Social Assessment of Older Patients

Sadhna Diwan, Megan Rose Perdue

Social assessment is an integral part of a comprehensive multidimensional assessment of older adult patients. Many studies on the effectiveness of comprehensive geriatric assessment include a social worker on the assessment team, whose mandate typically includes identifying and addressing social and community living needs.¹ Social assessment is a broad construct, encompassing many aspects of an older individual’s life. It includes assessment of functional ability, as measured by the ability to perform the basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs), social functioning (the older adult’s social network and support system), the need for supportive services, screening for cognitive function, and an assessment of psychological well-being (e.g. mood, quality of life, life satisfaction). Regardless of whether an older person lives in the community or in an institution, supportive activities provided by social networks are key to ensuring adequate care and maintaining well-being. Social functioning encompasses many aspects of a person’s relationships and activities, and a social assessment provides a snapshot of the resources and risks related to health and wellness experienced by an older patient.

The objectives of this chapter are as follows: (1) provide an overview of the relevance of social assessment in comprehensive geriatric assessments and to care provided by physicians; (2) describe various aspects of social functioning, their relationship to health and wellness, and key screening tools relevant for social assessment; (3) describe the impact of chronic illnesses and dementia on social functioning as related to the concept of caregiver burden; (4) discuss cultural considerations in social assessment.

Relevance of Social Assessment in Comprehensive Geriatric Assessment

A great deal of attention has been given by researchers to social issues and their impact on health and wellness of older adults. Recalling that frail older adults are at increased risk compared with others their own age, there is discussion about how to conceptualize where the risk comes from. A common formulation, typified in this book, is to distinguish between intrinsic risk and extrinsic risk. Intrinsic risk is reflected in ill health and factors of known, uncertain, or variable modifiability (e.g., exercise, epigenetics, genome, microbiome, smoking) and extrinsic risk. In this conceptualization, social vulnerability becomes an extrinsic risk. Clearly, protective and mitigating factors are also present, and these too can be seen as largely intrinsic or extrinsic.

Extrinsic social factors have been studied in different ways. One line of work on social issues, which is covered in Chapter 30 of this text, looks at social vulnerability, focuses on concepts such as social determinants of health,² and typically refers to the impact of macrosocial issues such as poverty, education, neighborhood conditions, and the built environment³ on the health status of individuals. Another line of research, which this chapter will address, focuses on the health impact of microsocial issues or social functioning and examines the role of formal and informal social networks, social support, social isolation, loneliness, and caregiver burden on individual health and functioning.

Impact of Social Functioning on Health and Well-Being

A large body of research exists on the impact of social functioning on the health and well-being of older adults. Research on older adults in several countries (Denmark, Holland, Japan, Britain, and the United States) has found that social isolation and loneliness are associated with increased mortality.⁴ Multiple studies have found greater level of social support to be related to better self-management of diabetes and dietary and exercise behaviors.⁵ Furthermore, social relationships such as marital status and friendship networks influence the practice of healthy behaviors such as smoking, alcohol use, physical activity, and dental visits, where dissolution of marriage or weaker social networks are associated with lower levels of healthy behaviors.⁶ In a meta-analysis of available studies, Barth and colleagues⁷ noted that good evidence exists for the positive relationship between lower perceived social support and a poorer prognosis for coronary heart disease (CHD). They suggested that an important step in increasing the survival of patients after a cardiac event might be a more thorough monitoring of patients with low social support to improve compliance with medication and adherence to healthy behaviors.

Finally, most older patients receive some level of care and support from family and friends, and for many this constitutes their sole source of support.⁸ Many caregivers of older persons are themselves older (typically a spouse or adult child). Caregiving for older persons with limitations in ADLs, chronic illnesses, or dementia is physically and emotionally challenging and has been documented to have serious adverse physical and mental health consequences, such as declining health and increased mortality among older caregivers.⁸ The experience of caregiver burden can result in impaired ability to provide adequate care to the older patient and may lead to medication errors, elder mistreatment or neglect, and family conflict.⁸^,⁹ Caregiver strain or burden is also associated with increased likelihood of institutionalization for the older patient.¹⁰ Therefore, including an assessment of an older adult’s ADL and IADL functioning, social functioning, including met and unmet need for services, and status of the caregiver(s) are critical components of a social assessment.

Functional Ability to Perform Activities of Daily Living

Since the development of the landmark Katz Index of Activities of Daily Living in 1963,¹¹ many scales have been developed to assess a person’s ability to perform the tasks involved in basic and instrumental activities of daily living. Activities categorized as basic ADLs include personal care (e.g., dressing, bathing, eating, grooming, toileting, getting in and out of bed or a chair, urinary and bowel continence) and mobility, which includes walking and climbing stairs. IADLs, on the other hand, include activities necessary for living in a community setting (e.g., cooking, cleaning, shopping, money management, use of transportation, telephone, medication administration). The measurement of the ability to perform these activities varies in terms of observation by professionals or self-reports by the older adult. The performance of these activities is usually assessed in terms of being independent, needing assistance (help from another person or mechanical device), or completely dependent on help from another person to perform the various activities. Increasing levels of difficulty in performing ADLs and IADLs are associated with an older adult’s progression along the continuum of care from independent to assisted living to nursing home care. See Chapter 36 for more details.

