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HomeMy WebLinkAboutsipp-forum-dr-perissinotto-loneliness-falls-2023ADDRESSING LONELINESS AND ISOLATION MEDICALLY AND WITH A PUBLIC HEALTH LENS March 2023 Carla Perissinotto, MD, MHS Professor of Medicine Division of Geriatrics University of California San Francisco Associate Medical Director Vitas Healthcare 2 OBJECTIVES 4 cases to contextualize how loneliness and isolation present in different medical settingsDiscuss Why loneliness and isolation should be viewed as a public health issue and something we as individuals cannot ignoreUnderstand Identify tools and frameworks to begin to imagine solutionsIdentify 4 CASES MAN, 93, WHO FROZE TO DEATH HAD RECEIVED HEAT SHUT-OFF NOTICES Bay City, Michigan Thursday, February 19, 2009 : Public records show a 93-year-old man found frozen to death in his Michigan home had received several utility shut-off notices… six letters were sent to Marvin Schur's home in the past two years. His body was found Jan. 17, several days after Bay City Electric Light & Power restricted electricity and a month after his final shut-off notice. Records suggest Schur was confused about how to pay. He tried at least twice to pay bills at his bank, which couldn't accept them. See also Widera JAMA 2011 JOHN, 82, STUCK AT HOME POST-COVID homebound since Dec 2020. Had COVID and fell Stairs getting into home Live in an ethnically marginalized and”unsafe” neighborhood has family nearby Has been dismissed from many practices for “inappropriate behavior” Recently described himself as “socially isolated” Has a landline and basic cell phone. Does not want to be bothered by any other technology MEL, 94, DYING OF CANCER Jewish, European Refugee Lives in assisted living that caters to people of a different heritage Identifies as Atheist, and some describe him as a Holocaust survivor Doesn’t participate in activities but enjoys religious conversation Hearing Impaired English is his second language Requests Aid in Dying GIANNA, 2.5 Y, BORN IN A PANDEMIC Born July 2020 Limited social contact initially Met family and friends to prioritize socialization Raised in a bilingual and multicultural family Day care 3 times a week Intergenerational home with nanny twice a week Recently traveled to visit friends and family in Italy for the first time E: Educate A: Assess R: Respond E: EDUCATE ESTIMATING HEALTH RISK LONELINESS AND ISOLATION IN THE CONTEXT OF SOCIAL DETERMINANTS OF HEALTH (SDOH) Gottlieb, UCSF Presentation 2017 CONTEXT: ESTIMATING HEALTH RISKS If you were Mr. Schur’s medical provider, or health system leader, or bank teller: how do you estimate health risks, and how do you help? 1.Cognitive Impairment 2. Mobility? 3. Social Isolation? CONTEXT: ESTIMATING HEALTH RISKS If you were John’s medical provider, or health system leader, policy maker, or neighbor: how do you estimate health risks, and how do you help? 1.COVID-19 2. Arthritis 3. Constipation 4. FALLS* 5. Social Isolation 6. Loneliness 7.Mobility 8.Tech Access 9.“Inappropriate Behavior” CONTEXT: ESTIMATING HEALTH RISKS How do you think about Mel who is nearing the end of life? 1.Cancer 2. Limited Mobility 3. Hearing* 5. Social Isolation 6.Loneliness 7.Living situation 8.Trauma/refugee/survivor CONTEXT: ESTIMATING HEALTH RISKS If you were Gianna’s medical provider, or health system leader, or her parent: how do you estimate health risks, ensure she has dignity, longevity and how do you help? RISKS: 1.Pandemic Baby 2.Limited Exposure to infectious diseases 3.2nd generation American* 4.Latina 5.Lives in an “unsafe” neighborhood Protective Factors: 1.Intergenerational home 2.2nd generation American* 3.Prioritize socialization DEFINING SOCIAL DETERIMINANTS OF HEALTH Social Connections, Loneliness and Isolation 16 HOW DO WE DEFINE LONELINESS? Cacioppo. U. Chicago 2009 Loneliness is the subjective feeling of being alone “the distress that results from discrepancies between ideal