Loneliness and Social Isolation: Podcast with Carla Perissinotto and Ashwin Kotwal

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we had a couple week break, but we’re back on. Who do we have with us today?

Alex: We’re back and we’re delighted to welcome Carla Perissinotto who is a geriatrician and palliative care physician, Professor of Medicine at UCSF in the Division of Geriatrics. Welcome to the GeriPal Podcast, Carla.

Carla: Thanks. Nice to see you all.

Alex: And we’re delighted to welcome back Ashwin Kotwal who is a geriatrician and palliative care physician as well, and is also a researcher and is Assistant Professor in the UCSF Division of Geriatrics. Welcome back, Ashwin.

Ashwin: Thanks. Great to be here.

Eric: We’re going to be talking about loneliness and social isolation in older adults and those with serious illness. But before we go into the topic, Carla, I think you got a song request, don’t you?

Carla: I do. I specifically requested Eleanor Rigby from the Beatles. It’s pretty neat to see a song that’s been around for a while that really touches on loneliness and lonely people. So felt quite appropriate.

Alex: It’s amazing that Paul McCartney wrote this a 24. Such a mature song for such a young person. Here’s a little bit. (singing)

Eric: I love it when the song perfectly aligns to the topic at hand.

Carla: You’re welcome. [laughter]

Eric: Hell of a choice, Carla. All right, Carla, I got a question for you. This may be a really stupid question, so I apologize in advance. Loneliness, social isolation, what is it? What’s the difference? How should we think about these two topics?

Carla: Yeah. So I actually don’t think it’s a stupid question because we get it wrong all the time and we use the terms interchangeably. And if you read things on the news, or in the media and in papers, they’re used interchangeably. They are related, they can coexist, but they are different things. What I mean by that is loneliness is really something that’s subjective. So it is how you are feeling. Do you feel that you are missing connections, that you’re isolated? It’s also something that’s distressing. And the importance of saying that it’s distressing is because some people are “alone” but aren’t distressed by it.

Carla: Social isolation, in contrast, is really about something that’s very quantifiable in terms of the number of relationships and people and contacts that people have. You can also think about it together, if you look at both of the terms together, calling it social disconnection, which really will encompass both loneliness and isolation. There’s so much more detail we can talk about it in terms of types of loneliness, but I think it’s really important that we know those two things up front and get that term straight, those terms straight.

Ashwin: I think because of loneliness being a feeling, it can really play into some of the assumptions that we want to avoid. So it’s like if you have people around you, you don’t feel lonely. We know that that’s not the case. The popular phrase is you can feel lonely in a crowd. So many people who are even married may feel lonely. And similarly with social isolation, we really need to think about what are the resources that people can reach out to, those social resources that people can rely on?

Eric: You said something interesting, Carla — types of loneliness?

Carla: Yeah. I mean, I think that there’s so many ways that you can become lonely. A lot of it also can do with the types of relationships or the quality of relationships that you have. It’s probably too much to go into really the types of loneliness. But the reason why I think that’s important to say that is because when you start thinking about what do we do about this, if we don’t actually understand how someone becomes lonely, then we may be applying the wrong answer.

Carla: A good example that I sometimes give is if someone has recently lost a spouse or a partner, there may be significant loneliness and grief from the loss of that spouse. If I tell that person, just go join the social group, you’re not really solving the underlying issue, you’re giving the wrong solution, which is also why this research is so hard. Because we’re applying these solutions very broadly, assuming all lonely people are exactly the same. It’s very frankly similar to geriatric principles, where we think like, let’s have one size solution fits all. That never works. Why would it work for this?

Eric: And I can also imagine you could be potentially lonely at home or for those who are working like lonely at work. I can imagine this is very complex trying to study this.

Carla: That is the understatement of the year. Correct.

Alex: What do we know about how common loneliness and social isolation are in geriatrics or in palliative care?

