Social Inclusion and Isolation: Research for the Post-COVID Era and Beyond

KEYWORDS:

• aging
• social isolation
• loneliness
• older adults
• social connection

“Solitude vivifies; isolation kills.”

Joseph Roux, 1834-1905, French poet

Fellow clinical gerontologists

For much of history, as the quote above suggests, both poets and scholars have been aware of the difference between the voluntary seeking of solitude for reflection or rejuvenation, and the deleterious effects of social isolation, particularly if it is unwanted or imposed. The era of the novel coronavirus (COVID-19) has been marked by a heightened sense of the importance of social connection amid the regulation of physical proximity and the enforced social isolation of members of societies globally, most significantly older people in residential aged care facilities. This appreciation of the value of social inclusion and connectivity has ramifications for social policy as well as innovation in research and intervention science.

Although this special issue of Clinical Gerontologist was conceived before COVID-19 was a reality, the research encompassed herein is reflective of both ongoing research enquiries into the nature and benefits of social connection, and the negative impacts of social isolation. The benefits of social connections, and interventions to improve such links. Special populations of interest, including Veterans and persons living with dementia and their care networks, as well as the most vulnerable, unbefriended older adults in medical settings, are also addressed in terms of behavioral survey, assessment and intervention research.

The first of these papers, by Townsend, Chen, and Wuthrich (2021) is a systematic review of the literature examining barriers and potential facilitators of social participation in older adults. The review produced four main types of barriers and facilitators: demographic, individual, environmental and social network factors. Personal motivations to pursue or maintain social connections, the value of preexisting social networks, and neighborhood cohesion contribute not just to social connectivity, but to the quality of these social interactions in older adults.

The evidence for the benefits of social connections are mounting in the broader literature, as well as the best methods to maintain social connections in later life. In this special issue, Giebel et al. (2021) examined the benefits of maintaining social support in a large sample of older adults primarily from disadvantaged neighborhoods. They found those with lower social support visited their GP more often, suggesting that social supports could buffer mild health concerns and unnecessary GP visits. In a study by Yang, Tng, Ng, and Yang (2021), they examined the mechanisms underlying the links between loneliness and increased risk for dementia. Whilst loneliness has recently been found to increase dementia risk, it is still unclear what drives this effect. Using mediational analyses, they found that sense of control mediated the relationship between loneliness and dementia risk, but not self-efficacy, suggesting that perceptions of the control over one’s social environment might be particularly relevant.

Several studies examined the use of technology to increase and maintain social connections. The study by Liddle et al. (2021) used qualitative interviews in a sample of people using technology-based solutions to maintain social contact due to health issues or living in a rural or remote area. The sample reported benefits of technology-based solutions included increased sense of support and ability to deal with health concerns, although some technology-solutions were associated with greater connection than others. Participants generally reported that whilst technology-based solutions were important for maintaining social connections they felt they were inferior to in-person contact, and even noted in some instances that technology-based solutions led to a perceived pressure to connect. Two studies looked at technology-based solutions to build and maintain social connections in people with dementia living in aged care facilities. In a qualitative study of people with dementia, Samuelsson, Ferm, and Ekström (2021) explored the benefits and sense of connection of a conversation group delivered via a digital communication platform to older adults living in different wards of a care facility. Participants chose from a set of topics and activities to engage in at each group session to provide some structure to the conversations. Feedback from participants was generally positive, with participants reporting benefits related to feeling connected to the group itself and enjoying the social interaction. Similarly, in a study of the impact of befriending delivered remotely during COVID-19 lockdowns, Fearn et al. (2021) found several impediments to befriending delivered remotely such as related to hearing impairments, discomfort with and need for assistance to use technology platforms, but despite the impediments, residents reported a preference for contact remotely over no contact, and like the study by Liddle et al. (2021), residents reported a strong preference for in-person contact over technology-based contact.

