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class="page-header default-page-header wpex-relative wpex-mb-40 wpex-surface-2 wpex-py-20 wpex-border-t wpex-border-b wpex-border-solid wpex-border-surface-3 wpex-text-2 wpex-supports-mods"> <div class="page-header-inner container"> <div class="page-header-content"> <h1 class="page-header-title wpex-block wpex-m-0 wpex-text-2xl"> <span>The importance of social connection: Julianne Holt-Lunstad, Thomas Cudjoe, & Carla Perissinotto</span> </h1> </div></div> </header> <nav class="site-breadcrumbs position-page_header_after wpex-text-4 wpex-text-sm wpex-py-15" aria-label="You are here:"><div class="container"><span class="breadcrumb-trail wpex-clr"><span class="trail-begin"><a href="https://geripal.org/" rel="home"><span>Home</span></a></span><span class="sep sep-1"> <span class="ticon ticon-caret-right" aria-hidden="true"></span> </span><span class="trail-post-categories"><span class="term-1"><a href="https://geripal.org/category/all-posts/"><span>All Posts</span></a></span>, <span class="term-572"><a href="https://geripal.org/category/chapliancy/"><span>Chapliancy</span></a></span>, <span class="term-358"><a href="https://geripal.org/category/geriatrics/"><span>Geriatrics</span></a></span>, <span class="term-361"><a href="https://geripal.org/category/hospice/"><span>Hospice</span></a></span></span><span class="sep sep-2"> <span class="ticon ticon-caret-right" aria-hidden="true"></span> </span><span class="trail-end">The importance of…</span></span></div></nav> <div id="content-wrap" class="container wpex-clr"> <div id="primary" class="content-area wpex-clr"> <div id="content" class="site-content wpex-clr"> <article id="single-blocks" class="single-blog-article wpex-first-mt-0 wpex-clr"> <div id="post-media" class="single-blog-media single-media wpex-relative wpex-mb-20"> <div id="blog-post-video"><span class="wpex-responsive-media"><iframe title="The importance of social connection: Julianne Holt-Lunstad, Thomas Cudjoe, & Carla Perissinotto" width="980" height="551" src="https://www.youtube.com/embed/6SZKxVPnutg?feature=oembed" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen></iframe></span></div></div> <ul class="meta wpex-text-sm wpex-text-3 wpex-mb-20 wpex-last-mr-0"> <li class="meta-date"><span class="meta-icon ticon ticon-calendar-o" aria-hidden="true"></span><time class="updated" datetime="2023-04-13">April 13, 2023</time></li> <li class="meta-author"><span class="meta-icon ticon ticon-user-o" aria-hidden="true"></span><span class="vcard author"><span class="fn"><a href="https://geripal.org/author/14150060020743621628/" title="Posts by Alex Smith" rel="author" itemprop="author" itemscope="itemscope" itemtype="https://schema.org/Person">Alex Smith</a></span></span></li> <li class="meta-category"><span class="meta-icon ticon ticon-folder-o" aria-hidden="true"></span><span><a class="term-1" href="https://geripal.org/category/all-posts/">All Posts</a>, <a class="term-572" href="https://geripal.org/category/chapliancy/">Chapliancy</a>, <a class="term-358" href="https://geripal.org/category/geriatrics/">Geriatrics</a>, <a class="term-361" href="https://geripal.org/category/hospice/">Hospice</a></span></li></ul> <div class="single-blog-content single-content entry wpex-mt-20 wpex-mb-40 wpex-clr"><div class="wpb-content-wrapper"><div class="vc_row wpb_row vc_row-fluid no-bottom-margins"><div class="wpb_column vc_column_container vc_col-sm-12"><div class="vc_column-inner"><div class="wpb_wrapper"> <div class="wpb_raw_code wpb_raw_html wpb_content_element vc_custom_1681342787070" > <div class="wpb_wrapper"> <iframe title="Libsyn Player" style="border: none" src="//html5-player.libsyn.com/embed/episode/id/26526030/height/90/theme/custom/thumbnail/yes/direction/backward/render-playlist/no/custom-color/00548f/" height="90" width="100%" scrolling="no" allowfullscreen webkitallowfullscreen mozallowfullscreen oallowfullscreen msallowfullscreen></iframe> </div> </div> <div class="vc_tta-container" data-vc-action="collapse"><div class="vc_general vc_tta vc_tta-tabs vc_tta-color-sky vc_tta-style-flat vc_tta-shape-square vc_tta-spacing-1 vc_tta-o-no-fill vc_tta-tabs-position-top vc_tta-controls-align-left"><div class="vc_tta-tabs-container"><ul class="vc_tta-tabs-list"><li class="vc_tta-tab vc_active" data-vc-tab><a href="#summary" data-vc-tabs data-vc-container=".vc_tta"><span class="vc_tta-title-text">Summary</span></a></li><li class="vc_tta-tab" data-vc-tab><a href="#transcript" data-vc-tabs data-vc-container=".vc_tta"><span class="vc_tta-title-text">Transcript</span></a></li></ul></div><div class="vc_tta-panels-container"><div class="vc_tta-panels"><div class="vc_tta-panel vc_active" id="summary" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#summary" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">Summary</span></a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <p><span style="font-weight: 400;">Social connections impact our health in profound ways, whether it is the support we receive from family and friends in navigating serious illness, the joy from shared social activities, or connecting with our community. Experiencing </span><b>social isolation</b><span style="font-weight: 400;">, the objective lack of contact with friends, family, or the community, or </span><b>loneliness</b><span style="font-weight: 400;">, the subjective feeling of lacking companionship or feeling left out, may be signs that our overall social life is struggling. But, should we as clinicians care about the social lives of our patients? Are there meaningful ways of assessing loneliness and social isolation in clinical settings and connecting patients with interventions? How can public health and policy experts address these needs, particularly in light of the COVID-19 pandemic which turned our social lives upside down?