Carla: Well, I can start a little bit with is in that, this actually relates to what you just asked, Eric, to start with. Is that if we don’t get the definitions right, then actually understanding prevalence rates and incidence rates are actually very hard. And in the study that I conducted in 2012, the prevalence that we saw amongst people over the age of 60 was a prevalence rate of 43% of people feeling sometimes lonely. If you look at other studies in the UK of people feeling severely lonely or always lonely, it’s less than 5%. And then if you look in populations with serious illness and at the end of life, Ashwin, you probably know some of that data, but it’s pretty variable depending on how its measured, but I would say at least 30% of people and it increases depending on different groups.

Eric: Ashwin, you just published in the Journal of American Geriatrics Society (JAGS), right? Loneliness and social isolation in serious illness or end of life?

Ashwin: That’s right. Yeah. I mean, we really built on some of the work Carla just mentioned. So we looked at older adults who are in their last four years of life, who had responded to the survey questionnaires on loneliness. And we found really high prevalence estimates of both loneliness and isolation. So loneliness was about 70% of people sometimes felt lonely, and about a quarter of people felt frequently lonely. So pretty common at the end of life amongst seriously older adults.

Eric: Had it changed with time the closer you got to the end of life?

Ashwin: It didn’t change as much as we thought it would. We thought that this was something that was really going to escalate in the last months or even last year of life, but it stayed relatively flat. Still at a really high prevalence, but pretty flat. And I think what we … Our senses that maybe people start to change what is adequate for themselves as they approach the end of life. They’re okay with not spending as much time with their friends or distant family members. But I think that something is still going on here, something distressing about their social situation that they’re experiencing as the end of life approaches.

Alex: And I think in that study, among people who didn’t die within the next four years or so, rates were much lower, suggesting that rates probably do climb, but it’s a more gradual process and it’s not strictly related to the end of life.

Ashwin: That’s right. We compared people to matched controls, so people who are not in that end of life. And we basically replicated the findings that Carla had before, that about 40% of people who are not in the last years of life were experiencing loneliness. So yeah, this does seem to be something that occurs more gradually. We didn’t pick up the exact timeframe when maybe that switch flips. So I think we really need to think about loneliness throughout the lifespan, not just the last years of life. How can we do things to improve people’s wellbeing before they’re in those last critical years?

Eric: I got a question. Why is this important for health care providers to either acknowledge, assess for or do something about it in some way? I mean, we’ve talked about this in a lot of different episodes in GeriPal. But the healthcare industrial complex is kind of like an octopus, it can kind of reach its tentacles out in a lot of different directions. What do we know about why it’s important, why we should do something about it? What are the downsides of loneliness?

Carla: We need like five hours talk about this. But I would say I think there’s just a couple of ways to think about this. One, it depends on what kind of clinician you are and what’s important to you. But ultimately, loneliness actually matters to our patients, it really has to do with quality of life. And if we do not ask about what is going on in people’s social lives, we’re missing out a huge part of their lives and what may be actually distressing. So we may be asking about hypertension, when really what they’re focused on is the fact that no one calls them all week. I mean, that is a very simple answer.

Carla: The more complex answer is that, across the board, both loneliness and isolation in different ways, and again, depending on how they’ve been measured, are linked with pretty serious health outcomes. Again, in the study that I published in 2012, we demonstrated that over a six-year period, people that reported higher rates of loneliness had higher risk of dying, 45% increased risk of dying and 59% increased risk of loss of independence and functional decline, outcomes that are significant and important to our patients. And then if you look at every other health outcome, cardiovascular disease, risk of dementia, diabetes outcomes, all cause mortality. They’re significant risks.

Carla: And then if you look at the finances, because God knows, American health care is complex and expensive, we know that one study done by AARP showed that people who were isolated, although I do think that there are people that were lonely also, had raised Medicare costs by over $6 billion a year. So this is not insignificant in terms of that personal effects, the familial effects, the societal effects and the economic effects.

Alex: Ashwin, anything to add to that?

