Assessing and Managing Social Isolation and Loneliness by Clinicians in Clinical Cardiovascular Practice

INTRODUCTION Social isolation and loneliness, especially amongst older persons, are increasingly being recognized as a global health concern.[1] It is a world-wide problem with older adults at greatest risk with a prevalence ranging from 20% to 58%.[2,3] Epidemiologic data have linked social isolation and loneliness to cardiovascular disease such as heart failure and coronary artery disease.[4] Public policy has highlighted social isolation/loneliness as a major social determinant of health. Yet translating this information into clinical practice has been both challenging and inadequate. Indeed, a recent set of guidelines concluded that there is a lack of literature on clinical practice in prevention, screening, assessment and intervention for social isolation and loneliness particularly for older adults.[5] The objective of this study is to review some of the relevant data connecting social isolation and/ or loneliness with heart failure and coronary artery disease with the objective of focusing on creating greater awareness for assessing and managing social isolation and loneliness in clinical cardiovascular practice. WHAT IS SOCIAL ISOLATION AND LONELINESS? There is general agreement that social isolation and loneliness are different but related entities. According to the World Health Organization, loneliness is a state of mind, a subjective experience, the pain we feel when social connections are not meeting our needs[1], or a generalized lack of satisfying human relationships.[6] Social isolation is a an objective measure of having a smaller number of social connections which may contribute to loneliness.[1] You can live alone and not feel lonely or socially isolated, and you can feel lonely while being with other people. Older adults are at higher risk for social isolation and loneliness because of changes in their health and social connections that can come with growing older such as impairment in hearing or vision, memory loss, disabilities or the loss of family and friends.[1,3] THE ASSOCIATION OF SOCIAL ISOLATION AND LONELINESS WITH MORTALITY The association of social isolation with an increased risk for mortality is comparable with well-established risk factors for mortality.[7-10] Several population studies have noted the association. For example, a representative Finnish cohort of 8,650 individuals from their cross-sectional Living Conditions Survey, with a 17-year follow-up period, was analyzed using Cox regression models adjusting for several possible confounding variables.[11] They concluded that social isolation and loneliness had distinct pathways to mortality and health.[11] A Danish study reconstructed a social network index combining four components - partnership, interaction with family/friends, religious activities, and membership in organizations/clubs.[12] After adjusting for potential important confounders, including psychiatric and somatic status, lifestyle, and socioeconomic status, they found that social isolation was associated with 60%-70% increased mortality.[12] This field has been summarized in several meta-analysis.[7,13-15] An analysis of 35 publications involving 77,220 participants reported that loneliness was a significant risk factor for all-cause mortality (pooled hazard ratio [HR] = 1.22); both for women (pooled HR = 1.26) and men (pooled HR = 1.44).[15] In a meta-analysis of 91 publications, with data on about 400,000 individuals, Shor and Roelfs reported that the mean HR for mortality was significantly (P < 0.05) higher among those with lower levels of social contact frequency.[14] In a meta-analysis of 148 prospective studies, with data from more than 300,000 participants Holt-Lunstad assessed measurements of structural (e.g., social integration, network size, marital status, living alone), functional (e.g., perceived support, received support, perceived loneliness) or combined aspects (e.g., complex social integration) of social relationships and related them to mortality.[13] The mean effect size (odds ratio, OR) was 1.50, indicating a 50% increased likelihood of survival for participants with stronger social relationships.[13] They did a subsequent meta-analysis and reported that across studies controlling for several possible confounds, the weighted average effect sizes (OR) were as follows: social isolation OR = 1.29, loneliness OR = 1.26, and living alone OR = 1.32, corresponding to an average of 29%, 26%, and 32% increased likelihood of mortality, respectively.[7] Interestingly they found no differences in the relationship whether there was objective assessment (questionnaire) or subjectively reported social isolation.[7] DATA LINKING SOCIAL ISOLATION AND LONELINESS WITH INCIDENCE OF HEART FAILURE In the UK Biobank cohort, using a self-reported question-naire[16], in 464,773 participants, social isolation and loneli-ness were significantly associated with an increased risk of heart failure (respective hazard ratios of 1.17 and 1.19). This association was independent of genetic risk for heart failure.[16] Deo et al. linked data from 1,012,351 US Veterans with stable type 2 diabetes mellitus without heart disease and their zip- code employing a derived population-level social deprivation index. Individuals in more socially isolated areas had a 53% higher relative risk of heart failure compared to individuals that were in an area that was not socially isolated.