Our understanding of how to treat loneliness and social isolation in older adults is still emerging, with some evidence that increasing the frequency of social contact might be necessary but not sufficient (Masi, Chen, Hawkley, & Cacioppo, 2011). Instead, it appears that improving the quality of social connections is important. Based on models of loneliness that indicate that loneliness is maintained by social isolation and cognitive misinterpretations of social situations, cognitive behavioral therapy (CBT) appears to be particularly promising. The study by Smith, Wuthrich, Johnco, and Belcher (2021) is a secondary analysis of a clinical trial to treat depression and anxiety in older adults, to test if using CBT to address maladaptive interpretations of social situations, reduce avoidance of social situations through graded exposure, and increase communication skills was associated with significant decreases in loneliness. The findings indicate that standard CBT for depression and anxiety was also associated with significant decreases in loneliness that were maintained at follow-up.

A special population of interest addressed by two articles in this special issue is Veterans. The first paper addresses issues of reintegration into the community following discharge from a nursing home facility. Qualitative interviews explored the Veterans’ experiences during this transition; social connections were a strong leitmotif throughout (Sullivan et al., 2021). The four themes that emerged from analyses included access and quality of social support networks, engagement in meaningful activities with friends and family, service providers facilitating social connectivity, and whether external stressors impacted social connections. The findings underscore that discharge planning must extend beyond physical and environmental aspects of the discharge setting to include ensuring social networks for Veterans returning to the community are facilitated. On a related theme of community housing, Winer, Dunlap, St Pierre, McInnes, and Schutt (2021) explored factors associated with social integration in public housing for formerly homeless Veterans. Homelessness in Veterans is associated with a variety of challenges including substance abuse (e.g. Schinka et al., 2017) and complex mental health needs (Karel et al., 2021); social connections are one aspect of wellbeing that is negatively affected by homelessness. As in the Sullivan et al. (2021) article, Winer and colleagues found that social engagement was key to successful adaptation and that the facilitation of social support networks by case management teams was important for overcoming social isolation.

A series of studies examined social connections in people with dementia, with a clear outcome across studies demonstrating that people with dementia benefit from, and appreciate a wide range of social activities and social inclusion mirroring the findings from the technology-based studies reported by Samuelsson et al. (2021) and Fearn et al. (2021). Using observational data and interviews with staff and people with dementia, the study by Motta-Ochoa et al. (2021) highlights the key practices of social inclusion related to enabling time and flexibility to build relationships, empowering decision-making and including family members, seeking feedback from people with dementia, and importantly, assisting people with dementia to assist in caring roles for others to foster active social connections, rather than just being recipients of care. The study by Ashida, Robinson, Williams, Hejna, and Thompson (2021) examines social support in the context of caregiving for a family member with dementia. They examine the nature of social support provided by community-based service providers to family carers, and the impacts of these on carers and staff member job satisfaction. They found carers reported higher satisfaction with higher perceived levels of social support from service providers, and service providers also reported higher job satisfaction with increased collaboration with family carers.

Finally, a interesting article by Farrell et al. (2021) examines a very vulnerable population increasing in prevalence, that is, unfriended older adults and adult orphans. These are older adults who have no social supports to guide decision-making about their care in medical settings. This study surveyed the frequency clinicians encountered these individuals, the challenges they had in treating this population, and the impacts on patient care. Clinicians reported managing unbefriended older patients was a frequent problem that resulted in prolonged hospital stays, delays to treatment including palliative care, increased psychological distress, as well as triggering significant moral distress in the clinicians themselves. This study highlights the worst-case scenario, older adults without social support when they most need it. The authors recommend a proactive approach to identifying vulnerable people early in treatment, and improvements to practices and processes to optimize care of the most socially isolated individuals.

The articles in this special issue reinforce not only the importance of social connections for physical and mental wellbeing, but the power of such connections to influence behaviors, and to be positively influenced in turn through targeted interventions. Particularly in the case of vulnerable individuals, efforts to enhance and maintain social networks are key to maintaining health and high quality of life.

Disclosure statement

No potential conflict of interest was reported by the author(s).