key: cord-1017346-8tzv0qtx
authors: Kotwal, Ashwin A.; Holt‐Lunstad, Julianne; Newmark, Rebecca L.; Cenzer, Irena; Smith, Alexander K.; Covinsky, Kenneth E.; Escueta, Danielle P.; Lee, Jina M.; Perissinotto, Carla M.
title: Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID‐19 Shelter‐in‐Place Orders
date: 2020-09-23
journal: J Am Geriatr Soc
DOI: 10.1111/jgs.16865
sha: 1e0bea32cb8a91ee6cc6df2ff55b5df6906df9c0
doc_id: 1017346
cord_uid: 8tzv0qtx

BACKGROUND/OBJECTIVES: Physical distancing during the COVID‐19 pandemic may have unintended, detrimental effects on social isolation and loneliness among older adults. Our objectives were to investigate 1) experiences of social isolation and loneliness during shelter‐in‐place orders and 2) unmet health needs related to changes in social interactions. DESIGN: Mixed‐methods, longitudinal phone‐based survey administered every 2 weeks. SETTING: Two community sites and an academic geriatrics outpatient clinical practice. PARTICIPANTS: 151 community‐dwelling older adults. MEASUREMENTS: We measured social isolation using a 6‐item modified Duke Social Support Index, social interaction sub‐scale, which included assessments of video‐based and internet‐based socializing. Measures of loneliness included self‐reported worsened loneliness due to the COVID‐19 pandemic, and loneliness severity based on the 3‐item UCLA loneliness scale. Participants were invited to share open‐ended comments about their social experiences. RESULTS: Participants were on average 75 years old (SD = 10), 50% had hearing or vision impairment, 64% lived alone, and 26% difficulty bathing. Participants reported social isolation in 40% of interviews, 76% reported minimal video‐based socializing, and 42% minimal internet‐based socializing. Socially isolated participants reported difficulty finding help with functional needs, including bathing (20% vs 55%, p = .04). Over half (54%) of participants reported worsened loneliness due to COVID‐19, which was associated with worsened depression (62% vs 9%, p < .001) and anxiety (57% vs 9%, p < .001). Rates of loneliness improved on average by time since shelter‐in‐place orders (4–6 weeks: 46% vs 13–15 weeks: 27%, p = .009), however, loneliness persisted or worsened for a subgroup of participants. Open‐ended responses revealed challenges faced by the subgroup experiencing persistent loneliness, including poor emotional coping and discomfort with new technologies. CONCLUSIONS: Many older adults are adjusting to COVID‐19 restrictions since the start of shelter‐in‐place orders. Additional steps are critically needed to address the psychological suffering and unmet medical needs of those with persistent loneliness or barriers to technology‐based social interaction.

On March 16 th , 2020, San Francisco was the first county in the United States to institute shelterin-place orders in addition to broader physical distancing recommendations. While these orders have been credited with reducing the spread of COVID-19, it is unclear whether such orders have had unintended consequences for older adults who may be uniquely vulnerable to experiencing social isolation and loneliness, two distinct markers of social well-being. 1, 2 Social isolation is an objective deficit in the number of relationships with and frequency of contact with family, friends, and the community. 3 By definition, shelter-in-place orders have isolated older adults to their homes, and this isolation might be greater for individuals who struggle to navigate video-and internet-based social interaction. While social isolation may not be emotionally distressing for all, it is associated with medical risks, increased health care costs, and limited access to key caregiver, financial, medical, or emotional support during the pandemic. [4] [5] [6] [7] In contrast, loneliness is a discrepancy between one's actual and desired level of social connection, and is associated with depression, anxiety, functional disability, and physical symptoms such as pain, and death. 3, 5, 6, 8, 9 During the COVID-19 pandemic, many older adults may have experienced new or worsened feelings of loneliness due to a disruption of in-person social activities, which are often essential due to pre-existing limitations from chronic medical conditions, vision or hearing impairment, or functional disability. 1 Social isolation and loneliness can exist separately, and it is not uncommon for them to co-exist.