and perceived social relationships.” LONELINESS OR ISOLATION? Loneliness Social isolation Subjective:feeling isolated Objective: being isolated Mismatch between actual and desired social relationships (*quality*)Low levels of social contact (*quantity*) Unpleasant Need not be unpleasant Low sense of control or choice May be chosen: “solitude” Loneliness "Subjective" assessment that social relationships are lacking. -Unpleasant “Quality” Social isolation "Objective" measure of connections to family, friends, or the community -not necessarily unpleasant “Quantity” Social Disconnection Emotional Functional Structural R<0.20 Figure from Dr. Ashwin Kotwal Cornwell EY, Waite LJ. 2009;64(suppl_1):i38-i46 Intersection of Loneliness and Isolation Loneliness 43% “Occasionally Lonely” 10% “Frequently Lonely” Social isolation 20% Socially Isolated 11% Severely Isolatedr<0.2 Perissinotto, Carla M., Irena Stijacic Cenzer, and Kenneth E. Covinsky. "Loneliness in older persons: a predictor of functional decline and death." Archives of internal medicine 172.14 (2012): 1078-1084. Cudjoe, Thomas KM, David L. Roth, Sarah L. Szanton, Jennifer L. Wolff, Cynthia M. Boyd, and Roland J. Thorpe Jr. "The epidemiology of social isolation: National health and aging trends study." The Journals of Gerontology: Series B 75, no. 1 (2020): 107-113. A: ASSESS MEASUREMENT Who is at risk IDENTIFYING LONELINESS AND SOCIAL ISOLATION NO “gold Standard” Multiple different measurement tools All scales have benefits and drawbacks Most developed for research purposes Little validation for clinical use Some of the most commonly used: UCLA-3 Lubben Social Network Scale Duke Social Support Index (DSSI) De Jong Gierveld Loneliness Scale Cornwell HOW DO WE MEASURE LONELINESS? Question Hardly Ever Some of the Time Often 1. I feel left out 1 2 3 2. I feel isolated 1 2 3 3. I lack companionship 1 2 3 UCLA Loneliness Scale ▪Original scale has 20 items. 3 most frequently used ▪Single Item question: “How often do you feel lonely?” -Kotwal et al. 2022 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17700 Hughes, Waite, Hawkley, & Cacioppo 2004. “A short scale for measuring loneliness in large surveys.” Research on Aging: 26(6):655-672. THE INSTITUTE OF MEDICINE •Recommends the inclusion of the Berkman-Syme Index in electronic medical records The Berkman-Syme Social Network Index (SNI) is a self-reported questionnaire for use in adults aged 18–64 years old that is a composite measure of four types of social connections: -marital status (married vs. not) -sociability (number and frequency of contacts with children, close relatives, and close friends) -church group membership (yes vs. no) -membership in other community organizations (yes vs. no) **SNI categorize into four levels of social connection: socially isolated,moderately isolated; moderately integrated; and socially integrated. RISK FACTORS Who is at risk “THE IRONY OF LONELINESS IS WE ALL FEEL ITAT THE SAME TIME -TOGETHER” Rupi Kaur, “the sun and her flowers” LOSSES PREDICT INCREASES IN LONELINESS AT THE LEVEL OF THE INDIVIDUAL (AND ISOLATION) Death of spouse Death or other loss of relatives, friends Change in living arrangements (less likely to be living with others) Institutionalization Deteriorating physical health Impairment of mobility Impairment of vision and/or hearing Reduced social activity Aartsen & Jylhä, 2011; Dykstra et al., 2005; Newall, Chipperfield & Bailis, 2014; Nicolaisen & Thorsen, 2014; Tijhuis et al., 1999; Victor & Bowling, 2012; Wenger & Burholt, 2004 Younger Person: Functional Domains Medical Cognitive/ Emotional Environmental Familial/ Social Financial FUNCTION Pacala, JT. Grand Rounds UCSF 2011 Multiple Chronic Diseases + Problems in Other Domains = Functional Decline The Challenge of Complexity: Older Person: Functional Domains Cognitive/ Emotional Environmental Familial/ Social Medical Financial FUNCTION WHERE BREAKDOWNS HAPPEN: Assume all adults