Social Assessment of Older Patients

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. 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, and typically refers to the impact of macrosocial issues such as poverty, education, neighborhood conditions, and the built environment 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. Multiple studies have found greater level of social support to be related to better self-management of diabetes and dietary and exercise behaviors. 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. In a meta-analysis of available studies, Barth and colleagues 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. 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. 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. Caregiver strain or burden is also associated with increased likelihood of institutionalization for the older patient. 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, 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. 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. 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. 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.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here