Addressing Social Isolation To Improve the Health of.pdf

Rapid Evidence Product
Addressing Social
Isolation To Improve the
Health of Older Adults:
A Rapid Review
e

Rapid Evidence Product
Addressing Social Isolation To Improve the Health of
Older Adults: A Rapid Review
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov
Contract No. 290-2017-00003-C
Prepared by:
Scientific Resource Center
Portland, OR
Investigators:
Stephanie Veazie, M.P.H.
Jennifer Gilbert, M.D., M.P.H.
Kara Winchell, M.A.
Robin Paynter, M.L.I.S.
Jeanne-Marie Guise, M.D., M.P.H.
AHRQ Publication No. 19-EHC009-EF
February 2019

ii
Purpose of Review
To rapidly evaluate the effect of interventions targeting social isolation/loneliness in community-
dwelling older adults (60 years and older) on outcomes of social isolation/loneliness, health and
health care utilization.
Key Messages
• Physical activity interventions to reduce social isolation showed the most promise at
improving the health of older adults; however, effects were inconsistent and short-term.
Three of the four interventions that found a positive effect on health or social isolation
met more than once per week and involved a health care professional in the delivery of
the intervention.
• Among interventions that improved social isolation or health/health care utilization
outcomes, there was no clear relationship between effects on social isolation and effects
on health or health care utilization.
• Looking across studies, we found several methodological issues: lack of consistency on
whether and how social isolation and/or loneliness are measured; follow-up not being
long enough to see health benefits, and lack of measurement of health care utilization or
potential harms.
• Interventions that connect socially isolated older adults to health services are
conceptually promising and need good-quality studies.

iii
This report is based on research conducted by the Scientific Resource Center under contract to
the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-
2017-00003-C). The findings and conclusions in this document are those of the authors, who are
responsible for its contents; the findings and conclusions do not necessarily represent the views
of AHRQ. Therefore, no statement in this report should be construed as an official position of
AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with
the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and
clinicians, health system leaders, and policymakers, among others—make well-informed
decisions and thereby improve the quality of health care services. This report is not intended to
be a substitute for the application of clinical judgment. Anyone who makes decisions concerning
the provision of clinical care should consider this report in the same way as any medical
reference and in conjunction with all other pertinent information, i.e., in the context of available
resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the
author and the Agency for Healthcare Research and Quality. This report may be used and
reprinted without permission except those copyrighted materials that are clearly noted in the
report. Further reproduction of those copyrighted materials is prohibited without the express
permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative
products that may be developed from this report, such as clinical practice guidelines, other
quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
Persons using assistive technology may not be able to fully access information in this report. For
assistance contact epc@ahrq.hhs.gov.
Suggested citation: Veazie S, Gilbert J, Winchell K, Paynter R, Guise J-M. Addressing Social
Isolation To Improve the Health of Older Adults: A Rapid Review. Rapid Evidence Product.
(Prepared by Scientific Resource Center under Contract No. 290-2017-00003-C.) AHRQ
Publication No. 19-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality;
February 2019. Posted final reports are located on the Effective Health Care Program search
page. DOI: https://doi.org/10.23970/AHRQEPC-RAPIDISOLATION.

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Preface
Recognized for excellence in conducting comprehensive systematic reviews, the Agency for
Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program is
expanding its portfolio to include Rapid Evidence Products. The program has begun to develop a
range of Rapid Evidence Products to assist end-users in making specific decisions in a limited
timeframe. The Scientific Resource Center (SRC) supports the activities of the EPC program,
including piloting and producing Rapid Evidence Products.
In 2014, AHRQ EPCs produced a taxonomy of rapid evidence products produced by leading
organizations around the world.abc
This taxonomy now informs the development of Rapid
Evidence Products. Based on level of synthesis, the report classified products as inventories,
rapid responses, and rapid reviews. On one end of the spectrum, evidence inventories offer an
assessment of the quantity and type of evidence without presenting results. On the other end,
rapid reviews adapt and streamline traditional systematic review methods to provide a limited
evidence synthesis.
To shorten timelines, reviewers must make strategic choices about which processes to
abridge. Common adaptations to provide rapid evidence include: narrowly focusing questions,
limiting the number of databases searched and/or modifying search strategies, using a single
reviewer and/or abstractor with a second to provide verification, and restricting to studies
published in the English language. However, the adaptations made for expediency may limit the
certainty and generalizability of the findings from the review, particularly in areas with a large
literature base. Transparent reporting of the methods used, the resulting limitations of the
evidence synthesis, and the strength of evidence of included studies is extremely important.
While tradeoffs will likely differ for each topic, they are described so readers can adjudicate the
limitations of the findings and conclusions of the review.
While rapid evidence products are often sufficient for decisionmaking on their own, at other
times they can uncover a large complex literature base that encourages end-users to seek a full
review. Even in this instance, the rapid evidence review can provide a map of the evidence and
assist decisionmakers in targeting resources to areas of highest interest and greatest potential
value.
AHRQ expects that these rapid evidence products will be helpful to health plans, providers,
purchasers, government programs, and the health care system as a whole. Transparency and
stakeholder input are essential to the Effective Health Care Program.
If you have comments on this report, they may be sent by mail to the Task Order Officer named
below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD
20857, or by email to epc@ahrq.hhs.gov.
a
Hartling L, Guise J-M, Hempel S, et al. EPC methods: AHRQ End-user perspectives of rapid reviews. Rockville
(MD): 2016. https://www.ncbi.nlm.nih.gov/pubmed/27195347
b
Hartling L, Guise JM, Kato E, et al. EPC Methods: An Exploration of Methods and Context for the Production of
Rapid Reviews. Rockville (MD): 2015. https://www.ncbi.nlm.nih.gov/pubmed/25654160
c
Hartling L, Guise J-M, Hempel S, et al. Fit for purpose: perspectives on rapid reviews from end-user interviews.
Systematic Reviews. 2017;6:32. doi: 10.1186/s13643-017-0425-7. PMID: PMC5316162.

