Aging & Mental Health

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/camh20

Cumulative effect of loneliness and social isolation

on health outcomes among older adults

Timothy L. Barnes, Stephanie MacLeod, Rifky Tkatch, Manik Ahuja, Laurie

Albright, James A. Schaeffer & Charlotte S. Yeh

To cite this article: Timothy L. Barnes, Stephanie MacLeod, Rifky Tkatch, Manik Ahuja,
Laurie Albright, James A. Schaeffer & Charlotte S. Yeh (2021): Cumulative effect of loneliness
and social isolation on health outcomes among older adults, Aging & Mental Health, DOI:
10.1080/13607863.2021.1940096

To link to this article: https://doi.org/10.1080/13607863.2021.1940096

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Published online: 02 Jul 2021.

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Aging & Mental Health
https://doi.org/10.1080/13607863.2021.1940096

Cumulative effect of loneliness and social isolation on health outcomes among

older adults
Timothy L. Barnesa, Stephanie MacLeoda, Rifky Tkatcha, Manik Ahujaa, Laurie Albrightb, James A. Schaeffera
and Charlotte S. Yehc
Research for Aging Populations, OptumLabs, Minnetonka, MN, USA; bUnitedHealthcare Alliances, Minneapolis, MN, USA; cAARP Services, Inc.,
a

Washington, DC, USA

ABSTRACT ARTICLE HISTORY

Objectives: Loneliness and social isolation are described similarly yet are distinct constructs. Numerous Received 12 December 2020
studies have examined each construct separately; however, less effort has been dedicated to exploring Accepted 31 May 2021
the impacts in combination. This study sought to describe the cumulative effects on late-life health KEYWORDS
outcomes. Loneliness;
Method: Survey data collected in 2018–2019 of a randomly sampled population of US older adults, social isolation;
age 65+, were utilized (N = 6,994). Survey measures included loneliness and social isolation using the health outcomes;
UCLA-3 Loneliness Scale and Social Network Index. Participants were grouped into four categories healthcare utilization;
based on overlap. Groups were lonely only, socially isolated only, both lonely and socially isolated, or healthcare costs;
neither. Bivariate and adjusted associations were examined. older adults
Results: Among participants (mean age = 76.5 years), 9.8% (n = 684) were considered lonely only,
20.6% (n = 1,439) socially isolated only, 9.1% (n = 639) both lonely and socially isolated, and 60.5%
(n = 4,232) neither. Those considered both lonely and socially isolated were more likely to be older,
female, less healthy, depressed, with lower quality of life and greater medical costs in bivariate analyses.
In adjusted results, participants who were both lonely and socially isolated had significantly higher
rates of ER visits and marginally higher medical costs.
Conclusion: Results demonstrate cumulative effects of these constructs among older adults. Findings
not only fill a gap in research exploring the impacts of loneliness and social isolation later in life, but
also confirm the need for approaches targeting older adults who are both lonely and socially isolated.
As the COVID-19 pandemic continues, this priority will continue to be urgent for older adults.

