Hearing and vision impairment and social isolation over 8 years in community-dwelling older adults

BACKGROUND

Little is known about the long-term impact of hearing and vision impairment on social isolation. This study quantifies the association between hearing, vision, and concurrent hearing and vision impairment (dual sensory impairment) and social isolation over 8 years among older adults.

METHODS

Data were from the National Health and Aging Trends Study (NHATS), a cohort study (2011 - 2019) of U.S. Medicare beneficiaries aged 65 years and older. Social isolation was measured by a binary indicator incorporating four domains: living arrangement, core discussion network size, religious attendance, and social participation. Hearing, vision, and dual sensory impairments were measured by self-report and modeled categorically (no impairment [ref.], hearing impairment only, vision impairment only, dual sensory impairment). Associations between sensory impairments and odds of social isolation over 8 years were assessed using multivariate generalized logistic mixed models and adjusted for demographic and health characteristics.

RESULTS

Among 5,552 participants, 18.9% self-reported hearing impairment, 4.8% self-reported vision impairment, and 2.3% self-reported dual sensory impairment. Over 8 years, hearing impairment only was associated with 28% greater odds of social isolation. Participants with hearing impairment only were more likely to live alone and have limited social participation.

CONCLUSION

Greater clinical awareness of hearing impairment as a risk factor for social isolation can increase opportunities to identify and aid older adults who may benefit from resources and interventions to increase social connection and mitigate social isolation.

Examining the Association of Social Isolation and Smoking in Older Adults

Background: Tobacco use remains a leading cause of preventable death among older adults, but few studies have examined social isolation as a risk factor for smoking in US. older adults. Methods: Using National Health and Aging Trends Study (NHATS) data, we conducted multivariate analyses of smoking in a sample of 8136 adults ages 65 and older. Results: Social isolation and severe isolation were associated with higher odds of smoking (OR: 2.48 and 5.48, p = 0.002 and p < 0.001). Individuals with mild (OR: 1.46, p = 0.006), moderate (OR: 1.80, p = 0.001), or severe (OR: 3.05, p = 0.001) symptoms of depression/anxiety also had higher odds of smoking. Conclusions: Social isolation is a significant risk factor for smoking in US older adults. Further research is needed to support the development of interventions to reduce social isolation and smoking behavior in older adults.

Association of Social Isolation With Hospitalization and Nursing Home Entry Among Community-Dwelling Older Adults

Importance

Social isolation is associated with adverse health outcomes, yet its implications for hospitalization and nursing home entry are not well understood.

Objective

To evaluate whether higher levels of social isolation are associated with overnight hospitalization, skilled nursing facility stays, and nursing home placement among a nationally representative sample of community-dwelling older adults after adjusting for key health and social characteristics, including loneliness and depressive symptoms.

Design, Setting, and Participants

This observational cohort study included 7 waves of longitudinal panel data from the Health and Retirement Study, with community-dwelling adults aged 65 years or older interviewed between March 1, 2006, and June 30, 2018 (11 517 respondents; 21 294 person-years). Data were analyzed from May 25, 2022, to May 4, 2023.

Main Outcomes and Measures

Social isolation was measured with a multidomain 6-item scale (range, 0-6, in which a higher score indicates greater isolation). Multivariate logistic regressions were performed on survey-weighted data to produce national estimates for the odds of self-reported hospitalization, skilled nursing facility stays, and nursing home placement over time.

Results

A total of 57% of this study's 11 517 participants were female, 43% were male, 8.4% were Black, 6.7% were Hispanic or Latino, 88.1% were White, 3.5% were other ("other" includes American Indian or Alaska Native, Asian or Pacific Islander, and other race, which has no further breakdown available because this variable was obtained directly from the Health and Retirement Study), and 58.2% were aged 65 to 74 years. Approximately 15% of community-dwelling older adults in the US experienced social isolation. Higher social isolation scores were significantly associated with increased odds of nursing home placement (odds ratio, 2.01; 95% CI, 1.21-3.32) and skilled nursing facility stays (odds ratio, 1.16; 95% CI, 1.06-1.28) during 2 years. With each point increase in an individual's social isolation score, the estimated probability of nursing home placement or a skilled nursing facility stay increased by 0.5 and 0.4 percentage points, respectively, during 2 years. Higher levels of social isolation were not associated with 2-year hospitalization rates.

