Age and Social Isolation

In older populations, the term social isolation refers to a lack of companionship, health care, and daily activities. For most of the aging population, social isolation is not an issue. Social isolation tends to occur among a minority of single women, aged 80 years old or older, whose yearly income level places them below the poverty line. Research noted here illustrates that social isolation in the elderly is correlated with depression, anxiety, and decreased longevity. Various sociological theories are discussed, as are specific examples of isolation. In addition, federal nutrition programs are also discussed.

Keywords: Fitness and Arthritis in Seniors Trial (FAST); General Social Survey (GSS); Reciprocity (Theory of); Social Contract Theory; Social Integration; Social Isolation; Social Relations; Social Support; Substitution Theory; Differential Primary-group Theory

Age & Social Isolation

Overview

Most people have heard that it is possible to feel lonely when in the company of others. Similarly, it is possible to feel content when completely alone; much of that contentment, though, is based on choice, as one can usually choose to be without company. However, choosing to be alone is very different from being isolated from opportunities to socialize. Additionally, when socialization means talking on the telephone, experiencing companionship, receiving formal or informal health care, or being transported to an appointment, it can seem like a necessity rather than an option. For most of the aging population, social isolation is not an issue. For others, however, social isolation can cause inconvenience. For example, an elderly person might find themselves unable to get to the grocery store when they run out of food. Being isolated and older can result in increased anxiety and depression, and a decrease in longevity.

According to the Administration of Aging’s Profile of Older Americans: 2012 there are more than 41.4 million people aged 65 or older in the United States. Approximately 28 percent of those people live alone. “For all older persons reporting income in 2011 (40.2 million), 17.8% reported less than $10,000. About 40% reported $25,000 or more. [Furthermore, approximately] 3.6 million elderly persons (8.7%) were below the poverty level in 2011." The profile also notes that almost three-quarters (72%) of the male population over 65 years old are married, whereas less than half of the women (45%) in the same age group are married. The people most negatively affected by social isolation are those over 65 who are single females, living alone, and who report an income below the poverty level.

Personal Interaction

According to Guyatt, Feeny, and Patrick (1991), health-related quality of life (HRQL) is defined as a "patient-centered assessment of overall health and wellbeing" (as cited in Sherman et al, 2006, p. 464). Naughton and Shumaker (1995) note that HRQL "is a multidimensional construct that assesses both physical (e.g., pain, disability, health perceptions) and psychosocial dimensions (e.g., mood, life satisfaction, social roles)" (as cited in Sherman, et al., 2006, p. 464). In trying to measure HRQL, Sherman, et al. conducted a study called Fitness and Arthritis in Seniors Trial (FAST), which uses physical exercise and various social measures to determine a person's HRQL. Sherman and his colleagues assessed data at the beginning of the trial (baseline) and in a follow-up study 18 months after the initial FAST was completed (p. 464).

During the FAST study, a sequence of "resistance training and aerobic exercise interventions" was completed by 439 participants ranging in age from 59 to 87 (p. 467-468). No social support intervention was included during the 18-months of the FAST trial, and participant functioning (at baseline and at follow-up) was measured based on a combination of FAST results and the following constructs (p. 467).

• Social support (the perception of having supportive relationships)

• Social integration (the quantity [rather than the quality] of social interactions)

• Observed physical functioning

• General health

• Depressive symptomatology

• Life satisfaction

• Social functioning (Sherman et al., 2006, pp. 468-469)

FAST results show a correlation between social support (the perception of having adequate social interactions) and enhanced physical functioning—both at the baseline trial and at the 18-month follow-up (Sherman et al., p. 470). Indeed, simply thinking that one has supportive relationships can be beneficial to one's health.

In addition to these findings, baseline social support scores were associated with better baseline functioning in all measured areas of HRQL. At the end of the FAST trial, baseline perceived support significantly predicted psychosocial functioning, but was not predictive ofperceived health or observed physical functioning measures (Sherman et al., pp. 474-475).

What is most significant to Sherman and his colleagues is that "social support remained a significant predictor of improved psychosocial well-being after 18-months" (p. 475). However, while the psychosocial well-being of a person remains intact with the perception of social support, physical functioning does not, according to this data (p. 475). In actuality, these researchers note that a person's physical health and "exercise treatment are the best predictors of follow-up physical functioning" (p. 477). For psychosocial well-being to continue, a person in this age group needs social interaction; however, social support is not correlated to physical functioning.