A better understanding of experiences of social isolation and loneliness among older adults during the COVID-19 pandemic and health needs stemming from changes in social interaction is needed. While many older adults may be successfully adjusting to social restrictions, more detailed information about older adults who may not be adapting to restrictions Accepted Article This article is protected by copyright. All rights reserved. could guide evolving policies and strategies for supporting those who need more help. Moreover, a recent National Academy of Sciences report highlighted the need for clinicians to be aware of and actively address the health effects of social isolation and loneliness. 10 We therefore conducted a mixed-methods study of community-dwelling older adults primarily in the San Francisco and Bay Area during shelter-in-place orders. Our objectives were to 1) investigate experiences of social isolation and loneliness during shelter-in-place orders, and 2) examine unmet health needs related to changes in social interactions.

Study Subjects and Design. We included participants from three sites to ensure a diverse sample:

Services, and 3) the Curry Senior Center, with an overall response rate of 40%. The UCSF geriatrics programs included a sample of community-dwelling adults (n=79) receiving outpatient and home-based care. Covia Senior Services is a non-profit community program where participants (n=24) were recruited from two existing service programs: Well-Connected and Social Call. Finally, we included older adults from the non-profit Curry Senior Center (n=48) within San Francisco's Tenderloin neighborhood, a socioeconomically and ethnically diverse area of the city. Eligible participants were community-dwelling, age 60+, and able to participate in a 15-45 minute interview. We included participants speaking English, Spanish, Mandarin, Cantonese, and Russian with interviewers who were native speakers in the participant's primary language. Potential participants were excluded if they were unable to complete the consent process or if a prior diagnosis of cognitive impairment precluded them from consenting.

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between April 8 th to June 23 rd , 2020, and follow-up interviews were primarily conducted over the phone every 2 weeks, with few by mail or via e-mail if preferred. Shelter-in-place orders were in place during the entire study time period. The study protocol and contents were approved by the UCSF Institutional Review Board.

Social Measures. Several measures of social connections were included based on standard scales or adapted to measure social experiences during the coronavirus pandemic (Supplementary Table 1 ). We used a modified Duke Social Support Index social interaction sub-scale. 11, 12 The six-item scale includes the number of local contacts the participant feels close to or can depend on, the frequency of participation in community activities in the past week, and the frequency of social interaction (excluding interactions with co-residents) via telephone, video, internet, or inperson communication, for a total range of 0-17 points. We categorized individuals as socially isolated if scoring ≤6 points on the 17-point scale, which represents minimal support or interaction from all sources. 13, 14 Given the lack of consensus on an appropriate cut-off for social isolation, especially during the pandemic, we conducted sensitivity analyses of the social interaction scale both as a continuous variable and as a categorical variable with higher or lower cutoffs which yielded similar results (results available on request). In addition, we measured the frequency of communication with different social relationships (children or family, friends or neighbors, or volunteers).

Loneliness was measured in two ways. First, we assessed self-reported change in loneliness by asking participants whether their feelings of companionship, feeling left out, or feeling isolated were "worse," "about the same," or "better" due to to Accepted Article This article is protected by copyright. All rights reserved. measure the severity of loneliness, we used the 3-item UCLA Loneliness Scale (Range 0-6 points), categorizing 3+ points on the scale as high loneliness. 15, 16 Demographic and Clinical Measures. We measured several covariates to characterize the sample and which are relevant to social isolation and loneliness, including age, gender, race/ethnicity, education, and financial stress ("in general, how do finances typically work out at the end of the month?"). 17, 18 Health conditions included self-reported diagnoses of depression, anxiety, hypertension, diabetes, non-skin cancer, chronic lung disease, heart disease, or prior stroke.