</span></p> <p><span style="font-weight: 400;">On today today鈥檚 podcast, we are joined by guest host and UCSF geriatrician Ashwin Kotwal as we welcome three renowned scholars in the field: 1) Dr. Julianne Holt-Lunstad, Professor of Psychology and Neuroscience at Brigham Young University, an international expert on loneliness, social isolation, and social interventions, who has served on the National Academy of Sciences committee on social isolation and loneliness and advised the UK Loneliness Campaign, 2) Dr. Thomas Cudjoe, Assistant Professor of Medicine at Johns Hopkins University, who has conducted groundbreaking work on the measurement of social isolation and mechanisms of impact on health, and 3) Dr. Carla Perissinotto, Professor of Medicine at UCSF, who has pioneered the clinical and policy approach to addressing loneliness and social isolation.聽</span><span style="font-weight: 400;">聽聽</span></p> <p><strong>We talk about: 聽</strong></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Their personal and clinical inspiration for studying loneliness and social isolation, and hurdles encountered in bringing these needs to the clinical world.聽</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">The Listening “EAR” approach that simplifies assessment of loneliness and social isolation in clinical settings, and other practical pointers.聽</span></li> </ul> <p><strong>Check out some of their recent work, including:</strong></p> <ul> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Dr. Holt-Lunstad鈥檚 and Dr. Perissinotto鈥檚 powerful </span><a href="https://www.nejm.org/doi/full/10.1056/NEJMp2208029"><span style="font-weight: 400;">perspective piece in the New England Journal of Medicine</span></a><span style="font-weight: 400;"> which provides a clinical framework for addressing loneliness and social isolation.聽</span></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Dr. Cudjoe鈥檚 recent work demonstrating the impact of </span><a href="https://pubmed.ncbi.nlm.nih.gov/36628523/"><span style="font-weight: 400;">social isolation on dementia risk</span></a><span style="font-weight: 400;">, </span><a href="https://pubmed.ncbi.nlm.nih.gov/35415872/"><span style="font-weight: 400;">populations at risk</span></a><span style="font-weight: 400;">, and how our social lives </span><a href="https://pubmed.ncbi.nlm.nih.gov/34698366/"><span style="font-weight: 400;">“getting under our skin.”</span></a></li> <li style="font-weight: 400;" aria-level="1"><span style="font-weight: 400;">Dr. Kotwal’s </span><a href="https://pubmed.ncbi.nlm.nih.gov/36420540/"><span style="font-weight: 400;">work showing how social isolation impacts end-of-life health care use</span></a><span style="font-weight: 400;">, including hospice and acute care.</span></li> </ul> <p><span style="font-weight: 400;">We touch briefly on (and build on) topics discussed in prior podcasts such as loneliness during the pandemic. Tune in to hear Alex鈥檚 acoustic rendition of Outkast鈥檚 Hey Y鈥橝ll! </span><span style="font-weight: 400;">聽</span></p> <p><span style="font-weight: 400;">-Ashwin Kotwal</span></p> </div> </div> </div></div><div class="vc_tta-panel" id="transcript" data-vc-content=".vc_tta-panel-body"><div class="vc_tta-panel-heading"><h4 class="vc_tta-panel-title"><a href="#transcript" data-vc-accordion data-vc-container=".vc_tta-container"><span class="vc_tta-title-text">Transcript</span></a></h4></div><div class="vc_tta-panel-body"> <div class="wpb_text_column wpb_content_element" > <div class="wpb_wrapper"> <p><b>Eric:</b> Welcome to the GeriPal podcast. This is Eric Widera.</p> <p><b>Alex:</b> This is Alex Smith.</p> <p><b>Eric:</b> And Alex, we got a lot of people out with us, including someone between us.</p> <p><b>Alex:</b> We have a connected group of people here. First, I’ll introduce Julianne Holt-Lunstad, who is Professor of Psychology and Neuroscience at Brigham Young University and also the scientific chair for the Foundation for Social Connection.</p> <p>Welcome to the GeriPal podcast, Julianne.</p> <p><b>Julianne:</b> Thanks for having me on.</p> <p><b>Alex:</b> We’re also delighted to welcome Thomas Cudjoe, who is Assistant Professor of Medicine at Johns Hopkins and a geriatrician.</p> <p>Thomas, welcome to the GeriPal podcast.</p> <p><b>Thomas:</b> Hey, how are you all?</p> <p><b>Alex:</b> Good, good. Good to have you on.</p> <p>We’re also delight to welcome Carla Perissinotto, who is a geriatrician palliative care doc at UCSF in the division of geriatrics.</p> <p>Welcome back to the GeriPal podcast.</p> <p><b>Carla:</b> Thanks so much. Nice to see you all.</p> <p><b>Alex:</b> And we’re delighted to welcome back Ashwin Kotwal, who is an assistant professor medicine and geriatrician and palliative care doc in the UCSF division of Geriatrics, who’s the guest host today.</p> <p>Welcome back, Ashwin.</p> <p><b>Ashwin Kotwal:</b> Excited to be back.</p> <p><b>Eric:</b> Now, it’s interesting. This topic we’re going to be covering, social isolation and loneliness, it’s great that for this podcast we have so many people with us today.</p> <p>But before we jump into that, I think Thomas, you have a song request for Alex.</p> <p><b>Thomas:</b> Yeah, yeah. Was hoping to hear Hey, Ya by OutKast.</p> <p><b>Eric:</b> Can I ask why’d you pick this song?</p> <p><b>Thomas:</b> Oh, I grew up in Georgia and OutKast was pretty big during my childhood. I thought it was a song that people would know and be familiar to others, so wanted something that could have meaningful connection to others.</p> <p><b>Alex:</b> Great. All right. I did say acoustic guitar, so we’re going to do an acoustic version of this. Here we go.</p> <p>(Alex singing)</p> <p>“My baby don’t around because she loves me so, and this, I know for sure. But does she really wanna but can’t stand to see me walking out that door?</p> <p>Can’t stand to fight the feeling because the thought alone is killing me right now. But thank God for Mom and Dad for sticking to together ’cause we don’t know how.</p> <p>Hey ya! Hey ya! Hey ya! Hey ya!”</p> <p>You’ll have to wait till the end for the shake it like a Polaroid picture part [laughter] That’ll come at the end.