[17] The occurrence of heart failure was disproportionate greater in Black persons.[17] Socially isolated older women are at increased risk for developing heart failure, independent of traditional risk factors for heart failure. In a cohort of 44,174 postmenopausal women of diverse race and ethnicity in the Women’s Health Initiative study, after multivariable analyses, adjusting for sociodemographic, behavioral, clinical, and general health/functioning, socially isolated women had a significantly higher risk of incident heart failure than non-isolated women (HR = 1.23).[18] Neither depressive symptoms, age, race or ethnicity altered this association.[18] Prognosis with heart failure Patients in hospital for heart failure are more likely to be readmitted to hospital after discharge if social isolation is present. In a study of consecutive patients (n = 148) aged 55 years who were hospitalized due to heart failure, socially isolated individuals were significantly more likely to experience re-hospitalization for heart failure within 90 days of initial discharge.[19] The patients with social isolation had similar comorbidities compared with those without social isolation. In multivariate analysis, social isolation was one of the strongest predictors of heart failure re-hospitalization, with a greater impact than living alone, unemployment and other established risk factors.[19] In 149 hospitalized patients with heart failure, those reporting loneliness had significantly more days in hospital and more readmissions to hospital compared to those without loneliness despite not having different degrees of heart failure.[20] A meta-analysis of patients with heart failure, found that social isolation, living alone, lack of social support, and/or poor social network, were associated with a significant 55% greater risk of hospital readmission in patients with heart failure (OR = 1.55).[21] Amongst patients with heart failure, associations between social risk factors and outcomes (emergency department visits and hospitalizations) were assessed using Andersen-Gill models. Amongst the factors with the strongest association with hospitalizations was social isolation.[22] Social isolation is a marker of increased subsequent mortality in heart failure In a cohort of 298 patients diagnosed with stable heart failure, during a median follow-up of 362 days, loneliness was significantly related to the risk of time to the composite of death or any hospital readmission (HR = 1.83).[23] Women (OR = 2.09) and widowhood (OR = 3.25) were significantly associated with a higher risk of loneliness.[23] Maneman et al. surveyed 2,003 residents from 11 southeast Minnesota counties with a first-ever diagnosis for heart failure.[24] Individuals reporting high perceived social isolation had a significant 3.5 times increased risk of death (HR = 3.74), 68% increased risk of hospitalization (HR = 1.68) and 57% increased risk of emergency department visits (HR = 1.57) compared with patients who self-reported low perceived social isolation.[24] In hospitalized patients with heart failure aged ≥ 65 years, consisting of a group from the FRAGILE-HF (Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure) and the Kitasato cohort, social isolation but not loneliness, was significantly associated with 1-year death in Cox proportional hazard analysis, after adjustment for conventional risk factors.[25] DATA LINKING SOCIAL ISOLATION AND LONELINESS WITH CORONARY ARTERY DISEASE Social isolation and loneliness are associated with an increased risk of coronary artery disease. Several studies are worthy of being singled out. Incidence of coronary artery disease Among 57,825 women in the USA, mean age, 79.0 years, those with both high social isolation and loneliness scores had a 13.0% to 27.0% higher risk of incident cardiovascular disease than did women with low social isolation and loneliness scores.[26] Social support was not a significant modifier of the associations.[26] Prognosis with coronary artery disease Psychosocial stress, such as living alone was associated with increased cardiovascular mortality in patients with stable coronary artery disease, despite optimal medical secondary prevention as assessed by a questionnaire in 14,577 patients.[27] Adjusted Cox regression models were used to assess associations between individual stressors, baseline cardiovascular risk factors and outcomes.[27] Living alone was related to significantly higher risk of cardiovascular death (HR = 1.68) and the primary composite end-point cardiovascular death, nonfatal myocardial infarction or nonfatal stroke (HR = 1.28).[27] In a large-scale study of 5,845 patients (4,415 male patients, 1,430 female patients) in the Osaka region of Japan involving consecutive patients admitted to hospital with acute myocardial infarction, the association between living alone and longitudinal risk of cardiovascular events following discharge was evaluated.[28] Living alone was independently associated with a significantly higher risk of the composite endpoint consisting of major adverse cardiovascular events and total deaths (adjusted HR = 1.32).[28] In a set of 463 individuals with diabetes mellitus who had a percutaneous coronary intervention, those with the highest social isolation (highest quintile) had significantly higher risk of cardiovascular death and myocardial infarction as compared to those in the other or lower quintiles (adjusted HR = 1.72).