Conclusions and Relevance

This cohort study found that social isolation was a significant risk factor for nursing home use among older adults. Efforts to deter or delay nursing home entry should seek to enhance social contact at home or in community settings. The design and assessment of interventions that optimize the social connections of older adults have the potential to improve their health trajectories and outcomes.

The state of loneliness and social isolation research: current knowledge and future directions

In this editorial, we consider the current state of loneliness and social isolation research around the world, including knowledge gaps in the empirical literature.

Impact of technology on social isolation: Longitudinal analysis from the National Health Aging Trends Study

BACKGROUND

Social isolation is a key public health concern and has been associated with numerous negative health consequences. Technology is increasingly thought of as a solution to address social isolation. This study examines the longitudinal association between the access and use of technology and social isolation in older adults 65 and older, living in the United States.

METHODS

This observational cohort study included community-dwelling older adults (N = 6704) who participated in the National Health and Aging Trends Study. Regression analyses were conducted using data from 2015 to 2019. Information about technology access and use was ascertained using self-reported questionnaires. The primary outcome was the risk of social isolation.

RESULTS

At baseline, the majority of older adults that were not socially isolated had a working cell phone (88%) or computer (71%) and used email or text messaging (56%). Older adults that had access to (cell phone- incidence rate ratio [IRR] 0.62 [95% CI 0.48-0.81]; computer- IRR 0.63 [95% CI 0.51-0.78]), and used technology (email or text messaging- IRR 0.64 [95% CI 0.51-0.80]) in the year prior had a lower risk of social isolation than older adults who reported they did not access or use technology. Additionally, over four years, older adults who reported that they had access to a computer had a lower risk (0.69 [0.57, 0.84]) for social isolation than their counterparts.

CONCLUSION

In this cohort study, technology access was associated with a lower risk for social isolation among community-dwelling older adults. These findings suggest that technology has an important role in approaches that seek to prevent social isolation among older adults.

Prevalence of Mental Health and Social Connection among Patients Seeking Tobacco Dependence Management: A Pilot Study

INTRODUCTION

with regards to tobacco dependence management, there are certain barriers to successful smoking cessation for patients, such as untreated anxiety and depression. Complicating the impact of mental health morbidities on tobacco dependence may be the significant portion of patients whose mental health issues and limited social connections are undiagnosed and unaddressed. We hypothesize that patients with no prior mental health diagnoses who are treated for tobacco dependence have high rates of undiagnosed mental health morbidities.

METHODS

patients were recruited from a tobacco treatment clinic in 2021. Every patient who came for an inaugural visit without a prior diagnosis of mental health disease was screened for depression, anxiety, social isolation and loneliness. Sociodemographic variables were collected.

RESULTS

over a 12-month period, 114 patients were seen at the tobacco treatment clinic. Of these 114 patients, 77 (67.5%) did not have a prior diagnosis of a mental health disease. The mean age was 54.3 ± 11.2 years, 52 (67.5%) were females, and 64 (83.1%) were Black/African American. The mean age of starting smoking was 19.3 ± 5.2 years, and 43 (55.8%) had never attempted to quit smoking in the past. With regards to mental health screening, 32 (41.6%) patients had a score of 9 or greater on the Patient Health Questionnaire (PHQ) 9, 59 (76.6%) had a score of 7 or greater on the Generalized Anxiety Disorder (GAD) 7, 67 (87.0%) were identified with social isolation and 70 (90.1%) for loneliness on screening.

CONCLUSION

there was a high prevalence of undiagnosed mental health morbidities and social disconnection in patients who were actively smoking and were struggling to achieve smoking cessation. While a larger scale study is necessary to reaffirm these results, screening for mental health morbidities and social disconnection may be warranted in order to provide effective tobacco dependence management.