Functional impairment included self-reported difficulty with bathing, preparing meals, shopping for groceries, medication management, and accessing transportation. 19 Medical needs, psychological distress, and open-ended feedback. Participants were asked how worried they were about worsening health due to delayed medical care and about worries of food insecurity during the pandemic. 20 Individuals reporting functional impairment with bathing, preparing meals, shopping, medication management, or accessing transportation were asked if they had difficulty finding help with the task during the pandemic. Anxiety was measured using the Generalized Anxiety Disorder 2-item (GAD-2) scale and by asking if these feelings changed due to coronavirus ("worse," "same," or "better"). 21 Depression was measured using the Patient Health Questionnaire-2 (PHQ-2) and asking if these feelings changed due to coronavirus ("worse," "same," or "better"). 22 Finally, we provided an opportunity for participants to share open-ended thoughts or comments about the coronavirus pandemic of which 77% participated (n=115).

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Analytic Approach. We analyzed available data on June 23 rd , 2020. We conducted descriptive and bivariate statistics to characterize the social experience of older adults and the association with health access, medical needs, and psychological distress. We then assessed the change over time of social connection measures and loneliness since the start of shelter-in-place orders using random effects models to account for repeated measures within individuals. For qualitative analysis, all comments were reviewed using open coding in which themes that emerged repeatedly in the data were defined and saved as codes. After a set of preliminary codes was created, free-text comments were then reviewed by each coder (AK and RN) and a constant comparative approach was used to finalize codes fitting concepts suggested by the data. The research team discussed codes to ensure reliable applications of the data. Themes and reported experiences of participants were compared with individual participants' UCLA loneliness scores at different time points.

460 interviews were conducted with 151 participants. The mean age of our sample was 75 years (SD=10), 64% were female, 8% African American/Black, and 8% Asian ( Table 1) .

Approximately 31% reported fair/poor hearing, 40% had fair/poor vision, 26% reported difficulty with bathing, and 35% difficulty shopping for groceries. Regarding social characteristics, 64% lived alone, 28% widowed, 43% reported no close children, 10% no close contacts, and 26% had only 1-2 close contacts.

Participants reported levels of social interaction consistent with social isolation in 40% of study interviews ( Table 2) . Examining individual indicators, telephone interaction was the most

This article is protected by copyright. All rights reserved. common medium of social interaction (Daily: 43%, 3x/week: 28%). In contrast, there were low rates of weekly video-based socializing (None: 46%, 1-2x/week: 30%) and internet-based socializing (None: 26%, 1-2x/week: 16%), with rates consistent by time since shelter-in-place.

The overall rate of weekly community participation was 15%, and this rate increased with time since shelter-in-place (Week 4-6: 10% versus Week 13-15: 27%, p=0.04). Individuals who were socially isolated were more likely to report difficulty finding help with functional needs, particularly bathing (55% versus 20%, p=0.04) ( Table 3) .

In examining open-ended responses, several participants reported successful use of technology to sustain connections with community activities and loved ones ( Table 4 ), and that their relationships with technology changed during the pandemic as more services and interactions moved online or they were provided help:

However, several participants mentioned either discomfort with technology or not having adequate access to the internet or equipment which limited their social interactions.

Limited use of technology often led to an inability to engage with a broader social network and individuals being confined to interacting with family members or no one at all. Participants further described barriers in obtaining help with household chores, cooking, and accessing transportation ( Table 4 ).

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Overall, 54% of participants attributed worsened feelings of loneliness to the coronavirus pandemic at least once during the study period. The rate of reporting worsened loneliness declined by time of interview since shelter-in-place orders (4-6 weeks: 41% to 13-15 weeks: 27%, p=0.009) ( Table 2) . Regarding psychological health, individuals reporting worsened loneliness were more likely to self-report worsened depression due to COVID-19 (62% versus 9%, p<0.001) and screen positive on the PHQ-2 (42% versus 17%, p<0.001), as well as report worsened anxiety (57% versus 9%, p<0.001) and screen positive for anxiety on the GAD-2 (46% versus 17%, p<0.001) ( Table 3 ). In addition, participants with worsened loneliness reported being extremely or very worried about coronavirus (56% versus 29%, p=0.002), worries about worsening health due to delays in medical care (21% versus 5%, p<0.001), and food insecurity (20% vs 9%, p=0.05) ( Table 3) .

