GeroCentralopens in new window.