[29] The culmination of evidence resulted in a statement published by the American Heart Association in 2022, acknowledging the cardiovascular risk from objective and perceived social isolation.[30] Among the evidence, was a synthesis of data across 16 independent longitudinal studies demonstrating that poor social relationships (social isolation, poor social support, loneliness) were associated with a 29% increase in the risk of incident coronary heart disease.[31] Subgroup analyses did not identify any differences by gender.[31] POTENTIAL NEUROHUMORAL MECHANISMS LINKING SOCIAL ISOLATION AND LONELINESS WITH HEART FAILURE AND CORONARY ARTERY DISEASE Several studies have reviewed the diverse potential mechanisms that might be operative to link social isolation and loneliness with heart failure and coronary artery disease.[32,33] Activation of the hypothalamic-pituitary- adrenocortical (HPA) axis as well as the sympathetic nervous system appear to be involved.[32,33] Activation of the HPA axis is a consistent finding in lonely individuals.[34] Other pathophysiologic factors include glucocorticoid resistance, oxidative stress and upregulation of proinflammatory gene expression.[32] These may act at the level of the heart or the vasculature[32,33] to induce atherosclerosis or trigger a cardiovascular event. The relationship to other cardiovascular risk factors exists but can be complex.[35,36] CLINICIAN ASSESSMENT OF SOCIAL ISOLATION AND LONELINESS IN PATIENTS WITH HEART FAILURE AND CORONARY ARTERY DISEASE Several authors have castigated physicians for not addressing social isolation and loneliness in the assessment and management of patients with heart disease. Scheidt suggested that there are five reasons for the lack of attention to social isolation and loneliness.[37] These are: (i) suggestions that the case is not sufficiently proven, to be accepted by many cardiologists and/or psychologists; (ii) inadequate awareness of mind-heart relationships; (iii) lack of training of practitioners; (iv) behavioral interventions are too challenging, costly and often not appropriately reimbursed; (v) uncertainty about the effectiveness of psychologic or behavioral interventions.[37] Moser suggests two additional factors why clinicians do not devote sufficient efforts to psychosocial determinants of cardiovascular health specifically lack of (i) agreement about how to measure psychosocial factors in patients; and (ii) curiosity from clinicians about the role of psychosocial factors in their patients.[38] Several counties have recently published guidelines or suggestions for assessment and management of social isolation and loneliness.[5,39] Canadian Clinical Guidelines on Social Isolation and Loneliness in Older Adults have recently been published by the Canadian Coalition for Seniors Mental Health.[5] These guidelines can be utilized by clinicians addressing patients with heart disease in the following ways. Awareness, knowledge and education/training Cardiovascular clinicians should include in their continuing medical education programs or individual learning, an increased awareness and knowledge of the major risk factors for social isolation and loneliness in adults especially older individuals.[40] Patients often tell their cardiovascular clinician about the recent loss of their partner or family member and information about their change in residence or living location and other changes in life circumstances that are critical risk factors for social isolation and loneliness. Screening and Assessment Whenever possible, clinicians should use evidence-based screening tools to identify patients/clients who are socially iso-lated and/or lonely, to assess the severity of the problem, to use in routine follow-up and to record these in their health record.[5] There are a number of different tools that can be utilized. We focus on two of them [Figure 1].Figure 1: LSNS and CARED Score questions for all categories. LSNS = Lubben Social Network ScaleThe Lubben Social Network Scale (LSNS) is a widely adopted tool for studies of social health.[41] It has been condensed to a 6 items scale (LSNS-6) that demonstrates validity and reliability in different populations.[42-45] This assessment tool involves 6 questions and includes a 6 entry scale for each item [Figure 1]. The total score is an equally rated sum of the six items. The maximum total score is 30 (5 times 6). The higher the score the lower is the likelihood of social isolation while scores between 0 and 11 are consistent with social isolation. While this may be cumbersome to formally assess patients, a copy of the questionnaire could be given to patients to complete. An alternative strategy is to ask each of the six questions and record the answer (see Figure 1 for the questions). Cardiovascular clinicians have become accustomed to completing a risk assessment for thromboembolism in patients with atrial fibrillation[46] or assessing the risk of coronary artery disease in patients after exercise stress testing[47] to name a few. Another tool that measures both social isolation and loneliness[5,48] focuses on the following areas and could be easily asked and recorded in the health record by the clinician - often referred to as CARED: C = Connection, A = Activities, R = Relationships, E = Emergency contact, D = Dwelling. See the questions for all categories in Figure 1. Total scores range from 0 to 5 with higher scores indicative of social isolation and loneliness. 