Isolation intensifies ICU impacts

Older adults who have little social contact may be at greater risk for disability and death after an ICU stay, a recent study found.

Researchers used data from the National Health and Aging Trends Study from May 2011 through November 2018 to examine post-ICU disability and mortality in community-dwelling older adults. Social isolation preceding ICU admission was assessed using a validated six-question measure of social connectedness with partners, families, and friends, plus participation in valued life activities. The results were published Sept. 7, 2021, by JAMA Internal Medicine.

There were 997 patients in the mortality cohort and 648 in the disability cohort, and the median patient age was 81 years. After adjustment for demographic characteristics and illness severity, each one-point increase in the social isolation score was associated with a 7% greater disability count and a 14% increase in mortality risk at one year. This means that the most socially isolated older adults were at risk of a 50% greater disability burden and a 119% higher risk of death in the year after an ICU stay.

“Our team became interested in exploring social isolation before COVID,” said senior author Lauren E. Ferrante, MD, MHS. “We started planning the analysis, and then three or four months later, COVID hit the United States. Social isolation suddenly became a much more relevant issue for everyone.”

Dr. Ferrante, who is an assistant professor of pulmonary medicine at Yale University School of Medicine in New Haven, Conn., and director of the operations core at the Yale Claude D. Pepper Older Americans Independence Center, recently spoke to ACP Hospitalist about the findings.

Q: What about your results surprised you?

A: In our study, the primary outcome was disability, and I hypothesized that social isolation would be associated with increased disability after an ICU stay. Our secondary outcome was mortality, and I was actually surprised and a little bit disheartened to see that there was such a striking association there. The social isolation scale goes from zero to six, and we saw an increase with each level. An increasing amount of social isolation was associated with increasing disability, and also an increasing risk of death, such that the most socially isolated older adults had a 119% increase in the hazard of death and a 50% higher disability burden.

Q: Biological impairments, challenges accessing needed health care services, and trouble navigating the health care system were cited in your study as factors that can affect ICU recovery. Could you tell which factor had the biggest role in the outcomes?

A: Our study wasn't designed to answer the question of mechanisms by which social isolation exerted its effects on disability and mortality, but we thought it was important to list three things in the context of other work that has been previously published on social isolation. One takeaway that's very relevant to the hospitalist community is that a hospitalization may represent the only opportunity to identify the most socially isolated older adults. Once someone survives their ICU stay, they go to the medical floor, and they're usually there for several days before they go home. That is the time when we need to identify who is socially isolated because that's our chance to intervene. Potential actions include arranging closer follow-up or services that might help them navigate follow-up and obtain the resources they need for recovery.

Q: Are there recommended screening tools for social isolation?

A: To my knowledge, no one has tested a screening tool, but the six-item scale that we used in our study is pretty straightforward and easy to use. If somebody could read and write, they could just circle the answers on a brief questionnaire or answer them verbally. I think probably it makes more sense to administer the tool on nursing intake to the floor (from the ICU) or when case management is going through discharge planning preparations with the patient. You want the whole team to know about it—physicians, nursing, case management—and you want to know that it's being done systematically. This type of tool could be built into the EHR, because the questions are very straightforward. For example, the first one is, “Are you currently married, living with a partner, separated, divorced, widowed, or never married?” Points are assigned based on the answer. Another one is, “In the past month, did you ever participate in clubs, classes, or other organized activities?” That's a yes or no.

Q: What action should be taken once a socially isolated patient is identified?

A: That's really where we all need to be thinking about next steps. Some of the interventions that have been studied are geriatric buddy programs and weekly phone calls. I do think for an ICU survivor, since they just survived such a serious “hit,” you would want to try to make targeted efforts to socially integrate them but also facilitate recovery from serious illness. Perhaps you would want to offer some of these other things that have been studied in the community, but also add in the more practical resources that can help them with recovery. From a hospitalist standpoint, I would suggest letting the case management team know and also thinking about this with regard to discharge disposition. For someone who's socially isolated, I think we'd want to err on the side of more services, closer follow-up, and connecting them also with a patient navigator. This would have to be an interdisciplinary discussion between the physician and probably physical therapy and case management to see what they think would be best for that patient.

Q: COVID-19 has increased isolation, but has it also complicated solutions, since people may be isolating to keep themselves safe?

A: We are all less socially connected right now because of COVID restrictions. We've actually explored a lot of other ways that older adults have stayed connected. One great example is my mother-in-law, who had done tai chi with her best friends in person before COVID, and since COVID, it's been moved to a virtual format. They all Zoom with the instructor twice a week, and they do tai chi together, chatting and connecting socially in their living rooms. Then they say their goodbyes and go on with their day, but it's allowed them to remain socially connected with each other. The other point I would like to highlight is that not everything needs to be on Zoom. Especially for older adults, the telephone is a great way to maintain social contact. For decades, people talked on the phone, and I think especially for older adults, a regular phone call with family or friends is great way to stay connected.

Q: What's next in this field?

A: The suggestions I've made should be systematically studied. We want to start with the feasibility of screening for social isolation in the hospital. I really do think it would be feasible and not very difficult at all, but of course, it should be studied. Also, a lot of effort needs to go into figuring out the right type of intervention, especially because once the person goes home, the worry is that whatever forces were in play that contributed to their being socially isolated in the first place are likely to still be in place after hospital discharge. Effective interventions that not only will help with recovery but that encourage meaningful social interaction, to alleviate the social isolation itself, are needed. We'll probably see many different types of interventions being studied in the coming years.