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Clinical Practice Keywords Isolation/Loneliness/

Retirement/Bereavement/Low mood
Review
Assessment This article has been
double-blind peer reviewed

In this article...
● T
 he links between social isolation and poorer health and wellbeing
● Key aspects of the assessment of the social domain of health in older people
● Suggested reflective exercises based on two case studies

Assessment of older people 5:

assessing the social domain
Key points
Authors Hanneke Wiltjer is lecturer in nursing, HZ University of Applied Sciences,
All humans need to Vlissingen, the Netherlands; Nyree Kendall is senior lecturer and lead for district
socialise and engage nursing, University of Bolton, UK.
with others
Abstract The multidisciplinary and holistic assessment of older people allows health
Older people are at professionals to gain insight into their individual needs and provide them with
an increased risk of person-centred care. The social domain is one of five key domains that must be
social isolation and explored when assessing older people. Social interaction and engagement are
disengagement essential needs of all human beings but, as people age, they become more at risk of
social isolation and disengagement, which can have multiple detrimental effects on
There is a clear both their mental and physical heath. This fifth article in a six-part series explores the
link between social health needs of older people and how nurses can help address them.
social isolation and
poorer physical Citation Wiltjer H, Kendall N (2019) Assessment of older people 5: assessing the
and mental health social domain. Nursing Times [online]; 115: 9, 53-56.

S
Exploring older
people’s social ocialising is an essential need of them, women outnumbered men by 2:1
needs is part of all human beings; their interac- (Office for National Statistics, 2013). Being
holistic nursing tions with others influence the in bad or very bad health was reported by
assessments decisions they make and the roles 24% of men and 26% of women (ONS, 2013).
they play in society (Hurrelmann and Bauer, Among those living in private households,
A wide range of 2017). Occupation – or engagement, as 69% of women and 41% of men lived alone
interventions are Squires and Hastings (2002) called it – is (ONS, 2013).
available to increase another essential human need and often In a survey by Thomas (2015), loneliness
older people’s social implies interaction with others. was identified to be one of the key factors
interactions As people age, they are exposed to an that affects wellbeing. The ONS (2013)
increasing risk of reduced interactions and found that older people were more likely to
reduced engagement. Many factors con- live alone; reported figures indicated that
tribute to this, including loss of physical 59% of the over-85s and 38% of people in
and/or mental function, bereavement, and the 75-to-84-year age group lived alone.
detachment from society (Thomas, 2015). The same report suggested there was a cor-
Economic and social issues can result in, relation between poor health conditions
or compound, isolation. This article, the and loneliness, which increases with age.
fifth in a six-part series on the assessment Beach and Bamford (2015) acknow-
of older people, describes key aspects of ledged that, due to the stigma and shame
the social domain of health assessment. attached to loneliness, the number of men
who report feeling lonely may be lower
Social isolation and ageing than the number who actually feel lonely.
On the day of the 2011 census, there were The incidence of loneliness in older men
1.25 million people residing in England may be much greater than reported and
and Wales who were aged 85 or over, com- older men are more likely to be isolated
ALAMY

pared with 1.01 million in 2001; among than women (Beach and Bamford, 2014).

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Clinical Practice
Review

Negative effects of social isolation 2017). The continuity theory, developed in l V