</p> <p><b>Eric:</b> I feel like resurgence is not the right word, but social isolation and loneliness seems to be a hot topic. I think in part because the entire world has experienced some component of social isolation and loneliness in the last three years during this pandemic.</p> <p>I don’t remember ever being taught about these words in med school.</p> <p><b>Alex:</b> No.</p> <p><b>Eric:</b> Fellowship.</p> <p><b>Alex:</b> No.</p> <p><b>Eric:</b> Residency, anything.</p> <p><b>Alex:</b> No, no.</p> <p><b>Eric:</b> It’s really just lately.</p> <p>I’m going to start off with Julianne. How did you get interested in this topic? Because you’ve been doing this for a while.</p> <p><b>Julianne:</b> Yes, I have. Yeah, I’ve been studying this for now over two decades. Of course, I’m not the first one to be working on this topic. I mean, the research has been around for a long time.</p> <p>I initially got into it because I was really looking at the psychophysiology of stress, and so how stress affects our health and how relationships were always a component of that. Whether it be how our connections to others help us cope with stress, or lacking connections can be a source of stress, or even how our relationships themselves can be a source of stress.</p> <p>But then recognizing that our relationships impact our health even outside the context of stress. And so it just evolved over time.</p> <p><b>Eric:</b> Yeah. Do you feel like more people are interested in this topic of late?</p> <p><b>Julianne:</b> It’s interesting because I think I read somewhere that a finding in science often takes about, on average, 17 years to make it into medical practice.</p> <p><b>Eric:</b> You’ve timed it perfectly. We’ll talk about is it in medical practice yet? We may got a couple more years left to…</p> <p><b>Julianne:</b> Exactly.</p> <p>But it’s interesting because I started seeing, even though for instance I was working on this much earlier, but I published my large meta-analysis linking this to risk for premature mortality back in my first one in 2010. And then the second one in 2015.</p> <p>It was probably around, I would say, 2017 when I started seeing a lot of interest and starting to see things like the UK Minister for Loneliness. Many people starting to talk about loneliness epidemic.</p> <p>And so there started to be a bit of more interest prior to the pandemic, but certainly, as you say, now we’ve all felt it a bit in the last past or the last three years for sure.</p> <p><b>Eric:</b> How about you, Thomas? How’d you get interested in this as a topic?</p> <p><b>Thomas:</b> Yeah, so I think it was probably two occurrences that are pretty fixated in my mind. I moved to Baltimore in 2015 and did clinical fellowship in geriatrics.</p> <p>At the time in one of my first few rotations, I was out doing house calls and began to see a patient over and over the course of the academic year. Something about that patient stood out to me in terms of how myself, or my colleagues on our interdisciplinary team, felt that this patient would not let us leave her house. She tried to extend conversations beyond what was medically, I think, necessary for the encounter. Would go to the ED, call 911 and go to the ED, for reasons that weren’t medically necessary in many instances.</p> <p>It came after engaging her. Something about it wasn’t necessarily right in terms of her desire to be always with us.</p> <p>And so I began to think about the training that I had and that there was no mental health condition that was diagnosed. But think about other things that potentially were impacting her and began to try to research things.</p> <p>Really, only thing that I think was really in the biomedical health services literature at that time was probably Carla’s paper on loneliness. There wasn’t much at all.</p> <p>Then I think one of the other things that I think about, or occasions that occurred, is I was doing a health talk in a subsidized housing community. The older adults in that session were talking about how they didn’t feel connected to one another, even though they were in a congregate setting in that housing community. They didn’t feel connected to the people in their broader community.</p> <p>And so it was those two things that I think helped me begin thinking about this and realizing. Then of course learning about Julianne’s work and those and that of others is really I would test was what I got exposed to at the time. Has kept me interested, the patient experience and the older adults in the community, their experience.</p> <p><b>Eric:</b> Well, I wonder what would be helpful. It would be helpful for me because this is the second podcast on social isolation and loneliness that we…</p> <p>Second?</p> <p><b>Alex:</b> I think so.</p> <p><b>Eric:</b> Second podcast, I always forget the difference in the terms.</p> <p>Ashwin, can you give us a broad overview of how you think about social isolation and loneliness as far as definitions?</p> <p><b>Ashwin Kotwal:</b> Yeah. I feel a little weird jumping in on this topic because everybody here is such an expert. Feel free to chime in, everyone.</p> <p>There’s a lot of different definitions, but some of the ones I like the most. I think of loneliness as this subjective experience. The emotional distress that you feel when you lack companionship. You feel isolated from others. I say this all the time, but you can be in a crowded room and still feel lonely. People who have many children or who are even married may feel lonely.</p> <p>For isolation, I think of that as more of an objective experience. These are people who are really lacking contact from the rest of society. They may have few family members, live alone. They may not be able to go to church or go to other community activities. And so they really lack contact with society. And so you can be lonely or isolated, or you can be both. Often, these two things don’t travel together.</p> <p><b>Eric:</b> Thoughts from the rest of the group? Does that sound about right? Anything else you want to add?