Ashwin: Yeah. I would just add that I think it’s something we’re seeing clinically, especially during the pandemic. People come into the clinic, they feel lonely. Sometimes people will actually ask about loneliness. Do you feel lonely? How frequently Are you feeling lonely? Is this affecting other aspects of your health? But sometimes we’re not picking up on loneliness. We’re picking up on kind of the downstream effects. So I’ve seen very frequently that loneliness is deeply intertwined with physical and psychological symptoms that we’re more likely to talk about. Things like pain, difficulty sleeping, depression, anxiety.

Ashwin: So we actually just recently published a paper that was looking at medication use for these symptoms, which all tend to be high risk medications to treat physical and psychological symptoms, things like benzodiazepines, opioids, and NSAIDs. And we found that individuals who are more lonely tended to use these medications more frequently, sometimes twice the rate of benzodiazepine or sleep aids compared to people who are not lonely. I think that makes a lot of sense clinically.

Ashwin: We see this in the pandemic as well, people used to be able to manage their pain by spending time with their grandchildren, having a meal with their neighbor, going for a walk with a friend, and now they don’t have those social relationships to distract them, to kind of improve their overall health. You can kind of see how that pain that they might have had before isn’t relieved by Tylenol anymore. That’s something that they’re talking to their physicians more about.

Carla: You know what’s interesting, Ashwin, I was just thinking about this because it’s very neat. Like, when you think about loneliness and isolation, a lot of it is common sense. In other ways, there are some findings that are sometimes surprising. This is what’s fascinating to me about being a clinician, and then also bridging over to research because you see things in your clinical practice and then you see it in the number.

Carla: So to know about your research, and that you see the medication use, and then we have this evaluation and study that we’re doing have a friendship line, an outreach program for people in crisis who need someone to talk to. And we have some qualitative data where someone says, hey, because I was able to call this person, I didn’t have to take my anxiety medications. I mean, like that’s pretty neat to hear that. And then you have Ashwin’s study confirm that. This is real stuff that we actually see on a day-to-day basis.

Alex: So there are certainly important to patients, these are the social lives of our patients. To what extent is it the responsibility of like doctors, like geriatricians, palliative care doctors to ask about these issues as opposed to a domain of say, social workers?

Carla: That’s a great question, Alex. I would think it depends, again, on how do you see what is the role of health and healthcare. As we know when you look at research and you look at findings like what actually goes into someone’s health, bulk of it is actually social and much less what we’re taught in medical school. So, in my very humble but loud opinion, if you are only asking about health and medical things and not asking about social things and giving that to the social workers, you’re not doing your job. However, is it only for me to solve? Absolutely not. But I think it is just as much of part of my role to understand all the things that are affecting my patients health.

Carla: Be it food security, be it safety in the streets, be it loneliness, it’s all these determinants. I mean, there’s a reason why social determinants of health, not like they’re new, it’s just that we’re finally talking about them again. But like maybe the things are aligning that we realize we actually have to spend some money and time on this rather than close our eyes, pretend it doesn’t exist, and then be surprised when our healthcare is not good and why we’re spending so much money and not getting the outcomes we want.

Alex: I also wanted to ask, because we started out talking about how loneliness and social isolation are related but distinct. Of course, we’re putting them in the same podcast, so many papers put them together, et cetera. There’s a lot of misunderstanding, as you said, Carla, about them. Loneliness seems more of, it’s a subjective state, as you said, Ashwin. Social isolation may be a choice. Right? Some people may prefer to be alone or may prefer to die alone. So I wonder, like thinking about as clinicians who are screening, assessing, thinking about these concepts, does one carry more weight than the other?

Ashwin: Yeah. That’s a great question. I think it’s just easier to wrap your head around loneliness sometimes. By definition, it’s distress. People are unhappy with their social situation. They feel like they lack companionship, they’re left out. And so it’s easier sometimes to wrap that into psychological risk profiles, depression and anxiety, it can be very related to that. Sometimes we’re thinking about what might help them feel better. I think social isolation has many distinct mechanisms of how it impacts health. I think a lot about people’s access to resources to help them cope, especially during external stressors like the pandemic.

