Social determinants of health is a term that is tossed around with increasing frequency. Literature and policy makers tout it as an effective way to address patient health in a more comprehensive manner in order to improve outcomes and reduce costs. For providers, there is a very real application of social determinants of health to patient care. Knowing about it can make all the difference in how well your patients comply with care when they are at home. When it comes to working with older patients, these determinants can sometime increase in volume. 

Defining Social Determinants

The Centers for Disease Control (CDC) defines social determinants of health as the “circumstances in which people are born, grow up, live, work, and age. This also includes the systems in place to offer health care and services to a community. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”

As a provider, it’s the circumstances your patients live in that can positively or adversely impact their ability to carry out your care and treatment plan.  

• Do they have the intellectual ability and health literacy to understand the importance of your directives?
• Can they afford to buy medications, healthy food, and home medical devices? 
• Are the supplies and medications they need easily accessible? 
• Do they have transportation to get the things they need? 

Those are just a few of the myriad factors that can create obstacles to care once your patients leave your office. There are two others that are shown to be powerful obstacles to compliance; social isolation and cognitive health. A recent study shows that older adults living alone have very real barriers to decision making and social integration and its compounded when memory loss is present as well. 

Understanding Isolated Seniors

Elena Portacolone, an assistant professor at the Institute for Health & Aging and Pepper Center Scholar at the Division of Geriatrics in the Department of Medicine at UCSF conducted a study to understand the daily experience, social networks and decision-making ability of isolated seniors in order to design culturally sensitive interventions that improve their health, well-being and social integration. Unlike other studies that focus on the personal traits and behaviors of seniors, Portacolone’s study is focusing on the role that “institutions, social policies and ideologies play in exacerbating the social isolation of vulnerable individuals”.  

Perhaps the saddest finding is that many of these seniors want to be socially involved, but societal obstacles prevented them from doing so, including: 

• Fear of being robbed
• Distrust of neighbors 
• Limited availability of appropriate services 
• Dilapidated surroundings 
• Limited meaningful and positive relationships
• Having few friends or family members attuned to their concerns 

The bottom line is that Portacolone’s study findings fly in the face of the assumption that seniors live alone by choice. The seniors in her study expressed a strong desire to be socially active but find it difficult given the barriers listed above. In addition, many are forced to live alone because of rental agreements that allow only one person per apartment. 

The picture is worse for seniors with cognitive deficiencies who are living alone. Portacolone found that these seniors often feel shunned and that friends don’t visit them again once they realize the senior is suffering with memory loss. They also tend to isolate themselves from family members in order to hide the extent of their memory loss. They don’t want to tell others, including family members, that they need help for fear of being forced from their homes. Even if they are squeezed into a one room apartment, living alone is better than being sent to an institution. As a result, they don’t share their suffering with loved ones and don’t get the support they need. Portocolone’s study found that as a result, older adults with cognitive impairment who live alone, spend an inordinate amount of their time managing their household and their health. 

Lacking Cognitive Impairment Services

To add insult to injury, services that address the specific needs of those with cognitive impairment and living alone are severely limited. Not all home care aides are trained to provide cognitive support or dementia/memory loss care. When they are available, many seniors cannot afford the specialty fees. When cognitive impairment results in driver’s licenses being revoked, the isolation worsens. 

The study provides important new insights into seniors and their lifestyles, including the barriers that impede their ability to care for themselves. As providers, being aware of the impact of these social issues and asking patients about them can make a significant difference in their care. Opening a dialogue and connecting these patients with social services may improve their ability to adhere to care and treatment plans. Removing fear from the situation and reassuring seniors that help is available, without threatening their home, can go a long way to improving their health and overall outcomes.