v
Gopal Khanna, M.B.A.
Director
Stephanie Chang
Director
Evidence-based Practice Center Program
Center for Evidence and Practice
Improvement
Arlene S. Bierman, M.D., M.S.
Director
Improvement
Christine Chang, M.D., M.P.H.
Task Order Officer
Improvement

vi
Peer Reviewers
Prior to publication of the final evidence report, the SRC sought input from independent Peer
Reviewers without financial conflicts of interest. However, the conclusions and synthesis of the
scientific literature presented in this report do not necessarily represent the views of individual
reviewers.
Peer Reviewers must disclose any financial conflicts of interest greater than $5,000 and any
other relevant business or professional conflicts of interest. Because of their unique clinical or
content expertise, individuals with potential nonfinancial conflicts may be retained. The TOO
and the EPC work to balance, manage, or mitigate any potential nonfinancial conflicts of interest
identified.
The list of Peer Reviewers follows:
Chantelle Garrity, D.C.S., M.Sc.
Senior Research Program Manager
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada
Lisa Hartling, M.Sc., Ph.D.
Director, Alberta Research Center for Health Evidence
University of Alberta
Edmonton, Alberta, Canada
Elaine Wethington, Ph.D.
Professor
Cornell University
Ithaca, NY

vii
Addressing Social Isolation To Improve the Health of
Older Adults: A Rapid Review
Structured Abstract
Background. Social isolation and loneliness in older adults are substantial public health
problems. Interventions have been examined for their effect on reducing social isolation and
loneliness; however, it is unclear which are effective at improving health outcomes and avoiding
unnecessary health care utilization.
Purpose. To review recent literature evaluating the effectiveness of interventions that target
social isolation and loneliness to improve health and/or health care utilization.
Methods. We used rapid review methods to evaluate recent research. We systematically
searched Ovid/Medline®
, PsycInfo®
, and CINAHL®
from 2013 to 2018 for systematic reviews
and from 2016 to 2018 for primary studies. We used predetermined criteria to select primary
studies from systematic reviews published in 2018, in addition to the primary study search. We
extracted study-level data, conducted quality assessments, and synthesized results.
Findings. Sixteen studies were included: one good-quality randomized controlled trial [RCT],
seven fair-quality studies (6 RCTs and 1 pre-post), and eight poor-quality studies (7 pre-post and
1 cross-sectional with post-test survey). Of the eight good- or fair-quality studies, five examined
physical activity, two examined social interventions, and one examined an arts and recreation
intervention. Two were associated with a positive effect on health outcomes: a resistance
training, nutrition, and psychosocial support intervention improved functionality, depression,
diet, and social capital, and a physical/leisure activity intervention improved quality of life but
not social support. Two interventions (group tai chi and facilitated group discussion) improved
loneliness but not health outcomes (e.g. quality of life or depression). Of the four fair- or good-
quality studies reporting a positive impact on social isolation or health outcomes, three involved
a health care professional in delivery, and three met more than once/week. Most poor-quality
studies showed improvement in health but not social isolation; however, study design issues
limited the reliability of these results. Five of 16 studies reported on harms and none were
clinically significant. Three reported on health care utilization, with conflicting results.
Implications. Of interventions to reduce social isolation, physical activity interventions show the
most promise at improving the health of older adults; however, effects were inconsistent and
studies short term. Information on the effect of interventions on health care utilization is sparse
and inconsistent. Health systems should target interventions to the needs of their population
while keeping in mind that the documented impact of such interventions specific to social
isolation, health, and health care utilization outcomes is limited. Health systems should
rigorously evaluate their efforts to increase the evidence base and share results with other health
care systems.