Ashwin: So when people aren’t married, they may not have clear resources to help handle emotional distress or a caregiver to help when they fall and they break their hip, or they’re hospitalized and they need extra support, they may not have someone to provide transportation to health care visits. In palliative care, we think a lot about access to home hospice. One of the key requirements for accessing home hospice, though, is having a 24-hour home caregiver. If you don’t have that, it’s hard to access what’s really vital service at the end of life. And so I think social isolation can impact people’s well-being in so many different ways that clinicians need to be aware of.

Ashwin: I think of it less as we need to mobilize support to make people feel better. It’s more so mobilizing these external support services so that people aren’t falling through the cracks of our healthcare system, a healthcare system that really relies on kind of social relationships and caregivers to help people through hard times.

Eric: Before we get into talking about what we can do about it, how should we assess for it? Can you give us some practical tools of how we should assess for loneliness or social isolation? What questions should we ask?

Carla: So one resource that’s really important for the audience to be aware of is that the National Academies of Sciences, Engineering, and Medicine released a report in February of last year, ironically, right as a pandemic was starting on loneliness and isolation and what the healthcare system should be doing about that. And there’s actually some fabulous information that really goes through all the data and on questions. There’s a couple things to know about here is that there actually is currently no gold standard internationally. We have measures we use here in the US and there’s some that are used in Europe.

Carla: However, there’s a couple summary points that I can give you. Is one, if you’re going to measure it, be consistent. So don’t ask one patient one way and another patient another way and another health system another way. So try to use the same scale. There is a scale called The UCLA Loneliness Scale, which is three items. Which is actually used quite a bit in part because as we all know in clinical practice or in lives, like doing anything more in depth is really challenging, that’s a good way to start. And it’s a good way to get things. It asks people if they feel isolated, if they feel left out, and if they lack companionship. So that’s for loneliness.

Carla: That is not the only scale. So there are many more you can read about, but that is the main one. For social isolation, it’s even more complex in terms of what the standard is. Some people argue for a single item like, do you live alone? I think that is incorrect because it doesn’t get at, are you living alone by choice? And are you distressed by this? There is something called the Berkman-Syme Index, which is what was actually recommended by the Institute of Medicine to be included in electronic medical records as part of social determinants of health. So there are recommended tools there.

Eric: Ashwin, you’re in clinic, in a palliative care clinic, you probably do the ESAS in clinic, which is like 10 different symptoms. Do you have like an 11th for loneliness?

Ashwin: There are kind of just single questions that sometimes you can ask about. Are you feeling lonely, is probably my go to. But you can also ask about do you feel like you’re connecting with friends in the way that you want to, connecting with family and friends in the way that you want to? Do you need help forming social connections? I think another way that we’ll sometimes get at social isolation, especially during the pandemic is assessing people’s access to technology, and how they’re using the internet or video devices or other things to connect. That’s one of the, I think, the limitations in some of the prior scales. They don’t fully assess all these different modes of communication that people might use that’s especially important for right now. So I think we need to just be aware of some of those different dimensions and make sure that we’re getting at what’s important to people and their kind of individual situation.

Carla: I think to add to that, sorry, Eric, but like I think what’s been very interesting during the pandemic is that, yes, a lot of these scales focus on like in group activities and in person things. So Ashwin and I really had to think about how do we ask these questions outside of in person interactions to get a sense of who is actually really still staying isolated, even though we’re all forced into mass isolation? Many of us were able to still connect in this way via Zoom, where some people absolutely have zero contact. So important to understand that more.

Eric: Let’s say you do … I guess, this is the question, we’re always taught in like our training in medicine, at least, like don’t order a chest X-ray or a lab test if it’s not going to change management. And I’m hearing that it’s really important. I’m wondering if one potential management, does it … If somebody is saying that they’re lonely, they’re isolated, does it make you think about assessing for other concurrent medical illnesses like depression, anxiety disorders, and things like that?