</p> <p>Carla, I’m going to go to you. I think the first time I heard about loneliness too was from your paper. Why’d you get interested in this?</p> <p><b>Carla:</b> Because I’m nuts.</p> <p><b>Eric:</b> Aside from that.</p> <p><b>Carla:</b> Because I was trying to make Ken Covinsky’s life more difficult. [laughter]</p> <p>So truth be told, I had to do some research as part of residency. I think very similar to Thomas’ experience, there were people in my own practice that I was seeing. I think my research interests always stemmed from what I see clinically and what’s going on that we’re not measuring.</p> <p>I think, just as you all started saying, these weren’t things that we were traditionally taught in medical school and residency. I’m also trained as an anthropologist, and so I think I’ve always really thought about health holistically in terms of where is the person situated in the context of their family, community, and world at large. Because our division of geriatrics has such expertise in secondary data analysis and how their retirement studies, can set me off on this task to go read the code books in HRS.</p> <p>I came across these questions on loneliness that I had never heard of. Just as Julianne said, there had been decades of work done before me. But this was really fascinating, and I thought, “I wonder if this is actually underlying some of our older adult experiences.”</p> <p>I’m ageist as a geriatrician that I like older people as I always say, not the younger folks. And so I was really thinking about why are some of my people that are hospitalized doing better than others? It wasn’t always explained just by their “traditional medical issues.”</p> <p>I think something Thomas just said is they were going off the traditional medical topics when I saw them. But yet those non-medical topics were actually where I felt like I was doing the best for my patients, was talking about their families and talking about their lives or talking about their isolation. That’s really what started me on this path.</p> <p><b>Eric:</b> What do we know about how common loneliness and social isolation is?</p> <p><b>Carla:</b> Depends on who you ask, and it depends on what study you look at, and depends on how it’s defined, and depends on how it’s measured.</p> <p><b>Eric:</b> You got an ish around that? Rough ish? Very common, very-</p> <p><b>Carla:</b> It is common. From Thomas’s work we know, I think it’s from your work, Thomas, that we say anywhere from one in four adults with isolation. My paper showed 43% of people experiencing some degree of loneliness, and some estimates saying about 10% of people in different setting exhibiting severe or extreme loneliness.</p> <p>But anyone else want to counteract some figures?</p> <p><b>Julianne:</b> I mean, you’re absolutely right in the sense of it depends on if you’re looking at any level of loneliness or more the severe end of loneliness.</p> <p>It also depends on if you’re looking at overall population or just older adults or just a certain age group. I’ve seen some as high as 75%.</p> <p>It really, again, depends on not only how it’s being defined but also how it’s being measured.</p> <p><b>Eric:</b> I guess it’s also, I’m just thinking about depression. Major depression is not just, “Do you feel sad today,” or, “Do you feel sad one day,” because people feel sad and then they don’t feel sad.</p> <p>I feel like I’m guessing the same thing with loneliness. You can feel lonely one day and not the other. How do people think about that from a research perspective as we try to get prevalence data? I could imagine there’s a lot of variability day to day with loneliness.</p> <p><b>Thomas:</b> Yeah, no, I mean I’ve been thinking about that a bit, of course from our longitudinal studies. These epidemiologic studies, which they do measurements once a year and some of them less often than that. How do we really come to conclusions about this?</p> <p>And so I mean, think we have to think about social isolation and loneliness like we think about other things that matter for our health. They’re dynamic circumstances. I think sometimes when we think about these social things or psychosocial things, we try think about them as these static things.</p> <p>But I think it’d be important as we advance in the science to think about these as dynamic states in which people may be move in and move out. Some of the risks really exist when they persist.</p> <p><b>Ashwin Kotwal:</b> Yeah, and Thomas, I know this is something we’ve talked about as a group too, which is how do you translate some of these scales that we use in large studies to our clinical practice?</p> <p>I’m wondering, you talked about that patient who was really isolated and coming to the emergency room. Were you administering scales to pick up on loneliness and isolation? Or was that just the lingering conversations? Were those just things that you picked up on that didn’t quite need a scale? You just knew it?</p> <p><b>Thomas:</b> Yeah, yeah. No, I mean, I think I had the initial feeling or thought about this being present after I learned about it and were thoughtful with senior mentors about it.</p> <p>I did actually go back in and administer scales at least one time.</p> <p><b>Ashwin Kotwal:</b> Oh, wow.</p> <p><b>Thomas:</b> But the person did screen and used a little bit of the and Social Network Scale and the UCLA Loneliness Scale. Like I said, the patient screened positive for it.</p> <p>I reviewed grants and things where people talk about using… What is it, EMA? Is it EMA? The momentary assessment, but I worry that some repeated measures they may miss the mark with, I think, repeated measures that are captured so often.</p> <p>But I do think we have to be thoughtful about people’s experience over time.</p> <p><b>Carla:</b> I think what’s also interesting, Thomas, if I can just say about that, is that there was a study a couple years ago looking at general practitioners and their availability, or their ability not availability, ability to recognize their patients who are disconnected. What it found is that healthcare providers are better at identifying people that are connected more than disconnected.