 ariation in understanding of the
Toepoel (2013) found a link between ageing 1971 by Robert Achtley asserted that, as outcome (Ebrahimi and Chapman,
and a reduction in people’s social net- people age, their personality and behaviour 2018).
works, resulting in social disengagement. traits remained the same. Furthermore, while reablement may
Nicholson (2012) found that there was a Twigg and Martin (2015) discussed the seem the right thing to do, it may have
link between social isolation and health idea that ageing is socially constructed, unintended consequences, for example
decline in older people – especially those referring to Berger and Luckmann’s (1966) leading to social isolation and a paradox-
who live in the community – and explained view that interaction and institutionalisa- ical increase in hospital admissions.
that social isolation would “impact the tion in society determine social position How can older people be supported to
health, wellbeing and quality of life of and standing. Social class will affect how a live independently while also maintaining
numerous older adults now and in the person ages: according to Moody and social engagement? One possible answer is
foreseeable future”. Sasser (2018), earlier-life events such as supportive community living, which Six-
Pohl et al (2018) identified a link between education, employment, relationships and smith et al (2017) argued can have a posi-
social isolation and increased risk of falls, financial security determine the success of tive impact on the health and wellbeing of
which has also been noted by the National the transition into older age. older people. It needs to be underpinned
Institute for Health and Care Excellence by partnership working and the provision
(2013). Older people can become disen- “Older people can become of affordable housing but its benefits
gaged from their social support networks disengaged from their include:
because of falls or the fear of falling, so
interventions to reduce the impact of falls
social support networks l I mproved mental wellbeing;
l R educed isolation;
may not only improve physical func- because of falls or the fear l R educed burden on informal carers.
tioning but may also maintain social of falling”
engagement (Sherrington and Tiedemann, Social isolation versus loneliness
2015). Older people’s risk of falls needs to Independence and isolation When people live alone and have limited
be managed using a multifactorial The focus of the National Health Service contact with others, they are said to be
approach (see part 3). and Community Care Act 1990 (Bit.ly/Com- socially isolated. This is closely linked to,
Shankar et al (2011) found there was a munityCareAct1990) was to enable people but not quite the same as, being lonely.
link between loneliness and low levels of to remain in their own home for as long as Social isolation can be measured objec-
physical activity, in addition to increased possible, but the reality is that older people tively through variables based on quantita-
engagement in risk behaviours such as who have been hospitalised are likely to be tive data. Loneliness, however, is subjec-
smoking. discharged to a care home (Gaughan et al, tive in nature, which means that research
2017). Landeiro et al (2016) suggested the on it requires a qualitative approach
Social theories of ageing reason for many delayed discharges after (Shankar et al, 2011).
Ageing is often considered to be the result hospitalisation for hip fracture was isola- According to Pohl et al (2018), social iso-
of biological processes leading to a gradual tion, as hip fracture patients waiting to be lation can be measured by counting the
deterioration of physical and mental func- discharged to their own home stayed in contacts a person has during a period of
tion. However, it should not be viewed hospital longer than those waiting to be time and by using indicators such as net-
through a single lens and other possible discharged to a care home. However, there working and social participation. How-
reasons for the ageing process need to be are other potential reasons why discharges ever, the researchers did not necessarily
considered (Collins, 2014). Social theories are delayed, such as overcautious health consider the quality of contacts and recog-
focus on how changes in people’s roles, professionals and a lack of resources and/ nised this as a limitation.
relationships and status affect them as or suitable accommodation in the commu- For Beutel et al (2017), loneliness is an
they age. nity (Kar, 2015). emotional, subjective state that depends on
In 1961, Cumming and Henry developed In recent years, an approach called rea- the individual’s experience of social rela-
the disengagement theory, based on the blement has been introduced to help older tionships since their late adolescence. They
idea that, when progressing towards older people live independently for longer, in the investigated loneliness in a large represent-
age, people gradually withdraw from their hope it can avoid hospital admissions and ative sample of German adults aged
roles in society (Künemund and Kolland, institutionalisation in long-term residen- between 35 and 74 years. One in 10 partici-
2007). People become disengaged because tial care. Reablement is an intensive, time- pants reported some degree of loneliness;
they are being removed from normative limited intervention provided in people’s in addition, loneliness was stronger in
control – for example, after they retire – homes or community settings; it is often women, participants without a partner, and
and this is associated with health prob- multidisciplinary in nature and focuses on those living alone and without children.
lems and a reduced ability to engage with helping people regain skills around daily
new groups of people. activities (Aspinal et al, 2016). Assessing social isolation
The suggestion that all older people dis- Reablement is likely to aid social and Shankar et al (2011) used a number of tools
engage from society brought about much psychological recovery, allowing people to to measure the extent of loneliness and
debate and opposing theories developed. take control of their lives through engage- isolation, including the Social Isolation
The activity theory proposed that there ment, however the implementation of rea- Index, which uses variables such as living
were benefits to the older person not disen- blement plans may encounter barriers alone, having restricted contact with
gaging from society and that, if an older such as: family members and social engagement.
person disengaged, it was not always volun- l A
 nxiety and fear; The higher the score, the greater the risk of
tary or intentional (Coleman and O’Hanlon, l N
 o incentive to participate; social isolation.