Introduction Academies of Science, Engineering and Medicine (NASEM) to

examine the current science and future directions of loneliness
Loneliness and social isolation have separate and distinct defi-
and social isolation in older adults. Their consensus 2020 report
nitions; however, in some instances, the terms can be found
highlights many risk factors that are associated with loneliness
used interchangeably and as a proxy for one another in pub-
and social isolation including social, cultural, and environmen-
lished commentaries and research studies. Loneliness is typi-
tal factors (e.g. age, gender, housing, location, living alone),
cally defined as the subjective state of a person’s desired and
psychological and cognitive factors (e.g. depression, anxiety,
actual relationships and a measure of relationship quality
impairment), and physical health factors (e.g. health status,
(Cacioppo et al., 2002; Cornwell & Waite, 2009; Musich et al.,
2015; Ong et al., 2016). In contrast, social isolation is an objec- presence of chronic diseases, and limited function). In addition,
tive count of relationships, social interactions, and social con- many associated health outcomes have been associated with
tacts, determined by their quantity and sometimes quality the two constructs including cardiovascular disease, stroke,
(Cudjoe et al., 2020; MacLeod et al., 2018). While these con- dementia, and mortality (NASEM 2020).
structs can overlap, not all assessment, evaluation, and inter- An adaptation of the NASEM guiding framework of loneli-
vention approaches work universally for these constructs; thus, ness and social isolation is shown in Figure 1. Overall, the the-
they should be considered differently yet relative to one oretical framework demonstrates that there is a bidirectional
another (NASEM 2020). relationship between loneliness and social isolation under the
Previous studies indicate up to 55% of US older adults age umbrella term social connection (Holt-Lunstad et al., 2017) as
65 years or older report some level of loneliness (Musich et al., well as a relationship with pre-existing risk factors, and specific
2015; Perissinotto et al., 2012). Meanwhile, social isolation is health outcomes (Donovan & Blazer, 2020; NASEM 2020). As
estimated to impact up to 40% of older adults age 60 and older mentioned, previous studies have demonstrated that loneli-
(Cudjoe et al., 2020; MacLeod et al., 2018). Furthermore, current ness and social isolation are both independently associated
evidence suggests that many older adults are either socially with similar negative physical and mental health outcomes
isolated, lonely, or both, which can put their health at risk in later in life including higher rates of mortality, depression, and
many ways (Courtin & Knapp, 2017). Recently, the AARP cognitive decline (Beutel et al., 2017; Drageset et al., 2013; Holt-
Foundation commissioned a committee through the National Lunstad et al., 2010; 2015; 2017; Kelly et al., 2017; Kuiper et al.,

CONTACT Timothy L. Barnes [email protected]

© 2021 UnitedHealth Group. Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/
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upon in any way.
2 T. L. BARNES ET AL.

Figure 1. Theoretical framework of loneliness, social isolation, and associated health outcomes. Note. Adaptation of guiding framework developed by the
Committee on the Health and Medical Dimensions of Social Isolation and Loneliness in Older Adults 2020 (NASEM 2020).