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Contents
Background ................................................................................................................................... 1
Objective and Guiding Questions............................................................................................... 2
Methods.......................................................................................................................................... 3
Findings ......................................................................................................................................... 5
Question 1. Among older adults, what is the effectiveness of interventions (volunteerism, peer
support, transportation programs, etc.) that target social isolation and loneliness to improve
health and reduce unnecessary health care utilization? .............................................................. 7
Question 2. Among older adults, what are the harms associated with interventions
(volunteerism, peer support, transportation programs, etc.) that target social isolation and
loneliness to improve health and reduce unnecessary health care utilization?......................... 11
Discussion..................................................................................................................................... 12
Summary................................................................................................................................... 12
Limitations................................................................................................................................ 13
Limitations of Rapid Review Methodology.......................................................................... 13
Limitations of Primary Studies ............................................................................................. 13
Research Recommendations..................................................................................................... 14
Conclusion ................................................................................................................................ 15
References.................................................................................................................................... 16
Tables
Table 1. Inclusion and Exclusion Criteria
Table 2. Selected intervention characteristics and outcomes data from fair- and good-quality
studies
Figures
Figure 1. Analytic framework
Figure 2. Literature flowchart
Appendixes
Appendix A. Full Methods
Appendix B. Search Strategies
Appendix C. Study Details
Appendix D. Poor-Quality Studies
Appendix E. Characteristics of Interventions in Fair- to Good-Quality Studies
Appendix F. Social Isolation and Loneliness Definitions and Measures

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Background
One in five Americans report feeling socially isolated or lonely.1
A recent analysis found that
162,000 deaths each year in the United States are attributable to low social support; that is more
than the number of deaths due to lung cancer.2, 3
Social isolation and low support are particularly
concerning for older adults.
The population of the United States is aging, with the number of adults aged 65 and older
growing from 35 million in 2000 to 49.2 million in 2016.4
Older adults are at higher risk for
being socially isolated due to age-related changes in health and social connections, such as
limitations to hearing and vision, reduced mobility, and loss of family and friends.1
These
changes can contribute to social isolation and loneliness, defined respectively as the lack of
sustained meaningful connection to other people and the perceived lack of interaction with
others.5
In recent nationally representative surveys, 40 percent of older adults reported feeling
lonely6
and 24 percent were socially isolated.7
Adults who are lonely or socially isolated self-
report worse physical health,8
are at higher risk of dementia,9
have more physician visits,10
and
have higher rates of mortality.6, 11
The relationship between social isolation, health, and health care utilization is complex.12
Poor health has been theorized to be both a contributor to social isolation (e.g., declining health
may keep older adults from maintaining social relationships) and a result of social isolation (e.g.,
the stress brought on by social isolation may affect health outcomes).13, 14
Along the same lines,
previous research has found that older adults with weaker social relationships have higher rates
of certain types of high-cost and potentially avoidable health care services such as hospital
readmissions and longer hospital stays, but similar rates of lower cost services such as
ambulatory care visits.15 16
Due to the evidence linking social isolation with poor health and potentially avoidable health
care utilization, there have been large-scale efforts to promote the inclusion of older adults into
society. Initiatives include the World Health Organization’s creation of the Global Network for
Age-friendly Cities and Communities17
and the United Kingdom’s assignment of a Minister of
Loneliness.18
These groups have also issued guidelines on addressing social isolation. The World
Health Organization (WHO) recommends identifying and supporting networks for older adults,
providing access to appropriate assist devices, and developing confidence in using technology.19
In addition, the WHO notes that interventions that are participatory and have a theoretical
foundation are usually more effective than those without. The UK’s National Institute for Health
and Clinical Excellence (NICE) recommends health care practitioners identify and address social
isolation among older adults by providing advice and resources about social activities and
consider contracting with voluntary and community sectors to provide these services. 20
In the
US, Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid
Services (CMS)—recommend that health systems collect information on social determinants of
health, ideally in electronic health records.21
Increasingly, there has been interest from health systems, payers, public health departments,
advocacy groups, and community organizations to play a role in developing and implementing
interventions to address the social determinants of health, including social isolation and
loneliness.22-25
This topic was nominated for a new rapid evidence product by Kaiser Permanente
Northwest (KPNW) Center for Health Research (CHR), representing a large integrated health
system in the United States. KPNW CHR partnered with a major academic integrated statewide
health system (Oregon Health & Science University [OHSU]) and a community access program
(Project Access Now) to hold a healthy aging summit that brought together community groups,

2
the public, and health systems to develop and implement interventions and develop a research
agenda to improve health outcomes and health care utilization for older adults in Oregon. Social
isolation was a major focus of this summit.
An up-to-date review of recent evidence on the effectiveness of social isolation interventions
on health and health care utilization in older adults was conducted to inform and support the
summit that was occurring in a matter of months.
Objective and Guiding Questions
Our objective was to rapidly evaluate and synthesize the most recent evidence on
interventions to reduce social isolation and loneliness to improve health and reduce unnecessary
health care utilization among older adults. The following questions guided the literature search
and inclusion/exclusion criteria.
1. Among older adults, what is the effectiveness of interventions (volunteerism, peer
support, transportation programs, etc.) that target social isolation and loneliness to
improve health and reduce unnecessary health care utilization?
2. Among older adults, what are the harms associated with interventions (volunteerism, peer
support, transportation programs, etc.) that target social isolation and loneliness to
improve health and reduce unnecessary health care utilization?
Figure 1, below, is an analytic framework depicting the relationship between the questions and
population, interventions, and outcomes of this rapid review.
Figure 1. Analytic framework

