Damian Sendler: Coronavirus disease pandemic has made isolation and loneliness buzzwords for older adults, but these are long-standing issues. In the emergency department, there is currently no rapid or succinct tool that can be used to screen for either or a consensus of evidence-based ways to correct these problems. Because loneliness and social isolation have been linked to poor health, this is a cause for concern. Isolation and loneliness are exacerbated when one is sick or disabled. If an older adult experiences any of these health issues, he or she may be forced to go to the hospital’s emergency room, where medical tests and treatment can be started right away. In this article, emergency nurses can learn about questions they can ask to determine whether or not an elderly patient is lonely or socially isolated, as well as what to do if they encounter an elderly patient who complains of loneliness or social isolation. Updated information about loneliness and social isolation in older adults, a pressing issue during the current coronavirus disease pandemic, is the goal of this article. A list of screening tools that can be used in the ER is provided.
Damian Jacob Sendler: The St. Paul Pioneer Press published a front-page story on June 21, 2020 about the “cause of death or contributing factor” on the death certificates of three elderly people over the age of 90, all of whom were described as “socially isolated.” Even though only one of the seniors tested positive for coronavirus disease (COVID-19), they all lived in long-term Alzheimer’s care facilities that had taken precautions to reduce their risk of exposure to the virus, according to the reporter’s findings. As a result, each patient was confined to their room and was not allowed visitors, including family members. These seniors’ routines had been disrupted, but the staff continued to interact with them and provide care. Reported by a facility staff member, patients showed a “decreased interest in eating, more time sleeping, seemed to lose interest in living and developed ‘failure to thrive'” over the course of the three months of confinement. 1
Dr. Sendler: Social isolation and loneliness have been on the minds of many people in light of the COVID-19 pandemic. When caring for a senior citizen who is at risk of social isolation and loneliness because of a condition like COVID-19, it makes sense to look at both the causes and the consequences on their health, as well as possible treatment options that emergency nurses could use.
Loneliness and social exclusion aren’t the same thing, even though they’re often associated.
Loneliness can be defined as a patient’s perception of a lack of companions or social connections/network.
The term “isolation” refers to a lack of social ties. Older adults (usually over the age of 65) who described themselves as socially isolated but did not experience loneliness in previous studies, as well as those who claimed to be lonely despite not being socially isolated, have both been studied. The studies also found that as people age, they are more likely to become socially isolated and lonely due to life events like death, divorce, and bereavement. Because loneliness and social isolation have been linked to poor health outcomes, it is important for emergency care providers to identify older adults at risk of being lonely or socially isolated. In addition, there are steps that can be taken to address these issues.
When a spouse, significant other, or close friend passes away, it’s a common cause of isolation and loneliness. This is especially true when the person’s support system or mode of transportation is also taken away.
There are other obvious risk factors for loss, such as when children grow up, leave home, and become preoccupied with their own lives; or when moving to a smaller home, condominium, assisted living facility, or nursing home, and losing friends in the neighborhood. 10, 12 Loneliness can set in if you stop seeing your coworkers and friends on a regular basis once you retire. 9.10.15 Being the primary caregiver can lead to social isolation and loneliness in the caregiver, especially if the ill partner was doing the driving before becoming ill. 8; 15
It’s possible that an older adult’s loneliness or sense of isolation is rooted in something else besides the obvious decline that comes with age. People who can no longer drive due to physical or cognitive changes, or who are concerned about their own or others’ safety while driving, may have fewer opportunities for social interaction. Some of the most common reasons for people to stay at home and risk social isolation are the dangers of slipping and falling, increased crime and personal safety (especially when it comes to infectious diseases like influenza or COVID-19). 9, 10, 15 Frailty, mobility issues, and financial constraints have led many older adults, particularly those with mobility issues, to avoid socializing because they are afraid of being humiliated in public (e.g., eating out with friends, going to movies, playing bingo) or becoming an embarrassment. Elderly people who are unable to hear or see what others are saying or seeing can also stay at home because of the need for durable medical equipment (oxygen tanks, walkers, wheelchairs, and so on). 17 and 16
“They’re old, so they won’t want to,…they can’t keep up,…they prefer to be in bed,…they need frequent restroom stops,…they can’t hear,…they can’t see,…they won’t understand the situation” are examples of ageism and stereotyped thinking that has led to older adults being excluded from social events or reluctance in attending themselves, leading to social isolation.
The following numbers are in order of appearance: 9, 10, 12, and 15 And it’s even worse if the older adult is brought to an event, only to be ignored by everyone else because of these attitudes. 10 The lesbian, gay, bisexual, transgender (LGBT) community is more likely to report loneliness than other groups because of language barriers, according to a study. 7 & 12
The “common” reasons for an elderly person to feel isolated, lonely, and disconnected are readily apparent (loss of spouse or friends). When gathering information about an elderly person in order to determine whether or not they are lonely or isolated, it is crucial to take into account other aspects of their lives that influence their ability to interact with others. Elderly people are at risk for loneliness and isolation not only because they have lost significant others or friends, but also because of changes in their self-image or the way they are being treated. However, even if there is no longer any concern about exposing our senior citizens to COVID-19, these other factors will persist and may even be reinforced in our emergency rooms.