are the same Create systems that cater to younger adults and expect everyone else to adapt Focus only on the “medical” Do not recognize heterogeneity of aging Do not understand decreased physiological reserve in aging Failure to recognize this: FUNCTION SERIOUS ILLNESS WHY SHOULD WE CARE ABOUT THESE TOPICS IN THE LAST YEARS OF LIFE? Steinhauser, K. E., Christakis, N. A., Clipp, E. C., McNeilly, M., McIntyre, L., & Tulsky, J. A. (2000). Factors considered important at the end of life by patients, family, physicians, and other care providers. Jama, 284(19), 2476-2482. •Individuals and family members care about social needs •“Have someone who will listen” -99% •“Share time with close friends” -85-91% •“Presence of family” -81-95% •“Be able to help others” -88% •Individuals may be less able to cope with loneliness •Socially isolation may become more common and impact quality of life and health care SERIOUSLY ILL OLDER ADULTS Nearly 4 in 5 older adults are lonely (79%) Social Isolation doubles in the last 6 months of life (34%) Kotwal, A. et al. Journal of the American Geriatrics Society. 69(11). (2021): 3081-3091. *Adjusted for time before death, age, sex, race/ethnicity, and education **Spouses of patients with dementia have HIGHER levels of loneliness and depression OLDER ADULTS WITH COGNITIVE IMPAIRMENT IN THE LAST 4 YEARS OF LIFE Kotwal, A. et al. Journal of the American Geriatrics Society 69, no. 11 (2021): 3081-3091. 36 Subgroups at Risk for Loneliness *Adjusted for time before death, age, sex, race/ethnicity, and education Kotwal, A. Cenzer, I., Perissinotto, C., Yaffe, K., Smith, A. Journal of the American Geriatrics Society 2022. At the end of life, socially isolated older adults with cognitive impairment have: -Lower Hospice Use -Lower end-of-life acute care (ED, hospital stays, ICU stays) CONTEXT: MEL’S RISKS Older Terminal Illness Homebound He is losing mobility He has hearing impairment He is incontinent He is an immigrant English is not his first language He has experienced Trauma, and is a survivor ISOLATION DURING COVID -19 Kotwal, A., Perissinotto, C et al. 2020. Journal of the American Geriatrics Society HEALTH EFFECTS Understanding the risks ▪National survey of 1604 adults aged >60 followed for 6 years ▪Asked if they were lonely -UCLA Loneliness Scale -classified as lonely if responded “some of the time or often to any of the 3 questions” ▪Outcomes: -Death-Decline in Function ▪Activities of Daily Living (ADLs) ▪Other mobility tasks Perissinotto C. JAMA (Archives) Internal Medicine 2012 July 23, 2012 Loneliness in Older Persons: A Predictor of Functional Decline and Death Carla Perissinotto, MD, MHS, Irena Cenzer, MA, Kenneth Covinsky, MD, MPH STUDY CONCLUSIONS ▪Loneliness is common ▪It is an independent predictor of functional decline (59% increased risk) ▪It is an independent predictor of death (45% increased risk) ■6500 men and women over 7 years ■Mortality higher in socially isolated AND lonely April 9, 2013 Social isolation, loneliness, and all-cause mortality in older men and women Andrew Steptoe, Aparna Shankar, Panayotes Demakakos, and Jane Wardle In 2020, still see worse health outcomes in adults with BOTH loneliness and isolation September 7, 2021 Association of Social Isolation with Disability Burden and 1-Year Mortality Among Older Adults with Critical Illness Jason R. Falvey, PT, DPT, PhD1; Andrew B. Cohen, MD, DPhil2; John R. O’Leary, MA2; Linda Leo-Summers, MPH2; Terrence E. Murphy, PhD2; Lauren E. Ferrante, MD, MHS3 ▪997 older adults hospitalized in the ICU ▪Each 1 point increase on the social isolation score: •7% increase in disability count •14% increase in mortality LONELINESS AND PHYSICAL & PSYCHOLOGICAL SYMPTOMS ▪Lonely older adults experience higher rates of: ▪pain ▪Anxiety ▪Depression ▪and insomnia Kotwal, A. Steinman, M., Cenzer, I., Smith, A 2021. JAMA Internal Medicine HEALTH EFFECTS May be harmful at any age, and likely worse for older