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Clinical Practice
Review

The revised UCLA Loneliness Scale can

Box 1. Interventions used to reduce isolation in older people
also be used in various age groups but has
been considered to be particularly useful l Social engagement interventions, for example ‘dementia friends’
in the assessment of older people (Hughes l Psychological and/or physical therapies, for example, yoga, mindfulness classes
et al, 2004). Despite the existence of var- l Animal therapy
ious assessment tools, however, there is l Befriending interventions
currently no consensus on which is the l Leisure activities or educational intervention to encourage new skill development,
most reliable and effective at helping for example, cake decorating or flower arranging
health professionals assess social isolation Sources: Windle et al (2011); Gardiner et al (2018)
and/or loneliness in older people.
When assessing the social aspect of
older people’s health, health professionals Box 2. Reflection exercise: social domain assessment in
need to remember that some will be reluc- hospital
tant to admit they are isolated because
they perceive this to be stigmatising. Ethel Anderson* is a 72-year-old woman admitted to the acute ward via the accident
Health professionals also need to consider and emergency department after an exacerbation of chronic obstructive pulmonary
how an individuals’ personal experiences disease. She lives alone in her own home, where a carer from an agency visits her
may act as a barrier to participation in twice a day for 15 minutes to prompt her to take her medication. Her husband was
society (Kinsella, 2015). her main carer until he died a year ago from a myocardial infarction. On arrival,
Nicholson (2012) suggested that, when Mrs Anderson explains to the nurse proceeding with her admission that she has been
addressing the needs of the older person, a feeling low in mood lately. This information has been passed on to the team. You are
risk assessment approach should be used one of the nurses on the team:
and the variables that may affect the per- l What do you need to know to assess Mrs Anderson holistically?
son’s health should be considered. The l What are her likely care needs?
assessment of older people should focus l Who else needs to be involved in her care?
on improving both their physical health l What would you include in a care plan designed to meet her social needs?
and their social wellbeing, as one cannot *
The patient’s name has been changed.
be separated from the other. Nurses
working in the community have been con-
sidered the best-placed health profes- Box 3. Reflection exercise: social domain assessment in the
sionals to carry out such assessments community
(Nicholson, 2012).
Jim Carter* is 91 years old and lives alone in his own home. Six months ago he fell
Reducing social isolation and sustained a hip fracture, and was admitted to hospital for a hip replacement.
Reducing social isolation is likely to have a Before that hospital stay, Mr Carter did his own shopping and met friends twice a
positive impact on health and mortality. week at the local bowling green. However, since his discharge, he has been unable
However, it could be more effective to to leave the house independently and relies on his friends for transport and company.
target interventions at older people con- At a recent GP visit, Mr Carter explained that he feels increasingly lonely and low in
sidered to be at greatest risk (for example, mood. You are a practice nurse and have been asked to assess Mr Carter:
those recently bereaved, those with lower l What impact could social isolation have on Mr Carter?
incomes and those with poorer health), l What information do you need from him to understand his social health needs?
rather than offering them indiscriminately l Who needs to be involved in his care for optimal support?
(Kinsella, 2015). Routasalo et al (2009) l What services are available locally to address his needs?
stated that using psychosocial group reha- *
The patient’s name has been changed.
bilitation to empower older people experi-
encing loneliness benefits not only their
psychological wellbeing but also their “To meet older people’s Input from occupational therapy ser-
physical outcomes.
Gardiner et al (2018) found that a
needs, it is important to vices, using tools such as behaviour modi-
fication therapy, can increase an older per-
number of interventions have been used consider signposting or son’s confidence and ability to self-care
successfully to increase older people’s referral to other agencies (Cara and MacRae, 2005). The occupational
social interactions (Box 1). However, they and services” therapist can help by identifying the risks
noted that it was difficult to identify associated with withdrawal from society
whether the reduction in social isolation Signposting and referrals and act as a mediator and educator for the
was a result of an intervention, or to what To meet older people’s social needs, it is older person and their relatives (Barney
aspect of a multifactorial intervention it important to consider signposting or referral and Perkinson, 2016).
might be due. Patients need to participate to other agencies and services, such as: Social services can help by assessing the
in the assessment of interventions in l O ccupational therapy; person’s needs for, and entitlement to, ser-
which they are engaged so the health pro- l S ocial services; vices provided by local authorities or char-
fessional can establish what type of inter- l B ereavement counsellors; ities such as Age UK (White and Harris,
vention is likely to meet their needs (Gar- l L ocal charities; 2001). Looking at interventions to reduce
diner et al, 2018). l M ental health services. the impact of social isolation in vulnerable

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Clinical Practice For more articles

on older people, go to
Review nursingtimes.net/olderpeople

older people and increased rate of admission and

Box 4. Questions to assess the social health of older people length of stay in hospitals. Journal of Geriatric Care
and Research; 2: 2, 28-30.
l Do you have family and friends? Kinsella S (2015) Older People and Social Isolation: A
l How often do you get to see them? Review of the Evidence. Bit.ly/KinsellaSocialIsolation
l How often do you leave the house? Künemund H, Kolland F (2007) Work and
retirement. In: Bond J et al (eds) Ageing in Society:
l Do you have the energy to engage in social relationships?
European Perspectives on Gerontology. London:
l Who normally does your shopping and cleaning? Sage.
l Do you ever feel lonely? If so, what triggers these feelings? Landeiro F et al (2016) The impact of social
l Do you have hobbies? Do you currently actively engage in them? isolation on delayed hospital discharges of older
hip fracture patients and associated costs.
l Are you a member of any organisations or interest groups?
Osteoporosis International; 27: 2, 737-745.
l Are there people around you who would be able to help you feel less isolated? Moody HR, Sasser JR (2018) Aging: Concepts and
Controversies. Thousand Oaks, CA: Sage.
National Institute for Health and Care Excellence

“Many local authorities

(2013) Falls in Older People: Assessing Risk and
and negative health outcomes. Nurses Prevention. Nice.org.uk/cg161
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Nicholson NR (2012) A review of social isolation:
an important but underaddressed condition in
or low-cost activities such incorporate the social domain of health older adults. Journal of Primary Prevention; 33:

as exercise classes, coffee into their assessments, alongside the other

2-3, 137-152.
Office for National Statistics (2013) What Does the
mornings, excursions and four domains discussed in this series. The 2011 Census Tell us about the “Oldest Old” Living in

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CLINICAL
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