2015; Luo & Waite, 2014; Musich et al., 2015; Ong et al., 2016; With this in mind, the purpose of this study was to examine
Perissinotto et al., 2012). However, most of these studies exam- loneliness and social isolation in a large older adult population,
ined the two constructs independently of each other. and to serve as one of the first studies to examine both con-
For instance, loneliness has shown independent associations structs in a cumulative manner. Specifically, this study aimed to
with depression, poor sleep, hypertension, cognitive decline, 1) describe the overlap between loneliness and social isolation
and other poor health outcomes (Hackett et al., 2012; Hawkley by identifying those who are both lonely and socially isolated,
et al., 2010; MacLeod et al., 2018; Musich et al., 2015; Perissinotto lonely only, socially isolated only, or neither; and 2) examine the
et al., 2012; Steptoe et al., 2004). Meanwhile, social isolation has cumulative effect of loneliness and social isolation on various
been associated with increased cardiovascular disease, inflam- health outcomes. Outcomes of interest included QOL, health-
matory processes, increased dementia risk, disability, cognitive care utilization and medical costs. Based on the research liter-
decline, mortality, and reduced quality of life (QOL) in indepen- ature, we hypothesized that study participants who were both
dent analyses (Barth et al., 2010; Bassuk et al., 1999; Grant et al., lonely and socially isolated would be more likely to be older,
2009; Heffner et al., 2011; Shankar et al., 2011; Steptoe et al., female, with poorer health and greater risk factors compared
2013). In addition, social isolation puts older adults at an to adults who were only lonely, socially isolated, or neither. In
increased risk for loneliness (Dickens et al., 2011; MacLeod et addition, study participants who were both lonely and socially
al., 2018; Masi et al., 2011). isolated would be more likely to have lower QOL, higher health-
Despite the awareness of loneliness and social isolation as care utilization, and higher medical costs.
serious independent health risks, the combined and cumulative
impact of these constructs has not been studied extensively. A
handful of studies have attempted to examine both loneliness Methods
and social isolation in the same analyses (Beller & Wagner, Study participants
2018a, 2018b; Donovan et al., 2017; Hakulinen et al., 2018;
Holwerda et al., 2014; Ong et al., 2016; Shankar et al., 2013; Approximately 5 million individuals are covered by an AARP®
Steptoe et al., 2013; Wilson et al., 2007). Specifically, these stud- Medicare Supplement Insurance Plan from UnitedHealthcare
ies have primarily modeled both loneliness and social isolation (UHC), herein referred to as AARP Medicare Supplement
as separate predictors of various health outcomes but have not insureds. These plans are offered in all 50 states, Washington
examined their cumulative effect. For instance, Steptoe et. al DC, and various US territories.
found that social isolation remained the strongest predictor of In 2018 and 2019, random samples of AARP Medicare
mortality as compared to loneliness when modeled together Supplement insureds, 65 years or older, with 12 months of con-
(Steptoe et al., 2013). To our knowledge, no study has examined tinuous coverage, were surveyed as a larger research effort to
the impact of having both loneliness and social isolation as a improve customer experience. Surveys were administered from
predictor variable. June through August of each year in which 16,000 AARP
Elsewhere, researchers have found that reduced QOL, Medicare Supplement insureds (per year) were mailed surveys
increased healthcare utilization, and overall higher medical using a nationally randomized methodology. In total, 8,672
costs can be attributed to loneliness and social isolation in participants completed surveys (4,696 respondents in 2018 and
joint analyses (Gerst-Emerson & Jayawardhana, 2015; Greysen 3,976 respondents in 2019), an overall 27% response rate. After
et al., 2013; Hawker & Romero-Ortuno, 2016; Jakobsson et al., accounting for duplicates (n = 4); eligibility and potential cost
2011; Shaw et al., 2017; Valtorta et al., 2018). Nevertheless, outliers (n = 53); and missing/incomplete survey responses
research exploring the outcomes of older individuals experi- (n = 1,621), 6,994 survey participants were included in this study
encing concurrent loneliness and social isolation remains lim- analysis. This study was approved by the New England
ited. It’s been suggested that the health risks associated with Institutional Review Board.
loneliness and isolation are equivalent to the well-established
detrimental effects of smoking and obesity (Holt-Lunstad et
al., 2010). Furthermore, loneliness and social isolation are par- Survey and data collection
ticularly problematic in old age due to decreasing economic
and social resources, functional limitations, the death of rela- Surveys were developed by UnitedHealthcare to assess cus-
tives and spouses, and changes in family structures and mobil- tomer experience and aspects of health including psychosocial
ity (Courtin & Knapp, 2017). Thus, interventions that promote and wellness constructs on a yearly basis. For this study, mea-
improving social connectedness and eliminating social barri- sures of loneliness and social networks (an indicator of social
ers could be extremely important in improving outcomes in isolation) were examined in relation to several other survey
older adults including promoting active aging (Stathi et components (e.g. quality of life), and administrative and medical
al., 2020). claims data.
 Aging & Mental Health 3

Loneliness scores indicating better physical and mental QOL. Cronbach’s

α = 0.99.
Loneliness was captured using the 3-item Revised University of
California, Los Angeles (UCLA-3) Loneliness Scale (Hughes et al.,
2004). The UCLA-3 asks how often respondents 1) feel left out, Demographics and socioeconomic factors
2) feel lack of companionship, and 3) feel isolated from others.
For each item, possible responses were: ‘never or hardly ever’ (3 Demographic factors included age and gender; socioeconomic
points), ‘some of the time’ (2 points), and ‘often’ (1 point). indicators were based on zip codes. Age groups were defined
Responses were then reverse-coded and summed to a score as 64–69, 70–74, 75–79, 80–84, and ≥85 years. Geographic
ranging from 3 to 9, with higher scores indicating greater lone- regions (Northeast, South, Midwest, and West), Rural Urban
liness. Cronbach’s α for this measure was 0.73. For the purpose Commuting Area (RUCA) (e.g. urban, suburban, rural), and low,
of this study, we classified participants as ‘lonely’ with a score medium, and high minority areas and medium household
of 6 or higher, which is consistent with participants who income were geocoded from respondents’ zip codes.
responded ‘some of the time’ or ‘often’ to at least two of the three
components.
Health status