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Methods
We conducted a rapid review of the last 5 years of research to inform health systems’
decisionmaking on a leading social determinant of health for the elderly—social isolation. This
rapid review was guided by established rapid review methodology26, 27
and took the following
steps to complete a product on a 4-6 month timeline:
• Defined a narrow scope (see Table 1).
• Conducted searches in a limited number of databases.
• Focused inclusion criteria on articles published in the last 5 years, articles in the general
population of older adults, and articles published in English.
• Relied heavily on existing systematic reviews to identify primary studies.
• One reviewer assessed articles for inclusion and risk of bias and a second reviewer
checked a 25 percent sample.
• Conducted focused data extraction.
We refined the scope of this rapid review in consultation with the nominator and a topic
expert. The protocol was developed based on input from experts, registered in the PROSPERO
database28
(CRD42018100102) and publicly posted on the Agency for Healthcare Research and
Quality (AHRQ) Effective Health Care Program Web site.29
We provide a full description of our
methods in Appendix A and provide a brief description here.
A librarian conducted formal searches for systematic reviews in PubMed®
, PsycInfo®
, and
Cumulative Index of Nursing and Allied Health (CINAHL) ®
from January 2013 to May 2018,
and targeted searches in databases routinely searched during topic development for the AHRQ
Evidence-based Practice Center Program. The librarian updated the searches in PubMed,
PsycINFO, and CINAHL in November 2018. See Appendix B for search strategies and the full
list of databases searched. These systematic reviews provided a source from which to identify
primary studies published since 2013. We searched for primary studies (January 2016 to May
2018) in PubMed, PsycInfo, and CINAHL based on the end date of the search of the most recent
and most comprehensive systematic review. The librarian updated the searches in PubMed,
PsycINFO, and CINAHL in November 2018 for both systematic reviews and primary studies.
We specified and refined our inclusion and exclusion criteria based on the populations,
interventions, comparators, outcomes, timing, and settings (PICOTS) of interest for this review
(Table 1).
Table 1. Inclusion and exclusion criteria
PICOTS Inclusion/Exclusion Criteria
Population Include: Older adults (Medicare or retirement age [60 years or older]), community dwelling
Exclude: People less than 60 years of age, exclusively focused on a single health condition
(physical or sensory disability, specific mental illness, etc.), non-community dwelling (nursing
home, institutional setting, etc.), exclusively focused on a specific subpopulation (indigenous
populations, immigrants, veterans, etc.)
Intervention Include: Interventions that target social isolation to improve health outcomes or reduce
unnecessary health care utilization. Examples include volunteerism, programs delivered by peers
or health care practitioners, transportation programs, etc.
Exclude: Case management delivered by a trained health care professional, information
technology (IT) focused interventions, telehealth, interventions not focused on reducing social
isolation, not an intervention, interventions that did not measure impact on health outcomes.
Comparator Include: Any comparator, no comparator

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Outcomes Include*
Primary:
• Physical and mental health outcomes (including but not limited to depression, quality of life,
and chronic disease management)
Secondary:
• Social isolation and loneliness
• Health care utilization (including but not limited to emergency department visits,
hospitalizations, primary and specialty care appointments)
• Harms (e.g., adverse events, worsening of health or social isolation, costs)
Setting Include: Community settings
Exclude: Low and middle-income countries, skilled nursing facilities, assisted living facilities,
hospitals.
Study
Design
Include: Quantitative or mixed-methods studies including observational studies. (We included only
quantitative data.)
Exclude: Qualitative studies, single timepoint studies (i.e., post-intervention survey)
Language Include: English
* Systematic reviews were included if they report any of the primary or secondary outcomes of interest. Primary studies were
only included if they report the primary outcome. PICOTS = population, intervention, comparator, outcomes, time, setting.
One reviewer evaluated titles, abstracts, and full texts of systematic reviews and primary
studies based on predetermined criteria, and a 25 percent sample was verified by a second
reviewer. One reviewer evaluated risk of bias using U.S. Preventive Services Task Force
criteria30
to evaluate study quality and a second reviewer checked a 25 percent sample. The risk
of bias criteria are detailed in Appendix A. Data were extracted by one reviewer, and a second
reviewed for accuracy and completeness. We also searched for guidelines and reached out to
several research centers and health care collaboratives to identify ongoing and recently
completed studies.
AHRQ did not directly participate in the literature search, determination of study eligibility
criteria, data analysis, or interpretation of this report. AHRQ reviewed this report to assess
adherence to methods. Two methodological experts, one topic expert, three AHRQ staff, and the
nominator, a health system expert, peer reviewed the draft report.

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Findings
The literature flow diagram (Figure 2) summarizes the search and selection of articles. We
identified 272 systematic reviews. Eight met inclusion criteria, and we selected the four5, 31-33
most recent systematic reviews, which were published in 2018. We evaluated the 131 unique
primary studies contained in these systematic reviews as well as 1,572 primary studies from a
search from the past 2 years. After applying predefined inclusion and exclusion criteria, we
included 16 studies34-49
—9 from systematic reviews34-37, 39, 41, 42, 45, 46
and 7 from primary study
searches.38, 40, 43, 44, 47-49
Of the 16 included studies (7 randomized controlled trials [RCTs],38, 44-49
8 pre-post,34-37, 39-42
and 1 cross sectional with a post-test survey43
) including 17,656 patients, 5
involved physical activity interventions,45-49
5 involved social interventions,35, 40-42, 44
4 involved
arts and recreation-based interventions,34, 36-38
and 2 involved improving health services access.39,
43

