Abstract
Long-term care (LTC) residents may be susceptible to social isolation if living in facilities located in neighborhoods lacking social connection. To characterize the social isolation of residents living in LTC facilities in the US. This cross-sectional study included 730 524 LTC residents from 14 224 LTC facilities in 8652 zip code tabulation areas (ZCTAs) in the US in 2011. A nationwide LTC database with ZCTA data was linked to population-level geographic data from the US Census Bureau. Statistical analysis was performed from January 2019 to December 2020. The primary variable of interest was the social isolation of LTC neighborhoods defined as the percentage of households in the ZCTA with individuals aged 65 years or older who lived alone and categorized into quartiles of social isolation. Maps were generated to illustrate geographic variation of LTC facilities at the ZCTA level by the quartile of socially isolated neighborhoods. Generalized estimating equations were used to estimate the adjusted likelihood that LTC facilities were located in areas of highest social isolation. We also used multilevel logistic regression models to assess the association between the social isolation of neighborhoods of LTC facilities and 30-day all-cause mortality after LTC admission. Subgroup analyses were conducted by race and ethnicity. Among 33 120 ZCTAs in the US, 8652 (26.1%) had at least 1 LTC facility. Among the 730 524 LTC residents included in the study's 14 224 LTC facilities, 458 136 (62.71%) were female, 610 802 (83.61%) were non-Hispanic White, and 419 654 (57.45%) were aged 80 years or older. Location of LTC facilities was associated with increasing levels of social isolation (quartile 1 = 9.72% [n = 840]; quartile 2 = 18.60% [n = 1607]; quartile 3 = 32.23% [n = 2784]; quartile 4 = 39.45% [n = 3408]; P < .001). In multivariate models, LTC facilities were 8 times more likely to be located in ZCTAs with the highest percentages of older adults residing in single-occupancy households (odds ratio [OR], 8.46; 95% CI, 7.44-9.65; P < .001), compared with ZCTAs with the lowest percentages. This association held across ZCTAs with a majority population of African American and Hispanic individuals, although it was strongest in ZCTAs with a majority population of White individuals. LTC residents entering facilities in neighborhoods with the highest levels of social isolation among older adults had a 17% higher risk of 30-day mortality (OR, 1.17; 95% CI, 1.10-1.25; P < .001) compared with those in neighborhoods with the lowest levels of social isolation among older adults. This study found that LTC facilities were often located in socially isolated neighborhoods, suggesting the need for special attention and strategies to keep LTC residents connected to their family and friends for optimal health.
Highlights
In mid-March of 2020, long-term care (LTC) facilities were required by the Centers for Medicare and Medicaid Services to ban all nonessential visitors and group activities in response to COVID-19 safety rules
LTC facilities were 8 times more likely to be located in zip code Tabulation Area (ZCTA) with the highest percentages of older adults residing in single-occupancy households, compared with ZCTAs with the lowest percentages
This association held across ZCTAs with a majority population of African American and Hispanic individuals, it was strongest in ZCTAs with a majority population of White individuals
Summary
In mid-March of 2020, long-term care (LTC) facilities were required by the Centers for Medicare and Medicaid Services to ban all nonessential visitors and group activities in response to COVID-19 safety rules. Within a few months of the lockdown, LTC staff and clinicians began reporting increased levels of depression, anxiety, worsening dementia, and failure to thrive in residents.[1] These accounts have drawn attention to the role of social isolation in LTC facilities. Social isolation—generally defined as having few social network ties or infrequent social contact—is an important public health concern that affects many older adults.[2] Living alone or living in neighborhoods with a high proportion of single person households have been found to be predisposing factors to social isolation.[3] In the community setting, 28% (14.7 million) of all older adults aged 65 years or older live alone (5.0 million men, 9.7 million women).[4] By age 85, 39% of older adults live alone.[5] Socially isolated adults experience high rates of negative health outcomes, including premature mortality and a 50% increase in the risk of dementia.[6,7] Living alone is a strong risk factor for LTC placement.[8,9] Growing evidence suggests differences in social isolation by race/ethnicity,[10] an association between mortality risk and social isolation has been found in both non-Hispanic White individuals and African American individuals.[11]
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