0 is not at risk; 1-2 is a low risk but a recheck is suggested and 3-5 indicates social isolation.[5,48] The cardiovascular clinician should aim to explore the possible cardiovascular and other medical conditions that may be contributing factors to their patients’ social isolation and loneliness.[5] Improving the management of their coronary artery disease or heart failure may reduce their symptoms and permit them to interact more with others. Interventions Cardiovascular clinicians should be knowledgeable about the available interventions that can help their patients who are experiencing social isolation and loneliness. Referral to resources can be helpful for their patients. These referrals for interventions should be made by the clinicians mindful of the patient’s cultural background and lived experience. In collaboration with the patient, the cardiovascular clinician can assist to identify their interests, and the community supports that may be available. Clinicians should encourage their patients/clients to engage in group and/or individual physical activity as a means to reduce social isolation and loneliness and to improve their overall health.[5,49,50] Psychological therapies should be considered for some older adults experiencing social isolation and/or loneliness.[51] Psychological therapies include, but are not limited to cognitive behavioural therapy, social cognitive therapy, reminiscence therapy and mindfulness-based stress reduction. There is good evidence for psychological therapies in reducing loneliness compared to social isolation.[5] There is evidence for the potential efficacy of integrated interventions that combine (social) cognitive behavioral therapy with short-term adjunctive pharmacological treatments when clinically indicated.[52] Clinicians are encouraged to discuss leisure-skill development and activities as an opportunity for older adults to learn new skills and engage in the local community. These activities and skills may include leisure education, art therapy, bibliotherapy, horticulture and nature-related interventions and music therapy, amongst others[5,53-57] Since it may be difficult for an individual who is social isolated to engage in community activities, many community groups have developed programs and services to help connect with socially isolated individuals such as friendly visiting programs in-person and by telephone, congregate meals and peer support programs. More recently, there has been a recognition for the value of navigation services that help to link isolated older adults to support services in their communities. A key program that is becoming more significant is social prescribing. Some countries such as have an for Social Social programs health to activities is and their patients to community and programs to assist and connect them with a range of services to improve their health and and help their social isolation or For example, a cardiovascular during a who is alone with limited physical The can a (social to a community or that can a to with the on a and The US on as of the of Health has developed a of to and reduce social isolation and These are helpful for individuals and are important for clinicians to become knowledgeable about and suggestions to patients for addressing social isolation and loneliness. These - to patients to of to stress and as and as possible, should aim for at of activity each and activities they This is consistent with that is given to patients. with and in activities including and is a with the that is living alone, attention is to help the connect with a individual and with and community support Clinicians have an important role to in creating greater awareness of the risk factors of social isolation and loneliness in the with other and to this growing of social isolation and loneliness that has to have health Social isolation and loneliness are increasingly being recognized as a global health and have been linked to cardiovascular disease, especially heart failure and coronary artery disease. Cardiovascular clinicians should include in their knowledge and skills to identify especially older individuals, who may be socially isolated or lonely, using evidence-based screening tools such as the CARED score or the Lubben 6 The cardiovascular clinician can encourage these patients to or to and The cardiovascular clinician can an important in their patients to navigation services and social if available in their to link their patients to resources that can assist in addressing the growing of social isolation and loneliness. There is an important opportunity for cardiovascular clinicians to a in screening for the of social isolation and loneliness, with local and patients about changes to this cardiovascular clinicians should be in to all levels of for that improve not to health but social supports for individuals who experience social isolation and loneliness to reduce cardiovascular and the literature of the clinical studies, did the data the of the clinical and reviewed the the literature of the studies, did the data the of the and reviewed the authors have given the of the to be statement statement is not for this of is not for this statement is not to this as no were or analyzed during the support and There was no support for this of is an of Heart and The was to the with peer review independently of and the There are no of

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.