Ashwin: Yes. Absolutely

Carla: It does.

Ashwin: Some of the questionnaires for depression or anxiety actually include questions about loneliness. So they’re really closely related, I think, but I think sometimes … So it’s definitely important to ask about mental health, coexisting mental health issues. There’s also recent research that shows that loneliness can coexist with a number of other symptoms, which can become more prevalent at the end of life. Things like pain, nausea, shortness of breath, and even end of life healthcare use. So there’s a lot of different things that loneliness might give a clue to other symptoms that people might be experiencing. I think there’s also questions about what to do about all these topics.

Ashwin: So part of it is addressing all these related symptoms, you definitely want to be aware of everything that’s going on. Carla mentioned the National Academy of Sciences report that really displayed a need for better evidence and interventions to address loneliness and isolation. But just because the evidence is wanting, it doesn’t mean we shouldn’t do anything for the distress that we’re seeing in the clinic. So I think there’s a lot of steps that clinicians can take to, at least, many first steps that we can take, and then ways that we can work with our interdisciplinary team, social workers, community health workers to get people connected to community programs that may help.

Carla: I have to add that while they’re related, it’s really important to know that in many of the papers, and particularly in mine, the majority of the people that were lonely were not depressed, number one. Majority of people that were lonely were living with other people. So again, it gets at some of these stereotypes. My hypothesis, frankly, is that we have many people that we are treating for clinical depression and not addressing their loneliness and therefore not getting better. And I have a feeling we’re treating people with SSRIs, when really we should be focusing on their loneliness. So watch out for more research to come because I think this is where we need to go and learn more about these nuances.

Eric: All right, let’s get into practical issues. We’re going to start off from a provider perspective, and then maybe move into a systems or a policy perspective, what we can do for individuals who are lonely or socially isolated. So from a provider standpoint, in addition to assessing for some of these symptoms or mental health issues, what else should we be doing? What’s in our purview?

Carla: I think what’s in your purview is asking if someone wants your help. I mean, I think we often as clinicians assume that we’re supposed to be solving everything. And that’s not always the case. And I think that’s where we messed up, is giving the solution before asking if someone wants help and asking the why. So I’ll give you another example that I’ve used for decades, because it was one of the most humbling experiences, I think. Well, early on is that someone had read in the chronicle when my paper was first published. And they said, “You know, Dr. Perissinotto, I’m lonely, but maybe not like you think I am, or in the traditional way.” And I said, “Well, tell me more.” And she says, “Well, I used to work in retail and I really miss it.”

Carla: That would not have been in my toolbox didn’t tell her to go get a job at the gap. But actually, what we did for her is that she started volunteering at Salvation Army in the retail store. That was her solution. So that means that as a clinician, or as someone working with older people, or whoever it may be, once you find out that there may be some loneliness is like, okay, well, do you want to do something about it? And do you have any insight as to why this may be and what may help? And then you think about, are there interventions that have evidence? If there are, you go for them? And when there’s not evidence, you pick the next base thing is based on interest and what you think the etiology is matching to what the problem is.

Ashwin: Exactly. This is classic geriatrics, taking an individualized approach to address situations where the evidence hasn’t quite caught up yet. So we’re often asking what do people think might help, and trying to think about the individual contributors to loneliness that might be going on in that situation. If a person has recently lost a spouse, and is grieving, then putting them in a large community exercise group is probably not the right thing for them at that time. Maybe it is and it’s worth exploring with them. But sometimes in those situations, we might think about telephone friendship lines to just check in on someone, provide-

Carla: Grief counseling.

Ashwin: Provide grief counseling, exactly. We might think about different support groups that may help. We might even think about some of the functional losses that people may have when they lose a spouse. Maybe their partner was someone who used to do most of the driving or do most of the financial activities. Maybe they just need some support to learn how to take over those tasks. So I think there’s a lot that you can uncover when you start asking about loneliness and the drivers of those experiences. And an individualized approach is key.

