January/February 2017 Issue

Aging & Isolation — Causes and Impacts
By Lauren Snedeker, LMSW
Social Work Today
Vol. 17 No. 1 P. 24

Many older adults experience aging as a positive time because they remain active and connected to others, but many other elders become disconnected from family, friends, and community. This article examines the causes and results of isolation and how social workers can help reduce its impact.

Older adults comprise the fastest growing segment of the population, with some 10,000 baby boomers turning 65 every day, a rate the U.S. Census Bureau estimates will continue until the year 2030. By 2020, it is estimated that approximately one in six Americans will be age 65 or older. As people are living longer and the number of older adults in America's population is increasing, the diversity of their needs and interests is also evolving. Psychologist Abraham Maslow, PhD, proposed that healthy human beings have a specific collection of needs arranged in a way according to function: physiological needs, safety, love and belonging, esteem, and self-actualization. From person to person, this hierarchy can and will shift. Shifts can be caused by age, values, environment, beliefs, and more.

Social workers are clinically trained to evaluate and triage clients' needs in efforts to provide adequate and efficient support. If some of the most basic needs go unmet, it can cause the entire pyramid to fall. And while the specific needs of the aging population continue to change, connectedness remains a core constant for maintaining an optimal quality of life. Yet too often, older adults experience loneliness and isolation. Understanding the causes of isolation can help position social workers to help mitigate feelings of loneliness and isolation in their clients and contribute to a much-needed societal change.

Potential Causes of Isolation
A variety of factors can contribute to isolation. An ecological approach is critical in understanding the complex and dynamic relationship between any aged people and their environment. Our bodies naturally experience changes that may cause our capabilities to shift. Aging can, at times, include some form of vision, hearing and/or muscle impairment—factors that can put an individual at greater risk for falls.

In the United States, emergency departments treat an older adult for a fall every 11 seconds (National Council on Aging, 2016). Further, some 27,000 older adults have died as a result of falls, equating to about 74 per day (Centers for Disease Control and Prevention, 2016). Because falls can cause serious injury and sometimes death, older adults may develop a fear of falling and seek to avoid falls. Sometimes the fear can be so pervasive that individuals may no longer wish to leave their home. This can compromise access to food, socializing with family and friends, attending medical appointments, picking up prescriptions, going to work or to volunteer, and other recreational activities that help alleviate stress and promote a positive quality of life. Practitioners must acknowledge this and help older adults address this fear through education and support, and by empowering them to take preventive measures, such as utilizing slip-proof footwear, and installing grab bars or other adaptive equipment in the home.

One's personal capabilities and physical status are not the only limiting factors contributing to isolation of the aging. Environment can also play a big role. Many community settings are not aging friendly. The vast majority of older adults prefer to age in place. In order to achieve this goal, every community—rural and metropolitan—will need to adapt. As reported by Partners for Livable Communities (2007), design that makes it difficult to walk may contribute to older adults' isolation and therefore may negatively impact quality of life. Additionally, a lack of affordable and accessible housing may force older adults to transition to facility-based care. Following are some additional settings and causes of isolation.

Geography and Accessibility
Rural or nonmetropolitan areas in the United States have been found to have a higher amount of older adult residents in comparison with more metropolitan areas. Twenty percent of older adults in America live in nonmetro areas (Hartman & Weierbach, 2013). Research has shown that rural areas have higher incidences of poverty and less access to community resources, such as activity centers, grocery stores, pharmacies, and town halls. For older adults in rural areas, lack of access to these services is often the greatest challenge faced. Without them, it is difficult to continue to live independently and meaningfully. Lack of transportation or professionals to staff such sites as activities or senior centers can contribute to this challenge. But regardless of whether isolation is imposed by one's environment or chosen by the individual, its effects are of significant concern for the growing aging population and are in need of more attention.

There may be an assumption that metropolitan areas, which offer public transportation, are more supportive to older adults However, what many do not realize is that the physical problems that can make driving difficult for older individuals can also make using public transportation difficult. For example, individuals with physical disabilities may have trouble crossing wide streets to reach bus stops, or may have difficulty climbing the high stairs of a bus or train. Or, perhaps, an individual has always driven but now has to rely on public transit and needs assistance with navigating the route or timetable. Customer service may not always be willing or able to respond to those needs (Burkhardt, McGavok, & Nelson, 2002).

There are pros and cons to rural and metropolitan areas. Despite the challenges transit systems may face in terms of functionality for an aging population, they nonetheless outnumber what is available in rural areas. It is no surprise that rural residents endure longer travel times to get to the closest shopping areas and other resources. For people who no longer are able to drive and have no nearby family, the chances of isolation and the many health outcomes it brings can increase. In 2013, the National Rural Health Association produced a policy brief stating concerns of rural elder health. Within the brief, Firestine (2011) states that according to the Department of Transportation Bureau of Statistics, "between 2005 and 2010, 3.5 million rural residents lost access to scheduled intercity transportation, increasing the percent of rural residents without access to intercity transportation from seven to 11 percent." Not only does the lack of transportation for rural older adults impact their ability to connect with family and friends, it also impacts their ability to get food and medicine and to see medical providers. Budget cuts are often the reason public programs, such as transportation for elders, get cut, and such cuts make this vulnerable population even more so.