</p> <p>I think part of that has to do with the assumptions that we make about people in terms of who we assume is isolated based on our own judgments about people, which is why I think it’s interesting in terms of having standard assessments.</p> <p>But I agree with you. I think early in my practice I didn’t do any standardized assessments. It was just this, “I think they’re lonely.” But when you ask people specifically, you get interesting questions.</p> <p><b>Eric:</b> Well, do you do them now, Carla?</p> <p><b>Carla:</b> I do, and I have different ways of doing it. I’m partial to asking about loneliness just because I like the loneliness questions better. I think that there’s something about the distress that feels more human, about human experience, about loneliness, that people to open up.</p> <p><b>Eric:</b> What are your screeners? Is it one or two questions or do you-</p> <p><b>Carla:</b> Yeah, so I do two things. Sometimes I actually just as an open depends on who the person is. I sometimes will ask them, “Do you feel lonely?”</p> <p>I actually just had a woman that I care for on hospice who I asked, “Do you feel lonely?” She said no. But then when I asked her the UCLA Three, which was, “Do you feel isolated from others? Do you lack companionship,” she said yes to all these.</p> <p>It was really interesting, which is why I sometimes like a multimodal approach. But I really incorporate it into my practice in a conversational way, while sticking to the way the questions are asked.</p> <p><b>Eric:</b> What do you do, Thomas?</p> <p><b>Thomas:</b> Yeah, so I think, like I shared before, about using those standard assessments if I want to use them.</p> <p>I mean, I think some of it becomes apparent in your clinical encounters of people if people are isolated. I would say that I primarily skew my questioning towards isolation. I think some of that is from some of my thinking about maybe what I can potentially think about with the individual to support them.</p> <p>I do think the interventions that have to be applied are characteristically different. I would say that. I haven’t been trained as a psychologist. I’ve had some training in psychiatry, but I think some of the things that we’ll need to do to develop interventions with loneliness will be characteristically different in isolation.</p> <p>I think I feel more comfortable as a provider in trying to support people in their isolation.</p> <p><b>Eric:</b> Do you think that’s common amongst providers? I don’t want to talk about loneliness because what if I find out that they’re lonely? What the heck am I going to do about it?</p> <p><b>Thomas:</b> Yeah, no, it’s tough. It’s tough. And so that’s why we have a lifetime worth of work ahead of us to figure out what we need to be doing.</p> <p><b>Alex:</b> Also, I’ll say that on in my clinical practice doing palliative care consults, on the last time I was on service, I resolved to ask each patient, who could answer, which is a subset of the patients who I see, if they were lonely.</p> <p>I found that a really interesting question, and it uncovered aspects about their lives and about their situations that I would not have otherwise uncovered. I didn’t use the UCLA Loneliness Scale. Do you know why? Because I can’t remember it, but I can remember to ask people whether they feel lonely.</p> <p>I’m just a simple clinician from the flat parts of Michigan. Yeah.</p> <p><b>Carla:</b> I love that you said that, Alex and I, and I think that’s exactly right. When you ask this, it really gives a window into people’s lives. It’s so beautiful and tough.</p> <p>I think I’m going to challenge Thomas a little bit in that I worry actually that we frame loneliness in the psychological framework, that this must be like… I’m not sure. I may be paraphrasing and over jumping what you said, but I’m not a psychiatrist so I can’t deal with this. Or any social determinant of health just means that means the clinician refers to social work.</p> <p>I think some of the work that we’ve been doing, and that Julianne and I have written about, is that this is a multi-pronged approach to talk about loneliness and isolation. It’s at least identifying and figuring out who your partners in this and having a structured way of asking, assessing, and moving forward.</p> <p><b>Thomas:</b> Yeah, I appreciate that. I do think that we do need approaches that me and colleagues can leverage. I think you all’s recent piece in The New England Journal helps us with advancing that.</p> <p><b>Alex:</b> It’s good. He’s moving us along. [laughter]</p> <p><b>Eric:</b> Yeah, yeah. Are you aiming for our job here, Thomas? [laughter]</p> <p><b>Alex:</b> East Coast GeriPal host. I love it.</p> <p><b>Eric:</b> Well, let me ask about that New England Journal piece because it started off, Julianne, with a description of both of your parents, that they both died during the COVID-19 pandemic. I think 2021.</p> <p>But in the opening paragraph, you said they didn’t die of COVID. Do you want to describe what you wrote there?</p> <p><b>Julianne:</b> Yeah, well I talked about… Well, first of all, I should back up a little bit in the sense of originally the paper was written about some of the evidence on why we should take this seriously and why it’s a medical issue.</p> <p>The reviewers came back and said, “We’d like a case study.” I’m not a physician. I don’t see patients, and I sat there for a while struggling. Where am I going to come up with a case study?</p> <p>I immediately realized that I had witnessed this play out in my own parents, and I guess I can share a few details. In essence, so my parents sadly passed away within 17 days of each other. My parents, like most families, we were trying to protect them during the pandemic.