Social isolation, homebound status, and race among older adults: Findings from the National Health and Aging Trends Study (2011-2019)

BACKGROUND

Multiple factors may influence the risk of being homebound, including social isolation and race. This study examines the relationship between social isolation and homebound status by race over 9 years in a sample of adults.

METHODS

Utilizing a representative sample of 7788 Medicare beneficiaries aged 65+ from 2011-2019, we assessed the odds of becoming homebound by social isolation. We defined social isolation as the objective lack of contact with others. We defined severe social isolation as scoring a 0 or 1 on a social connection scale from 0 to 4. Homebound status was defined as never leaving home or only leaving home with difficulty. Utilizing a multivariate Cox proportional hazards model adjusting for age, gender, marital status, income, and education, we examined the association between social isolation at baseline and becoming homebound during the study in those who were not initially homebound.

RESULTS

Older adults in this study were on average 78 years old. Overall, most were white (69%), female (56.3%), and married (57.8%) and reported that they had a college education or higher (43.9%). Also, at baseline, approximately 25% of study participants were socially isolated, 21% were homebound, and 6.3% were homebound and socially isolated or severely socially isolated. Homebound status at baseline varied by race: Black, 23.9% and white, 16.6% (p < 0.0001). After 9 years, socially isolated black (hazard risk ratio, HRR 1.35, 95% confidence interval CI [1.05,1.73], p < 0.05) and white (HRR 1.25, 95% CI [1.09,1.42], p < 0.01) older adults were at higher risk of becoming homebound.

CONCLUSION

Socially isolated black and white adults are more likely to be homebound at baseline and become homebound over time. Further research is needed to determine whether community-based strategies and policies that identify and address social isolation reduce homebound status among community-dwelling older adults.

The effect of COVID-19 pandemic-related financial challenges on mental health and well-being among U.S. older adults

Background

Despite profound financial challenges during the COVID‐19 pandemic, there is a gap in estimating their effects on mental health and well‐being among older adults.

Methods

The National Health and Aging Trends Study is an ongoing nationally representative cohort study of US older adults. Outcomes included mental health related to COVID‐19 (scores averaged across eight items ranging from one to four), sleep quality during COVID‐19, loneliness during COVID‐19, having time to yourself during COVID‐19, and hopefulness during COVID‐19. Exposures included income decline during COVID‐19 and financial difficulty due to COVID‐19. Propensity score weighting produced covariate balance for demographic, socioeconomic, household, health, and well‐being characteristics that preceded the pandemic to estimate the average treatment effect. Sampling weights accounted for study design and non‐response.

Results

In weighted and adjusted analyses (n = 3257), both income decline during COVID‐19 and financial difficulty due to COVID‐19 were associated with poorer mental health related to COVID‐19 (b = −0.159, p < 0.001 and b = −0.381, p < 0.001, respectively), poorer quality sleep (OR = 0.63, 95% CI: 0.46, 0.86 and OR = 0.42, 95% CI: 0.30, 0.58, respectively), more loneliness (OR = 1.53, 95% CI: 1.16, 2.02 and OR = 2.72, 95% CI: 1.96, 3.77, respectively), and less time to yourself (OR = 0.54, 95% CI: 0.40, 0.72 and OR = 0.37, 95% CI: 0.27, 0.51, respectively) during COVID‐19.

Conclusions

Pandemic‐related financial challenges are associated with worse mental health and well‐being regardless of pre‐pandemic characteristics, suggesting that they are distinct social determinants of health for older adults. Timely intervention is needed to support older adults experiencing pandemic‐related financial challenges.

Second Victims: Aftermath of Gun Violence and Faith-Based Responses

In the aftermath of gun violence, those impacted and left to mourn are regarded as second victims. These individuals experience and are often burdened by mental and physical sequelae while attempting to cope with the trauma. The objective of this report is to highlight the support and resources of congregational and faith-based leaders available in an urban city with a high prevalence of gun violence. We describe information and insights presented during a symposium uniting medical-religious partners to discuss actions and programs to address trauma from gun violence. Faith-based persons from various Abrahamic religions, ranging from imams to reverends to hospital-based chaplains, discussed key strategies to allocate resources to second victims. These strategies included religious rituals meant to cope with trauma, memorials, and providing insight into resiliency for difficult times. Resources were identified for both within the hospital and community. Such medical-religious resources should be considered for future interventions which aim to attenuate the consequences of gun violence for second victims.