Social isolation Medical claims data were used to describe health status using
the Charlson Comorbidity Index (CCI) (Charlson et al., 1987;
Social isolation was based on questions from an adapted Social Sundararajan et al., 2004). The CCI focuses on the presence and
Network Index (SNI) (Musich et al., 2019), which counts the num- quantity of specific comorbid conditions. Higher CCI scores
ber of social connections. Specifically, five questions were used indicate a greater number of comorbidities and poorer overall
to assess SNI: 1) In a typical week, how many times do you talk health status. Finally, the number of emergency room (ER) visits
on the telephone with family, friends, or neighbors?, 2) In a typ- and inpatient (IP) admissions within the past 12 months were
ical week, how often do you get together with friends or rela- collected as well as total medical cost from participants’ medi-
tives, such as going out together or visiting in each other’s cal claims.
homes?, 3) How often do you attend church or religious services
or activities of your religious organization (per month)?, 4) How
often do you attend meetings of the club or organizations you Statistical analyses
belong to (per month)?, and 5) Are you married or living
together with someone in a partnership? Responses to ques- Prior to initiating primary analyses, survey respondents and
tions 1–4 were scored 0 times = 0, 1–2 times = 1, 3–4 times = 2, non-respondents were assessed to account for any potential
and 5 or more times = 3. Responses to married or living together selection bias; however, no significant differences in character-
were scored yes = 1 and no = 0. All responses were summed for istics emerged. Participants were then grouped into four cate-
a score ranging from 0 to 13, with a high score indicating greater gories based on their loneliness and social isolation
social diversity, and a lower score indicating greater social iso- classifications using the UCLA-3 Loneliness Scale and SNI. Thus,
lation. Categories of social networks were formed based on the participants were categorized into groups aligned with their
SNI score: 0–4 represented a ‘limited’ social network, 5–7 a overlap of loneliness and social isolation: lonely only, socially
‘medium’ social network, and ≥ 8 a ‘diverse’ social network (Aung isolated only, both lonely and socially isolated, and neither
et al., 2016; Musich et al., 2019). For this study, ‘socially isolated’ (Figure 2). Bivariate and adjusted associations between groups,
participants were defined by SNI scores of 0–4, distinguishing sociodemographic status, and healthcare characteristics were
those participants with limited social networks. then examined. Descriptive analyses for respondents’ loneliness
and social isolation included basic summary statistics and bivar-
iate comparisons across all respondent demographics and sur-
Depression vey responses. For QOL and total medical costs, multivariate
regression models were assessed and adjusted for sociodemo-
Depression was measured using the self-reported Patient graphic characteristics (e.g. age, gender) and health status (CCI).
Health Quesionnaire-2 (PHQ-2) (Kroenke et al., 2003), a 2-item Multivariate logistic models were performed for ER visits and IP
depression screening tool that is well validated and used fre- admissions. For all models, neither was designated as the
quently in clinical settings. The 4-level responses were scored
0 (not at all) to 3 (nearly every day) for a total score range of 0
to 6. The score was then dichotomized as not depressed (PHQ-2
score < 3) and depressed (PHQ-2 score ≥ 3). Cronbach’s α = 0.75.

Quality of life
Quality of life (QOL) was assessed using the 12-item Veteran’s
RAND (VR-12) (Selim et al., 2009). The VR-12 is a validated gen-
eral health questionnaire resulting in a measure asking partic-
ipants about their health-related QOL in the previous four
weeks. Two subscales scales were derived from this measure:
physical component (PCS) and mental component (MCS) scores. Figure 2.  Distribution of loneliness and social isolation in our sample of older
These measures are scored on a scale of 0 to 100, with higher adults (N = 6,994). Note: 60.5% were Neither (n = 4,232).
4 T. L. BARNES ET AL.