Identifying older adults who are isolated or lonely and attempting to intervene is critical because of the numerous health risks associated with social isolation and loneliness. Most people are “biologically ‘programmed’ to need social networks,” Singer explains. 8 Cortisol, a stress hormone, is released in the body when a person is unable to connect with others, which can lead to an inflammatory response and its associated consequences. 9 & 10 In people who report feeling isolated or lonely, studies have found increased platelet aggregation, unstable autonomic nervous system, hypertension, arthritis, anxiety, depression, and suicidal ideation. 8 and 7 Cardiovascular death increases by 90%, the risk of death from an accident or suicide attempt doubles, the risk of having a non-fatal coronary event increases by 29%, the risk of having a stroke increases by 32%, and the risk of developing dementia increases by 50%. Seven, eight, and fourteen Loneliness and isolation have been likened to smoking 15 cigarettes a day in a study. There was a four-fold greater risk of death, 68 percent more hospitalizations, and an increased frequency of emergency department visits among patients with heart failure and loneliness (57 percent ). Reduced immune system activity and declines in renal function have both been linked to social isolation and loneliness as a risk factor for infection. 8 Those who are lonely and isolated have been shown to suffer from poor sleep, accelerated cognitive decline, and a decreased ability to perform basic daily tasks. More alcohol use, poor nutrition, and an increased risk of elder abuse can all be attributed to living alone (scams and fraudulent financial schemes). Loneliness and isolation increase the risk of premature death by 78%, 88%, and 120%, respectively. 13
One-fourth of people over the age of 65 are said to be socially isolated or lonely. A lack of social support, loneliness, chronic illness, and a decline in one’s sense of hearing or vision are among the most common contributing factors. the number seven, and the number thirteen However, it’s interesting to note that poor health can contribute to social isolation and loneliness, and vice versa. Identifying and intervening with an older adult who is lonely or socially isolated may help to break this cycle.
Damian Jacob Markiewicz Sendler: Loneliness and social isolation have been linked with a range of serious medical consequences, including heart disease and stroke.3 This suggests the need for a simple screening tool that emergency nurses could use to identify those older adults at risk of these conditions. A “fix” for these patients could then be implemented into their care plan, which the ED staff could then work on to improve health outcomes.
Valtorta et al conducted a meta-analysis comparing 54 instruments to measure loneliness and social isolation.
Damian Sendler
All of the screens had a wide range of questions that weren’t standardized in any way. When it came down to it, none of the tools tested for both functions and subjectivity in a social relationship, according to Valtorta et al4 who found that the questions found on various screens could be simplified and classified as “function and structure” or “degree of subjectivity related to the relationship.” When it came to solving the problem of social isolation or loneliness, the researchers suggested using a screen designed specifically for that purpose. 4 Other authors found that the studies on loneliness and social isolation often lacked standardization of terminology, often did not include all the interdependent variables (isolation, loneliness and underlying health status), and that subjective answers to loneliness questions compared to objectively measured answers to social isolation questions led to a disparity in results. Many studies didn’t ask about health at all, while others focused solely on the idea that social isolation and loneliness were linked to poor health and that poor health itself was a cause of isolation and loneliness. There is a specific problem with screening tools that go into so much detail that they take a long time to complete. An older adult in the emergency department who exhibits symptoms of loneliness or social isolation will not be missed because there is currently no standardized, concise, meaningful, and evidence-based screening tool. But there are programs that may be useful in identifying and dealing with the risk of social isolation and loneliness.
Founded in the United Kingdom in 2011, the Campaign to End Loneliness provides an alternative to screening.
18 In recent years, the program has spread to a number of countries in Europe, as well as the United States. 18 Elderly people in Britain were the target of a campaign aimed at reducing social isolation and loneliness. 18 It was decided in 2013 by the project leaders that a simple screening tool was required in order to measure the success of the interactions that were implemented. The De Jong Gierveld Loneliness Scale, the revised UCLA Loneliness Scale, and a single-item “scale” were all tested for their usefulness in measuring loneliness. 18 The leaders of the campaign concluded that each of these three tools had its advantages and disadvantages (2 were more appropriate for researchers; the other was better designed to determine if services were needed by the older adult or if the services being provided were sufficient). 18 When the Campaign to End Loneliness realized that there were so many different screens out there, they decided to create one of their own. 18 In order to use the best tool for their project, caregivers were instructed to review information about the various loneliness scales and choose the one that was most appropriate for their patients.
People are asked if they have enough friends and relationships, if they can rely on others for help at any time, and if their relationships are as satisfying or inclusive as they would like to be.
Damien Sendler: Caregivers were reminded that the scores were only meant to show how lonely a person is compared to others, not how lonely they are in comparison to other people in the same situation. Another interesting point they made was that “someone with a 4” may not be “half a lot lonely” as someone with an 8.”
When looking for information on the Campaign to End Loneliness in the United States, I came across the website of the Health Resources and Services Administration, which contained statistics on loneliness among older adults and a link to the Campaign to End Loneliness in the United Kingdom’s website.