Eric: As we start thinking about systems of care, I also feel like in the last year and a half, we’ve created a lot of social isolation and loneliness, especially for individuals living in institutional care. Lack of ability for loved ones to visit. That essential caregiver workforce became all of a sudden non-essential in long term care facilities. Your thoughts on that?

Carla: I feel like I say this ad nauseam, but we are so agist, and so I think what’s really sad … I have mixed feelings about this because the pandemic has really made isolation and loneliness front and center to many people. And so suddenly it’s like, oh, my goodness, there are actually old people in the world. And there are people that are lonely, because suddenly I’m 43 and experiencing it for the first time. And suddenly, I have this awareness that it’s going on. So it’s sad that this is what it’s taken for us to be aware of it. That being said, great, we’re now aware of it. Let’s do something. And I think this is something where we cannot continue to relegate this to something that we ignore.

Carla: I think, Eric, your point about long term care is really rethinking what an essential caregiver is. The fact that we had hospitals that would allow parents and for children, but not a loved one for someone who with dementia, where their risk of poor outcomes is even stronger than for children is really devastating. I think thankfully, we’ve seen some of our public policies start to catch up and say, compassionate visits, this is not just end of life, this is for people that really rely on that essential care giver, as you say, for companionship and recognizing that companionship is just as essential to health.

Carla: We have been trying to prevent deaths by protecting from COVID, not realize that we were actually probably causing deaths in the process. We haven’t studied this, we will probably never know. But I am so certain that we have caused more deaths. Not necessarily more deaths and COVID, but more deaths than are needed that we could have saved.

Eric: Yeah. It’d be a really interesting study, having seen a lot of nursing home patients this last year and a half. Again, it’s hard to know because functional decline happens in nursing home patients. I am just surprised at the functional declines that we’ve seen over the last year and a half.

Carla: In ourselves, you mean?

Eric: Everybody. Actually, I’ve been walking more than I’ve ever have in my entire life.

Carla: Really? That’s good.

Eric: But it would be really interesting to see like how different the last year and a half has been as far as functional decline in nursing home patients. Like, we have the data, it’s all there in the MDS to see if it really has changed at all.

Carla: But then you take the assisted living community, which is really hard to get data because the regulations vary from state to state, county to county. So, yeah.

Alex: I’d love to hear more about what … It sounds like deep understanding of what are the underlying causes of loneliness or social isolation in our patients is critical. And then matching the response, offering response and then a matching response to those underlying causes is critical. You were asking clinicians to have a robust understanding of support services, for example, that are available in their communities. And I think that’s a reasonable ask. I wanted to ask also about other innovative approaches. Like for example, you both just had a paper accepted at JAGS about a peer support intervention. I wonder if you could tell us a little bit more about that.

Ashwin: Yeah, absolutely. I think there are a number of amazing community level programs that are out there. And part of Carla and my approach to these programs is, how can we connect them with our healthcare system so we know about them, and we’re also building the evidence base, so clinicians can feel comfortable sending their patients to these programs to address complex social needs. So this recent paper evaluated a peer outreach program that’s based out of Curry Senior Center, but is actually a program that’s supported by San Francisco as a city. And it matches people who want help forming social connections with peers who … And by peers, I mean, people who have shared backgrounds. Similar age, maybe similar life histories, may need to be matched by language preferences.

Ashwin: But the point is that they feel there’s kind of a built in connection there, and they build that connection and rapport and trust over time. So we found that these relationships when people were matched with peers, people have reduced feelings of loneliness, reduced depression, have reduced barriers to socializing that people might have built up over time over many years, and it also improves socialization. So this was, I think, a good example of where social connection can hit all of these different domains of health to improve people’s well being over time.