reference group. All analyses were completed using SAS also more likely to have an IP admission (OR = 1.36, 95% CI: 1.07,
Enterprise Guide Version 7.1 (SAS Institute Inc., Cary, NC, USA). 1.72) compared those who were neither. Finally, participants
who were both lonely and socially isolated had greater medical
costs in adjusted models; however, the difference was only mar-
Results ginal with a p-value of 0.060.
Demographics and health status
Among survey participants, 9.8% (n = 684 of 6,994) were classi- Quality of life
fied as lonely only, 20.6% (n = 1,439 of 6,994) as social isolated
only, 9.1% (n = 639 of 6,994) as both lonely and socially isolated, Mental well-being as indicated by the VR-12 measures showed
and 60.5% (n = 4,232 of 6,994) as neither (Figure 1 and Table 1). that participants who were both lonely and socially isolated had
Respondents were primarily female (55.0%, n = 3,843 of 6,994), lower scores on average (mean = 43.2, SD = 11.1) compared to
70–74 years of age (27.1%, n = 1,899 of 6,994), and residing in participants in the socially isolated group (mean = 54.7, SD =
an urban area (70.5%, n = 4,931 of 6,994). Approximately 54% 8.7) or neither group (mean = 56.8, SD = 6.4) in bivariate anal-
(n = 3,772 of 6,994) of participants lived in communities desig- yses (Table 2). Interestingly, socially isolated only participants
nated as low minority (e.g. White) and 37.2% (n = 2,601 of 6,994) had the lowest average physical well-being score (mean = 38.5,
and 48.3% (n = 3,380 of 6,994) lived in medium- and high-in- SD = 12.5) as compared to the other three groups. When adjust-
come zip codes, respectively. Thirty-seven percent of partici- ing for demographic characteristics and health status, this rela-
pants had no co-morbidities based on CCI. The average CCI tionship remained consistent (Table 4). Finally, for both mental
score was 1.93 (SD = 2.27) (Table 2). and physical well-being, participants who were both lonely and
Significant differences by age, gender, region, and health socially isolated had significantly lower scores, followed by
status were present in bivariate analyses across groups (Table those who were lonely only, and then those who were socially
1). Overall, participants who were both lonely and socially iso- isolated only.
lated were older and less healthy as compared to other groups.
Furthermore, a higher proportion of participants (22.4%,
143/639) were both lonely and socially isolated in the oldest Discussion
age category (≥ 85 years). Additionally, there was a higher per-
centage of female participants compared to males in the lonely In recent months, the COVID-19 pandemic has highlighted the
only, both lonely and socially isolated, or neither groups. Only critical need for interventions to address loneliness and social
the socially isolated only group had a higher percentage of isolation among vulnerable older adults (Health Affairs 2020).
males (55.0%, 792/1,439 vs. 45.0%, 647/1,439). Finally, there Guidelines during the pandemic have recommended that older
were no significant differences by other factors including adults stay home as much as possible to avoid the risk of serious
minority designation, median household income, or RUCA. illness. While these recommendations are warranted, the lasting
impacts of physical and social distancing on older adults’ mental
health could be significant, including increased loneliness and
Loneliness and SNI scores social isolation (Wu, 2020).
In this study conducted in 2018–2019 prior to the pandemic,
Unadjusted, bivariate results for quantitative characteristics are we observed greater risks among participants experiencing
displayed in Table 2. Of survey participants who were both both constructs compared to those with either loneliness, social
lonely and socially isolated, a higher mean UCLA-3 Loneliness isolation, or neither. Specifically, we determined that nearly 40%
score (mean = 6.96, SD = 1.11) was observed along with a lower of participants were either lonely, socially isolated, or both, sim-
SNI (mean = 2.83, SD = 1.1) on average compared to the other ilar to prevalence rates published elsewhere (Cudjoe et al., 2020;
three groups. In contrast, participants with neither loneliness NASEM 2020; Perissinotto et al., 2012). Notably, 9.1% of all par-
nor social isolation had a lower UCLA-3 Loneliness score (mean ticipants in the current study were classified as both lonely and
= 3.78, SD = 0.67) and higher SNI (mean = 7.26, SD = 1.87). socially isolated, which is important considering that most pre-
vious studies have focused on the distribution of those who are
either versus both (NASEM 2020).
Healthcare utilization and costs
Our key findings align with previous studies assessing the
Approximately 30% of respondents on average had an ER visit impacts of loneliness or social isolation separately (Dickens et
within the past year, while only 12% had an IP hospitalization al., 2011; Musich et al., 2015; Ong et al., 2016; Steptoe et al.,
(Table 2). Unadjusted analyses revealed a higher percentage of 2013); for instance, emerging evidence has suggested that
ER visits on average among participants who were either lonely social isolation and loneliness can have a negative effect on
only (34%) or both lonely and socially isolated (34%) compared QOL (Musich et al., 2015; NASEM 2020). However, our results
to neither (29%), while those who were socially isolated had a demonstrate that the cumulative effect may be greater than
much lower percentage of ER visits on average (26%). just one factor alone. In fact, the negative impact on selected
Participants who were both lonely and socially isolated had the health outcomes including QOL was more pronounced in par-
highest percentage of IP admissions (18%), as well as the high- ticipants who were both lonely and socially isolated compared
est total medical cost (mean=$13,008, SD=$17,137). to those who were only lonely, only socially isolated, or neither.
When controlling for multiple sociodemographic character- Aside from the health indicators of loneliness and social iso-
istics and health status, participants who were socially isolated lation, both conditions may also significantly impact healthcare
were significantly less likely to have an ER visit (OR = 0.83, 95% utilization and medical costs; however, research on these out-
CI: 0.72, 0.95) compared to participants who were neither (Table comes has been limited, with mixed results. We observed that
3). Participants who were both lonely and socially isolated were participants who were both lonely and socially isolated had the
Table 1.  Bivariate, unadjusted relationship between socio-demographic and health characteristics and loneliness and social isolation (N = 6,994).
Overall Lonely only Socially isolated only Both Neither
N % n % n % n % n % P-valuea
6,994 684 9.8 1,439 20.6 639 9.1 4,232 60.5
Age
  65–69 years 1312 18.8% 93 13.6% 306 21.3% 105 16.4% 808 19.1% <0.001
  70–74 years 1899 27.1% 169 24.7% 403 28.0% 151 23.6% 1176 27.8%
  75–79 years 1548 22.1% 145 21.2% 301 20.9% 137 21.4% 965 22.8%
  80–84 years 1155 16.5% 141 20.6% 186 12.9% 103 16.1% 725 17.1%
  ≥85 years 1080 15.4% 136 19.8% 243 16.9% 143 22.4% 558 13.2%
Gender
 Male 3151 45.0% 214 31.3% 792 55.0% 250 39.1% 1895 44.7% <0.001
 Female 3843 55.0% 470 68.7% 647 45.0% 389 60.9% 2337 55.3%
Minority (proxy by zip code)
  Low 3772 53.9% 367 53.7% 758 52.7% 336 52.6% 2311 54.6% 0.470
  Medium 2994 42.8% 291 42.5% 642 44.6% 284 44.4% 1777 42.0%
  High 228 3.3% 26 3.8% 39 2.7% 19 3.0% 144 3.4%
Median HH income (proxy by zip code)
  Low 1013 14.5% 120 17.6% 202 14.0% 96 15.0% 595 14.1% 0.050
  Medium 2601 37.2% 272 39.8% 519 36.1% 231 36.2% 1579 37.3%
  High 3380 48.3% 292 42.6% 718 49.9% 312 48.8% 2058 48.6%
Region
  Northeast 1719 24.6% 158 23.0% 355 24.7% 187 29.3% 1019 24.1% 0.000
  Midwest 1381 19.7% 132 19.3% 256 17.8% 120 18.8% 873 20.6%
  South 2411 34.5% 255 37.3% 473 32.9% 201 31.5% 1482 35.0%
  West 1483 21.2% 139 20.4% 355 24.7% 131 20.5% 858 20.3%
Rural urban commuting area
  Urban 4931 70.5% 472 69.0% 1009 70.1% 454 71.0% 2996 70.8% 0.870
  Suburban 1125 16.1% 108 15.8% 237 16.5% 102 16.0% 678 16.0%
  Rural 938 13.4% 104 15.2% 193 13.4% 83 13.0% 558 13.2%
Charlson comorbidity score
  No comorbidity 2586 37.0% 211 30.9% 545 37.9% 150 23.5% 1680 39.7% <0.001
  CCI score (1–2) 2447 35.0% 257 37.5% 475 33.0% 235 36.8% 1480 35.0%
  CCI score (3–4) 1146 16.4% 129 18.9% 244 17.0% 131 20.5% 642 15.2%
  CCI score (≥5) 815 11.6% 87 12.7% 175 12.2% 123 19.2% 430 10.2%
a
Chi-square test for categorical variables, significance at p-value <0.05.
CCI = Charlson Comorbidity Index.

