January/February 2023

Social Isolation: A Matter of the Heart
By Michele Deppe
Today’s Geriatric Medicine
Vol. 16 No. 1 P. 18

Loneliness and isolation may contribute to poor cardiovascular health in older adults.

Many of us experienced true social isolation for the first time during the pandemic lockdown. Or, perhaps, we were feeling lonely. There is a difference between the two, says Natalie M. Yarish, PhD, a researcher and assistant professor at Old Dominion University in the School of Community and Environmental Health in Virginia.

“Social isolation and loneliness are mildly correlated and can occur simultaneously, but they are not mutually exclusive,” Yarish says. She explains that social isolation is physically being away from people, like not touching or seeing or talking to others. Loneliness is a feeling that can be experienced even by people who are regularly in contact with others. A socially isolated person is not always lonely; conversely, a person experiencing loneliness is not necessarily socially isolated.

Crystal Wiley Cené, MD, MPH, FAHA, a professor of clinical medicine and chief administrative officer for health equity, diversity, and inclusion at the University of California San Diego Health, agrees with Yarish and adds that social isolation is typically the more objective, structural measure, referring to the frequency of contact and quantity of social connections. “Loneliness is more subjective,” Cené says. “It’s a measure of perceived isolation. If you perceive that you’re isolated, it really speaks to whether you have the level of connectedness you desire.” The prevalence of loneliness is a little higher than that of isolation, she says. “And there is a direct correlation to health. Social isolation is not having frequent contact with various types of social relationships, and it is thought to be a stressor on the body.”

According to a scientific statement from the American Heart Association (AHA), social isolation and loneliness may cause a 30% increase in the risk of heart attack, a 32% increased risk of stroke and stroke death, and a 50% rise in the risk for dementia.1 Cené, who was chair of the writing group for the AHA statement, says the public health impact is quite significant given our prevalence of social disconnectedness, which affects nearly one-quarter of US adults 65 and older, alongside estimates of loneliness at 22% to 47%.1 The AHA states that people with heart failure who had few social contacts exhibited a 60% lower survival rate over five years.1 And during a six-year follow-up study, data showed that socially isolated adults with heart disease were more likely to die.1

Social Isolation and Loneliness Are Bad for the Heart
Social isolation has been studied for about 40 years, according to the AHA study, and there’s “documented robust evidence” that isolation increases the risk of premature death from all causes.1 The pandemic quarantine allowed researchers a unique glimpse into isolation and loneliness.

Isolation and loneliness are a growing public health concern, Yarish says, as they are associated with health conditions that increase the risk of cardiovascular disease (CVD), including obesity, smoking, physical inactivity, poor diet, high blood pressure, and high cholesterol. “Our study shows that social isolation and loneliness independently increased CVD risk by 8% and 5%, respectively,” she says.2 “When we included all health behaviors and conditions in our study and adjusted for diabetes and depression, social isolation and loneliness remained strongly linked with increased risk for heart disease, supporting the importance of studying these social conditions.”

Reviews of various studies look at the associations between isolation or loneliness and inflammatory biomarkers, and those data have been inconsistent, Cené says. It’s possible that the stress of being lonely can trigger chronic inflammation in the body, which could lead to changes in the vessels and may result in heart disease, stroke, or dementia. Behavior is another biomarker that may change in response to feelings of loneliness and isolation, possibly resulting in poor sleep, less exercise, drinking too much alcohol, and poor diet.1

“We know that people who lack social connectedness may have a higher allostatic load, which refers to the cumulative burden of chronic stress and life events, which can harm cardiovascular health,” Cené says. Patients with allostatic overload and essential hypertension and coronary heart disease had a “higher disease-related emotional burden, poor psychosocial functioning, and high rates of psychopathology,” according to a review published in Psychotherapy and Psychosomatics.3 Adverse effects could also be measured in patients with atrial fibrillation, in whom the allostatic overload was the “only significant predictor of subsequent cardiac outcomes, including complications and death,” after an implantable cardioverter defibrillator.4 According to the review, the allostatic load was mainly linked to an increased risk of coronary heart disease, ischemic heart disease, and peripheral arterial disease.3

Older People vs Younger
As social networks shrink, Yarish explains, older adults are more at risk for social isolation and loneliness. Jeffrey Burr, PhD, a professor at the University of Massachusetts Boston, in an AHA article, notes that socially isolated older people may stop taking prescriptions, keeping medical appointments, and following medical advice because they don’t have anyone to encourage or prompt them.5