There was substantial diversity in the severity of loneliness over time (as measured by the UCLA loneliness scale) and open-ended feedback among individual participants. We examined participants who reported worsened loneliness due to the coronavirus pandemic and who had at least two interviews during the study period (n=63) (Figure 1 ). Among these participants, several experienced loneliness scores which increased in severity over time (n=18, 28%, Figure   1A ) or loneliness scores that remained high over time (n=27 (42%, Figure 1B) . In open-ended responses, these individuals described COVID-19 restrictions amplifying prior social losses (e.g. widowhood), difficulty using technology-based alternatives to socializing, overwhelming feelings of being trapped, and loneliness affecting their physical and mental health: 

Others reported worsened loneliness that was relatively mild over time (UCLA scores of 0-2 points) (n=13, 21%, Figure 1C) . These participants reported a developing sense of boredom and dullness, but managing their loneliness through keeping busy with activities at home and adopting new technologies.

Among participants with at least two interviews who never reported worsened loneliness due to COVID-19 (n=67), open-ended feedback corresponded with two general sub-groups.

First, this included participants who were already isolated due to prior social deficits or functional impairments: isolation in our study. These findings are consistent with prior literature on barriers to internet use and communication technologies among older adults. [23] [24] [25] This digital divide is complex in that it may reflect both inadequate access to technologies or discomfort with available technologies. 26 Discomfort with technology might impact not only social interactions, but also accessing essential telehealth services, medication delivery programs, or technology-based food delivery programs. 27 Our study found that social isolation was further associated with difficulty finding help with bathing, meal preparation, grocery shopping, and accessing transportation.

Consequently, identifying social isolation or deficits in social support may provide a gateway for identifying critical unmet needs among older adults. In the short-term, we caution against an over-reliance on technology-based solutions for facilitating medical or social interactions as these may not be inclusive of many older adults with limited comfort or access to these options. 27 In these circumstances, clinicians may need to take the lead on making exceptions to allow in-person interactions for older adults. This can complement messaging from public health and community organizations. On the other hand, a majority of older adults had used video-or internet-based platforms to socialize at least once during shelter-in-place orders, and open-ended feedback included enthusiastic stories of adopting new technologies for socializing or community participation. These findings point to the potential for novel or agefriendly technological interventions among older adults, especially in situations where available classes, volunteers, family or friends can facilitate the use of unfamiliar technologies. 23, 24, 28 Our study found overall declines in loneliness over time, which is consistent with other surveys of older adults finding resilience to psychological distress during COVID-19. 29, 30 Important differences in the severity of loneliness over time and an ability to adapt were found among study participants, which highlights the importance of understanding nuances of

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individual experiences of loneliness. Among individuals who experienced loneliness that worsened or remained severe over time, common themes from open-ended feedback included an inability to cope emotionally, insufficient social support, and inadequate access or comfort with technologies for social interaction. In contrast, individuals who experienced no negative impact of the pandemic on loneliness reported the successful use of technology, positive emotional coping, and an ability to utilize city services (including senior center outreach, volunteer organizations, and services like Meals on Wheels) which is consistent with experiences in other parts of the country. 30 Notably, a minority of participants reported no difference in their loneliness during the pandemic because of already being isolated due to prior medical conditions (e.g. blindness, bedbound). In this sense, a lack of change during the pandemic reflected prior impairments rather than positive coping.

The diversity of experiences of loneliness suggest health care systems should conduct systematic assessments to identify the subgroup of individuals who are having a harder time adjusting in order to tailor outreach efforts. 29, 31 Assessments of loneliness can provide a window into addressing the additional psychological distress, worries about health, and trauma that many are experiencing and perhaps not openly discussing with family, friends, or health care providers.