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Figure 2. Literature flowchart
SR = systematic review; PICOTS = population, intervention, comparator, outcomes, time, setting

7
Question 1. Among older adults, what is the effectiveness of interventions
(volunteerism, peer support, transportation programs, etc.) that target
social isolation and loneliness to improve health and reduce unnecessary
health care utilization?
Of the 16 studies aimed at reducing social isolation or a related construct,34-49
440, 44, 45, 48
(3
RCT, 1 pre-post) demonstrated measurable improvement in loneliness, social capital, or social
participation; 634, 36, 38, 42, 46, 47
(3 RCTs and 3 pre-post) had no significant effect on loneliness,
social support, or social networks; and 635, 37, 39, 41, 43, 49
(1 RCT, 4 pre-post, and 1 cross-sectional)
did not report an effect or the effect could not be determined. Five (2 RCTs46, 48
and 3 pre-post36,
39, 42
) of 16 studies reported improvements in health outcomes, including quality of life, frailty,
depression, diet, functionality, stress, and chronic pain. Three studies40, 43, 49
measured health care
utilization, two40, 43
of which reported sufficient information to determine if there was significant
difference between groups over time. Half of the 16 studies were poor quality, making the
interpretation and application of findings difficult. Study findings are organized by intervention
and summarized below. Detailed study characteristics and findings are presented in Appendix C.
An overview of study findings for good- and fair-quality studies appears in Table 2, and study
findings for poor-quality studies are in Appendix D.
To better understand how the characteristics of these interventions might be contributing to
effects, we compared each of the good- and fair-quality studies in terms of intervention duration
and intensity, and whether a health care provider, lay person, or peer delivered the intervention,
and then compared these to whether there was an effect on either a social isolation construct or
health outcomes (Appendix E). Of the four fair- or good-quality studies45-48
that had a positive
impact on either health or social isolation outcomes, three had a health care professional
involved in the delivery (including a physical and leisure activity intervention delivered by a
physical therapist, occupational therapist, and public health nurse; a tai chi intervention in which
a nurse and social worker trained peer ambassadors to support older people in the intervention;
and a facilitated group discussion intervention delivered by National Health Service and social
care staff who were supervised by an occupational therapist). Of the same four studies, three
were high intensity, meeting more than once a week.
By contrast, among the three fair-quality studies35, 38, 47
of interventions that had no effect on
either health or social isolation outcomes, only one had a health care professional involved in the
delivery (intervention that provided a choice of exercise, social activity, or personnel counseling
had a rehabilitation counselor provide counseling), one was low intensity (met less than once a
week), and two were medium-low intensity (met less than once a week or once a week,
depending on intervention group). This suggests that having a health care professional involved
and delivering an intervention at least once a week may be important to improving outcomes for
older adults. Previous research has found that patients report better health and satisfaction when
they trust their health care provider (e.g., nurse, physician, general practitioner, or psychiatrist);50
it is therefore possible that interaction with a trusted health care provider played a role in
improving patient outcomes in these interventions.
Physical activity interventions. Five fair-quality RCTs45-49
evaluated physical activity
interventions in older adults.
Two RCTs46, 48
reported health benefits, both of which were multicomponent interventions
that combined exercise with other interventions including social, leisure activities (e.g. cooking),
and/or diet programming. One RCT (n=77)48
examined a 3-month, twice-weekly, 100-minute
resistance exercise program combined with either a nutritional or psychosocial program. This

8
intervention was delivered to pre-frail or frail older adults by trainers and study staff at a local
community center. The nutritional program aimed to increase food variety through lectures on
diet and group activities, while the psychosocial program involved group discussions of
participants’ hobbies, neighborhoods, and community resources. Improvements were seen in
social capital, frailty, depression, diet, and physical function as measured through the Timed Up
and Go test. The other RCT (n=52)46
found improvements in health outcomes but not a social
isolation construct. This study involved a 3-month multicomponent intervention delivered at a
community center, but was conducted less frequently (once a week vs. twice a week). This
intervention included two-hour sessions once a week of physical activity (e.g., walking,
stretching, and weights) combined with leisure activities (e.g., cooking, games, and crafts). This
study found no effect on social support but did report significant improvement in quality of life
at 3 months. This intervention was delivered by health care professionals (e.g., physical therapist,
occupational therapist, or public health nurse), while the other multicomponent intervention was
conducted with study staff and trainers of unclear professional background.
Of the three remaining RCTs, one (n=100)49
did not provide data to compare groups over
time, one (n=48)45
involved a 3-month intervention of tai chi and found no impact on social
networks, mental health, or self-esteem at 3 or 6 months but improvements in loneliness at 6
months, and one (n=223)47
that randomized patients to the choice of physical activity (n=45),
social activity (n=27), or counseling (n=33) reported no significant impact on loneliness,
depression, or melancholy at 6 months. Only one physical activity study49
reported health care
utilization outcomes (hospital admissions, emergency department visits, and primary care visits);
however, it did not provide data to compare groups over time.
Social interventions. Five studies39-42, 44
examined the effect of social interventions,
including one good-quality RCT,44
one fair-quality pre-post study with concurrent control,39
and
three poor-quality pre-post studies.40-42
Neither of the good- or fair-quality studies saw improvements in health outcomes or reported
health care utilization outcomes. The good-quality RCT44
(n=288) of facilitated group
discussions on goal setting, strengths, and skills saw no effect on mental health, depression, or
quality of life at 6 or 12 months, but did see an improvement in loneliness at 2 years. Study
authors cautioned this finding was “questionable” because it is not clear if this was a minimal
clinically important difference. The fair-quality pre-post study35
(n=80), in which older adults
read to children, found no effect on depression, but did note there was a significant group-x-time
interaction effect for sense of coherence (p < 0.10). Study authors conducted simple effects
analysis on subscales of the sense of coherence tool and determined there was a short-term effect
on the subscale of meaningfulness but not subscales of comprehensibility or manageability. This
study did not measure a social isolation construct.
Of the three poor-quality pre-post studies,40-42
two40, 42
reported improvements in health
outcomes including depression and perceived stress, but only one40
reported improvements in
loneliness and social participation. Only one poor-quality study reported health care utilization
outcomes and found an increase in nurse visits (but not general practitioner or social work visits)
over 1 year. However, it should be noted that the intervention was only 15 weeks long and it is
unclear how the timing of the 1-year time span for potential visits aligned with these 15 weeks.
Interventions in poor-quality studies ranged from older adults sharing memories with young
people to social gatherings to combined phone calls, home visits, and social engagements.
Findings of these studies should be interpreted with caution due to considerable potential for
bias. All three studies lacked a control group and failed to report if they conducted appropriate

