Social connection and self-neglect: A case for broader exploration.

Self-neglect (SN) is the most common report to Adult Protective Services (APS) and is associated with significant morbidity and mortality risks for older adults. Lack of instrumental support is a well-evidenced etiologic factor in the development and continuation of SN, but little is known about other modifiable social connection characteristics. The social connection framework, provides a host of evidence-based characteristics across structure, function, quality missing from SN studies that could be identified if explored. These factors could provide prevention and intervention targets related to poor health. We present a narrative case study using quantitative and qualitative data to explore social connection across structure, function, and quality in the context of SN. The findings highlight the complexity of social connection that may be frequently observed in SN cases reported to APS. Strategic utilization of direct and indirect social interventions to support social connection in this case is presented and provides general considerations that may be generalizable to other SN cases. Thoughts for future research on social connection in this population are provided.

Multimorbidity patterns in adult day health center clients with dementia: a latent class analysis.

BACKGROUND: Persons living with dementia (PLWD) in adult day centers (ADCs) represent a complex and vulnerable population whose well-being is at risk based on numerous factors. Greater knowledge of the interaction between dementia, chronic conditions, and social determinants of health would enable ADCs to identify and target the use of their resources to better support clients in need of in-depth intervention. The purpose of this paper is to (a) classify PLWD in ADCs according to their level of medical complexity and (b) identify the demographic, functional, and clinical characteristics of those with the highest degree of medical complexity. METHODS: This was a secondary data analysis of 3052 clients with a dementia diagnosis from 53 ADCs across the state of California between 2012 and 2019. The most common diagnosis codes were organized into 28 disease categories to enable a latent class analysis (LCA). Chi-square test, analysis of variance (ANOVA), and Kruskal-Wallis tests were conducted to examine differences among latent classes with respect to clinical and functional characteristics. RESULTS: An optimal 4-class solution was chosen to reflect chronic conditions among PLWD: high medical complexity, moderate medical complexity, low medical complexity, and no medical complexity. Those in the high medical complexity were taking an average of 12.72 (+/- 6.52) medications and attending the ADC an average of 3.98 days (+/- 1.31) per week-values that exceeded any other class. They also experienced hospitalizations more than any other group (19.0%) and met requirements for the nursing facility level of care (77.4%). In addition, the group experienced the greatest frequency of bladder (57.5%) and bowel (15.7%) incontinence. CONCLUSIONS: Our results illustrate a high degree of medical complexity among PLWD in ADCs. A majority of PLWD not only have multimorbidity but are socially disadvantaged. Our results demonstrate that a comprehensive multidisciplinary approach that involves community partners such as ADCs is critically needed that addresses functional decline, loneliness, social isolation, and multimorbidity which can negatively impact PLWD.

Brain health INnovation Diplomacy: a model binding diverse disciplines to manage the promise and perils of technological innovation.

BACKGROUND: Brain health diplomacy aims to influence the global policy environment for brain health (i.e. dementia, depression, and other mind/brain disorders) and bridges the disciplines of global brain health, international affairs, management, law, and economics. Determinants of brain health include educational attainment, diet, access to health care, physical activity, social support, and environmental exposures, as well as chronic brain disorders and treatment. Global challenges associated with these determinants include large-scale conflicts and consequent mass migration, chemical contaminants, air quality, socioeconomic status, climate change, and global population aging. Given the rapidly advancing technological innovations impacting brain health, it is paramount to optimize the benefits and mitigate the drawbacks of such technologies. OBJECTIVE: We propose a working model of Brain health INnovation Diplomacy (BIND). METHODS: We prepared a selective review using literature searches of studies pertaining to brain health technological innovation and diplomacy. RESULTS: BIND aims to improve global brain health outcomes by leveraging technological innovation, entrepreneurship, and innovation diplomacy. It acknowledges the key role that technology, entrepreneurship, and digitization play and will increasingly play in the future of brain health for individuals and societies alike. It strengthens the positive role of novel solutions, recognizes and works to manage both real and potential risks of digital platforms. It is recognition of the political, ethical, cultural, and economic influences that brain health technological innovation and entrepreneurship can have. CONCLUSIONS: By creating a framework for BIND, we can use this to ensure a systematic model for the use of technology to optimize brain health.

Loneliness in Older Adults Living with HIV.