Carla: And the other interesting thing about this innovative program is that when the program first started, I think with the city and the Mental Health Services Act were hoping that that people would be connected with mental health services and healthcare services. Now, that is not actually how the program went. Instead, it was like, let me form a connection. And then actually, now that we have a connection, maybe I can actually help you get to the doctor. And so it’s really awesome how that is. I mean, it’s very similar to what’s happening or what the rest of the world does, which is with easing of community health workers, and really using the people from your own community to help you form that link.

Carla: There are some great programs out there. I think we often forget that our communities and our community based organizations, they have the knowledge, we’re just not tapping into it. And they’re not being supported well because they’re grant funded. And so Ashwin and I really have been working with many of them, as many of our other research colleagues around the country are, is really building up the evidence base to say, hey, this works and let’s use this. Alex, I appreciate you saying that you think it’s reasonable for clinicians to know a little bit about resources. I don’t think everyone feels that way.

Carla: But I would say, I don’t see this being any different than if I’m treating someone for hypertension or heart failure, I should understand the reasons why they may have that and know the different medications and paths I may need to do. So there is sometimes a one size fits all, but often not. As we know, there’s often more exceptions than the norm. And so it’s this very similar thought process and evaluated process to get the right treatment.

Eric: Ashwin, in your JAGS paper, you also mentioned like a higher level, the campaign to end loneliness coming out of the UK. What is the high, higher level? Is that something that the US should be doing or what the heck is that?

Ashwin: I think we should be striving for it. So the UK has a national campaign to end loneliness. I really think of this as an integrated national effort. So at all different levels, how can we address this complex challenge? I think, in the US there have been a number of awareness campaigns that have occurred. So I think there’s a National Academy of Sciences report that Carla was a part of has helped to raise a lot of awareness, especially among researchers about loneliness and isolation. Our Surgeon General, Vivek Murthy, has taken this on as kind of a huge need. He wrote a recent book about the epidemic of loneliness. Provides a really detailed description of many different scenarios that contributes to this and how we might be able to address this complex need.

Ashwin: But really, I think what it comes down to is we need to start valuing social well-being in a similar way that we value the treatment of disease and traditional medical symptoms. I think, especially among older adults, where social well-being can be a core of people’s overall quality of life, can impact health in so many different ways. Perhaps this is a call, especially during the pandemic, this is a time where we should start thinking about how can we spend the money, some of the money that we’re spending on health care on social well-being? How can we redirect, reprioritize some of those resources to think about people’s overall health?

Eric: So my last question to you both. Let’s imagine there was a drug that costs $56 billion a year. And instead of using that drug, aducanumab, you had $56 billion to address this issue. What’s one thing, now this magic $56 billion magic wand, what’s one thing you would do? You can use all 56 billion if you want.

Carla: I am going to say I actually think since many of our older adults live in poverty, and many are dual eligibles and have Medicaid benefits, I actually think that using an in home support service workers and having a social companionship program as part of that, where you actually get certain number of hours for social companionship would be how I spend the money. And I will also point you too, Eric, and everyone, to your listeners, to the coalition to end social isolation and loneliness in the US so we are moving more towards what we’re seeing in the UK. Not yet, but there is great movement there.

Ashwin: I completely agree. Programs that start with the social needs and then potentially move out to addressing medical needs that come up, I think that’s a really nice way of providing a good foundation for relationships and solving a huge gap in our healthcare system right now.

Eric: Well, I want to thank both of you for joining us today talking about this important issue. We’re going to have links to your papers on the GeriPal post that accompanies this podcast. But before we end, Alex, a little bit more Eleanor Rigby. (singing). Alex, that was awesome. Carla and Ashwin, always great to have you on the GeriPal Podcast.

Ashwin: Thanks for having us.

Carla: Thanks for having us.

Eric: Thank you Archstone Foundation for your continued support of the GeriPal Podcast. And to all of our listeners, thank you for supporting us. And if you have any topics that you think we should cover on the GeriPal Podcast, please send me or Alex a tweet or an email suggesting the topics. With that, goodnight everybody.

Alex: Goodnight.