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Care of older adults occurs within the context of their community and social environment, of which health care generally plays only a small role. Geriatric care is most effectively provided within the framework of an integrated care team who understands the social factors that influence the health and quality of life of older adults and have expertise and knowledge regarding community resources available to assist them and their caregivers. This is particularly important for older adults facing functional decline, cognitive decline, or frailty. This chapter discusses the significance of the social context as it affects the health and care of older adults, focusing on the following areas:

  • Loneliness and social isolation

  • Food insecurity

  • Housing and long-term services and support

  • Finances

  • Legal issues


Definitions and Epidemiology

Loneliness and social isolation are increasingly recognized to adversely affect health and quality of life. Loneliness is a subjective feeling of isolation with a discrepancy between actual and desired social relationships, whereas social isolation is an objective measure of social relationships and connection. People can be both lonely and socially isolated, but these conditions do not always coexist. Both conditions are prevalent, with the prevalence of loneliness estimated at nearly half of community-dwelling older adults and up to 15% for social isolation. Together and independently, loneliness and social isolation have been shown to have a negative association with function, independence with activities of daily living (ADLs), specific health outcomes such as cardiovascular disease and dementia, and mortality. Social isolation has also been shown to be associated with increased Medicare spending compared to nonisolated individuals.

Screening and Intervention

As health care providers, screening for loneliness and social isolation can help identify these risk factors and prompt referrals to connect patients with appropriate resources. The 20-item University of California Los Angeles (UCLA) Loneliness Scale, the Revised UCLA Loneliness Scale, the UCLA Loneliness Scale (version 3) (Table 18-1), and the three-item loneliness scale in the Health and Retirement Study Psychosocial and Lifestyle Questionnaire ( are all validated screening tools. Although we do not yet have evidence for the most effective interventions for loneliness and social isolation, there are many options. Some focus on the individual such as improving social support, increasing opportunities for social interactions, and addressing maladaptive social skills. Communities may have senior centers, adult day programs, or friendly visitors. Other options work to minimize barriers such as screening for impaired hearing and recommending hearing aids if present, or using technology to increase connection and communication opportunities for older adults with limited mobility or community resources. Some older adults may be receptive to the use of simplified video devices or digital assistants to improve communication access with friends or family members (Table 18–2).

Table 18–1.UCLA Loneliness Scale ...

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