Fortunately, the recent reauthorization of the Older Americans Act has helped restore financial security to vital programs and services, including transportation, meals on wheels and nutrition, in-home services, legal programs, and caregiver support. One in five older adults currently receives services from Older Americans Act programs, which help them maintain their independence.

Further, research describes how threats of security, including elder abuse, have caused many older adults to stay home instead of venturing out for an activity. Unfortunately, as Gusmano and Rodwin (2010) indicated in their research, it has historically taken crisis to understand the significant lack of attention older adults receive in relation to public safety and security. Furthermore, while many may presume a city would offer more access to services, it may, in fact, contribute to greater isolation of the aging due to congestion, pollution, crime rates, and unaffordable housing.

Security, transportation, accessibility, and functionality of a neighborhood all serve to contribute to the isolation of older adults. While there are efforts being made to make communities more aging friendly, considerable progress must be made to meet the needs of this growing population.

Stigma and Stereotypes
Stigma also contributes to both voluntary and involuntary isolation of the aging population. Many people make assumptions about the aging and focus on aging stereotypes of what an individual can't do, without knowing an individual's capabilities. Statements such as, "You're too old for that," are uttered so often that perhaps they are perpetuating a self-fulfilling prophecy. Ageism long has been present in society and is a form of discrimination. It is important not only to do away with these stereotypes but also to avoid paternalistic tendencies. Older adults are not children and should not be treated as such. Social workers have an opportunity to promote the integrity of America's older adult population so that they feel confident in today's society and continue to lead purposeful lives.

Milestone Events
Retirement for many older adults can symbolize a significant life transition. People may have different attitudes toward this new stage of life based on their circumstances. Some look forward to traveling and exploring other activities, some may be wondering what they will do to occupy their time, and still others may be forced to retire due to age. Retirement may impose pressure to develop a new plan—perhaps one that is different from what the person originally envisioned. When working with any aged person, it is important to acknowledge that often one's profession is a crucial part of his or her identity. Retirement can sometimes be a shock to one's sense of self, as it may bring feelings of losing one's identity. Undoubtedly, retirement can cause a decrease in the amount of social contact individual experiences throughout the day. Many friendships or close relationships with former colleagues can be difficult to maintain after leaving the workplace and not seeing one another each day. Retirement not only impacts social connectedness but also can cause a shift in income and social role (Kaplan & Berkman, 2016). For some, retirement can be symbolic of an end. Even the word "retire" is defined as withdrawing from work at a certain age. While this process can represent a positive change, it deserves exploration and acknowledgment in clinical work with older adults in order to understand the intricacies of this population and its needs.

As people are living longer, they are now available to experience milestone events and, specifically, a new chapter of life that previous generations had not. AARP reports that 45% of people older than 65 are divorced, separated, or widowed. It is certainly possible for individuals who are living longer to outlive their children, spouses, and other members of their family and for relationships and status to change. Additionally, as societal norms continue to ebb and flow, it is possible for individuals to live longer as childless and spouseless by choice or not. In fact, research being conducted by Maria T. Carney, MD, chief of geriatrics and palliative medicine at Northwell Health in New York, suggests that nearly one-quarter of Americans older than age 65 may become physically or socially isolated and lack someone, like a family member, to care for them, according to a 2015 article in ScienceDaily. Because of this, it is and will be possible for an older adult to live longer than members of his or her support team, and to live longer acting as their sole support system.

The likelihood of living alone increases with age. According to the Institute on Aging (2010), nearly one-third of older adults in America lives alone, outside of a nursing home or hospital. This number is projected to rise in line with the growing efforts of aging in place programs and initiatives. Living alone does not necessarily equate to feeling lonely or being isolated; however, it can increase the odds. As Carney suggests, because so much of caregiving and support at this time is from family, people without such support may be particularly vulnerable, and it is important to recognize this and learn about what can help.

Potential Impacts of Isolation
Isolation of the aging population can be a result of a variety of complex factors. In addition to understanding why this may happen, it is also important to understand that this an emerging public health issue.

A study of social isolation and loneliness experienced by adults aged 52 and older found that both factors led to a higher risk of mortality (Steptoe, Shankar, Demakakos, & Wardle, 2013). This could be a result of limited contact, feeling uncared for or forgotten, or having little to no available resources. In 2009, research from the National Social Life, Health and Aging Project found that regardless of the facts related to an older adult's status of isolation, those who felt lonely and isolated were more likely to report having poor physical and mental health (Cornwell & Waite, 2009). In addition to emotional health, brain health and wellness are vital parts of successful aging, and a lack of social engagement and activity has been linked to poor cognitive performance (Cacioppo & Hawkley, 2009).