Functional Hearing Loss and Social Engagement Among Medicare Beneficiaries

OBJECTIVES

Hearing loss is common in older adults and limits communication. We investigated the independent association between functional hearing loss and social engagement in a nationally representative sample of older adults.

METHODS

Using data from the 2015 Medicare Current Beneficiaries Survey, we modeled the cross-sectional association between self-reported hearing ability and limitation in social activity over the past month using multivariable logistic regression.

RESULTS

The majority of the study population was female (54.8%) and non-Hispanic white (74.3%). Participants (40.4%) reported "a little trouble" hearing and 7.4% reported "a lot of trouble" hearing. Those who reported any trouble hearing had higher odds of limited social engagement in the past month. After adjustment for demographic, clinical, and functional covariates, those who reported "a lot of trouble" hearing had 37% higher odds of limited social activity in the past month compared to those with normal hearing.

DISCUSSION

These results suggest that hearing loss may be an important risk factor for limited social engagement and downstream negative health consequences, independent of other disability and health conditions.

Greater Subjective Well-Being Associated With Lower Inflammatory Proteins in an Older Adult Sample From the NHATS

Subjective well-being (SWB), comprised of cognitive and affective evaluations of life, is associated with better health outcomes and lower mortality, but mechanisms are poorly understood. We examine the associations between SWB and its subscales with two biomarkers: Interleukin-6 (IL-6) and C-Reactive Protein (CRP), both common inflammatory indicators associated with mortality and increased cardiovascular disease. Dried blood spot data collected from 4,648 older adults NHATS participants in 2017 was used. After adjustment for age, sex, race/ethnicity, education, tobacco, body mass index and chronic disease, we found greater SWB and greater scores on subscales including positive affect, self-realization and personal mastery were all significantly associated with decreased IL-6 and CRP. Conversely, increases in negative affect was significantly associated with increased IL-6 and CRP values. This study adds evidence of a potential mechanistic mind-body connection pathway.

Getting Under the Skin: The Association Between Social Isolation and Inflammatory Markers

Social isolation is a risk factor for morbidity and mortality comparable to well-established risk factors including smoking, hypertension, and a sedentary lifestyle. Specific mechanisms that connect social isolation to important health outcomes remain unclear. We examine the cross-sectional relationship between social isolation and two biological markers: Interleukin-6 (IL-6) and C-Reactive Protein (CRP) in a nationally representative population of community dwelling older adults (IL-6: n=4336, CRP: n=4178) from the National Health Aging Trends Study in 2017. Adjusting for age, gender, race, income, tobacco use, body mass index, and multiple chronic conditions, we found that social isolation compared to no social isolation was associated with higher levels of IL-6 (p = 0.043) and CRP (p = 0.038). These results suggest that investigating inflammatory pathways between social isolation and morbidity and mortality is important.

Household Accessibility and Residential Relocation in Older Adults

OBJECTIVES

It is unclear how home environmental factors influence relocation decisions. We examined whether indoor accessibility, entrance accessibility, bathroom safety features, housing type, and housing condition were associated with relocations either within the community or to residential care facilities.

METHODS

We used prospective data over 4 years from the nationally representative National Health and Aging Trends Study in the United States of Medicare beneficiaries 65 years and older living in the community (N = 7,197). We used multinomial regression analysis with survey weights.

RESULTS

Over the 4 years, 8.2% of the population moved within the community, and 3.9% moved to residential care facilities. After adjusting for demographics and health factors, poor indoor accessibility was found to be associated with moves within the community but not to residential care facilities. No additional home environmental factors were associated with relocation.

DISCUSSION

One-floor dwellings, access to a lift, or having a kitchen, bedroom, and bathroom on the same floor may help older adults age in place. Understanding which modifiable home environmental factors trigger late-life relocation, and to where, has practical implications for developing policies and programs to help older adults age in their place of choice.