9
statistical analyses to account for drop-outs or adherence. One study41
measured outcomes at 3
weeks, which was too short to see an effect on certain important health outcomes.
Arts and recreation interventions. Four studies,34, 36-38
including one fair-quality RCT38
and
three poor-quality pre-post studies,34, 36, 37
tested the effects of arts and recreational interventions.
The fair-quality RCT38
(n=31) involved a rhythm-centered music-making class and saw no
improvement in social network, quality of life, depression, or sleep. Of the three poor-quality
pre-post studies, one34
(n=36) provided singing lessons and two36, 37
(n=51 and n=12) involved
arts projects. The study34
on singing found that depression worsened in one intervention
subgroup; however, authors noted the effect was not clinically significant. This study reported no
effect on loneliness. One pre-post study36
on arts projects found an improvement in chronic pain
at 2.5 years but not daily function, health status, depression, self-esteem, or social support. The
other37
did not report sufficient information to make a determination on well-being and did not
measure a social isolation construct. These poor-quality studies had multiple methodological
limitations including poorly defined interventions, high attrition rates, lack of valid and reliable
outcome measurements, inadequate follow-up, and insufficient statistical analysis, which warrant
cautious interpretation. None of these studies measured health care utilization outcomes.
Health services access interventions. Two poor-quality studies39, 43
examined the effects of
linkages to health services in older adults—one pre-post and one cross-sectional study with a
post-intervention survey. Both involved training community members and elderly to recognize
older persons at risk and facilitate connections to the health system, although one pre-post study
(n=328) evaluated those who were connected to the health system and the other (n=15,719)
evaluated older adults who did the connecting. The study of those who were connected to
services reported reduced depression at 1 year but did not report any health care utilization
outcomes. The intervention using connectors reported reduced hospitalization days compared
with a standby group. The intervention directed at older adults connected to services reported
benefits in social isolation at 6 months,39
while the study of older adults who were the connectors
did not measure a social isolation construct.43
These studies have a high potential for bias, in that
they included groups that were not comparable at baseline, interventions were poorly defined,
and measures were not validated for outcomes.