Family Support

Much of a person's social interaction is of a personal nature and often includes one's immediate family. To determine the quality of care giving social support by family members, Sanders, Pittman & Montgomery (1986) conducted interviews with 91 caregivers of people 80 years of age and older. According to their data, approximately

Approximately 80% of the caregivers were offspring of the centenarians or spouses of the offspring, and their mean age was 70.2 years. Nearly 30% of the caregivers lived with a centenarian. Almost all of the caregivers lived within a 70-minute drive of the centenarian, 65% saw him or her daily and 90% rated the quality of their relationship as excellent or very good.[In addition], there was a statistically significant relationship between the amount of social and emotional support provided and relationship quality" (as cited in MacDonald, 2007, p. 113).

There appears to be a cyclical relationship between the provision of care and social support. Additionally, it is possible that quality care - and the sense of social support stemming from it - would equate to a lengthier life for the recipient of that care. Poon et al. (2000) conducted a longitudinal study to measure whether or not there was a correlation between social support and length of life (as cited in MacDonald, p. 121). Sampling over one-hundred thirty people ranging in age from 99 to 110 years old, Poon et al. noted that

Men, Whites, and those with greater physical ADL [activities of daily living] limitations had higher risks of mortality…At the level of simple, bivariate correlations, social support (talking on the phone, having someone to help, and having a caregiver) was related to survival length, as was family longevity (as cited in MacDonald, 2007, p. 121).

This is noteworthy information, as the provision of quality social support is not difficult to achieve between two people. Further, if members of a particular family tend to live longer than those in other families, it is not unrealistic to encourage efforts toward securing quality social relationships in an attempt to continue a pattern of longevity.

Mood & Social Interaction

Many people interact on a daily basis with people whom they do not like. It is important to consider whether or not negative interactions have an effect on mood. Rook (2001) investigated the social interactions of 129 people at least 70 years of age to find a link - if any - between types of exchanges (i.e.: positive versus negative) and the participants' mood. Rock's findings cover two separate collections of daily checklists from participants. At twelve-month intervals, participants completed daily checklists describing their social interactions for fourteen days. The results are summarized below:

Negative exchanges occurred less often but were related more consistently to daily mood than were positive exchanges [with both] positive and negative exchanges exhibiting distinctive associations with loneliness and depression. Positive exchanges also appeared to influence emotional health by offsetting the adverse effects of negative exchanges. [Furthermore, the] increase in day-to-day negative exchanges over a 1-year period was associated with an increase in depression (Rook, 2001, abstract).

In addition to this overall data, Rook noted some important information for future use. First, while more positive exchanges were correlated with participants feeling less lonely, the opposite was not striking in this study, as more negative exchanges were only minimally correlated to feeling lonely. Second, the lack of positive social exchanges had a stronger effect on feelings of loneliness than did an increase in negative exchanges. Clearly, being socially active is more important than having those social interactions be positive in nature when loneliness is at issue. Finally, an increase in negative exchanges does have a negative effect with regard to reported increases in depression and a lack of well-being (Rook, 2001). In 2013, the Journal of Poverty & Social Justice published a study (Lelkes, 2013) suggesting that regular internet use by the elderly can help reduce social isolation and its attendant challenges. An analysis of internet users among older age groups found that those who communicated with others by way of the internet reported being less lonely and isolated. According to the study, the relationship between internet use and a decrease in feelings of isolation was stronger among individuals with low education. The study did not examine the nature of the particular virtual interactions, who factor in specifics regarding who the internet-based conversation took place with. Nevertheless, as the study notes, the findings suggest that increased internet access may have positive social effects.

Further Insights

Social Isolation in Nursing Homes

What is important to consider is the status of social interaction from the perspective of participant inclination. Many of the participants in the Rook (2001) study noted talking on the telephone as being a social exchange. What happens, though, when the telephone rings and the person being called doesn't feel like talking? According to Carstensen & Fremouw (1988), when considering the population of elderly in nursing homes, social isolation can be related to feelings of anxiety or inadequacy just as much as it can be related to not having available social situations (p. 78).