Limitations in the performance of ADL and IADL tasks are a prerequisite for eligibility for services in all publicly funded home and community-based services programs. Many factors influence the performance of ADL and IADL tasks. These include an individual’s physical condition (frailty), emotional status (depression, anxiety, fear of falling), social issues (availability of social support), and external environment (type of dwelling, neighborhood conditions, climate), all of which can impede task performance and call for changes in a person’s living conditions.¹² A thorough social work assessment of functional ability as well as other factors influencing the performance of ADL and IADL tasks can be instrumental in developing a care plan that includes adequate service provision for the older adult and their caregiver, if applicable.

Aspects of Social Functioning and Assessment Tools

Social functioning is a multidimensional term used broadly to describe the social contexts through which individuals live out their lives. It includes concepts such as interpersonal relationships, social adjustment, and spirituality, which have been operationalized in the literature.¹³^,¹⁴ The assessment of social functioning may be complicated by personal biases and values (e.g., ageism, stereotypes, culture) that can influence the practitioner’s and older adult’s assessment.¹⁵ These issues may also influence a practitioner’s perception of how much social support or how large a social network is needed to protect an older adult from social isolation. Similarly, satisfaction with one’s level of social support may be influenced by one’s life experiences, personal values, group membership, and self-concept. Even so, physicians only need to identify older adults whom they have determined to be at risk for social isolation. In the following section, we present the most relevant aspects of social functioning to consider when providing geriatric care, which include the following concepts: social networks, social support, social roles, and social integration.

Social Networks

A social network is an aspect of social functioning that describes a person’s web of social relationships.¹⁶^–¹⁸ It is an objective concept that quantitatively describes a person’s combined social relationships instead of focusing on more subjective considerations, such as a person’s feelings about the quality of these relationships. Aspects of a person’s social network include the following: size (number of people considered to be part of the network); density (connectedness of the members); boundedness (traditional boundaries that define group members, such as family, neighbors, and church); homogeneity (similarities of members); frequency of contacts (regularity of member transactions); multiplexity (single or multiple transactions between members); duration (how long members have known one another); and reciprocity (the extent to which transactions of the members are reciprocal).¹⁶^,¹⁷

A person’s social network can be further understood as social relationships that exist along a continuum of proximity, often referred to as primary and secondary social relationships. A primary relationships consists of individuals with whom a person has the most frequent interactions, such as family members, spouses or partners, and good friends, whereas a secondary relationship refers to people with whom a person interacts less frequently, such as the mail carrier, grocery clerk, and members of a faith-based congregation.¹⁷ Within a social network, a person’s relationships can also be classified by degree of formality.¹⁸ Informal social networks are those made up of naturally forming social relationships, such as that of a friend, child, and spouse or partner. Semiformal networks are made up of social relationships formed as a result of joining a preexisting social structure, such as a neighborhood, church, club, or senior center. Finally, formal social networks are those social relationships or interactions with professional service staff, such as case managers, social workers, physicians, and nurses found in a formal organization, such as a medical clinic, hospital, or social welfare agency.

Although there are many aspects included in the concept of social network, it is not necessary for a physician to obtain such detailed information about a patient’s social relationships during a social assessment. Instead, a physician can condense his or her knowledge of social networks into several questions that can identify patients who are risk for social isolation. One way for physicians to accomplish this is to ask patients about the number and frequency of their social contacts (daily, weekly, monthly), as well as asking them to identify the nature of these contacts (in person, by telephone, by mail).¹⁵ Another more structured way to accomplish this is for the physician to administer a short evidenced-based screening tool, such as the Berkman-Syme Social Network Index,¹⁹ Social Network List,²⁰ or Lubben Social Network Scale-6 (LSNS-6).²¹ The LSNS-6, presented in Box 36-1, has been recommended for use in health care settings to help physicians identify patients who may be at risk for social isolation and in need of a more thorough social assessment by a social worker.¹⁷^,²¹ The LSNS-6 contains six questions that ask patients about the size of their social network and the tangible and emotional support received through their identified networks. Each of the six questions has a possible score of 0 to 5; a score of 0 indicates a lack of social network, and 5 indicates an above adequate social network, with the lowest total score being 0 and the highest score being 30. It is recommended that any older adult who scores at or below 12 on the LSNS-6 be referred to a social worker for a more in-depth social assessment.²¹

Box 36-1

Lubben Social Network Scale-6 (LSNS-6)

Use the following response categories for each question below (0 = none; 1 = one; 2 = two; 3 = three or four; 4 = five through eight; 5 = nine or more):

FAMILY: Consider the people to whom you are related (e.g., by birth, marriage, adoption).