Those who were socially isolated in childhood had more significant cardiovascular risks later in life, with risk factors in adults such as obesity, elevated blood glucose, and high blood pressure problems. Cené says research points to Gen Z—18- to 21-year-olds—as the loneliest generation.1 According to a Harvard University survey, this is attributed to younger people being online and having less meaningful in-person contact with others.6

“Older people have more experience and understand meaningful, in-person connections,” Cené says. “Young people are more likely to have greater social media use; they are forming identities, discovering where they fit in, and learning how to regulate the intense emotions of youth, all of which can be lonely at times. Older adults have figured these things out.” Older adults tend to be at higher risk of social isolation, Cené says, due to factors such as retirement, changes in mobility, and loss of a spouse, which causes a change in social networks.

Are Women at Greater Risk? (Yes and No)
In the United States, CVD is the leading cause of death in women and accounts for approximately 1 in every 5 deaths among women, according to the AHA. Traditionally, women seem more likely to seek and value relationships. Yet, the preliminary evidence shows that older women are more socially isolated than men. “Both men and women are at risk for social isolation and loneliness,” Yarish says. “We did not specifically examine men in our study. We know that women tend to live longer, thus more likely to be widowed and live alone, putting them at an increased risk of social isolation and loneliness than men.”2

Questionnaires were sent to more than 57,000 postmenopausal women from the Women’s Health Initiative Study from 2011 to 2012 and 2014 to 2015 to help researchers assess feedback about social isolation, loneliness, and social support. The participants were followed through 2019.2 Yarish concludes that even the brief questions asked in these questionnaires should be part of primary care, as 1,599 CVD events occurred among the women in the study. “If older women experienced high levels of both social isolation and heart disease, their risk rose 13% to 27% compared with women who reported low levels of social isolation and low levels of loneliness,” she says.

Yet, there seems to be a distinguishing difference in how men are affected. In a 2021 study by Hu et al, social health and CVD risk scores were observed among older men and women.7 “The authors found that social isolation in men was associated with a greater atherosclerotic cardiovascular disease risk score,” Yarish says. “Additionally, they found that loneliness was associated with greater Framingham Risk Score among men.” (Framingham scores are a simplified and standard tool for assessing the risk of coronary artery disease over 10 years).

In addition to these challenges, financial resources and culture also play a part in loneliness and isolation. A study published in the Journal of the American Geriatrics Society of 641 people who were on average 63 years old and had at least one chronic health condition found that 1 in 6 experienced persistent loneliness during the pandemic.8 More than one-half of older adults who were lonely were able to adapt. However, for people living below the poverty line (24%) and people identifying as Hispanic and Latino (28%), loneliness did not resolve over time compared with others in the study who seemed to adapt as the pandemic continued. Among the study’s findings is that the stress of poverty contributes to feelings of loneliness. Some older adults had to leave intergenerational households due to pandemic guidelines. Researchers note that these individuals were estranged from the close ties to the community and religious groups because of COVID-19 and that lower-income neighborhoods that depend on public transport and community programs, lack access to technology, and have low proficiency in English may have been disproportionately affected.

Screening Is a Must
The risk factors for disease indicate that screening patients for poor social interaction is essential. “Measures of social isolation and loneliness—even with brief questions as was done in our study—should be incorporated into standard care,” Yarish says. “We monitor our patients’ blood pressure, weight, and temperature, and it might also be beneficial to capture the social needs individuals may lack to understand cardiovascular risk better and develop solutions.”

“Having a relationship with your patient is the best foundation to assess social connections. Listening and taking notes are still critical, and people often desire a relationship with their clinicians. It’s important to understand what types of connections are important to them,” Cené says. Her screening includes questions to determine if the patients have any family and if they belong to a faith-based community. Ask questions about how they connect: Is it by phone or computer or going to lunch? How often? Who would they talk to when they’re feeling down? Cené says, “Their answers can also tell you something about how they function as a person and their mobility. This information gives us a sense of whether they might be socially isolated and feel lonely.”

The patient’s social connections should be added to the EHR, Cené says. Epic, she explains, is one example of a standard EHR software that furnishes built-in questions based on an extensive review of EHR from the National Academy of Medicine. “Systems like Epic exist and provide you with information based on a validated measure so that you can compare your patient’s feedback to validated survey data,” she adds.

Asking questions about social activity and loneliness allows clinicians to capture data on social determinants of health risk factors across many domains, Cené explains. These domains include access to transportation, how much family and community support an individual has, mental health issues, and employment status. Examining these factors helps build a comprehensive picture of health and social factors and is a great help in assessing in which areas a person might benefit from support.