The effects of social isolation on an elderly person's well-being have been studied for years.

Among the elderly, social isolation is related to entrance to nursing homes (Ross and Kedward, 1970), poor physical health (Blumenthal, 1979), psychological pathology (Roth & Kay, 1962; Saltzman, 1971), and suicide (Pelizza, 1979). Perhaps most compelling are recent epidemiological findings linking social isolation among the elderly to mortality (Berkman & Symer, 1979; Blazer, 1982) (as cited in Carstensen & Fremouw, 1988, p. 64).

Social isolation has been linked to three clinical disorders that Carstensen & Fremouw studied within a nursing home setting:

• Depression is usually demonstrated by behaviors like withdrawal and inactivity - both features of social isolation (p. 64).

• Social anxiety has been identified in situations in which high population density is a factor, like within nursing home settings (Freedman, 1972; Zlutnick & Altman, 1972, as cited in Cartensen & Fremouw, 1988, p. 64) or at rock concerts.

• Social competence (feeling confident in social situations) is also related to social isolation in that if a resident has a hearing loss, is introverted, or views himself as a social misfit, isolating himself socially may be a means of avoiding a stressful situation (pp. 64-65).

Over a three-month period, Carstensen & Fremouw (1988) gathered several pieces of data to interpret how social isolation may impact a nursing home resident's level of depression, social anxiety, and social competence. Fifty-one people were included in the study, with an average time in the nursing home being just less than two years. The average age of the participants was 75 for men and 80 for women (p. 66). Nine pieces of data were collected based on three observations per day per participant.

The study results are important as they represent data that can institute change in nursing home functioning. Surprisingly, when considering age, gender, length of residence in the facility, marital status, education and prior living situations, the length of residence in the facility was the only demographic variable that correlated with social activity self-ratings. The longer a participant had lived in the nursing home, the more socially active he described himself to be. Further, group participation was the only significant predictor of staff and self-ratings of social activity. Finally, "observed rates of social interactions and staff ratings of social activity were strongly related" (Cartensen & Fremouw, 1988, p. 76).

To summarize their findings, Cartensen & Fremouw (1988) note that, "individuals perceived by others as social isolates may not view themselves in the same way" (p. 76), and

… It may be that residents do not withdraw because they are depressed and lonely…they may withdraw because they are lacking privacy in the overcrowded environment of an institution (Lipman, 1968). [Further], the absence of a relationship between depression and social isolation also supports the contention that residents who are inactive are not passively withdrawing. More likely, they are actively avoiding interactions with others in the nursing home setting (pp.76-77).

It is important to note that this data alters the perception of the feeble senior citizen who is placed - not by choice - in a social situation while his room is being cleaned. On the contrary, if an activity is offered and Mrs. Jones does not want to take part, she can willingly choose to avoid the activity, even if by doing so she is labeled as antisocial by the staff or other residents. While there are people who are physically or cognitively unable to make choices about being socially isolated, understanding that when given a choice, a person can either opt in or opt out (in the best circumstance) could make the concept of residential living less frightening for some people. Also, the Rook's (2001) study noted that experiencing daily negative social exchanges for a period of a year was linked to an increase in depression. That there was no relationship between depression and social isolation in Cartensen and Fremouw's study may demonstrate that being isolated from social opportunities is more favorable than having repeated negative ones.

Lack of Transportation

While older people who reside in nursing homes can chose to avoid social situations, they cannot chose to avoid going to a doctor's appointment, nor can their nonresidential counterparts. Without access to transportation, however, planning activities like going to a doctor's appointment, buying groceries, meeting a friend, or attending a church service may revolve around someone else's schedule - someone who is willing to drive - and can be extremely stressful. These activities are taken for granted by most people because Americans are used to the independence of driving themselves wherever they want to go, whenever they want to go there. According to the Administration on Aging,

Transportation is the critical link that assures access to vital services such as health care and going to the grocery store. The availability of adequate transportation allows older Americans to live independently in their communities and helps prevent isolation and premature institutionalization. For many older people who do not drive an automobile, family and friends provide much of the transportation. However for others, community transportation is the only connection to the outside world (Administration on Aging, 2008).

