You can drop me off at Walmart,” wishes an elderly friend once she is freely able to leave the safety of her home, confined both by her health status and the request of her family. “My once-vibrant extroverted child has become withdrawn and depressed,” laments a concerned mother. “There is no way to meet new friends,” expresses the young adult who moved right before the pandemic started. While the health risks of COVID-19 have centered attention on our elderly population, especially those residing in nursing homes, the effects of distancing measures to reduce the spread of the disease has decreased meaningful social contact for people at all stages of life.
Social connectedness, how individuals connect with each other, is dependent on structural, functional and quality factors.1 The COVID-19 pandemic has exacerbated the problem of social connectedness for those who were already experiencing social isolation (a structural factor) and/or loneliness (a functional factor) prior to the pandemic. Research on the effects of social isolation and loneliness has shown detrimental effects on the physical and mental health of the elderly. Older people who experience social isolation and/or loneliness are at increased risk of cardiovascular disease, depression, decreased mobility and falls, and food insecurity.2-7 Health care access is impaired by business restrictions or concerns over contracting disease.8,9 There is also a strain on caregivers who experience more difficulty navigating the system for resources or are having increased relational conflict with the elderly patient.2 While adolescents and young adults are generally healthier, they are also experiencing more loneliness and higher rates of depression during the pandemic.10,11 It is important however to make the distinction between social isolation (living alone or apart from others), and loneliness (the subjective feeling of a lack of connection with others).1,12 People can be socially isolated and not lonely. They can also be surrounded by people and lonely.1,13
Martin Seligman’s positive psychology model for promoting psychological well-being involves the elements of positive emotion, engagement in enjoyable activities, healthy relationships, maintaining meaning and having accomplishments (PERMA).14 This is a useful lens through which we can view how to help others who are at risk for the negative effects of isolation and/or loneliness. In many ways, we have already creatively adapted to the COVID-19 containment measures that magnify social isolation and/or loneliness. State initiatives include programs encouraging citizens to reach out to their neighbors as well as partnering with community organizations to provide items such as food, music, or pets. For a full listing of state initiatives, refer to the publication by Advancing States.15 Individuals and groups are using virtual platforms to continue participation in social activities such as concerts, meals, parties, and game nights. When possible, people are also moving their activities outdoors, using parks, lawns and driveways as locations for safe conversations, celebrations, and group leisure. In health care, we have adapted to virtual technology, using it to maintain contact with patients and engage them in self-monitoring their diseases.
As the pandemic starts to come under control and containment measures are relaxed, the problems of social isolation and loneliness will still exist. The following is a list of strategies to address these problems.
More than just an Elvis song, meeting needs starts with identifying them and this begins with revisiting what we include in the social history. Simply, it involves asking our patients about their own living situation and social connectedness, as well as about the state of their families and closest friends. Knowing this then allows us to personalize the utilization of available resources to promote and sustain well-being in our patients. Questions can focus on who lives with them, how they are getting time to talk with others, maintaining relationships with peers, and participation in hobbies or extracurricular interests. Tools previously used in research such as the Berkman-Syme Social Network Index (measuring social isolation) and the UCLA Loneliness Scale can both be used to screen for aspects of social connectedness.15 We can also continue to consider the impact of social determinants of health by asking if they are able to access items for daily living and health care needs.
Those who are socially isolated can experience difficulty with access to food and hygiene items as well as getting to health care appointments. We should continue to strengthen the partnership and support for community organizations who provide food and transportation services. The need to limit contact with others also potentially decreases access to home care services. This can be addressed by encouraging ancillary health services to provide telehealth consultations when appropriate. While many took to the outdoors for relaxation, the elderly who already have difficulty with mobility risk worsening of their physical activity level and ability. Youth also are at risk for decreased physical activity as their classrooms moved online, increasing sit time and restricted participation in organized sports. So, consider connecting those who are unable to get to the grocery store or food drives with home delivery. Promote physical activity by connecting elderly with virtual group exercise classes or organizing family exercise. Community organizations such as the YMCA or local recreation centers have a wealth of exercise videos to access on YouTube. For youth, consider encouraging participation in online physical education activities and promote safe organized athletic participation respecting masking and distancing rules and splitting up team sports into smaller practice groups.
The rapid integration of technology to assist with the routine of life has been an integral part of how we have adapted to restrictions due to the pandemic. Telehealth has allowed us to maintain contact with our patients and continue to evaluate and manage both chronic and acute conditions of our patients. Even with the robust response to virtual platforms, many of our elderly patients still encounter difficulties with using technology, such as access to dependable internet connectivity and ability to learn how to use technology. This impact is worse in those with cognitive impairment and hearing/sight limitations. Even as restrictions are lifted, some patients may feel uncomfortable with coming to the clinic. Consider utilizing home visits to provide care, especially when a physical exam is needed.
Addressing mental health problems will take an individualized approach similar to the way we approach management of chronic disease. This starts with recognizing the diversity in people at all ages. Not all elderly are confined to their homes or have high-risk conditions. Some people need the element of physical touch or proximity to not feel lonely. Take time to discuss the risks and benefits of a more open social network. Help your patients come up with a core group of people that they need to physically see and strategies for maintaining the boundaries needed to ensure safety. For those who prefer to avoid the risks of increased physical contact, encourage the use of virtual group meetings. If they are unable to use technology, consider the tradition of hand-written correspondence. Encourage all family members to find ways to engage safely in activities that give them pleasure and provide meaningful connection. For further confirmation of mental health issues, screening tools such as the PHQ-9, GAD-7 and PSC-Y can be administered.
The disruption created by the COVID-19 pandemic can be viewed as an opportunity for family medicine. It has accelerated the provision of care outside the traditional office setting and heightened awareness about the consequences of decreased social connectedness for many groups. In response, we have bravely and creatively adapted the ways we interact with one another through technology and redefined what it means to gather together physically. As restrictions are gradually lifted and life returns to a semblance of normal over the coming months, let us continue to use the lessons that we learned this past year to help our patients, and us, thrive in life.
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