The author reports no relevant financial relationships.
Rancho/USC California Alzheimer’s Disease Center, Downey, CA; Keck School of Medicine of USC, Los Angeles, CA
Prior to the COVID-19 pandemic, the health risks associated with a lack of social interaction were becoming more recognized in medicine and in the general population. With the initiation of stay-at-home and social distancing measures, the negative impacts of social isolation were overlooked and also never reexamined despite extended stay-at-home orders. This columm iterates the risks that social isolation poses for individuals, especially older adults in the community, older adults living in care facilities, and older individuals with dementias. It is time to reevaluate the pros and cons of social distancing in relation to the real-world impact on mental and physical health.
In late February 2020, older adults across the globe were told to self-quarantine and shut themselves off from others to reduce the risk of exposure to COVID-19. In long-term care facilities, a common practice has been to ban visits from family members and friends as a way to minimize the risk of spreading the virus. These restrictions in a time of crisis are understandable but could have a significant negative impact on the health and well-being of these older adults.
Social connection has been shown repeatedly to play an important role in healthy aging, especially in reducing the risk of cognitive decline. People with more social ties have been found to live longer, to have better health, and to be less depressed.1 As one may expect, the opposite is also true: a lack of social connection can exacerbate both physical and mental decline. Regrettably, we have witnessed the real-world demonstration of these data over the past year with the COVID epidemic. Public health measures imposed physical and social isolation on vulnerable populations, especially adults over a specific age (older than 65 or 70 years, depending on geography) and those who reside in assisted-living facilities and nursing homes. Such measures, initially expected to last a few months at most, have left many older adults safe from the virus but alone and isolated—and for much longer than anyone anticipated. What was expected to be a benefit to vulnerable populations and communities has had a very real cost in mental and physical quality of life along with other unintended consequences. Public health leaders must reexamine the benefits vs drawbacks to blanket stay-at-home and isolation orders, which are becoming increasingly harmful rather than helpful.
Understated Yet Demonstrated Benefits of Social Interaction
People who regularly engage in meaningful social interaction have been found to maintain better brain health at all ages. Social participation has been associated with a wide range of positive outcomes including better quality of life, improved muscle mass and balance, better cognition, along with reduced comorbidities and levels disability in older people.2-4 Just 10 minutes of daily social interaction increases performance on cognitive assessments and can give an important cognitive edge as we age.5 Individuals with large social networks are less likely to develop dementia than those with small networks,6 and those with well-established social support networks have been found to have greater resilience to stress.
An active social life may reduce the risk of dementia and cognitive decline among older adults, but not all social interactions are the same. Some types of interactions have been found to be especially important and others less so. For example, just living with other individuals, whether it be family or in congregate housing, is not by itself enough.7,8 The benefit of social interaction requires engagement and participation in social activities, such as shared meals, conversations, group exercising, and playing games. These are the activities that came to a screeching halt with the onset of the pandemic stay-at-home orders at adult day care programs, senior centers, long-term care facilities, and other facilities.
Growing Social Isolation Risk Awareness, Actions Stifled by Pandemic
The idea that social isolation and loneliness are public health risks for the aging population was gaining recognition prior to the pandemic. Both are risk factors that have been linked with poor physical and mental health.3 In the United States, approximately one-quarter of community-dwelling older adults are considered to be socially isolated, and 43% report feeling lonely.9 The COVID-19 pandemic stay-at-home orders have led to an increase in the number of socially isolated older adults, though exactly how many remains unknown.
Increased levels of stress, anxiety, depression, and sleep disturbances have been reported during the pandemic lockdown.10 Isolated older people have less physical activity and more sedentary behavior than those nonisolated. Forced isolation at home, or to single rooms for those in long-term care, can logically be expected to contribute to physical decline. While loneliness is associated with a range of negative health outcomes, the relationship between loneliness and dementia remains unclear. For dementia patients, the disruption of regular routines, such as the inability to take a daily walk—even just down a hallway or around the block—can be especially stressful and is known to precipitate behavior changes and a decline in function.11 In early stages of dementia, one might expect social isolation and loneliness to be more likely to cause an exacerbation in cognitive decline. While individuals with moderate to advanced dementia may not experience loneliness as a result of social isolation, they are nonetheless likely to exhibit behavior changes and an exacerbation of decline in cognition and function due to decreased mental stimulation.
Call to Action
Why were the negative effects of social isolation not taken into consideration when determining lockdown measures? Even if the impact of isolation was not discussed at the onset of the public health recommendations, then it certainly should have been examined after 3, 4, or more months.
Was there any more heart-wrenching picture than that of families standing outside a nursing home window visiting with their older adult relative on the other side? Month after month of social distancing measures have led to the recognition that these quarantine-like restrictions have been taking their toll on older adults. To their credit, facility staff have gotten creative, using their smart phones to visually connect long-term care residents with family members; some facilities purchased tablets to further enable remote visual connections and to provide some programming for residents isolated in their rooms.
The long months of lock downs have brought the loosening of some restrictions, allowing family members to visit facilities, wearing masks, physically distanced on patios for limited in-person visits. These are welcome attempts to address dire needs created by public health policies, but they are not sufficient. The lack of physical touch, the inability to hug one another, the limitations on numbers and length of visits are well-intentioned efforts but ultimately inadequate to fully address the ongoing toll such measures are taking on older adults and their families, negatively and perhaps irreparably affecting their health.
Public health messaging noting the necessity of physical distancing is important, but it needs to be accompanied by the need to maintain social connection. Whole-person health means getting adequate social interaction and connection to maintain physical health.12 As the pandemic continues, this is more important than ever. Rather than impose policies universally, public health might consider identifying those at highest risk then develop appropriate clinical and public health interventions for older adults based on an examination of both the risks and benefits.
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