National Academies Press: OpenBook
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R1
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R2
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R3
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R4
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R5
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R6
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R7
Page viii Cite
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R8
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R9
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R10
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R11
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R12
Page xiii Cite
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R13
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R14
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R15
Suggested Citation:"Front Matter." 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. doi: 10.17226/25663.
×
Page R16

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

SOCIAL ISOLATION AND LONELINESS 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 PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25663 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America 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. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

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 LAURIE LOVETT NOVAK, Assistant Professor, Department of Biomedical Informatics, Vanderbilt University School of Medicine 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 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 Study Staff 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 Consultant MARITA G. TITLER, University of Michigan School of Nursing PREPUBLICATION COPY: UNCORRECTED PROOFS v

Reviewers 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, 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 College 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. 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. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Acknowledgements 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 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, Sara Czaja, James Coen, 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. PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Preface 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 the “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 PREPUBLICATION COPY: UNCORRECTED PROOFS xi

xii SOCIAL ISOLATION AND LONELINESS 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 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 PREPUBLICATION COPY: UNCORRECTED PROOFS

Contents SUMMARY S-1 1 INTRODUCTION 1-1 Study Context, 1-2 Charge to the Committee, 1-4 Relevant National Academies Reports, 1-6 Study Approach, 1-7 Overview of the Committee’s Report, 1-15 2 EVALUATING THE EVIDENCE FOR THE IMPACTS OF SOCIAL ISOLATION, LONELINESS, AND OTHER ASPECTS OF SOCIAL CONNECTION ON MORTALITY 2-1 A History of Understanding the Contributors to Human Health, 2-3 Discovering Social Connections as a Determinant of Health and Longevity, 2-4 The Current State of the Evidence on Impacts of Social Isolation, Loneliness, and Social Support on Mortality, 2-6 A Further Note on Social Isolation, and Social Connection More Generally, as a Potential Causal Risk for Mortality, 2-10 Findings and Conclusions, 2-12 Next Steps and Recommendations, 2-12 3 HEALTH IMPACTS OF SOCIAL ISOLATION AND LONELINESS ON MORBIDITY AND QUALITY OF LIFE 3-1 Impact on Health Outcomes, 3-3 Impact on Health-Related Behaviors, 3-8 Impact on Quality-of-Life Outcomes, 3-9 Findings and Conclusions, 3-11 Next Steps and Recommendations, 3-12 4 RISK AND PROTECTIVE FACTORS FOR SOCIAL ISOLATION AND LONELINESS 4-1 Physical Health Factors, 4-3 Psychological, Psychiatric, and Cognitive Factors, 4-6 Social and Cultural Factors, 4-8 Social Environmental Factors, 4-16 At-Risk Populations, 4-20 Findings and Conclusions, 4-22 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

5 MEDIATORS AND MODERATORS 5-1 Mediators: Behavioral, Psychological, and Biological Mechanisms, 5-4 Moderating Factors Influencing Mortality and Health Outcomes, 5-10 Findings and Conclusions, 5-13 6 ASSESSMENT OF SOCIAL ISOLATION AND LONELINESS IN RESEARCH 6-1 Measurement of Social Isolation and Loneliness, 6-1 Measuring Impact for Social Isolation and Loneliness, 6-7 Identification of Individuals and Populations at Risk, 6-8 Findings and Conclusions, 6-13 7 ROLE OF THE HEALTH CARE SYSTEM 7-1 Health Care Access and Utilization, 7-2 Social Determinants of Health and the Health Care System, 7-6 Clinical Assessment of Social Isolation and Loneliness, 7-8 Technology as Infrastructure for Coordination and Intervention, 7-13 Findings and Conclusions, 7-16 Next Steps and Recommendations, 7-17 8 EDUCATION AND TRAINING 8-1 Framework for the Role of Education in Catalyzing Change, 8-2 National Standards and Policy Priorities, 8-2 Current Education and Training of the Health Care Workforce, 8-6 Public Health Campaigns, 8-11 Changing Practice Behaviors, 8-14 Findings and Conclusions, 8-16 Next Steps and Recommendations, 8-17 9 INTERVENTIONS 9-1 Large-Scale Reviews of Interventions, 9-1 Types of Interventions Relevant to the Health Care System, 9-8 Coalitions and Partnerships to Address Social Isolation and Loneliness, 9-17 Technological Interventions, 9-19 Ethical and Practical Considerations for Intervention, 9-24 Financing of Interventions, 9-31 Reframing Intervention Using a Public Health Approach, 9-35 Findings and Conclusions, 9-38 Next Steps and Recommendations, 9-40 PREPUBLICATION COPY: UNCORRECTED PROOFS xiv

10 DISSEMINATION AND IMPLEMENTATION 10-1 Definition of Terms, 10-1 Overview of Implementation Strategies, 10-3 Addressing the Characteristic of the Topic, 10-3 Addressing Users of the Evidence-Based Information, 10-4 Communication Strategies, 10-6 Addressing the Social Context, 10-10 Sustainability, 10-12 Conclusion, 10-13 REFERENCES R-1 APPENDIXES A PUBLIC MEETING AGENDAS A-1 B COMMITTEE AND STAFF BIOGRAPHIES B-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xv

Next: Summary »
Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System Get This Book
×
Buy Prepub | $84.00 Buy Paperback | $75.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Social isolation and loneliness are serious yet underappreciated public health risks that affect a significant portion of the older adult population. Approximately one-quarter of community-dwelling Americans aged 65 and older are considered to be socially isolated, and a significant proportion of adults in the United States report feeling lonely. People who are 50 years of age or older are more likely to experience many of the risk factors that can cause or exacerbate social isolation or loneliness, such as living alone, the loss of family or friends, chronic illness, and sensory impairments. Over a life course, social isolation and loneliness may be episodic or chronic, depending upon an individual’s circumstances and perceptions.

A substantial body of evidence demonstrates that social isolation presents a major risk for premature mortality, comparable to other risk factors such as high blood pressure, smoking, or obesity. As older adults are particularly high-volume and high-frequency users of the health care system, there is an opportunity for health care professionals to identify, prevent, and mitigate the adverse health impacts of social isolation and loneliness in older adults.

Social Isolation and Loneliness in Older Adults summarizes the evidence base and explores how social isolation and loneliness affect health and quality of life in adults aged 50 and older, particularly among low income, underserved, and vulnerable populations. This report makes recommendations specifically for clinical settings of health care to identify those who suffer the resultant negative health impacts of social isolation and loneliness and target interventions to improve their social conditions. Social Isolation and Loneliness in Older Adults considers clinical tools and methodologies, better education and training for the health care workforce, and dissemination and implementation that will be important for translating research into practice, especially as the evidence base for effective interventions continues to flourish.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!