We conducted a cross-sectional study among HIV-positive adults age ≥ 50 in San Francisco to evaluate the frequency of loneliness, characteristics of those who reported loneliness, and the association of loneliness with functional impairment and health-related quality of life (HRQoL). Participants (N = 356) were predominately male (85%); 57% were white; median age was 56. 58% reported any loneliness symptoms with 24% reporting mild, 22% moderate and 12% severe loneliness. Lonely participants were more likely to report depression, alcohol and tobacco use, and have fewer relationships. In unadjusted models, loneliness was associated with functional impairment and poor HRQoL. In adjusted models, low income and depression remained associated with poor HRQoL, while low income, higher VACS index and depression were associated with functional impairment. A comprehensive care approach, incorporating mental health and psychosocial assessments with more traditional clinical assessments, will be needed to improve health outcomes for the aging HIV-positive population.

RESUMEN: Realizamos un estudio transversal en adultos mayores de 50 años con VIH en San Francisco para evaluar la frecuencia de la soledad, características de aquellos que reportan soledad, y la asociación de la soledad con el deterioro funcional y la calidad de vida relacionada con la salud (HRQoL). Los participantes (N = 356) fueron principalmente hombres (85%); 57% de raza blanca, la mediana de edad fue 56 años. El 58% reportó cualquier síntoma de soledad con un 24% reportando soledad leve, 22% soledad moderada, y 12% soledad severa. En los participantes que refirieron soledad era más probable que reportaran depresión, consumo de tabaco o alcohol, y menos relaciones sociales. En modelos sin ajustar, la soledad estaba asociada con deterioro funcional y baja calidad de vida relacionada con la salud. En modelos ajustados, tener bajos ingresos y depresión continuaron teniendo asociación con una baja calidad de vida relacionada con la salud, mientras que tener bajos ingresos, un índice más alto de VACS y depresión estaban asociados con deterioro funcional. Un sistema de cuidado integral, incorporando la salud mental y valoraciones psicológicas y sociales con evaluaciones médicas tradicionales, serán necesarios para poder mejorar los índices de salud de las personas VIH positivas que envejecen.

"Relationships, Very Quickly, Turn to Nothing": Loneliness, Social Isolation, and Adaptation to Changing Social Lives Among Persons Living With Dementia and Care Partners.

BACKGROUND AND OBJECTIVES: Persons with dementia and their care partners have known risks for loneliness and social isolation throughout the disease trajectory, yet little is described about social lives in a population heterogeneous for disease stage, syndrome type, and setting. RESEARCH DESIGN AND METHODS: We conducted a secondary analysis of qualitative interviews from multiple studies to triangulate responses from a cohort of persons with dementia (n = 24), and active (n = 33) or bereaved (n = 15) care partners diverse in setting, dementia type and stage, and life experience. Interviews explored challenges related to social lives and were analyzed thematically. RESULTS: Persons with dementia were on average 80 years old (range: 67-94), 38% female, and 78% diagnosed with Alzheimer's dementia; care partners were on average 67 years old (range: 40-87) and 69% female. We identified 3 primary themes. First, dyads lost external social networks due to complex factors, including discomfort of surrounding social networks, caregiving responsibilities, and progressive cognitive deficits. Second, care partners described disruptions of meaningful dyadic relationships due to progressive cognitive and functional deficits, leading to loneliness and anticipatory grief. Third, adaptive strategies centered on care partners facilitating shared social activities and programs addressing caregiver burden. An overarching theme of disease-course accumulation of barriers to social interactions and constant adaptations was present in all themes. DISCUSSION AND IMPLICATIONS: Isolation and loneliness are a shared experience and source of distress for persons with dementia and care partners. Results can inform interventions tailored to individual needs and disease stages of dyads that enhance social connectedness.

What Are "Social Prescriptions" and How Should They Be Integrated Into Care Plans?

Health consequences of social isolation and loneliness include worsened morbidity and mortality. Despite wide recognition of this fact, little is understood about how to intervene successfully. "Social prescribing" is one approach by which clinicians can intervene on social determinants of health, which include social isolation and loneliness. This commentary on a case defines social prescribing and suggests how to integrate it into practice.

End-of-life health care use among socially isolated and cognitively impaired older adults.