A 2014 Institute on Medicine (IOM) report suggested integrating psychosocial "vital signs" into the electronic health record (EHR). 32, 33 The Berkman-Syme social isolation index and UCLA Loneliness score are reasonable candidates for inclusion in the EHR during the COVID-19 pandemic, and measures of social isolation should include assessments of the use of technology for social connections. 3 A recent National Academy of Sciences report on interventions to address loneliness and the health effects of social isolation demonstrated a large knowledge gap. 10 During the COVID-Accepted Article 19 pandemic, there is a particular need to address this knowledge gap by developing and testing interventions that do not rely on in-person interactions. It may be reasonable to scale interventions for immediate health needs while concurrently developing the evidence base. For example, anecdotally, during the course of study interviews, research staff found participants wanted to discuss their social experiences, as this in-and-of-itself was therapeutic. Brief phone calls or inquiries about social isolation and loneliness during the pandemic may be feasible for primary care offices or community organizations and are often welcomed by older adults. 10 In addition, we suggest medical and health providers establish partnerships and referral networks to allow for "social prescribing" to local community-based support programs. 10, 34, 35 Lastly, our study demonstrates that technology can be a powerful tool to help adults connect during periods such as the COVID-19 pandemic. Yet, over-reliance on technologies can heighten or accentuate digital and socioeconomic divides. Before moving forward with technology-based interventions during the pandemic, it is important to assess who the interventions aim to serve, who may be left out, and how to address these gaps.

Our study has several strengths. While this study was primarily focused on residents of San Francisco, California, the diversity of our sample makes these results potentially applicable to other older adults throughout the United States. We conducted interviews over the phone, by e-mail, and by mail which allowed us to be inclusive of older adults with vulnerabilities exacerbated by the pandemic, including discomfort with technologies, functional impairment, hearing impairment, and vision impairment. Established relationships between community organizations and primary care clinicians further facilitated recruitment of participants who are traditionally excluded from studies. Our study also has limitations. First, our sample size for quantitative analysis was limited in detecting statistically significant differences over time and by

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subgroups, although several notable differences emerged from the data. Second, we did not gather data on social measures and functional limitations prior to the start of shelter-in-place orders, so cannot directly compare differences pre-and post-pandemic. Lastly, recall and social desirability bias may have affected residents' reports of social interactions and well-being.

In conclusion, the effect of the COVID-19 pandemic on social isolation and loneliness among older adults has been mixed. Many have positively coped and adapted, while others have experienced worsened feelings of loneliness and an inability to adopt new technologies to facilitate social interaction. Identifying older adults experiencing sustained loneliness during the pandemic is critical to improving their overall well-being. Moreover, our results raise the potential of age-friendly technology to improve access to social interactions among older adults, but caution against over-reliance on technological solutions especially in the short-term among our community's most vulnerable. As the pandemic progresses, particularly given the recent increases in infections which are forcing re-evaluation of public health policies, immediate interventions are needed to support the social well-being of older adults to compensate for prolonged social restrictions.

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We are grateful to the staff at Curry Senior Center, Covia Senior Services, and UCSF Medical Student and Pharmacy Student volunteers who were responsible for data collection. We are extremely appreciative of study participants for their participation. Sponsor's Role: The sponsor had no role in the design, methods, data collection, analysis, or preparation of the paper.

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This article is protected by copyright. All rights reserved.

b Close contacts was determined by asking "How many persons in your local area do you feel like you can depend on or feel close to?" c Financial stress was determined by asking "In general, how do your finances usually work out at the end of the month?" d Self-rated hearing and vision impairment was rated in 5-categories: Excellent, Very good, Good, Fair, and Poor.