1. How many relatives do you see or hear from at least once a month?

2. How many relatives do you feel at ease with that you can talk to about private matters?

3. How many relatives do you feel close to so that you could call on them for help?

FRIENDSHIPS: Consider all your friends, including those who live in your neighborhood.

4. How many of your friends do you see or hear from at least once a month?

5. How many friends do you feel at ease with that you can talk to about private matters?

6. How many friends do you feel close to so that you could call on them for help?

The LSNS-6 total score is an equally weighted sum of these six items. Scores range from 0 to 30.

Modified from Lubben J, Blozik E, Gillmann G, et al: Performance of an abbreviated version of the Lubben social network scale among three European community-dwelling older adult populations. Gerontologist 46:503–513, 2006.

Social Support

Although an understanding of a person’s social network may help the geriatric care team identify persons at risk for social isolation, this basic understanding does not allow the care team to understand how well their patients are supported by members within their social networks. For this reason, an assessment of social support is more important than an assessment of a social network because social support is more closely related to an older adult’s ability to remain independent in the community.²²^–²⁴ In spite of a large social network, without adequate social supports in place an older adult who experiences significant functional decline will be unable to safely remain living outside of an institutional setting.²²^–²⁴ In addition, studies have shown that without a robust social support system, older adults are less likely to follow medical advice¹⁷ and are at greater risk for significant negative health outcomes²² such as increased comorbidities,²⁵ cognitive decline,²⁶ depression,²⁷^,²⁸ poorer self-rated health,²⁹ and mortality.¹⁶ The convoy model of social relations can also help the geriatric care team understand the concept of social support within the context of their patients’ lives. According to this model, older adults surround themselves with social supports that move with them throughout their life course and largely contribute to their well-being. This theory maintains that the quality of social support is more important than the quantity. The longer the supports have been in place, the more significance they hold for older adults, and the more likely they will contribute to their satisfaction with social supports and, as a result, their overall well-being.³⁰

For the purposes of geriatric assessment, social support is defined as the tangible and intangible assistance derived from an older adults’ social network and the older person’s satisfaction with that help.¹⁵^,¹⁷^,²²^,³¹ Social support may be given in the form of the following: (1) emotional support (love and caring most often provided by a family member, spouse, or close friend); (2) instrumental support (tangible help with ADLs and IADLs); and (3) appraisal or informational support (providing information or advice to help someone make a decision about something that concerns them).¹⁶^,¹⁷^,³¹ Each of these types of social support is delivered through the informal, semiformal, or formal networks described earlier and is subjective, meaning that an older adult’s perception of that help is just as important as the actual help received. In fact, there is evidence that suggests that a person’s satisfaction with her or his level of social support is more closely correlated with psychological well-being than the actual help received.²²^,³¹

Similar to the concept of a social network, a physician does not need to master all the concepts included in the description of social support. Instead, a physician could condense this knowledge to identify patients who may be at risk of adverse health outcomes or premature institutionalization due to inadequate social support. One approach would be to ask patients to identify the types of help they need in ADLs and IADLs, find out who is available to offer the appropriate assistance for these things, and determine who would be able to step in if this person became unavailable.¹⁵ If the patient is independent in all ADLs and IADLs, the most appropriate approach would be to pose these questions hypothetically. Another approach is for physicians to use an evidence-based screening tool to screen for patients who may need additional interventions from the geriatric team. There are many screening tools that may be appropriate for this purpose, such as the Social Support Questionnaire,³²^,³³ Interpersonal Support Evaluation List,³⁴ MOS (Medical Outcomes Study) Social Support Survey,³⁵ and Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI).³⁶ A short instrument developed for use in a medical setting is the ESSI (Box 36-2), which is a seven-item self-report questionnaire. The ESSI was developed to examine the relationship between social support and cardiovascular disease outcomes because lower levels of perceived functional support and network support have been found to be associated with increased mortality and morbidity among patients with cardiovascular disease.³⁷ The ESSI measures a patient’s perception of his or her emotional, instrumental, informational, and appraisal social support systems. Possible scores range from 7 to 35, with a score at or below 18 indicating poor social support.³⁶^,³⁸ Thus, it is recommended that patients with a score at or below 18 on the ESSI be referred to a social worker for additional follow-up.

Box 36-2

Enriched Social Support Instrument (ESSI)

Use the following response categories for each of the questions below (1 = none of the time; 2 = a little of the time; 3 = some of the time; 4 = most of the time; 5 = all the time).