</p> <p>In fact, I had nightly phone calls with them every single night while I made dinner. I called my parents, and we talked. They had a little balcony that we would sometimes come and stand and visit them outside the balcony and chat with them.</p> <p>But when you don’t see each other in person, that isolation can have effects. I think in some ways it at least partially contributed to my father’s death in the sense that we didn’t realize to what extent his health was declining. We knew he was fatigued, but we’re all tired. I mean, we’re all frustrated with everything that was going on. They weren’t getting out much, so they weren’t getting much exercise.</p> <p>I could tell because you run out of things to say every night on those nightly phone calls when I was talking to them. I’d say, “Oh, well, here’s what I’m making for dinner. What are you having for dinner?” They’d be like, “Ah, I don’t know. We haven’t eaten yet.” I could get a sense that maybe they weren’t eating as well.</p> <p>But what we didn’t realize is that my dad’s health was declining and because there was less of that in-person contact. And so by the time we knew he needed medical attention, he was already in the very late stages of cancer.</p> <p>In fact from the time he was diagnosed, he passed away within two and a half weeks. And so in that sense, I could tell that literally just not having people around, had we perhaps caught that sooner, had been able to step in sooner, change various things, that perhaps that could have made a difference. In that sense, isolation could have potentially been a contributor.</p> <p>On the other hand, my mother, once my father was put into hospice, we all just surrounded my parents. And so she was no longer isolated, surrounded by a family every single day. But the loss of her partner contributed to significant loneliness. That as much as all of her children were very close, were around her and providing support, she was just deeply and profoundly lonely.</p> <p>Sadly, she was actually reaching for him in her sleep and fell out of bed. She ended up passing away three days later from her injuries. And so in that sense, I think to some extent, isolation and loneliness contributed to both of their deaths.</p> <p>But it was interesting because I was incredibly torn about whether to even share that personal experience. Because I mean not only is it something that’s very personal to me, and I didn’t want in any way to disrespect or in any way not be honoring my parents. But then also I didn’t want my personal story to take away from the mountains of scientific evidence. Because for so long, this issue has been seen as a personal issue and not a medical issue.</p> <p>I’ll give an example. My 2010 meta-analysis looking at the impacts of being socially connected on risk for premature mortality, it had 148 longitudinal prospective studies. 148 studies, okay?</p> <p>I submitted it to JAMA, and it was rejected because it was seen as not of interest to their readers, okay? I then submitted it to another medical journal, got the best reviews of my life. Not in terms of problems with the science. Again, rejected because it was not of interest to their readers.</p> <p>This was not viewed as a medical issue. In fact, one of the reviewers mentioned, “When if this is the case, what are supposed to do about it?” And so that’s 2010. That’s more than a decade ago that already this was viewed as something that either was not relevant or not of interest, or something that could not be acted upon in a medical setting.</p> <p>I’m at least hopeful that I think we’ve made a lot of progress since that time.</p> <p><b>Eric:</b> 2010 was so long ago, we barely had Amazon Prime then. Like it’s…</p> <p><b>Julianne:</b> But I mean the one thing that Carla and I did in this article was try to provide a framework of very practical steps that providers can use. This was in large part based upon our work with the National Academy of Science, a consensus report on social isolation and loneliness in older adults. Really, taking those recommendations and putting it into a framework that would be very easily hopefully remembered because we came up with an acronym: the EAR. The idea of listening with your ear, so E being educate, A, assess, and R, respond. And so really just so that there was something that could be done.</p> <p>I want to let Carla also speak to some of this, too.</p> <p><b>Eric:</b> Well, Carla, can you flush out EAR for me? Can you do it like a short period of time? If you were to do EAR on me because I’m lonely, what would that look like?</p> <p><b>Carla:</b> Yeah, so I think part of this is, as Julianne said, to make it approachable. But also to take a public health approach and to answer some of the things that scares clinicians that I don’t know what to do.</p> <p>Sometimes the solutions are much more simple, and something that we do is clinicians all the time is educate on the risks of things, educate on the benefits of doing things that are protective. And so we spend a lot of times as clinician talking about don’t smoke, watch your diet, exercise.</p> <p>But we don’t talk about our social connections and the impact on health. The educate is really about these are the risk factors, and they are significant. We cannot ignore them, number one.</p> <p>The second part is the assessment, which is really trying to use standardized measures. Pick your tool. We want it to be somewhat agnostic, even though we all have our own preferences as you’ve seen. We see everything from Thomas focusing more on isolation. I tend to use the UCLA Three. Ashwin has done some great work on a single-item question.</p> <p>The idea is to be consistent in what you’re doing so that you can track change over time.</p> <p>And then the third part-</p> <p><b>Eric:</b> And what’s your single-item question, Ashwin?</p> <p><b>Ashwin Kotwal:</b> How often do you feel lonely?</p> <p><b>Eric:</b> How? Okay, I can remember that one.</p> <p><b>Carla:</b> And the third part is respond. Julianne and I actually went back and forth quite a bit, months, maybe years during the pandemic, to figure out what we wanted the R about.