Wednesday, October 1, 2014

Leaving No One Behind: The International Day of Older Persons

By Anna Chodos, MD, MPH

I am wondering if Mr. Rose knows that today is the UN’s 24th celebration of the International Day of Older Persons (IDOP). The theme is “Leaving No One Behind: Promoting a Society for All.”

He does not talk to many people in a given day.  He lives on his own in a single-room occupancy (a bed and a small bathroom) in one of the many housing units for low-income adults in San Francisco.  At 75, he is one of its oldest residents.  When I visited him there for a home medical visit, he showed me his small fridge full of microwave pizzas and orange soda, which is what he can buy from the drug store near him.  He has difficulty walking, so he gets what he can from the nearest place that sells food.  He is fiercely independent so has refused help from a city in-home support worker that could help him with shopping.  And he said he did not have any friends or family who could help out.  But, he said, he did not feel lonely.

Such a broad theme for IDOP, which celebrates adults 60 and older, may not seem to speak to the specific needs of older adults like Mr. Rose, but it does. One reason to focus on promoting a “society for all” is to emphasize just how interconnected we are, not how separate older people are.  If a quarter of our population is over 60 years old by 2050 (that’s right: 2 billion older adults by 2050, including 26.6% of the US population), the health and wellbeing of these adults will affect us all.  And it means we need to stay connected.

As a primary care doctor and geriatrician (a doctor who sees mostly older adults), I think about this a lot. Many of the adults I care for, like Mr. Rose, show incredible resourcefulness, resiliency and, of course, happiness and joy in their later life.  But often a key issue I see is that they are also very socially isolated.  They are not engaged in social activities and have few social contacts. This happens for many reasons, including the fact that social networks are harder to maintain as we get older and people have health or mobility limitations that may become factors in getting out of the house.  This is different than loneliness, which is increasingly appreciated as a separate, though related, problem.  Both of these problems are related to an increased risk of disability and death in older people.

How do we promote social connectedness for older people?  Well, we have a unique disadvantage compared to other developed nations, which is that we spend far less of our GDP on social services and much more on health care. Our spending ratio of social services to medical services is by far the lowest among developed nations.  And people who care for older adults know that social services—such as adult day programs, in-home support, food programs— are the critical lifeline for many that allow them to be independent in the community.

One of my daily challenges is to address the unmet social need and social isolation in my patients with the resources we have to offer.  I feel outmatched.  Thankfully, I can often turn to our behavioral health team (with social workers and support staff) in clinic to help me.  I have also met incredible people in the community who support older adults in the work they do- such as the Friendship Line that calls people daily to talk, the Little Brothers program, the Department of Aging and Adult Services in SF, and Project Open Hand that provides meal programs for seniors.  These are a few of the dozens of examples just in SF reaching out to older adults.

Going forward, I hope we can remember the lessons of this year’s IDOP: that we should not leave anyone behind or, I submit, alone. Part of our work in medical care with older adults should be to discuss social isolation and loneliness, and to address these issues with perseverance and creativity.  There is never one singular nor universal answer.  It takes staying power and repeated attempts.  It takes a multipronged approach.  If they did not follow-up and check out the day center you recommended, suggest it again, or suggest that the one person they spend time with goes with them the first couple of times.  Suggest a different activity. Whatever you do- stick with it!

At his last visit, Mr. Rose saw another health care provider in the clinic who offered him an in-home support worker, which he tentatively accepted.  Going forward, Mr. Rose may have more company and I hope he or she may draw him out even further. 


How to ask about social networks to see if an older person is isolated:
  • Ask about who she lives with, if anyone.
  • Ask about who she sees often.
  • Is there someone she could count for help with personal or health-related needs?
  • Does she have any family, a partner or close friends that live near?  That she talks to regularly.
  • Ask about a typical day or week for her. Take a look at this scale if you want a questionnaire (used in research).
 How to ask about loneliness:
  • How often do you feel that you lack companionship: hardly ever, some of the time, or often?
  • How often do you feel left out: hardly ever, some of the time, often?
  • How often do you feel isolated from others: hardly ever, some of the time, often?
  • Loneliness may be present if they report some of the time or often to any of these questions.

 Shout outs!

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