A person is socially isolated if he or she defines the amount of contact with others as inadequate (Aquino, Altmaier, Russell, & Cutrona, 1996). It is important to remember that living alone does not necessarily make someone isolated; solitude can be a personal choice. For example, social isolation may refer to a physical separation from other people, such as living alone or living in a rural or isolated area. It may also refer to a person who chooses to be socially isolated; for example, the person who has chosen to live at some distance from family and friends. Also, the number of personal daily contacts may be a factor related to adequate social support. Social isolation appears to affect persons with fewer than three people in their social support network (Stuart-Shor, Buselli, Carroll, & Forman, 2003).
Social isolation can be defined and identified in two ways:

• The type and frequency of an individual’s social contacts.
• The degree to which a person perceives that certain types of social support are available.

Social Isolation comprises perceptions that one is alone or without social networks or social support. The North American Nursing Diagnosis Association defines social isolation as aloneness experienced by the individual (NANDA, 2000). Social isolation is perceived as a negative or threatening state. Some defining characteristics include not having interactions with close friends, neighbors, or family members. Other descriptors include not having interactions with members of work or church groups. Social isolation varies according to the degree of physical and emotional separation from other people. While physical distance may be a predisposing factor, it is neither a necessary or sufficient condition for social isolation. A person can feel lonely and socially isolated, despite living in close proximity to significant others (Tomaka, Thompson, & Palacios, 2006).

Individuals with smaller social support networks report the lack of a confidant, and attending fewer social functions. When elders over the age of 85 were asked about their number of friends, 42% reported a decrease in the size of their network. The mean size of an active social network for an elder has been reported to be from five to seven people (Stuart-Shor et al.) with older persons consistently reporting fewer people in their social support groups.

For many elders, their usual social network of close friends may begin to diminish because of ill health or death. In addition, elders may move to live either with or closer to family members, which may entail living further away from close friends and having to adjust to a new environment and new routines.

In a research study conducted by Murberg’s and Bru’s (2001), 153 Norwegian elders participated in a study to examine the influence social support and social isolation has on heart failure patients. The sample was predominantly male, with men averaging 69.9 years of age. In Murberg’s and Bru’s research, social isolation was assessed using four items:

• “Do you feel the disease makes it difficult to visit family and friends?”
• “Do you feel that the disease makes it difficult to receive visits from family and friends?”
• “Do you feel the disease makes it difficult to participate in social events?”
• “Do you feel that the disease makes it difficult to go on holiday with family and friends?”

Murberg and Bru found that the lack of social support from a spouse (more so than support from a primary or secondary network) strongly correlated to fatal outcomes. The practical application of this data is that, when providing care for a widowed or divorced elder with few friends, there may be a need for a social worker referral for follow up care.

Living alone is not uncommon among some groups. Peng et al. (2003) examined over twenty thousand records of patients registered in the Outcomes Assessment Information Set (OASIS) between 1999 and October 2000 and found that African American female elders were more likely than White, Hispanic, or Asian elders to be alone with no form of supportive care after a hospitalization. It has been traditionally assumed that African American elders would be taken care of by their adult children.

Hays and George (2002) used a prospective cohort study to describe race differences among 4,132 elders to estimate incidence and predictors of living alone among African American and White elders. The sample was a stratified four stage random sampling of households from five counties in north central North Carolina. Listing areas were stratified by racial characteristics to generate a sample in which approximately 55 percent of the respondents would be African American and 45 percent would not. Hays and George found three out of every five elders lived with others at the beginning of the study and continued to do so for the next 10 years or until their death. Younger and well educated African American elders lived alone more frequently. They also reported higher incomes, fewer biological children, and fewer living children. Accordingly, economic status does not necessarily mean
an elder has nowhere and no one to go to. It is entirely possible that a well off, educated elder may choose to live alone or have none or few children to live with. For nurses, it is important to understand emerging cultural trends in order to not make assumptions based on existing beliefs.

Hispanic elders are commonly expected to live with family in old age (Tomaka, et al, 2006). Tomaka and associates telephone interviewed 765 Southwestern U. S. inhabitants over the age of 60. Twenty three percent of the respondents reported their ethnicity as Hispanic. According to Tomaka, it is well known that the family and extended family play a central role in Hispanic culture and social lives. Therefore, family support plays a critical role in the health and well-being of the elderly Hispanic population (Tomaka, et al.). However, as Hispanics assimilate to the American culture, and young Hispanics move away from their nuclear families in search of additional employment or educational opportunities, the elders may be left behind to live alone. For nurses, it is important to note that as Hispanic adapt to American culture the Hispanic elder may not have children in the same community.