The Epidemiology of Social Isolation: National Health and Aging Trends Study

OBJECTIVES

Social isolation among older adults is an important but under-recognized risk for poor health outcomes. Methods are needed to identify subgroups of older adults at risk for social isolation.

METHODS

We constructed a typology of social isolation using data from the National Health and Aging Trends Study (NHATS) and estimated the prevalence and correlates of social isolation among community-dwelling older adults. The typology was formed from four domains: living arrangement, core discussion network size, religious attendance, and social participation.

RESULTS

In 2011, 24% of self-responding, community-dwelling older adults (65+ years), approximately 7.7 million people, were characterized as socially isolated, including 1.3 million (4%) who were characterized as severely socially isolated. Multinomial multivariable logistic regression indicated that being unmarried, male, having low education, and low income were all independently associated with social isolation. Black and Hispanic older adults had lower odds of social isolation compared with white older adults, after adjusting for covariates.

DISCUSSION

Social isolation is an important and potentially modifiable risk that affects a significant proportion of the older adult population.

Longitudinal and reciprocal associations between financial strain, home characteristics and mobility in the National Health and Aging Trends Study

BACKGROUND

Older adults need homes that suit their physical capacity. Financial strain may limit home repairs and modifications and prompt relocations; repairing, relocating or modifying may increase financial strain. Likewise, reciprocal relationships may exist between financial strain and home characteristics and mobility; financial strain and home characteristics may influence mobility and mobility declines may increase financial strain, limit home repairs and modifications and prompt relocations. We test cross-lagged associations between financial strain, home disorder, relocation, home modifications and mobility.

METHODS

In the National Health and Aging Trends Study, ability to complete a walking test, speed among those able to complete, financial strain, home disorder, relocating and modifying the home were recorded annually for 3 years (2012-2014). Structural equation models separately examined ability to walk and walking speed among those able, accounting for sociodemographic characteristics, social support, health prior health characteristics and autoregressive effects. Sampling weights accounted for the complex survey design and non-response over time.

RESULTS

In both models (n = 3234 and n = 2467), financial strain predicted greater home disorder and vice versa, but cross-lagged associations were not found with relocating and modifications. Greater home disorder predicted lower odds of ability to walk and slower speed among those able. Financial strain and home modifications predicted lower odds of ability to walk. Also, faster walking speed predicted lower odds of subsequent financial strain and lower subsequent home disorder scores and ability to walk predicted less subsequent home disorder and lower odds of relocating.

CONCLUSIONS

Home disorder links financial strain with reduced mobility in a national sample of U.S. older adults. Cross-lagged associations between financial strain and home disorder and between home disorder and mobility suggest reciprocal effects that may accumulate over time. Also, financial strain, reduced mobility, relocations and modifications predicted greater home disorder. Together, these results highlight home disorder as a social determinant of mobility for older adults. Greater attention should be given to repairing and modifying home environments and supporting stable housing for older adults with financial strain.

Longitudinal and reciprocal associations between financial strain, home characteristics and mobility in the National Health and Aging Trends Study

Background

Older adults need homes that suit their physical capacity. Financial strain may limit home repairs and modifications and prompt relocations; repairing, relocating or modifying may increase financial strain. Likewise, reciprocal relationships may exist between financial strain and home characteristics and mobility; financial strain and home characteristics may influence mobility and mobility declines may increase financial strain, limit home repairs and modifications and prompt relocations. We test cross-lagged associations between financial strain, home disorder, relocation, home modifications and mobility.

Methods

In the National Health and Aging Trends Study, ability to complete a walking test, speed among those able to complete, financial strain, home disorder, relocating and modifying the home were recorded annually for 3 years (2012–2014). Structural equation models separately examined ability to walk and walking speed among those able, accounting for sociodemographic characteristics, social support, health prior health characteristics and autoregressive effects. Sampling weights accounted for the complex survey design and non-response over time.

Results

In both models (n = 3234 and n = 2467), financial strain predicted greater home disorder and vice versa, but cross-lagged associations were not found with relocating and modifications. Greater home disorder predicted lower odds of ability to walk and slower speed among those able. Financial strain and home modifications predicted lower odds of ability to walk. Also, faster walking speed predicted lower odds of subsequent financial strain and lower subsequent home disorder scores and ability to walk predicted less subsequent home disorder and lower odds of relocating.