Table 2.  Bivariate, unadjusted associations between healthcare outcomes and loneliness and social isolation (N = 6,994).
Overall Lonely only Social isolated only Both Neither
n 6,994 n 684 n 1,439 n 639 n 4,232
Mean SD Mean SD Mean SD Mean SD Mean SD P-valuea
UCLA-3 Loneliness score, Range: 3–9 4.04 1.50 6.49 0.82 3.55 0.76 6.96 1.11 3.78 0.67 <0.001
Social network score, Range: 0–13 5.95 2.47 6.62 1.59 3.2 0.94 2.83 1.1 7.26 1.87 <0.001
Mental component score (VR-12-MCS), Range: 0-100 54.2 8.8 47.4 9.5 54.7 8.7 43.2 11.1 56.8 6.4 <0.001
Physical component score (VR-12-PCS), Range: 0–100 43.9 11.2 41.0 11.5 38.5 12.5 46.6 9.8 47.6 10.3 <0.001
Charlson comorbidity score 1.93 2.27 1.97 2.19 1.87 2.37 2.49 2.47 1.67 2.12 <0.001
PHQ-2 depression score, Range: 0–6 0.66 1.18 1.51 1.42 0.59 1.09 2.19 1.67 0.32 0.74 <0.001
Emergency department visit, % with ≥ 1 visits 0.30 0.46 0.34 0.47 0.26 0.44 0.34 0.47 0.29 0.45 0.005
Aging & Mental Health