Accepted Article Accepted Article This article is protected by copyright. All rights reserved. c The severity of loneliness was assessed based on the 3-item UCLA Loneliness Scale with 3+ points categorized as "high" d Social Isolation was measured using a 6-item modified Duke Social Support Index, social interaction subscale, including the number of local contacts the participant feels close to or can depend on, the frequency of participation in community activities in the past week, and the frequency of social interaction (excluding interactions with co-residents) via telephone, video, internet, or in-person communication, for a total range of 0-20 points. Social isolation was categorized as ≤6 points. e Community participation was determined by asking "In the past week, about how often did you go to meetings of clubs, religious meetings, or other groups that you belong to?" Accepted Article "There are always problems with cable and telephone and no to one to help with the problems."

Difficulty getting help with functional needs "The floors have not been washed in our hallways for 4 weeks and cockroaches are spreading." "I think social isolation has been overdone in SF. Seniors need bus lines for transportation to carry out their own essential tasks that need to be completed" (go to the bank, get medications, maintain independence, catch a bus")" "I'm starting to notice feeling more vulnerable from eyesight change… gives me a hurdle with going to a grocery store… especially with no busses in my neighborhood." Limited engagement with broader social network "I only see my daughter, son-in-law and 2 young grandchildren. I have not been out except to the garden, to take 30 to 45 minute walks, I have not been in any shops.

"I feel some sadness in knowing that both my age and the time this will take to stabilize might prevent me from ever travelling easily and freely again in my life. It is a reality that I have to accept" "I used to be around people all the time like going to church or grocery shopping. There is now no human contact because of the virus." 

This article is protected by copyright. All rights reserved. Participants included in the figure reported worsened loneliness due to the COVID-19 pandemic at least once during the study period and had at least two interviews (n=63). Participants were included in panels (A) "Loneliness scores increase" (n=18) if UCLA loneliness scores increased on average in follow-up interviews compared to baseline; (B) "Loneliness scores remain high" (n=27) if all UCLA scores were ≥3; and C) "Loneliness scores remain low" (n=13) if all UCLA scores were ≤2. Worsened loneliness due to COVID-19 was determined by asking: "Because of the recent coronavirus outbreak (in the last two weeks), are your feelings of lack of companionship, being left out, or isolated: (Responses: Worse, Better, the Same)." The severity of loneliness over time was then determined using the UCLA 3-item loneliness scale (Range 0-6 points), where 3+ points corresponds with "high" loneliness. Colored lines show the loneliness trajectory corresponding with the participants' quotes.

Accepted Article

Social distancing" amidst a crisis in social isolation and loneliness

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A practical approach to assessing and mitigating loneliness and isolation in older adults

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Responsiveness of the Duke Social Support sub-scales in older women

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Older adults can successfully monitor symptoms using an inclusively designed mobile application

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Accepted Article b p-values were determined based off chi-square tests c Social Isolation was measured using a 6-item modified Duke Social Support Index, social interaction subscale, including the number of local contacts the participant feels close to or can depend on, the frequency of participation in community activities in the past week, and the frequency of social interaction (excluding interactions with co-residents) via telephone, video, internet, or in-person communication, for a total range of 0-20 points. Social isolation was categorized as ≤6 points. d Screen positive for depression was determined based on the PHQ-2 e Depression due to COVID-19 was determined by asking: ""Because of the recent coronavirus outbreak (in the last two weeks), are your feelings being down, depressed, or hopeless, or having little interest or pleasure doing things: (Responses: Worse, Better, the Same)." f Screen positive for anxiety was determined based on the GAD-2 g Anxiety due to COVID-19 was determined by asking: ""Because of the recent coronavirus outbreak (in the last two weeks), is your ability to control worrying or feeling nervous, anxious, or on edge: (Responses: Worse, Better, the Same)." h Food insecurity was determined by asking "Due to the coronavirus outbreak, have you been worried that your food may run out before you have a chance to buy more?" i Individuals were asked if they could not find help with an activity during the coronavirus pandemic only if they described an inability to independently do the activity.Accepted Article