Table 2. Selected intervention characteristics and outcomes data from fair- and good-quality studies
Type of
Intervention
(Health Effect)
Study
Information
Description of
Intervention
Duration &
Intensity
Staffing
Requirements
Effect on
SI/Loneliness Effect on Health/Health Care
(+)
Kamegaya, 201446
RCT
n=52
Mean age: 75
Fair quality
Walking, stretching, &
weight exercise; games,
crafts, & cooking
(D) 3 months**
(I) 2 hours
1x/week††
Professional (PT,
OT, & nurse)
Lay person
No effect on social
support (3 mo)
Improved subjective QoL (3 mo)
(+)
Seino, 201748
RCT
n=77
Mean age: 75
Fair quality
Resistance exercise,
nutrition, & psychosocial
support
(D) 3 months**
(I) 1 hour 40
min
2x/week†††
Lay person
Improvement in
social capital (3 mo)
Decreased depression, improved
fraility, diet, and functionality (3 mo)
(-)
Chan,201745
RCT
n=48
Mean age: 77
Fair quality
Tai chi qigong exercise
(D) 3 months**
(I) 1 hour
2x/week†††
Lay person &
professional
(nurses and social
workers)
Improvement in
loneliness at 6 mo
but not 3 mo. No
effect on social
network (3 or 6 mo)
No effect on mental health & self-
esteem (3 & 6 mo)
(-)
Pynnonen, 201847
RCT
n=223
Mean age: 77
Fair quality
Choice of exercise; group
discussions, day-trips, &
art projects; or counseling
(D) 15-21
weeks**
(I) Max 2hrs
1x/week††
Min 1hr
1x/every 3 wks†
Lay person &
professional
(rehabilitation
counselor)
No effect on
loneliness (6 or 12
mo)
No effect on depression or melancholy
(6 mo)
(-)
Mountain, 201744
RCT
n=288
Mean age: 72
Good quality
Facilitated group
discussions on goal
setting, sharing strengths
& skills, & encouragement
(D) 4 months**
(I) Group:
1x/week†††
Facilitator:
1x/month†††
Professional (NHS
or social care staff)
Improvement in
loneliness at 2 yrs
but not 6 mo
No effect on mental health,
depression, self-efficacy or well-being
(6 mo & 2 yr)
(-)
Murayama, 201535
Pre-post
n=80
Mean age: 69
Fair quality
Reading to children
(D) 1 year***
(I) 1x/1-2
weeks†/†† Lay person NR No effect on depression (2 yr)
(-)
Yap, 201738
RCT
n=31
Mean age: 75
Fair quality
Rhythm-centered music
making with conga,
cowbell, Djembe, Ashiko
Tan-tans, Dunun, shakers,
and wood blocks
(D) 11 weeks**
(I) 1 hour x 10
sessions†
Lay person
No effect on social
network (11 weeks)
No effect on QoL, depression or sleep
(11 weeks)
(=)
Tarazona-
Santabalbina, 201649
RCT
n=100
Mean age: 80
Fair quality
Endurance, strength,
coordination, balance, &
flexibility exercises
(D) 6 months***
(I) 1 hour 5 min
5x/week†††
Professional (PT &
nurse)
NR (6 mo) NR (6 mo)
(+) = studies that had a positive effect on health/health care utilization outcomes; (-) = studies that had no effect; (=) = studies for which there was insufficient information to make a
determination; = Physical activity; = Social; = Arts and recreation; (D) = Duration of intervention; (I) = Intensity of intervention; (NR) = No results; (QoL) = Quality of life;
(GP) = General practitioner; * = Low duration; ** = Medium duration; *** = High duration; † = Low intensity; †† = Medium intensity; ††† = High intensity; (PT) = Physical therapist;
(OT) = Occupational therapist; (RCT) = Randomized controlled trial; (NHS) = National Health Service; (SI) = Social Isolation

11
Question 2. Among older adults, what are the harms associated with
interventions (volunteerism, peer support, transportation programs, etc.)
that target social isolation and loneliness to improve health and reduce
unnecessary health care utilization?
Of the 16 studies aimed at reducing social isolation or loneliness,34-49
1 good-quality44
and 3
fair-quality RCTs38, 45, 48
reported information on harms, 1 fair-quality RCT49
reported looking
for harms but did not report whether any were found, 1 poor-quality pre-post study34
reported a
worsening of a health condition and 10 studies (2 fair-quality RCTs, 1 fair-quality and 6 poor-
quality pre-post studies, 1 poor-quality cross-sectional study with a post-test survey)35-37, 40-42, 46,
47,39, 43
did not report looking for or finding information on harms.
We identified several studies that described costs of interventions and summarize these in
this section. Of the 16 studies, 342-44
reported information on costs: 1 RCT reported the cost of
delivering the intervention,44
1 pre-post study42
reported the fee charged to participants to
participate in the program, and the cross-sectional study with a post-test survey43
reported
reductions in health care costs in the intervention versus control group.
Physical activity interventions. Of the five fair-quality RCTs on physical activity
interventions, one49
reported looking for serious adverse events such as death and hospitalization
during follow-up but did not report whether any occurred, and two45, 48
reported no adverse
events (including one that explicitly reported no injuries) in either intervention or control groups.
The remaining two RCTs46, 47
did not report on whether they looked for or found harms of the
interventions. No studies of physical activity interventions reported costs.
Social interventions. One good-quality study44
on a facilitated group discussion intervention
reported that serious adverse events were similar across intervention and control groups, and that
serious adverse events in the treatment group were unrelated to the intervention. This
intervention was estimated to cost between $649 and $868 per person, depending on the location
in England or Wales during the study period of 2011 to 2015. The fair-quality study35
and two
poor-quality studies40, 41
on social interventions did not report whether they looked at or found
harms related to the interventions. The remaining poor-quality study42
of a community liaison
intervention did not report looking for or finding harms, but reported that the program charged
annual membership fees of $696 for an individual and $895 for a household and offered reduced
rates for lower income older adults, as of 2013.
Arts and recreation interventions. The fair-quality study on an arts and recreation
intervention reported looking for harms of the intervention, and reported no adverse events.38
However, one poor-quality study of weekly group singing sessions of in-home care recipients
and community participants found worsening of scores on the Geriatric Depression Scale for in-
home recipients but not in the community group.34
As noted previously, authors commented that
the difference was not clinically significant. The same study did not report whether they looked
for or found harms of the interventions. Similarly, the two other poor-quality studies36, 37
did not
report having looked for or finding harms related to the interventions.
Health services access interventions. Neither of the two poor-quality studies39, 43
on health
services linkage interventions reported whether they looked for or found harms. One poor-
quality study43
of a peer support intervention found that both the intervention and standby groups
had increases in medical expenses over a 2-year period between 2009 and 2013, but the increase
was greater by $432 in the standby group.