The number of Asian elders living alone has also risen, however there is little research addressing the mental health of those who live alone versus those who live with family (You & Lee, 2006). Traditionally, the assumption has been that Asian elders would be taken care of by their adult patients.

Shih, Gau, Lo, and Shih (2005) studied the health needs of elders living alone in Taiwan: 54 patients participated in the study; 48 were males and 61% of them (n=33) were unmarried. The principal diagnosis of 48% of subjects was coronary disease. The unmarried male elders reported that a perception of powerlessness occurred either in the pre-admission or hospitalization stage or was expected to occur after discharge. This group of Taiwanese elders living alone was found to have a low self-image and have greater needs from health care providers versus other elders who live with their significant others (Shih et al). In 2012 it was announced that in China rising social isolation and neglect of elders has prompted legislation to be considered in order to legally require adult children to care for their parents.

Social isolation also disproportionately affects women. In 2003, 44.3% of women ages 65 or older were widowed; 78.3% of women older than 84 were widowed and living alone (He, Sengupta, Velkoff, & DeBarros, 2005). In part, these statistics reflect the longer life expectancy of women compared with men in the U. S. However, there are also elements of choice. For example, it has been reported that women with higher incomes chose to live alone more frequently than women with lower incomes (Cheng, 2006).

According to Baker (2000), older Americans have the same desire for independence as young Americans. Independence is equated with life itself. Independence allows older adults greater autonomy to continue to define themselves and avoid feeling they are a burden to others. Letvak (1997) studied eight women living alone, all of whom expressed a desire not to change their life style. Living alone was highly valued and equated with power, freedom, and making one’s own decisions. The risk for physical functional decline and mental health problems may also be lower for women who live alone compared with women who live with family members (Michael, Berkman, Colditz, & Kawachi, 2001).

Bellin (2000) studied older women: these women reported combating loneliness through prayer, working part time, keeping busy, and raising pets to decrease their feelings of loneliness. Bellin’s study also demonstrated that having to face difficult tasks or health issues did not affect a woman’s decision to live alone. Older women reported having their own ways to maintain their health: staying active, eating right, getting enough sleep and using folk medicines to relieve bothersome symptoms (Cheng, 2006). In White’s (1997) study, older women living alone had an increased use of hospital and community services.

Bellin’s (2000) study demonstrated that most women did not receive care according to their actual health status. Health, and isolation may be viewed differently by the elder as compared to the perspective of the health provider. Decreased use of services may be due to income or transportation difficulties, not necessarily from noncompliance or dissatisfaction with the provider-patient relationship.

Social networks are believed to have a beneficial effect, provide positive interactional support and affirmation that leads to an overall sense of self-worth, self-esteem and positive affection. Social support also buffers the effects of stress and disease (Lincoln, Chatters, & Taylor, 2005). During the stressful situations that occur with disease, supportive social networks can help an elder reappraise and cope more effectively with stressors. Therefore, it is crucial for a nurse to ask pertinent questions related to social isolation during healthcare encounters in order to make appropriate referrals to other health care providers.

Nurses can ask simple question during an encounter such as:

1) Do you have family near you?
2) Does your family visit you?
3) Do you have someone you can rely on or talk to when things are bothering you?

If an individual does not have family, or a confidant to assist them, then an appropriate referral should be initiated to either a social worker or a community liaison or outreach worker. Nurses can inquire about likes, dislikes, and hobbies in order to gain insight into the person’s sociability. Questions could include:

• Are you a member of a church group?
• Are there any specific hobbies you enjoy?

In the event that an individual responds negatively to all of the above questions, the nurse can then begin to make formal referrals to case management and social services.

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Chen, H., Lanchbury, J., Senni, M., Bailey, K., & Redfield, M. (2002). Diastolic heart failure in the community clinical profile natural history, therapy, and impact of proposed diagnostic criteria. Journal of Cardiac Failure, 8(5), 279-287.

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You, K., & Lee, H. (2006). The physical, mental, and emotional health of older people who are living alone or with relatives. Archives of Psychiatric Nursing, 20(4), 193-201.