BACKGROUND: Social isolation is common in the last years of life, especially among individuals with cognitive impairment (CI), but it is unknown if social isolation is related to end-of-life health care use. METHODS: We used nationally-representative 2006-2018 Health and Retirement Study (HRS) data linked to Medicare claims, including adults age ≥65 interviewed in the last 4 years of life (N = 2380). We used a validated social isolation scale and three social isolation subscales: (1) household contacts (marital status, household size, nearby children), (2) social network interaction (with children, family, and friends), and (3) community engagement. End-of-life health outcomes included 2+ emergency department (ED) visits in the last month of life, hospitalizations or ICU stays in the last 6 months of life, and any hospice use. CI was defined using the validated Langa-Weir methodology. We used logistic regression to test the association of each social isolation measure with each end-of-life outcome, adjusted for sociodemographic covariates, and tested for interaction terms with CI (p < 0.2). RESULTS: The mean age of our sample of decedents was 81.2 (SD = 9.9), 53% were female, 8% Black, and 4% Hispanic. Overall, social isolation and the community engagement subscale were not associated with end-of-life health care use. Fewer household contacts were associated with lower hospice use (aOR = 0.74, p = 0.005). There were significant interaction terms between the social network interaction subscale and CI for ED use (p = 0.009) and hospitalizations (p = 0.04), and a trend for ICU stays (p = 0.15); individuals with both low social network interaction and CI had lower health care use across all three outcomes compared to other groups. CONCLUSIONS: Individuals with fewer household contacts had lower hospice use, and cognitively impaired individuals with low social network interaction had fewer end-of-life ED visits, hospitalizations, and ICU stays. Clinicians should consider mobilizing external support services to ensure access to goal-concordant care for older adults with limited end-of-life social contact when needed.

The Role of Digital Technologies in Facilitating Psychosocial Resilience to Sudden Social Isolation Among Older Adults: Lessons Learned from the COVID-19 Pandemic.

This study investigated how older adults adopted new technologies in response to sudden social isolation caused by the COVID-19 pandemic and how this adoption was related to their long-term psychosocial well-being. The study involved a 6-month longitudinal survey of 151 older adults and two phone-based focus groups, which informed a semi-structured interview guide and purposive sampling of diverse community-dwelling older adults. We then conducted twenty qualitative interviews and thematic analysis and mapped themes to 6-month quantitative trajectories of psychosocial health. Three themes emerged: first, most participants adopted multiple technologies to maintain social connection and psychosocial well-being. Second, participants felt left behind by certain technologies due to complicated systems or ageist societal norms. Third, pandemic-related community resources promoted technology independence among isolated older adults and those wanting to avoid "burdening" family. Results challenge ageist stereotypes and provide a framework for encouraging access and comfort with multiple technologies to adapt to sudden health crises or disruptive events.

Key Elements and Mechanisms of a Peer-Support Intervention to Reduce Loneliness and Isolation among Low-Income Older Adults: A Qualitative Implementation Science Study.

This paper describes the evaluation of a longitudinal peer-support program developed to address loneliness and isolation among low-income, urban community-dwelling older adults in San Francisco. Our objective was to determine barriers, challenges, and successful strategies in implementation of the program. In-depth qualitative interviews with clients (n = 15) and peers (n = 6) were conducted and analyzed thematically by program component. We identified barriers and challenges to engagement and outlined strategies used to identify clients, match them with peers, and provide support to both peers and clients. We found that peers played a flexible, non-clinical role and were perceived as friends. Connections to community resources helped when clients needed additional support. We also documented creative strategies used to maintain inter-personal connections during the COVID-19 pandemic. This study fills a gap in understanding how a peer-support program can be designed to address loneliness and social isolation, particularly in low-income, urban settings.

Persistent loneliness due to COVID-19 over 18 months of the pandemic: A prospective cohort study.