Conclusions

Home disorder links financial strain with reduced mobility in a national sample of U.S. older adults. Cross-lagged associations between financial strain and home disorder and between home disorder and mobility suggest reciprocal effects that may accumulate over time. Also, financial strain, reduced mobility, relocations and modifications predicted greater home disorder. Together, these results highlight home disorder as a social determinant of mobility for older adults. Greater attention should be given to repairing and modifying home environments and supporting stable housing for older adults with financial strain.

A Perspective on the Baltimore Freddie Gray Riots: Turning Tragedy Into Civic Engagement and Culture Change in an Academic Department of Medicine

PROBLEM

The Johns Hopkins University School of Medicine Department of Medicine (DOM) sought ways of enhancing community engagement after the death of Freddie Gray and consequent unrest in Baltimore City.

APPROACH

The DOM launched a five-part noon lecture series in May 2015-"Journeys in Medicine"-to facilitate discussion among DOM faculty, staff, trainees, and community residents regarding the city's unrest. This evolved into a department-wide civic engagement initiative in July 2016 to enhance employee and community engagement. The civic engagement committee is composed of two collaborative steering committees: Staff Engagement and Community Engagement.

OUTCOMES

The DOM has sponsored and/or participated in programs to address major concerns raised during the Journeys in Medicine series-improving the strained relationship between police and the community, mentoring young people, involving more DOM employees in community activities, sharing research results with the community, and addressing cultural differences to enhance relationships and communication. To enhance staff engagement, a Nursing Diversity Council, complementing the Faculty Diversity Council, has been established. DOM faculty and staff have participated in and championed several disease-focused physical activity endeavors (e.g., walks) that, collectively, have raised over $40,000. Community service projects include supporting registration and screenings at a local health fair, a professional clothing drive, and DOM Days of Service.

NEXT STEPS

The Johns Hopkins University School of Medicine DOM is developing an administrator leadership program and continuing to participate in meaningful activities, leading to tangible outcomes designed to strengthen connections to the surrounding neighborhood and enhance engagement among all DOM employees.

Perceived Social Isolation and Outcomes in Patients With Heart Failure

Background

Perceived social isolation has been shown to have a negative impact on health outcomes, particularly among older adults. However, these relationships have not been fully examined among patients with heart failure.

Methods and Results

Residents from 11 southeast Minnesota counties with a first‐ever International Classification of Diseases, Ninth Revision (ICD‐9) code 428 for heart failure between January 1, 2013, and March 31, 2015 (N=3867), were prospectively surveyed to measure perceived social isolation. A total of 2003 patients returned the survey (response rate, 52%); 1681 patients completed all questions and were retained for analysis. Among these patients (53% men; mean age, 73 years), ≈19% (n=312) had moderate perceived social isolation and 6% (n=108) had high perceived social isolation. After adjustment, patients reporting moderate perceived social isolation did not have an increased risk of death, hospitalizations, or emergency department visits compared with patients reporting low perceived social isolation; however, patients reporting high perceived social isolation had >3.5 times increased risk of death (hazard ratio, 3.74; 95% confidence interval [CI], 1.82–7.70), 68% increased risk of hospitalization (hazard ratio, 1.68; 95% CI, 1.18–2.39), and 57% increased risk of emergency department visits (hazard ratio, 1.57; 95% CI, 1.09–2.27). Compared with patients who self‐reported low perceived social isolation, patients reporting moderate perceived social isolation had a 16% increased risk of outpatient visits (rate ratio, 1.16; 95% CI, 1.03–1.31), whereas those reporting high perceived social isolation had a 26% increased risk (rate ratio, 1.26; 95% CI, 1.04–1.53).

Conclusions

In patients with heart failure, greater perceived social isolation is associated with an increased risk of death and healthcare use. Assessing perceived social isolation during the clinical encounter with a brief screening tool may help identify patients with heart failure at greater risk of poor outcomes.