Last week, I met an 88-year-old veteran who was admitted to our hospital with confusion related to severe kidney failure. In the emergency room, the staff was unable to understand from him any specific details of why he had come to the hospital; he lived alone, was not accompanied by anyone, and his emergency contact did not answer. Luckily he had just enough intuition and preserved consciousness to know that something was not right and to ask his neighbors if they could help him get to the hospital. On reviewing his lab tests, which revealed severe electrolyte disturbances and the cause for his confusion, it is clear that if it weren’t for his neighbors, he would have died alone in his home.
The story here and the problem it illustrates are all too common not just for our veteran population, but for many elderly Americans: Social isolation. It is difficult for many of us to fathom being alone on a daily basis, not having a job or regular social activity, securing food and paying the bills for warmth, and simply staying engaged in the activities of life instead of descending into depression, stagnation, and ill health. And when major illness strikes, we may only imagine not having anyone to stay with us in the hospital, having to decipher the medical terms without any help, wading through 10 to 15 prescription drugs and side effects on our own, and going to followup appointments often with physical disability and without transportation. And yet this is what millions of Americans do, and many of them are elderly.
In 2010, over 31 million Americans lived alone, and 11 million of them are older adults. Since the 1970s, marriage and childbearing patterns have changed, such that the U.S. has experienced a steady increase in the number of older people who lack spouses or children, so that 30% of all older Americans live alone. These elderly are more likely to suffer from chronic disease, disability, and depression. Living distant from or neglected by family, withdrawn from other social networks, they are left to manage (or not manage) their chronic diseases on their own.
Social isolation of our chronically ill and elderly is a sad and costly problem, both inefficient for our health care system to endure and unconscionable for our society to allow. When the unmanaged chronic illness of the socially isolated becomes acutely worsened, mortality rates are higher and serious functional and mental debilitation requires total care from the system.
Data abound on the risk that social isolation silently has for acute and chronic disease. Researchers have found that the absence of social relationships or those of low quality are independent predictors of all-cause mortality, even when controlling for baseline health status. Animal studies have found that social isolation lead to stressful biochemistry, through elevation of the hypothalamic-pituitary-adrenal axis and high cortisol states. Furthermore, social support from others has robust beneficial effects on the cardiovascular, endocrine, and immune systems, serving as a protective factor against disease and mortality.
The risks disproportionately affect the poor, the elderly, and minorities such as African Americans. The risk is particularly severe for the elderly. They are more likely to have small social networks, and as they age, experience the loss of their spouses and friends. After bereavement, they are more likely to develop health problems, depression, and deteriorating cognitive disease, and ultimately require more hospitalization and have higher mortality from all causes. Therefore, the elderly are in the most need for social support, even as they are often the most socially isolated.
What is worst is that we have known this for quite some time. In 1988, a report by the Commonwealth Fund Commission on the Elderly Living Alone reported that a third of elderly Americans lived alone, typically older women, often widowed and childless, and poorer and sicker as a result. http://wagner.nyu.edu/faculty/testimony/rodwinNycCouncil021106.pdf. And we are repeatedly reminded of the disproportionate risk for socially isolated elderly, especially during natural disasters. In Chicago in 1995, a dangerous heat wave killed over 700 people, most of whom were the elderly poor living alone in the urban center with no air conditioning and afraid to open their windows for fear of crime. Those who lived in better socially connected neighborhoods fared better, even if they lived alone and had low income. Other disasters, such as Hurricane Katrina, uncovered similar vulnerabilities. As two public health experts testified to the New York City Council Committee on Aging, the catastrophic consequences for the poor, sick, and alone reminded us of “how visible otherwise invisible problems become.”
Despite the clear associations of social isolation and disease, and the implications for public health, the health care system does little to reach out to isolated individuals. Despite being the largest insurer of older Americans, Medicare spent only 4 percent of expenditures on home health services, and these are usually initiated after acute illness disables seniors.. The fee-for-service system largely incentivizes treatment when an elderly person gets sick and shows up in the clinic or the emergency room, rather than preventing this illness at home.
Admittedly, the solutions may only seem to be common sense. But most interventions designed to improve social contact have produced somewhat disappointing results, mostly because the specific mechanisms that lead to and sustain social isolation are still unknown. In addition, the entrenchment of isolation seems particularly difficult to unravel, from the perspective of both psychological and social interventions.
Could we improve the public health of the U.S. by reaching out to isolated Americans in the community, to provide social support to those who are chronically ill and depressed? Could we reduce health care utilization in this population and perhaps even save money by preventing complications of chronic disease, improving medication non-adherence, and establishing end-of-life preferences before severe illness strikes? These questions need to be researched much more intensely, and policy solutions need to be developed. Our health care system can no longer afford to ignore the socially isolated, and our conscience for caring for the less fortunate demands it.