Many perceive that the challenges that impact the lives of young adults do not impact those of the older adults. For example, alcohol and drug misuse is often overlooked in this population; however, the signs are clear. Depression, a condition that can contribute to young adults' misuse of substances, is also a factor for many older adults. According to the National Council on Alcoholism and Drug Dependence, Inc. (2015), widowers older than age 75 have the highest rate of alcoholism in the United States. Just as younger adults may turn to alcohol and drugs as a method for coping, so may older adults and, too often, they are the individuals who are underscreened, overlooked, and misdiagnosed.

Without a more robust workforce to address and incorporate new interventions to help reduce incidences of isolation, more of America's population will be vulnerable to the potentially compromised quality of life that isolation brings.

What Can We Do?
Society can no longer afford to treat the aging population as invisible. Population health is a significant determinant of success and because individuals are living longer, the health of older adults is finally becoming a factor. Unfortunately, the lack of professionals working with the aging as well as being educated about their needs is another issue that must be addressed.

NASW estimates that up to 70,000 geriatric social workers will be needed to help address the needs of the growing aging population (Pace, 2014). According to the American Geriatrics Society's "Projected Future Need for Geriatricians," there were only 7,029 certified geriatricians practicing throughout the United States in 2009—roughly one-half the number currently needed.

An increase in aging education is also warranted in other disciplines. For example, per a 2008 report from the Institute of Medicine, fewer than one-half of pharmacy schools in the United States offer a course in geriatrics despite the fact that per capita prescription drug use by people 65 and older is triple that of younger individuals.

The aging population's growth is an opportunity not only for more social workers, nurses, and medical providers to offer their clinical services but also for individuals in different professions and from all over the country to come forward and contribute to a positive and healthy societal change. It is an opportunity to address an emerging public health issue and to ensure that all individuals feel valued and connected at every stage of their lives.

— Lauren Snedeker, LMSW, is with the Alzheimer's Foundation of America.

References
Burkhardt, J. E., McGavock, A. T., Nelson, C. A., & Mitchell, C. B. G. (2002). Improving public transit options for older persons. Federal Transit Administration, Transit Cooperative Research Program, Report 82. Retrieved from http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rpt_82v2a.pdf.

Cacioppo, J. T., & Hawkley, L. C. (2009). Perceived social isolation and cognition. Trends in Cognitive Sciences, 13(10), 447-454.

Centers for Disease Control and Prevention. (2016). Older adults fall prevention. Retrieved from http://www.cdc.gov/media/dpk/healthy-living/injury-falls-older-adults/older-adult-falls.html.

Cornwell, E. Y. & Waite, L. J. (2009). Social disconnectedness, perceived isolation, and health among older adults. Journal of Health and Social Behavior, 50(1), 31-48.

Firestine, T. ( 2011). The U.S. rural population and scheduled intercity transportation in 2010: A five-year decline in transportation access. Retrieved from https://www.rita.dot.gov/bts/sites/rita.dot.gov.bts/files/publications/
scheduled_intercity_transportation_and_the_us_rural_population/2010/pdf/entire.pdf.

Gusmano, M. K., & Rodwin, V. G. (2010). Urban aging, social isolation and emergency preparedness. Global Ageing, 6(2), 39-50.

Hartman, R. M., & Weierbach, F. M. (2013). National Rural Health Association policy brief: Elder health in rural America. Retrieved from https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/
ElderHealthinRuralAmericaFeb2013.pdf.aspx?lang=en-US.

Institute on Aging (2010). Information on senior citizens living in America. Retrieved from http://www.ioaging.org/aging-in-america.

Kaplan, D. B., & Berkman, B. J. (2016). Effects of Life Transitions on the Elderly.
Retrieved from http://www.merckmanuals.com/home/older-people's-health-issues/
social-issues-affecting-older-people/effects-of-life-transitions-on-older-people.

National Council on Aging. 2016. Falls prevention: Fact sheet. Retrieved from https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/.

National Council on Alcoholism and Drug Dependence, Inc. (2015). Alcohol, drug dependence and seniors. Retrieved from https://www.ncadd.org/about-addiction/seniors/alcohol-drug-dependence-and-seniors.

Pace, P. P. (2014). Need for geriatric social work grows. Retrieved from http://www.socialworkers.org/pubs/news/2014/02/geriatric-social-work.asp.

Partners for Livable Communities & The National Association of Area Agencies on Aging. (2007). A blueprint for action: Developing a livable community for all ages. Retrieved from http://livable.org/storage/documents/reports/AIP/blueprint4actionsinglepages.pdf.

Steptoe, A., Shankar, A., Demakakos, P., & Wardle, J. (2013). Social isolation, loneliness, and all-cause mortality in older men and women. Proceedings of the National Academy of Sciences of the United States of America,110(15), 5797-5801.