BACKGROUND: Loneliness was common early in the COVID-19 pandemic due to physical distancing measures, but little is known about how loneliness persisted into later stages of the pandemic. We therefore examined longitudinal trajectories of loneliness over 18 months of the pandemic and subgroups at risk for persistent loneliness. METHODS: We used data from the COVID-19 & Chronic Conditions study collected between March 27, 2020 to December 10, 2021, including 641 predominantly older adults with ≥1 chronic condition who completed six interviews at approximately 3 month intervals. Participants reported loneliness (defined as some, most, or all of the time) during the past week due to COVID-19. We used trajectory mixture models to identify clusters of individuals following similar trajectories of loneliness, then determined subgroups likely to be classified in different loneliness trajectories using multivariable regression models adjusted for sociodemographic and clinical covariates. RESULTS: Participants were on average 63 years old, 61% female, 30% Black, 20% Latinx, and 29% were living below the poverty level. There was an overall reduction in loneliness over time (March to April/2020: 51% to September to December/2021: 31%, p = 0.01). Four distinct trajectory groups emerged: (1) "Persistent Loneliness" (n = 101, 16%); (2) "Adapted" (n = 141, 22%), individuals who were initially lonely, with feelings of loneliness decreasing over time; (3) "Occasional loneliness" (n = 189, 29%); and (4) "Never lonely" (n = 211, 33%). Subgroups at highest risk of the "Persistently Lonely" trajectory included those identifying as Latinx (aOR 2.5, 95% CI: 1.2, 5.2), or living in poverty (aOR 2.5; 95% CI: 1.4, 4.6). CONCLUSIONS: Although loneliness declined for a majority of older adults during the pandemic in our sample, persistent loneliness attributed to the COVID-19 pandemic was common (1 in 6 adults), particularly among individuals identifying as Hispanic/Latinx or living in poverty. Interventions addressing loneliness can ease pandemic-related suffering, and may mitigate long-term mental and physical health consequences.

A peer intervention reduces loneliness and improves social well-being in low-income older adults: A mixed-methods study.

BACKGROUND: Evidence-based interventions addressing loneliness and social isolation are needed, including among low-income, community-dwelling older adults of diverse racial and ethnic backgrounds. Our objective was to assess the effect of a peer intervention in addressing loneliness, isolation, and behavioral health needs in this population. METHODS: We conducted a mixed-method, two-year longitudinal study of a peer-outreach intervention in 74 low-income older adults recruited via an urban senior center in San Francisco. Structured participant surveys were conducted at baseline and every 6 months for up to 2 years. Outcomes included loneliness (3-item UCLA loneliness scale), social interaction (10-item Duke index), self-perceived socializing barriers (range: 0-10), and depression (PHQ-2 screen). Data were analyzed using mixed-effects linear and logistic regression adjusted for age and gender. Qualitative, semi-structured interviews with participants (N = 15) and peers (N = 6) were conducted in English and Spanish and analyzed thematically. RESULTS: Participants were on average 71 years old (range: 59-96 years), with 58% male, 15% LGBT, 18% African American, 19% Latinx, 8% Asian, 86% living alone, and 36% with an ADL impairment. On average, 43 contact visits (IQR: 31-97 visits) between participants and peers occurred over the first year. Loneliness scores decreased by, on average, 0.8 points over 24 months (p = 0.015). Participants reported reduced depression (38%-16%, p < 0.001) and fewer barriers to socializing (1.5 fewer, p < 0.001). Because of the longitudinal relationship and matching of characteristics of peers to participants, participants reported strong feelings of kinship, motivations to reach out in other areas of life, and improved mood. CONCLUSION: Diverse older adults in an urban setting participating in a longitudinal peer program experienced reduced loneliness, depression, and barriers to socializing. Matching by shared backgrounds facilitated rapport and bonding between participants and peers.

A Home-Based Care Research Agenda by and for Homebound Older Adults and Caregivers.

Homebound older adults have not had a voice in establishing a research agenda relevant to their needs and perspectives. We engaged homebound older adults receiving home-based primary care and caregivers to serve as stakeholder advisors to develop a patient- and caregiver-centered research agenda for home-based care. Over 9 months, we facilitated eight tablet-enabled videoconference meetings. We oriented advisors to patient-centered outcome research and research question development. Advisors developed and prioritized a list of 14 research domains and 127 associated research questions. The top three prioritized research domains in descending rank order (number of associated research questions) were out-of-pocket costs of caregiving (10), access to home-based care and related policy issues (19), and relationship with doctors (15). This research agenda can guide researchers' efforts to focus on areas of importance to the ultimate end users of their research.

Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders.