adults. Social isolation and loneliness are associated with: ▪Worsened heart disease ▪Worse control of diabetes ▪Poor Sleep and depression ▪Increased Dementia risk ▪Frailty and functional decline ▪HIGHER health care costs ▪Increased mortality Feb 3, 2017 WHAT DOES IT MEAN TO BE OLDER? Physiologic age more important than chronological age Not just age but comorbidity, functional loss, frailty Singh M et al. Mayo Clin Proc. 2008;83:1146-1153 R: RESPONDTRANSLATING FINDINGS TO PRACTICE The role of social prescribing SOCIAL ISOLATION AND LONELINESS IN OLDER ADULTS: OPPORTUNITIES FOR THE HEALTH CARE SYSTEM RECOMMENDATIONS Develop a more robust evidence base Translate current research into health care practices Improve awareness Strengthen ongoing education and training Strengthen ties between the health care system and community-based networks and resources POPULATION LEVEL FRAMEWORK Primary Prevention: Identify people at risk for loneliness and Isolation Women, lower SES, older, LGBTQ Recent losses Secondary Prevention: decrease the consequences for those who are lonely and or isolated Requires screening Knowing which interventions work Isolated Disconnecting At Risk AARP Public Policy Institute 2018; Flowers et al., 2017; Shaw et al., 2017; COSTS: $6.7 billion every year $1,608/person/year THE ROLE OF SOCIAL PRESCRIBRIBING TIME TO BENEFIT How long do we have to experience loneliness before we see the negative health effects? Or Can we reduce the risk of negative consequences? AND How can we proactively protect our health LESSONS LEARNED: SOCIAL PRESCRIPTIONS 1. FOCUS on CONNECTION 2.AND talk about other health risks 3. Advanced care planning 1.Who do I focus on 2.What are the risks 3.What am I treating 4.Why am I treating 5.For how long 6.Who else can help 55 Framework for clinical interventions a.Direct interventions: Social support, enhancing interactions, address maladaptive cognition b.Indirect interventions: Vision & Hearing, Functional Needs c.Downstream consequences: Early Advanced care planning, Address related Symptoms (pain, depression, trauma) Policy changes which incentivize addressing social needs Mann et al. 2017 Social Psychiatry and Psychiatric Epidemiology DIRECT: OPPORTUNITIES FOR SOCIAL CONNECTIONS ▪Community-based programs ▪Peer support programs ▪Telephone Support ▪“without walls programs” ▪Foundation for Art and Healing ▪Caregiver support Kotwal et al. 2021. Journal of the American Geriatrics Society. Social Skills, Social Support IS TECH THE SOLUTION? CONNECTIVITY GAPS INTERSECT WITH OTHER FACTORS •Older adults with low educational attainment (less than a high school degree) and incomes below $25,000 are 10X more likely to be offline •Ethnicity is a major factor •Health status •Geography Broadband gap varies widely by state Source: Aging Connected report, OATS and the Humana Foundation (January 2021) VIRTUAL CONNECTIONS ARE NOT A SUBSTITUTE FOR IN- PERSON INTERACTIONS Hawkley, L., Finch, L., Kotwal, A., Waite, L. 2021. Journal of the American Geriatrics Society IN SUMMARY ASSESSMENT FRAMEWORK https://www.nejm.org/doi/full/10.1056/NEJMp2208029 WHAT TO DO WHEN EVIDENCE IS LIMITED 1. INDIVIDUALIZE 2. TALK ABOUT IT 3. THINK CREATIVELY •Strategies for Individuals •Strategies at the population level REVISITING OUR CASES: INDIVIDUAL VS. POPULATION •Where did he get missed, or forgotten? •Is addressing the structural environment the answer? •Can addressing his “challenging behaviors” help? •Can we change his life course? 65 IN SUMMARY We defined loneliness and social isolation and framed them in case studies We examined how loneliness and isolation are linked to serious illness, cognitive impairment, and the COVID-19 pandemic We applied a public health perspective to understand interventions and solutions We identified examples of evidence based solutions We talked about the unique needs of people with life limiting illness We ARE connecting with each other TODAY THANK YOU! 66