Exploring Solutions
People have different needs, but there seems to be a tipping point. “The older data suggest that less than two contacts with others in a week would be considered social isolation,” Cené says. Would two contacts be sufficient to be considered protective against adverse health effects? Not necessarily, she says, because people can have many contacts in a week, perhaps even be surrounded by people, and still feel lonely. Quality, frequency, and satisfaction contribute to whether a connection assuages loneliness. Cené says that only individuals can know if their social needs are met.

The American Geriatrics Society study led researchers to conclude that promising interventions include intergenerational volunteers, peer support, friendship lines, and programs that help people learn to connect through technology.8

The National Institute on Aging (NIA) has an online toolkit to share with clinical staff and patients.9 The advice from the NIA suggests that phone calls and video chats can be helpful ways for people to make connections. The NIA recommends in-person activities such as going to the community center for a seminar or class, taking up a hobby with others, or joining a new book club and participating in discussions. Caring for a pet also can help fill the need for companionship.

The AHA encourages people to find a method of meditation to mitigate stress, which can cause an increase in blood pressure. Being in the moment (mindfulness), meditation, and moving meditation (for example yoga or tai chi) can lower blood pressure and stress, reduce inflammation, enhance cognition, and support the immune system.10

Conclusion
To help and encourage older people whose experience falls within the parameters of the definition of social isolation, it may be helpful to consider a quote by Judy Poey, a health program officer for the United Way of Central Maryland. Calling attention to the fact that not everyone who lives alone will struggle with isolation or loneliness, Poey says. “It’s a risk factor. It’s not deterministic.”5

“There are a lot of research gaps and an urgent need for further studies and strategies to help people reduce the negative effects of social isolation and loneliness, especially for at-risk populations. But I think we can say that avoiding social isolation and loneliness are critically important for health and that those issues are a major driver of mortality,” Cené says. The literature, she adds, hasn’t examined proven interventions that affect specific clinical conditions. “But in the interest of cardiovascular health,” she says, “we have to continue to screen patients, develop and test interventions, and establish further programs to help patients who are isolated or lonely.”

— Michele Deppe is a freelance writer based in South Carolina.

References
1. Cené CW, Beckie TM, Sims M, et al. Effects of objective and perceived social isolation on cardiovascular and brain health: a scientific statement from the American Heart Association. J Am Heart Assoc. 2022;11(16):e026493.

2. Golaszewski NM, LaCroix AZ, Godino JG, et al. Evaluation of social isolation, loneliness, and cardiovascular disease among older women in the US. JAMA Netw Open. 2022;5(2):e2146461.

3. Guidi J, Lucente M, Sonino N, Fava GA. Allostatic load and its impact on health: a systematic review. Psychother Psychosom. 2021;90(1):11-27.

4. Gostoli S, Bonomo M, Roncuzzi R, Biffi M, Boriani G, Rafanelli C. Psychological correlates, allostatic overload and clinical course in patients with implantable cardioverter defibrillator (ICD). Int J Cardiol. 2016;220:360-364.

5. Williamson L. How social isolation can harm health as you age—and how to prevent it. The American Heart Association website. https://www.heart.org/en/news/2021/05/07/how-social-isolation-can-harm-health-as-you-age-and-how-to-prevent-it. Published May 7, 2021. Accessed August 29, 2022.

6. Weissbourd R, Batanova M, Lovison V, Torres E. Loneliness in America: how the pandemic has deepened an epidemic of loneliness and what we can do about it. Harvard University website. https://mcc.gse.harvard.edu/reports/loneliness-in-america. Published February 2021.

7. Hu J, Fitzgerald SM, Owen AJ, et al. Social isolation, social support, loneliness and cardiovascular disease risk factors: a cross-sectional study among older adults. Int J Geriatr Psychiatry. 2021;36(11):1795-1809.

8. Kotwal AA, Batio S, Wolf MS, et al. Persistent loneliness due to COVID-19 over 18 months of the pandemic: a prospective cohort study [published online August 25, 2022]. J Am Geriatr Soc. doi: 10.1111/jgs.18010.

9. Social isolation and loneliness outreach toolkit. National Institute on Aging website. https://www.nia.nih.gov/ctctoolkit

10. Meditation to boost health and well-being. The American Heart Association website. https://www.heart.org/en/healthy-living/healthy-lifestyle/mental-health-and-wellbeing/meditation-to-boost-health-and-wellbeing. Accessed August 29, 2022.