Social isolation and loneliness are established risk factors for disease and early death. Routinely asking about patients about their social support system (or lack thereof) allows us to give more effective care.
It was Christmas Eve in the clinic and I was eager to get home to my toddler before his bedtime. I tapped my foot on the linoleum floor, feeling rushed as my last patient of the afternoon slowly shuffled into the exam room. He was a new patient and in an effort to make quick small talk as he settled in, I asked, “Any special holiday plans this year?”
“No doc,” he replied softly. “I’m alone.”
His answer stunned me. I gave my full attention as he explained what he meant—strained family relationships, recent homelessness, his parents’ struggle as new immigrants to build a life far away from home. He was painfully socially isolated. By the time our visit concluded, in addition to addressing his high blood pressure and chronic knee pain, had also arranged for him to meet our social worker for help with housing and hot meals. Later that night as I rocked my son to sleep, I wondered how my patient had become all alone in the world and what I should do to help.
Why social isolation matters
Beyond the innate humanism that calls us to care for patients as whole human beings, there’s a rich medical literature that explores the relationship between social networks and health outcomes. Both isolation (being alone) and loneliness (feeling alone) are independently associated with all-cause mortality through suspected pathways including chronic over-activation of hormonal pathways and the sympathetic nervous system, and fundamental cognitive rewiring leading to hypervigilance, hostility, and poor impulse control. Observational studies show correlations between severe loneliness and increased IL-6 levels, glucocorticoid resistance, chronic hypertension, fragmented sleep, and pro-inflammatory states. Among patients with cancer, poor social support correlates with higher reported pain, depression, fatigue, and increased cognitive difficulties. Chronic loneliness is also associated with cognitive decline and risk of clinical dementia in later life. Isolation matters, and as clinicians, we should take note.
Screening for social isolation
Considering social isolation as a risk factor for poor health outcomes is often absent from the doctor’s office and hospital bedside, and is rarely noted in a standard social history. It’s a phenomenon we see more often than not—elderly patients who lack companionship and face physical limitations to socialization; homeless and recently incarcerated patients with few reliable connections; individuals facing discrimination due to race, gender, language, or sexual orientation and worried about rejection or violence; those with a history of (or current) abuse, and post-traumatic stress that prevents development of new connections. It’s also well-documented that caregivers can suffer debilitating feelings of isolation and associated stress.
Given this diversity of presentation, how exactly do we measure a patient’s level of social isolation? There’s not yet a standardized survey for isolation in the clinical setting and this drastically limits the quality of evidence on loneliness as a social determinant of health. But there are a few validated tools used in research, such as the Berkman-Syme Social Network Index and the UCLA Loneliness Scale. The Berkman-Syme scale focuses on four elements of network size and activity including marriage, number of friends, participation in community groups, and frequency of attending religious services. The UCLA Scale, in its briefest form, asks the questions:
1. How often do you feel that you lack companionship?
2. How often do you feel left out?
3. How often do you feel isolated from others?
Ultimately, there’s no “right” questions to ask, but whichever questions you ask, it’s important to make assessing social support an essential element of a routine social history. I usually start with a specific, “Do you live alone or with others?” If alone, “Do you have social supports and feel supported?” If living with others, “Do you feel safe and have healthy relationships at home?” A key to all of this is that chronicity matters. One of the masters of research on this topic, Dr. John Cacioppo, said that loneliness is like hunger—a little is fine, as it pushes us to seek healing connections, just as hunger prompts us to eat. But in excess it can be dangerous and even deadly. So we need to evaluate how isolated our patients feel not just at a first visit, but at every visit. Asking about social networks is a crucial grounding process that humanizes patients and provides valuable insight into how we can address concerns effectively together.
Making connections to make a difference
Since our Christmas Eve visit, I’ve had several follow-ups with my lonely patient. Over time, he was able to establish stable housing and meet a phenomenal case manager. He still struggles with fractured family relationships, but he feels a newfound sense of security. His hypertension has resolved, and while I can’t attribute that entirely to social interventions, it’s refreshing to see him on fewer medications, with fewer worries.
Since that visit I’ve also become more routine, standardized, and sensitive about how I explore a patient’s social fabric. I see it as an essential component of their overall health and as an area of potentially positive intervention in collaboration with other healthcare professionals or community members. I still wonder how to “measure” if a patient is improving or not? Am I doing enough? Because in the same way we lack standardized tools to screen for social isolation, we also lack an explicit “scoring system” to make a formal diagnosis, or suggest key points for intervention, or what those interventions even are.
Here are 6 resources to consider when working to increase patients’ social supports:
1. Social work expertise for connecting patients to specific community resources.
2. Establishing care with a home health aide when applicable.
3. Community health professional care, including home visits, for more frequent and personalized health interventions.
4. Participation at community centers like adult day cares, religious and cultural groups, and neighborhood associations (in COVID-safe ways).
5. Telemedicine interventions that allow for more frequent and accessible communication with healthcare professionals.
6. Identifying and providing support for patients to leave toxic and dangerous relationships.
These resources are neither exhaustive nor perfect in themselves. For example, many patients still lack access to meaningful telemedicine connectivity. And COVID places an enormous strain on gathering safely. But they are places to start. As 2021 begins, patients are at even higher risk for isolation and loneliness due to COVID, and we must remember to routinely take a pulse on our patients’ social lives. May we provide tangible resources to increase and enhance social connection. May we make space to acknowledge distress with openness, warmth, and compassion.