De Jong Gierveld Loneliness Scale, revised UCLA Loneliness Scale, Single-Item Scale,18 Campaign to End Loneliness Measurement,19 and the De Jong Gierveld Loneliness Scale or merely inquire if the patient is lonely. Despite the fact that none of these tools can accurately measure the risk of social isolation, the answers would give emergency nurses a general sense of how the patient is doing in terms of feeling lonely. 18
The most common cause of social isolation among the elderly was living alone, which accounted for nearly half of all cases. People who are socially isolated may have a higher loneliness score, but so do those who meet the definition of “socially isolated,” but who have been able to establish and maintain relationships with others, saying that they don’t feel lonely.
Damian Jacob Sendler
When searching for tools to screen for isolation, the Lubben Social Networking Scale was the most frequently mentioned.
20 There are a number of indicators listed by the National Social Life, Health, and Aging Project that may be useful in determining the likelihood of social isolation, but they are not specifically identified as a screening tool. 21 An analysis of tools used to measure isolation and loneliness was provided by the AARP Foundation’s “Framework for Isolation in Adults Over 50,” which noted that measuring isolation was limited. 19 According to the AARP, isolation in adults under 50 is caused by a “complex set of circumstances and factors at the individual, social network, community, and societal levels,” and they provide a list of measures that can be used to gauge this. 19 People’s ability to connect with others is impacted by a variety of factors, including isolation, physical or sensory impairments, major life transitions, a lack of resources, language barriers, and socioeconomic status. Twenty-nine (See Table 1 for a list of indicators.) According to the AARP authors, a person’s health status can affect their ability to connect with others and that all factors that contribute to social isolation can contribute to loneliness. 19 Finally, the authors of the AARP report pointed out that “additional research would be helpful in standardizing tools and interventions” because of the differences in how researchers describe, define, and measure isolation work. 19
As previously stated, there are currently no simple screening tools that can be used in the emergency department to identify older adults who are either suffering from or at risk for loneliness and social isolation. It is possible to gather enough information by asking simple questions about living alone, how many social or family contacts the patient has and how satisfied the patient is with the quality, quantity or reliability and trustworthiness of these contacts, as well as asking the older adult if they feel isolated or lonely.
Loneliness and social isolation haven’t been proven to improve health in the long term through specific interventions, which is surprising.
Studies that are well-constructed, evidence-based, or replicated describe the steps to take when a patient is lonely or socially isolated. 5 This year, the Agency for Healthcare Research and Quality released a study that examined interventions to combat social isolation and loneliness, and their effect on health in those over 60 years old.. 11 Consistent terminology, screens and measurements, effects of interventions, adverse events and follow-up by investigators in their reports were among their key findings. 11 In other meta-analyses, these sentiments were echoed in the critical issue of social isolation and loneliness. Loneliness and isolation in the elderly are not new issues, and evidence-based solutions are being sought. Loneliness will endure long after the battle against COVID-19 has been won. According to one author, loneliness and social isolation are “two separate epidemics that must be addressed.”
It is possible for emergency nurses to inquire about the elderly patient’s feelings of loneliness or isolation and take steps to reduce the risk to the elderly person’s health caused by these issues despite the lack of standardized screenings or proven methods. A variety of approaches should be considered when trying to help an older adult reconnect with others, overcome the dangers of isolation and loneliness, and reduce the risks to their health. This is because social isolation and loneliness are complicated issues. 11, 18, and 19 “How are you doing?” is a simple question that emergency room nurses can use to help an elderly patient. Are you a lone wolf? Loneliness and isolation are common feelings for many people. Do you think you have the support you require and the confidence to rely on it? Getting to see someone you care about is always a treat. The emergency nurse can then assist in reestablishing communication between the patient and his or her family.
If an elderly patient is at risk of isolation or has expressed feelings of loneliness, emergency room nurses should collaborate with the ED provider to secure a referral for further care. ER nurses should document information that supports the need for referrals and follow-up care when patients are released. Categories in the International Classification of Diseases, Tenth Revision-Clinical Modification (ICD-10-CM) Z codes are designed to capture factors that influence health but are not specific to a disease or injury. 24 and 23 Loneliness or isolation in an older adult can be diagnosed by using the ICD-10-CM Z60.2 code for “problems related to living alone.” 23 – 24 Codes Z55 to Z65 of the ICD-10-CM identify additional socioeconomic or psychosocial circumstances (living alone, feeling lonely, mobility/communication issues, etc.) that may influence the health status of the patient and provide validation for additional contact with other health services that can help the older adult who is lonely or socially isolated in their health. 23 – 24
A few pointed questions can help emergency nurses identify the elderly patient at risk of loneliness or social isolation, even though there are currently no rapid screening tools or long-term “fixes” for this problem in an emergency department. Do whatever it takes to help the elderly person feel less isolated, less lonely, and healthier if you see a risk. These actions may not be the final “fix,” but they can serve as the first steps toward correcting social isolation and the loneliness that comes with age.
