In the last decade, I lost both of my maternal grandparents. I can remember both of them as vibrant, active and engaged. However, when my grandfather began to develop significant medical problems and declined cognitively, things really changed. His medical problems eventually necessitated a move to a skilled nursing facility. It was at this point that I began to notice a precipitous decline in my grandmother. She began to become reclusive (she was formerly a good golfer and avid traveller). She became depressed. When my grandfather died, she began to develop more medical problems. Eventually she was admitted to a full time skilled nursing facility. Her mental capacities dwindled, she stopped participating in any type of rehab and ultimately died in the facility. We have all heard of spouses that die within a few months of each other and I have always believed that profound loneliness and sadness must follow the loss of a lifelong partner. I believe that this loneliness certainly played a role in my grandmother’s demise.
Recently, two interesting articles were published in the Archives of Internal Medicine addressing the impact of loneliness and isolation on mortality and cardiovascular disease in the elderly. In a manuscript by Perissinotto et al, the relationship between loneliness and functional decline/death was examined. In this cohort, loneliness was significantly associated with a decline in ADL activities, decline in mobility, and increased risk of death. In a second paper, Udell, et al investigated whether living alone was associated with increased mortality and cardiovascular risk using the REACH registry data. Living alone was found to be associated with a higher 4 year mortality and cardiovascular death. This association is important. Nearly 1 in 7 American adults are living alone and this isolation may provide additional stressors such as depression, anxiety and additional economic pressures. These stressors certainly may contribute to cardiovascular events in susceptible patients. Moreover, social isolation has been associated with changes in health behavior and access to care among patients. Patients who live alone may be less likely to seek care for recurrent symptoms and may not be compliant with drug therapy or other medical recommendations without support.
Previous studies have demonstrated similar findings. A 2012 study in Circulation reported that patients who have had a spouse die suddenly are 20 times more likely to die from a cardiovascular event such as a heart attack in the first 6 weeks surrounding the loss. Separate studies involving couples in Scotland and in Israel demonstrated that the risk of death among widows or widowers approaches 30-50% in the first 6 months after the death of a spouse. We can certainly infer that the bereaved were lonely and may have felt socially isolated.
There is no easy answer to this problem. Our patients today are sicker and have more limited resources. Financial pressures are forcing physicians to tackle larger clinic schedules with overall increased workload demands. But, as providers of health care, we must assess social isolation and loneliness in our patients. We must identify “at risk” patients and make attempts at intervention. Since these studies suggest that living alone is an independent prognostic factor for mortality and CV disease, clinicians must work to counsel their patients about seeking appropriate medical attention when needed and, in appropriate cases, refer patients to programs with psychological intervention. Many of these patients have no families, no adult children and no support group. In these cases, we must do our best to fill in the gaps (yes, all in a busy office full of patients). Healthcare costs in the US continue to skyrocket and there are no easy fixes in the works. I believe that a simple, although potentially time consuming, intervention such as talking with lonely and socially isolated patients when they are in the office for a visit, is a low cost preventative measure. By taking time to hold a lonely patient’s hand, we may potentially make a positive impact. Data such as those presented in the Archives this month certainly point out the risks of loneliness and suggest that patients without social support in place do very poorly and develop significant cardiovascular illness.