BACKGROUND/OBJECTIVES: Physical distancing during the COVID-19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to investigate (1) experiences of social isolation and loneliness during shelter-in-place orders, and (2) unmet health needs related to changes in social interactions. DESIGN: Mixed-methods longitudinal phone-based survey administered every 2 weeks. SETTING: Two community sites and an academic geriatrics outpatient clinical practice. PARTICIPANTS: A total of 151 community-dwelling older adults. MEASUREMENTS: We measured social isolation using a six-item modified Duke Social Support Index, social interaction subscale, that included assessments of video-based and Internet-based socializing. Measures of loneliness included self-reported worsened loneliness due to the COVID-19 pandemic and loneliness severity based on the three-item University of California, Los Angeles (UCLA) Loneliness Scale. Participants were invited to share open-ended comments about their social experiences. RESULTS: Participants were on average aged 75 years (standard deviation = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% had difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video-based socializing, and 42% minimal Internet-based socializing. Socially isolated participants reported difficulty finding help with functional needs including bathing (20% vs 55%; P = .04). More than half (54%) of the participants reported worsened loneliness due to COVID-19 that was associated with worsened depression (62% vs 9%; P < .001) and anxiety (57% vs 9%; P < .001). Rates of loneliness improved on average by time since shelter-in-place orders (4-6 weeks: 46% vs 13-15 weeks: 27%; P = .009), however, loneliness persisted or worsened for a subgroup of participants. Open-ended responses revealed challenges faced by the subgroup experiencing persistent loneliness including poor emotional coping and discomfort with new technologies. CONCLUSION: Many older adults are adjusting to COVID-19 restrictions since the start of shelter-in-place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology-based social interaction.

The epidemiology of social isolation and loneliness among older adults during the last years of life.

BACKGROUND: Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life. OBJECTIVES: To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life. DESIGN: Nationally representative, cross-sectional survey. SETTING: Health and Retirement Study, 2006-2016 data. PARTICIPANTS: Adults age > 50 interviewed once in the last 4 years of life (n = 3613). MEASUREMENTS: We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest. RESULTS: Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment. CONCLUSIONS: Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.

Understanding the Daily Experiences and Perceptions of Homebound Older Adults and Their Caregivers: A Qualitative Study.

More than 7.3 million older adults in the United States have difficulty leaving their homes or are completely homebound, yet little data exist on the experiences of homebound older adults and their caregivers. We conducted 30 semi-structured qualitative interviews with homebound older adults and caregivers recruited through home-based medical care practices in Baltimore and San Francisco. Thematic template analyses revealed that homebound older adults experience varying degrees of independence in activities of daily living, although their degree of dependence increases over time. Caregivers have a multifaceted, round-the-clock role. Both patients and caregivers experience burdens including social isolation and guilt. Navigating medical care and caregiving was further complicated by the complexity of the U.S. health care system; however, home-based medical care was viewed as a high-quality alternative to hospitals or nursing homes. Our findings suggest that providers and health care systems should expand the availability and accessibility of home-based care and improve caregiver support opportunities.

Attitudes of Homebound Older Adults and Their Caregivers Toward Research and Participation as Research Advisors.

BACKGROUND AND OBJECTIVES: Homebound older adults and their caregivers have not historically been engaged as advisors in patient-centered outcomes research. This study aimed to understand the attitudes of homebound older adults and their caregivers toward research and participation as research advisors. RESEARCH DESIGN AND METHODS: Descriptive thematic analysis of semistructured interviews conducted with 30 homebound older adults and caregivers recruited from home-based medical care practices. Interview questions addressed opinions on research and preferences for engaging as research advisors. RESULTS: Of 30 participants, 22 were female, 17 were people of color, and 11 had Medicaid. Two themes emerged related to perceptions of research overall: (a) utility of research and (b) relevance of research. Overall, participants reported positive attitudes toward research and felt that research could affect people like them. Three themes emerged related to participating as research advisors: (a) motivators, (b) barriers, and (c) preferences. Participants were open to engaging in a variety of activities as research advisors. Most participants were motivated by helping others. Common barriers included time constraints and caregiving responsibilities, and physical barriers for homebound individuals. Participants also reported fears such as lacking the skills or expertise to contribute as advisors. Many were willing to participate if these barriers were accommodated and shared their communication preferences. DISCUSSION AND IMPLICATIONS: Diverse homebound older adults and caregivers are willing to be engaged as research advisors and provided information to inform future engagement strategies. Findings can inform efforts to meet new age-inclusive requirements of the National Institutes of Health.