</p> <p>Because we wanted to be specific about it didn’t mean you had to automatically refer to something. I think earlier it was like, “Oh, old person lonely. Send to senior center.” But we wanted the respond really to be about reassessment, re-checking in, re-talking about sometimes referring but doing something.</p> <p>I think that moves us away from automatically saying, “Oh my goodness, it’s like I have to give a statin because they have high cholesterol.” Well, the menu of options is still pretty broad, and the evidence around solutions is still evolving. But at least it gives us away to just asking about it and talking about it. You all know from palliative care is a huge step in terms of a “treatment.”</p> <p><b>Eric:</b> And I remember from my last podcast, Ashwin, it was about individualizing our approach to loneliness too, right?</p> <p><b>Ashwin Kotwal:</b> Yeah, that’s right. I mean, think as so many of these stories bring up, there are many different contributors to why people may be lonely, or why decades of social disconnection has led to really severe forms of isolation.</p> <p>And so really thinking about people’s individual experiences, what might help for them. Inviting them to brainstorm into that process can be important.</p> <p>One other way to think about palliative care skills applied to addressing loneliness, particularly for people with serious illness, is to think of this as an emotional experience. Putting our skillsets to use related to helping people process some of the really important life changes that may bring on loneliness. Asking people to tell you more about what is it that’s bringing on the loneliness. Really helping people to normalize some of that experience and removing some of the stigma that’s attached to the term.</p> <p><b>Julianne:</b> I’ll also add I mean another potential approach is also integrating social connection into existing treatment plans.</p> <p>For example, I also recently published a meta-analysis on psychosocial interventions in medical settings. These included anything from including a patient’s family members or caregivers as part of their treatment to ensure adherence or compliance or management of that, to the kinds of more emotional supports that they may need, to peer support groups of other patients that are dealing with similar kinds of situations, to volunteers or even nursing staff that help support patients.</p> <p>What we found was that, these were all RCTs, so among patients that received some kind of support as part of their medical treatment, had a 20% increased survival relative to just treatment alone. And so this can be part of a treatment rather than something that’s referred out, as Carla mentioned earlier.</p> <p><b>Ashwin Kotwal:</b> Yeah.</p> <p>One question I have for you all is technology gets a lot of attention right now, especially as we’re emerging from the pandemic. Thomas, I know you had your paper recently published that showed maybe technology helps to reduce isolation.</p> <p>Thoughts on that? Do you feel like up to a point? Is it complementary?</p> <p><b>Eric:</b> TikTok for everyone?</p> <p><b>Thomas:</b> That wasn’t quite the measures that were included in [inaudible 00:36:22]</p> <p>No, but when people ask me about technology, and I think we have to be thoughtful about it and its ability to support existing connections. I think that’s where great strength is. When people have connections, it can be leveraged to continue to maintain those connections. And so that’s how I think about that.</p> <p>I appreciate Julianne and Carla giving more story behind the framework. I would just say that hearing it again, really I appreciate the responding, the open-endedness and because I think it gets at… I feel like it was in favor of a lot of people were talking about precision medicine and in terms of tailoring solutions for people.</p> <p>And so I think we have to begin thinking about how can we leverage certain platforms or conceptual frameworks to support people in terms of intervening and supporting them in a way that meets their needs, meets them where they are, understands the risks that they have and the protective factors that may exist that they have, and bolstering those things when we think about interventions. Not just some cookie cutter thing that is going to be good for everybody and missing the people who are actually having trouble with certain factors.</p> <p>I mean, I really appreciate that. I think it’s something that I think we should definitely carry forward as we think about how we can address this problem.</p> <p><b>Eric:</b> And I feel like for each part of the EAR, I love that. I can remember that. Even someone like me can remember that, is that we got a lot of work in each one of those to figure out what works. Even what are the risk factors? What’s the risk of it? Julianne brought up the risk of mortality that she’s found in her meta-analysis.</p> <p>Thomas, you got a lot of press recently on dementia, loneliness being a risk factor for dementia?</p> <p><b>Alex:</b> Social isolation or loneliness.</p> <p><b>Eric:</b> Which one?</p> <p><b>Thomas:</b> Social isolation, yeah. This paper was published recently in the Journal of American Geriatric Society Lead.</p> <p><b>Eric:</b> Woo-hoo. We like that one. Yeah.</p> <p><b>Alex:</b> We like that journal.</p> <p><b>Eric:</b> That’s our favorite right there.</p> <p><b>Thomas:</b> The lead author was Alison Huang, and I’m the senior author on this paper. And so we essentially leveraged the National Health Aging Trend Study and looked over from a period from 2011 to 2019 to essentially look at the trajectory of people developing dementia in the sample over time.</p> <p>Essentially, we identify that individuals who were socially isolated had an increased risk for developing dementia over that period.</p> <p><b>Alex:</b> You did get big press. Can you say what press you got from this?