Turcott (2006) conducted a study to determine whether or not access to transportation was an issue with regard to older people leaving their homes. Using data collected from the General Social Survey in 2005, Turcott notes that most seniors (65 years old and older) had a vehicle, had access to one, or had access to public transportation at the time of the study (p. 43). Specifically, Turcott separated the survey participants into four separate groups, those who

• Owned a vehicle and a valid driver's license (71% of seniors);

• Did not have a valid driver's license but did have access to a household vehicle as a passenger (9%);

• Did not have access to a vehicle but did have access to public transit (14%);

• Had access to neither a household vehicle nor public transit (6% of seniors) (p. 44).

After compiling the data collected from the 2005 survey, Turcott was able to estimate that without access to public transportation or a personal vehicle (either driving one or riding as a passenger in one), there was a 49% probability that respondents stayed home on the day referenced by the survey. Conversely, those older adults who had a car only had a 19% probability of being at home, and those who were passengers in cars had a 32% probability of being at home on the referenced day (p. 44). Turcott does point out that the people in the first category (without transportation or access to it) could have chosen to be at home for a variety of reasons not correlated with the lack of a vehicle (p. 45). However, it is predictable that many individuals in that cohort remained at home because transportation was not available to them.

The Elderly Without Families

Most of the transportation assistance an older person receives is provided by family members. What does a person do, though, who does not have family? Goldberg, Kantrow, Kremen & Lauter (1986) proposed that various sociological theories may outline how someone would replace nonexistent family members.

Goldberg and colleagues note that substitution theory holds that when closest kin are not available, individuals turn to more distant relatives for support. Differential primary-group theory suggests that because each of the major primary groups has a different structure, each is best suited to a different type of supportive. Single and childless persons may have relatives [siblings, for example] and friends who, although they can provide certain types of support and companionship, cannot substitute for spouses and children. [The theory of] reciprocity, or the mutual exchange of support, is [also] a factor that has been found to be conducive to security in old age (p. 104).

Goldberg et al. studied 52 single, childless women 65 years old or older who were living in non-institutional settings to determine if one, two, or three of these social theories hold true with regard to this population. The study participants had either always been childless or had lost a child prior to the child becoming an adult. In addition, they had either never been married or had been single (widowed or divorced) for at least three years prior to the study (p. 105). Happily, the findings are positive:

Siblings were next of kin for most of the women, and nearly three-fourths felt close to one or more siblings. Respondents, however, tended to have more close friends than they had relatives. There were no women in the sample who were without both a close friend and a close relative (p. 107).

With regard to the three social theories, Goldberg et al. (1986) state that substitution theory and differential primary-group theory were viably demonstrated. The theory of reciprocity was not:

There was qualified support for substitution theory. On the one hand, most women were able to meet important needs with the aid of primary-group rather than formal organization supports. On the other hand, the sample comprised mostly younger elderly women who were in good health and who had not tested their supports during illness. Friends were less likely than relatives to provide support for most tasks during illness. This finding is consonant with differential primary-group theory and research on the elderly. However, for some critical functions, friends usually do not substitute for relatives (p. 110).

A Sample Program for the Isolated Elderly

The Title III Elderly Nutrition Program (ENP), sponsored by the federal government Department of Health and Human Services provides nutrition services to many participants (aged 60 years old or older) in two different ways. Congregate programs provide services to those in residential units: nursing homes, assisted living facilities, or older population communities. Home-delivered programs focus assistance on older people with the most need but who are living somewhat independent lives. According to the ENP Evaluations Report, "In general, home-delivered participants are older, more functionally impaired, have lower incomes, get out of their homes less often, and have more need for a variety of in-home supportive services than do congregate participants."

Nutrition programs are not provided simply to ensure that vulnerable people eat, although that is a priority. The purpose of these programs is to make certain that as many older people as possible are aging in a healthy way. ENP assesses each participant to determine who might be at an increased nutritional risk. Also, from a social perspective, almost 90% of participants "have contact with the meal delivery person four or more times per week;25 percent report that the meal delivery person spends some time with them to talk and see how they are doing" (ENP Evaluations Report). Unfortunately for many older people, this is the only social contact they receive.

