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Whole Person Care for Older Adults

Younger women hugging elderly women
                                        Read time 5 minutes

Social isolation and loneliness have been associated with increased risk of chronic conditions such as cardiovascular disease, type 2 diabetes, chronic stress, depression, and anxiety.1-4 Perceived and objective social isolation have also been linked to increased all-cause mortality.1,2,5 Compared to other age groups, isolation and loneliness may be more harmful to the physical, mental, and emotional health outcomes of older adults, who may have reduced mobility and daily activity engagement or be managing multiple chronic conditions and mental health challenges. Social isolation is a public health issue6 and always relevant when considering optimal health for older adults. With the continued need for recommended physical distancing during the COVID-19 pandemic, the connection between isolation, loneliness, depression, and negative health outcomes for older adults highlights an important health challenge for this vulnerable population.7-9

Isolation’s Impact on Healthcare Costs

A 2017 study released by AARP indicated that social isolation among older adults added an additional $6.7 billion dollars in annual Medicare spending.10 An in-depth analysis of the study indicated that objective isolation not only predicts higher Medicare spending due to increased hospitalizations and institutionalization, but also predicts greater risk of mortality despite the additional health care.11 A 2019 study investigated the association between loneliness and incidence of emergency department (ED) visits for patients with chronic obstructive pulmonary disease (COPD).12 Patients with an average age of 65 responded to questionnaires that asked about loneliness and social isolation. Results indicated that loneliness in patients with COPD is significantly and independently associated with increased ED visits and with a poorer perception of health.12 This study suggests that addressing loneliness may not only improve a patient’s health perception and quality of life, but potentially decrease their ED visits and subsequent healthcare costs.

Patient-Centered & Whole Person Care

Older adults in long-term care, dementia care, and hospice care services with complex needs have benefited from patient-centered care practices; however, an implementation gap exists for conventional medicine in outpatient care.13 A 2016 systematic review of 132 sources identified the most prominent factors that define patient-centered care, including:13

  • Whole person care
  • Respect and value
  • Choice
  • Dignity
  • Self-determination
  • Purposeful living

Expanding on the patient-centered healthcare strategy, the Whole Health model is personalized, patient-driven care that also emphasizes the patient’s relationship with their community and those self-care strategies that are based on the patient’s values, needs, and goals.14,15 A recent study investigated the benefits of implementing a Whole Health model at a community mental health center that offered outpatient mental and substance use disorder treatment services.16 Besides monitoring patients’ overall health needs and their wellness education within treatment services, the Whole Health model improved care coordination between providers and reduced Medicare expenses, ED visits, and hospitalization rates.16

Lifestyle Practices

Nutrient-dense diets, exercise programs, and healthy relationships all contribute to a patient’s optimal wellness, and social isolation may disrupt these vital routines and activities. For example, grocery shopping or accessing food and nutrition assistance programs may be interrupted. Food security is a suggested risk factor for depression, stress, and anxiety, and older adults are at a higher risk of depression due to food insecurity according to a 2020 meta-analysis.17 Ensuring access to adequate amounts of healthy foods and following healthy dietary patterns like the Mediterranean diet may improve health outcomes and quality of life. A 2018 systematic review found that for older adults, maintaining a healthy dietary pattern led to better self-rated health and quality of life that spanned physical, social, and emotional well-being.18

Exercise and physical activity reduces the risk of many chronic diseases, may increase longevity and healthy aging,19 and has been suggested to alleviate depressive symptoms in older adults.20 A 2020 meta-analysis of 15 randomized controlled trials (n=596) compared the effectiveness of aerobic, resistance, and mind-body exercise programs in clinically depressed adults older than 65 years of age.20 Results suggested the largest improvement on depressive symptoms after mind-body exercise, followed by aerobic and resistance exercise routines.20 Researchers also suggested that since there were no statistically significant differences between the exercise types, patient preference would be highly encouraged for optimal treatment implementation and sustainability.20

Social disconnection is a potential risk factor for chronic diseases, and increasing social connection may help reduce disease risk through reduction of chronic stress and allostatic load.21 Within an environment of increased physical distancing, personalized therapeutic strategies that address social support related to physical, mental, and emotional well-being help to promote optimal patient health. In addition, practitioners can offer increased contact frequency for their lonely, isolated patients. High-touch care with virtual health coach visits and/or shared medical appointments may be a relevant option for a patient’s health strategy.

Conclusion

The functional medicine model addresses how social factors such as isolation and loneliness may contribute to chronic disease risk and progression for older patients. Examining the mental, emotional, and spiritual components of a patient’s health journey is a foundational aspect of the patient-centered, whole person, therapeutic approach of functional medicine care. A collaborative patient-practitioner relationship reinforces patient empowerment through personalized health plans that address modifiable lifestyle factors. These factors may help to enhance social connectivity, mend disrupted self-care routines, and identify those nutrition and mobility strategies that support physical and mental health resiliency. Learn more about developing collaborative patient-practitioner relationships that empower your patients in their health journeys at IFM’s Applying Functional Medicine in Clinical Practice (AFMCP).