</p> <p><b>Thomas:</b> Yeah. It was on NPR, Washington Post. There was actual video on Good Morning America. They didn’t give me a shout-out, though [laughter]</p> <p><b>Eric:</b> And now it’s on GeriPal. You get big time. [laughter]</p> <p><b>Alex:</b> It’s bigger than NPR.</p> <p><b>Eric:</b> I guess one question, when it comes to this, around loneliness, I would love your thoughts is, does loneliness increase the risk for dementia? Or do people with dementia develop-</p> <p><b>Alex:</b> Social isolation.</p> <p><b>Eric:</b> Or social isolation develop loneliness more often because they have dementia? Or developed social… I keep on messing those two up.</p> <p><b>Alex:</b> Yeah, yeah, yeah. It’s easy to mess them up.</p> <p><b>Eric:</b> See, I can only remember one thing, and right now its EAR. [laughter]</p> <p><b>Carla:</b> It’s because you’ve been isolated, and you’re now cognitively impaired. [laughter]</p> <p><b>Eric:</b> Julianne, when we’re thinking about mortality, is it that people who are approaching the end of life become more socially isolated or lonely, versus the social isolation and loneliness begets higher risk for mortality? And can we-</p> <p><b>Julianne:</b> Yeah, so yeah, we were able to specifically look at that.</p> <p>First of all, the majority of the studies were initially healthy participants that were followed over time. And so we were able to see their level of social connection predicted mortality years, often decades, later. On average, I think it was seven and a half years later. There were some that were much, much longer than that.</p> <p>Among clinical patients, the study’s always adjusted for age and initial health status. But also in addition, so that rules out reverse causality. But also we’re able to control for a number of lifestyle factors. Things like smoking status, level of physical activity, a variety of other lifestyle and biological risk factors that may be alternative explanations. In essence, establishing these as independent risk factors for premature mortality.</p> <p><b>Eric:</b> And Thomas, isn’t there a study you did on IL something something? IL-2 or inflammatory markers?</p> <p><b>Thomas:</b> Yeah, that was a cross-sectional study where we saw an association between social isolation and IL-6 and CRP.</p> <p>I appreciate you bringing it up because I think there is, I think, increasing interest at least from funders in terms of examining mechanisms by which we see these associations. I think some of that, it has a role for thinking about potential interventions. When we understand the mechanisms by which these things occur and how they impact worse health, we can understand maybe if there’s opportunities to intervene upon certain things that are in that path.</p> <p><b>Eric:</b> I realize we’re almost out of time.</p> <p>Lightning round: magic wand. You can use it on one thing to either have government, individual providers, healthcare systems do one thing differently. What would it be?</p> <p>Carla?</p> <p><b>Carla:</b> Oh, easy. Have Medicare recognize social health as an important topic that is actually reimbursable in terms of services.</p> <p><b>Eric:</b> Awesome.</p> <p>Julianne?</p> <p><b>Julianne:</b> I would say redesign our communities. Because oftentimes what we’re doing is either getting things too late in terms of trying to treat them, or putting far too much burden on individuals.</p> <p>If we can just tackle the existing barriers in our communities to make it easy for people to be connected, hopefully that could make a huge difference.</p> <p><b>Eric:</b> Do you think it’s getting worse with robot delivery of food and all of these interventions versus…</p> <p><b>Julianne:</b> It does it make it a lot easier for us.</p> <p><b>Eric:</b> Thomas, your one thing?</p> <p><b>Thomas:</b> Yeah. No, I agree with the previous sentiments. I think increasing our awareness of its impact on our lives is something that continually needs. As physicians, we need to be reminded.</p> <p>Then I think broader public awareness about its impact on our health is so, so important. I think more things are being done, but more could be done as we move forward.</p> <p><b>Eric:</b> Ashwin?</p> <p><b>Ashwin Kotwal:</b> Yeah, to build on the prior suggestions, funding community programs that are addressing isolation and loneliness.</p> <p>Carla and I’s work, we’ve just been really privileged to work with these groups that really understand the needs of local communities. Are doing really fantastic work building connection for people who are incredibly isolated and having complex social medical issues, so they need more funding. They need it more easily.</p> <p><b>Alex:</b> Yeah, we need to shake things up so that people don’t feel so outcast. [laughter]</p> <p><b>Eric:</b> I had one of those coming out. [laughter]</p> <p><b>Alex:</b> Sorry. [laughter]</p> <p><b>Eric:</b> I was going to include outcasts. [laughter]</p> <p><b>Alex:</b> (Alex singing) Shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it, shake it like a Polaroid.</p> <p>Hey ya! Hey ya!</p> <p><b>Eric:</b> Well, I want to thank everybody for being on this call. Thomas, Carla, Julianne, and Ashwin, thank you for joining us.</p> <p><b>Thomas:</b> Thank you.</p> <p><b>Ashwin Kotwal:</b> Thanks for having us.</p> <p><b>Carla:</b> Thanks for having us.</p> <p><b>Eric:</b> And to all of our listeners, thank you very much for supporting the podcast.</p> </div> </div> </div></div></div></div></div></div></div></div></div></div> </div></div> <div class="post-tags wpex-mb-40 wpex-last-mr-0"><a href="https://geripal.org/tag/podcasts/" rel="tag">Podcasts</a></div> <div class="wpex-social-share style-flat position-horizontal wpex-mx-auto wpex-mb-40 wpex-print-hidden" data-target="_blank" data-source="https%3A%2F%2Fgeripal.org%2F" data-url="https%3A%2F%2Fgeripal.org%2Fthe-importance-of-social-connection-julianne-holt-lunstad-thomas-cudjoe-carla-perissinotto%2F" data-title="The importance of social connection: Julianne Holt-Lunstad, Thomas Cudjoe, & Carla Perissinotto" 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