Inpatient admission, % with ≥ 1 admission 0.12 0.33 0.13 0.33 0.12 0.33 0.18 0.38 0.11 0.31 0.147
Total medical cost (in $) $9,761 $15,544 $10,350 $15,695 $9,476 $15,643 $13,008 $17,137 $9,292 $15,175 <0.001
a
Analysis of Variance (ANOVA) performed for difference between continuous variables, significance at p-value <0.05.
5
6 T. L. BARNES ET AL.

Table 3.  Adjusted association between healthcare utilization and social isola- skill-building that may be more beneficial for social isolation.
tion and loneliness (N = 6,994). However, few studies have demonstrated strong evidence of
ER visits IP admissions a significant and lasting effect on loneliness (NASEM 2020).
Odds 95% confidence Odds 95% confidence Elsewhere, efforts to address loneliness and social isolation
ratio limits ratio limits
through mindfulness strategies have been attempted, show-
Lonely only 1.151 0.963 1.374 0.979 0.751 1.262
Socially isolated 0.828 0.719 0.952 1.083 0.889 1.313
ing in certain cases that individuals who receive mindfulness
Only training subsequently report reduced loneliness (Gilmartin
Both 1.096 0.911 1.314 1.360 1.069 1.720 et al., 2017; Lindsay et al., 2019; Tkatch et al. 2020). However,
Neither – – – – – –
the potential of mindfulness intervention strategies to
Multivariate logistic regression models performed adjusted for socio-demo-
graphic characteristics and health status, Neither designated as reference
improve both loneliness and social isolation remains
group. unproven; thus, further research is warranted to examine the
ER = Emergency Room. impact on each construct.
IP = Inpatient.
The key strengths of this study include results from a large
random sample of older adults in the US, as compared to similar
highest rate of ER visits compared to participants who were studies performed in other countries (NASEM 2020). In addition,
socially isolated only, or neither. However, those who were only this research provides assessment of both loneliness and social
socially isolated versus both had significantly fewer ER visits, isolation in one analysis, utilizing robust data encompassing
perhaps suggesting a consequence of decreased outings from both psychosocial and claims-based measures. As such, this
home among socially isolated older adults. Finally, we observed study adds to growing evidence on the importance of main-
that participants who were both lonely and socially isolated had taining strong social connections to support optimal health
a higher rate of IP admissions, supporting previous studies outcomes within older age groups.
demonstrating that both loneliness and social isolation are This study has some limitations, including a low response
associated with increased hospitalizations among older adults rate, and potential vulnerability to unaccounted selection bias.
(Gerst-Emerson & Jayawardhana, 2015; Greysen et al., 2013; Further, this study was conducted in a population of AARP
Jakobsson et al., 2011). Medicare Supplement insureds which may not generalize to all
One noteworthy study examined the medical costs associ- older adults or other Medicare Supplement beneficiaries in the
ated with experiencing loneliness or social isolation as com- US Although this study utilized a randomized sampling meth-
pared to having neither. Researchers found that socially isolated odology including assessment of respondents and non-respon-
people incurred higher annual healthcare expenses compared dents, there still could be some unaccounted bias. That said,
to those with greater social networks (Shaw et al., 2017). Further, our response rate of 27% is comparable and not uncommon in
researchers concluded that social isolation, and not loneliness, mailed surveys conducted among older adults (Edelman et al.,
was significantly associated with higher costs in adjusted anal- 2013). Other limitations include the metrics capturing loneliness
yses including both as predictors. In our study, we found that and social isolation. Although, the ULCA-3 Loneliness Scale and
participants who were both lonely and social isolated had the SNI have been validated and successfully used in many stud-
higher medical costs; however, the finding was only marginally ies, there is potential for misclassification bias due to the nature
significant after controlling for demographic characteristics and of the survey questions and recall bias by study participants. In
health status. addition, older age can affect self-report responses due to
Various intervention strategies to address loneliness and changes in cognitive and communicative functioning (Knäuper
social isolation have been attempted prior to the COVID-19 et al., 2016). Meanwhile, we did not have a full assessment of
pandemic (Cacioppo et al., 2015; Masi et al., 2011). Common depression, which has been found to be highly associated with
interventions have included efforts to improve social skills, both constructs. For this reason, analyses were limited when
social support, and provide opportunities for social interaction using the PHQ-2. Finally, classification of participants into
(MacLeod et al., 2018). In addition, interventions focused on ‘lonely’ and ‘socially isolated’ groups is just one of several poten-
volunteering, physical activity, community engagement, and tial options of assessment. Altering the classification of loneli-
others integrating multi-dimensional components have shown ness or social isolation could impact the magnitude of
potential effectiveness and feasibility among older adults associations. Future analyses could explore different cut points
(MacLeod et al., 2018; Musich et al., 2015). and continuous metrics.
The most successful interventions have included several key In this study, we sought to explore the cumulative effect of
factors in combination, including active participation of partic- both loneliness and social isolation among older adults.
ipants, integration of education and/or skills training, and group Previous studies have addressed these constructs separately or
interaction (NASEM 2020). interchangeably, despite the different definitions and
Despite these strategic efforts, the subjective nature of approaches needed. In this study, we observed greater risks
loneliness may require a more cognitive-based approach of among participants who were both lonely and socially isolated,
intervention as compared to social prescribing or demonstrating the potential combined negative outcomes of