Viewpoints

A Social Contract of Many

Social contract theory posits that the members of a society work collaboratively to gain what cannot be gained without collaboration. This social framework holds that society members have equal ability and the result of collaboration yields a gain of 1+1=2 (Lloyd-Sherlock & Nussbaum, 2004, p. 279). It is clear from the research noted here that people who are 65 years old or older are not considered to have equal standing in this society. In addition, Lloyd-Sherlock & Nussbaum suggest that the social contract - which is unrealistic - be replaced by an approach of capability: each person within a society contributing what he is capable of contributing (p. 278). Using this approach, those with fewer resources are not isolated from those who have the most.

Each member of a society experiences phases of development in which he needs the assistance of others. At that phase, he cannot be considered on equal footing. However, he can be considered valuable in different ways. Babies, young children, and adolescents offer their care providers information on a regular basis. So too, do older populations provide valuable contributions to their caregivers, companions, and family members. It is important to note that while many people, especially women, seem to provide more can than is physically possible, at one time, they were provided for and at another time, they will be provided for again.

Negative Effects for a Small Population

The majority of senior citizens are not isolated. They are not poor, and they have access to transportation. If discussing the truly isolated older population means to discuss only a fraction of those aged 65 years and older, the discussion revolves around about ten percent of 37 million people . However, any fraction of 37 million people is an unacceptable number when the research noted here illustrates the negative affects of social isolation. According to the Anti-Agesim Task Force (2006), men fare better than women in old age with regard to being isolated.

The financial, political, and social toll that women bear due to inequality throughout their lives, coupled with the fact that women outlive men (in the United States, the average life expectancy of females is 5.3 years more than that of males), results in a significant number of older women who are isolated, vulnerable, and poor (p. 43).

On the other hand, it is important to note that social isolation needs to be separated from the act of knowingly and willingly avoiding social situations. For an introvert (who becomes anxious or feels incompetent), a social situation can be just as harmful to his mental and physical well-being as the lack of social interaction is for an extrovert. It is also important to note that as Baby Boomers age, the cohort of senior citizens changes. In the near future, older people will be better educated than their predecessors. They will drive much longer than older people did in years past, and some will have better incomes and more money saved than did retired populations of the past. The prospect is positive, but it is not all-inclusive.

Terms & Concepts

Differential Primary-Group Theory: Sociological theory suggesting that each individual may be good at offering a different supportive task to a relationship based on the structure of the group from which each individual comes.

Fitness and Arthritis in Seniors Trial (FAST): A two-part measure of physical functionality - uses resistance training and aerobic interventions.

Reciprocity (theory of): Sociological theory based on the premise that people establish and maintain support systems based on a mutual exchange of behavior.

Social Contract Theory: Sociological theory positing that members of a society cooperate with each other in order to gain what is lacking without that cooperation; maintains that members have equal contributions to offer.

Social Integration: The number of (rather than the quality of) formal and informal ties a person has.

Social Isolation: The state of being separated from social structures (family, friendships) or communities (churches, organizations).

Social Relations: A term used to describe the whole of social concepts, like social integration, social support, social network, and social strain.

Social Support: The perceived quality of (and) or satisfaction with, available social ties.

Substitution Theory: Sociological theory suggesting that if close family members are not available, an individual will turn to more distant relatives (sometimes even friends) for support

Bibliography

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Lelkes, O. (2013). Happier and less isolated: internet use in old age. Journal Of Poverty & Social Justice, 21, 33-46. Retrieved October 22, 2013 from EBSCO online database, SocINDEX with Full Text: http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=85909223&site=ehost-live

Lloyd-Sherlock, P. & Nussbaum, M. C. (2004). Chapter 13: Care, dependency and social justice: A challenge to conventional ideas of the social contract. Living Longer: Ageing, Development & Social Protection, p. 275-299. Retrieved May 30, 2008 from EBSCO online database, SocINDEX with Full Text: http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=31554917&site=ehost-live

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Nutrition: Evaluations Report (2008) Administration on Aging. U.S. Department of Health and Human Services. Retrieved May 28, 2008 from Administration on Aging website: http://www.aoa.dhhs.gov/prof/aoaprog/nutrition/program_eval/er_vol1ch2a1.asp

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