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References

  1. Leigh-Hunt N, Bagguley D, Bash K, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health. 2017;152:157-171. doi:10.1016/j.puhe.2017.07.035
  2. Xia N, Li H. Loneliness, social isolation, and cardiovascular health. Antioxid Redox Signal. 2018;28(9):837-851. doi:10.1089/ars.2017.7312
  3. Hossain MM, Sultana A, Purohit N. Mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence. Epidemiol Health. 2020;42:e2020038. doi:10.4178/epih.e2020038
  4. Christiansen J, Lund R, Qualter P, Andersen CM, Pedersen SS, Lasgaard M. Loneliness, social isolation, and chronic disease outcomes. Ann Behav Med. Published online August 31, 2020. doi:10.1093/abm/kaaa044
  5. Yanguas J, Pinazo-Henandis S, Tarazona-Santabalbina FJ. The complexity of loneliness. Acta Biomed. 2018;89(2):302-314. doi:10.23750/abm.v89i2.7404
  6. Gerst-Emerson K, Jayawardhana J. Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. Am J Public Health. 2015;105(5):1013-1019. doi:10.2105/AJPH.2014.302427
  7. Smith ML, Steinman LE, Casey EA. Combatting social isolation among older adults in a time of physical distancing: the COVID-19 social connectivity paradox. Front Public Health. 2020;8:403. doi:10.3389/fpubh.2020.00403
  8. Gariépy G, Honkaniemi H, Quesnel-Vallée A. Social support and protection from depression: systematic review of current findings in Western countries. Br J Psychiatry. 2016;209(4):284-293. doi:10.1192/bjp.bp.115.169094
  9. Wu B. Social isolation and loneliness among older adults in the context of COVID-19: a global challenge. Glob Health Res Policy. 2020;5:27. doi:10.1186/s41256-020-00154-3
  10. Flowers L, Houser A, Noel-Miller C, et al. Medicare spends more on socially isolated older adults. AARP Public Policy Institute. Published November 27, 2017. Accessed November 5, 2020. https://www.aarp.org/ppi/info-2017/medicare-spends-more-on-socially-isolated-older-adults.html
  11. Shaw JG, Farid M, Noel-Miller C, et al. Social isolation and Medicare spending: among older adults, objective social isolation increases expenditures while loneliness does not. J Aging Health. 2017;29(7):1119-1143. doi:10.1177/0898264317703559
  12. Marty PK, Novotny P, Benzo RP. Loneliness and ED visits in chronic obstructive pulmonary disease. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):350-357. doi:10.1016/j.mayocpiqo.2019.05.002
  13. Kogan AC, Wilber K, Mosqueda L. Person-centered care for older adults with chronic conditions and functional impairment: a systematic literature review. J Am Geriatr Soc. 2016;64(1):e1-7. doi:10.1111/jgs.13873
  14. Krejci LP, Carter K, Gaudet T. Whole health: the vision and implementation of personalized, proactive, patient-driven health care for veterans. Med Care. 2014;52(12 Suppl 5):S5-S8. doi:10.1097/MLR.0000000000000226
  15. United States Department of Veterans Affairs. What is whole health? Updated October 13, 2020. Accessed November 3, 2020. https://www.va.gov/wholehealth/
  16. Bouchery EE, Siegwarth AW, Natzke B, et al. Implementing a whole health model in a community mental health center: impact on service utilization and expenditures. Psychiatr Serv. 2018;69(10):1075-1080. doi:10.1176/appi.ps.201700450
  17. Pourmotabbed A, Moradi S, Babaei A, et al. Food insecurity and mental health: a systematic review and meta-analysis. Public Health Nutr. 2020;23(10):1778-1790. doi:10.1017/S136898001900435X [published correction appears in Public Health Nutr. 2020;23(10):1854].
  18. Govindaraju T, Sahle BW, McCaffrey TA, McNeil JJ, Owen AJ. Dietary patterns and quality of life in older adults: a systematic review. Nutrients. 2018;10(8):971. doi:10.3390/nu10080971
  19. Gopinath B, Kifley A, Flood VM, Mitchell P. Physical activity as a determinant of successful aging over ten years. Sci Rep. 2018;8(1):10522. doi:10.1038/s41598-018-28526-3
  20. Miller KJ, Gonçalves-Bradley DC, Areerob P, Hennessy D, Mesagno C, Grace F. Comparative effectiveness of three exercise types to treat clinical depression in older adults: a systematic review and network meta-analysis of randomised controlled trials. Ageing Res Rev. 2020;58:100999. doi:10.1016/j.arr.2019.100999
  21. Larrabee Sonderlund A, Thilsing T, Sondergaard J. Should social disconnectedness be included in primary-care screening for cardiometabolic disease? A systematic review of the relationship between everyday stress, social connectedness, and allostatic load. PLoS One. 2019;14(12):e0226717. doi:10.1371/journal.pone.0226717

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