Table 4.  Adjusted association between healthcare cost, quality of life, and social isolation and loneliness (N = 6,994).
Mental well-being (VR-12-MCS) Physical well-being (VR-12-PCS) Total medical cost
Beta SE p-value Beta SE p-value Beta SE p-value
Lonely only −9.42 0.27 <0.001 −3.84 0.36 <0.001 $130.44 574.95 0.821
Socially isolated only −2.74 0.30 <0.001 −2.53 0.39 <0.001 −$395.46 425.99 0.353
Both −14.15 0.39 <0.001 −7.62 0.51 <0.001 $1,116.61 593.92 0.060
Neither – – – – – – – – –
Multivariate regression models performed adjusted for socio-demographic characteristics and health status, Neither designated as reference group.
 Aging & Mental Health 7

these two constructs later in life. Ultimately, interventions older U.S. adults. International Journal of Geriatric Psychiatry, 32(5), 564–
addressing both loneliness and social isolation in combination 573. https://doi.org/10.1002/gps.4495
Drageset, J., Eide, G. E., Kirkevold, M., & Ranhoff, A. H. (2013). Emotional
could have a substantial impact within this population.
loneliness is associated with mortality among mentally intact nursing
home residents with and without cancer: A five-year follow-up study.
Journal of Clinical Nursing, 22(1-2), 106–114. https://doi.org/10.1111/
Disclosure statement j.1365-2702.2012.04209.x
Edelman, L. S., Yang, R., Guymon, M., & Olson, L. M. (2013). Survey methods
No potential conflict of interest was reported by the authors. and response rates among rural community dwelling older adults.
Nursing Research, 62(4), 286–291. https://doi.org/10.1097/NNR.
0b013e3182987b32
Gerst-Emerson, K., & Jayawardhana, J. (2015). Loneliness as a public health
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