12
Discussion
Summary
Based on the past 5 years of research, there is limited available evidence that interventions to
improve social isolation or a related construct have a significant effect on health outcomes, with
the most promising evidence supporting physical activity interventions. Only two interventions
with fair- or good-quality studies improved health outcomes, both of which were relatively time-
intensive physical activity interventions combined with leisure, psychosocial, or nutritional
activities. These two interventions did not measure costs, and only one recorded adverse events.
Two additional interventions with fair- or good-quality studies—one a physical activity
intervention and one a social intervention—were associated with a positive effect on social
isolation, but not health outcomes. Only two studies measured quality of life (measured via the
Satisfaction in Daily Life scale46
and EQ-5D-3L44
), one of which saw an improvement. Health
care utilization outcomes were measured in only one of the good- or fair-quality studies, but the
study did not present analysis of between-group difference in differences so we could not
determine if the intervention had effects on those outcomes. Interventions that were associated
with a positive effect on either health or social isolation outcomes were more likely to have a
health care provider involved in the implementation and deliver the intervention at least once a
week than interventions that did not have an effect, although this was based on a small number of
studies (n=8).
Of note, only one-quarter of the studies reported on harms. Two of these studies reported
finding adverse events: one reported similar rates in both intervention and control groups, and
one found worse outcomes (depression) in intervention versus control, but neither was clinically
significant. Harms that were measured included death, hospitalization, and general adverse
events. Only one study specifically said no injuries occurred, which is an important harm to
report given the physical nature of many of the interventions and the health impact of injuries in
older adults.
Our review is consistent with the four systematic reviews that met our criteria but were
published prior to 201851-54
in that there is limited evidence that interventions involving physical
activity and social interactions/social roles can positively impact social isolation/loneliness51, 52,
54
and health;53
and that studies on the effectiveness of interventions to alleviate social
isolation/loneliness are methodologically flawed.51-53
However, our review adds to the evidence
base by assessing the effect of these interventions on health care utilization and examining
potential harms. The lack of evidence we identified on these outcomes points to the need for
future researchers to address health care utilization and harms, as these are important
considerations for health care decisionmakers.
It is perhaps not surprising that physical activity interventions, which are centered around
improving health, had a positive effect on health outcomes. However, it is surprising that we did
not see an association between reducing social isolation and improving health among physical
activity or other interventions, as these two concepts have been linked in previous research. It is
possible that the complexity of reasons contributing to social isolation, paired with the
accumulating effect of isolation on health (such as gradual declines in health from age or chronic
disease, or the loss of a life-long relationship with a sibling or spouse that cannot be replaced
with a new relationship) means that a single, short-term intervention is not enough to change
outcomes. If this is the case, larger, more intensive efforts that target the underlying reasons why
people are socially isolated may be required.

13
Because the evidence supporting particular interventions for addressing social isolation is
limited, health systems may want to focus on approaches that have been recommended to
improve older adults’ health outside of social isolation and leverage those programs to also
address social isolation. For example, the National Prevention Council recommends physical
activity, increasing access to and use of clinical preventive services and behavioral health care,
and increasing access to healthy food to improve the health of older adults.55
Physical activity in
particular also been shown to have mild positive effects on cognition for adults both with and
without cognitive impairment.56
Health systems should target the interventions to the needs of
their population and may want to consider piloting new efforts to address social isolation to
improve health to inform future decisionmaking.
Limitations
Limitations of Rapid Review Methodology
Rapid reviews take streamlined steps in order to complete the work on a rapid timeline. In
this review, narrowing the search to the past 5 years, identifying studies from the four 2018
systematic reviews and a recent search for primary studies (2016-18), and conducting single
reviewer study inclusion with 25 percent check may have resulted in missing eligible studies.
Additionally, for the sake of time we excluded qualitative studies which made it difficult to
explain the mechanism through which these interventions addressed social isolation (e.g.,
through improving relationships, increasing access to health services, improving patients’ self-
efficacy, etc.).
Limitations of Primary Studies
We recognize that by limiting our population to only community-dwelling adults, we may
have missed some populations of older adults which are most likely to have social isolation, such
as those in long-term care. It is possible that the broader body of evidence (including these other
populations) would have limited generalizability to our population of focus and vice versa.
As previously discussed, serious issues in the design and conduct of studies resulted in
moderate to high risk of bias and serious inconsistency in study findings.
Studies varied in whether they measured a social isolation construct and if they did, what
measures they used, with most studies measuring the subjective feeling of loneliness. Because of
the variety of definitions and measurements used to capture these constructs, we could not draw
any conclusions on the comparative effect of interventions on addressing social isolation or
loneliness as separate entities. We describe the definitions of social isolation and loneliness used
in each review in Appendix F, Table F-1. In general, social isolation is conceptualized as an
absence or paucity of contacts and interactions, whereas loneliness is conceptualized as “a
subjective feeling state of being alone, separated or apart from others, and has been
conceptualized as an imbalance between desired social contacts and actual social contacts.”31
Studies varied widely in their conceptions about social isolation and what if anything was
measured: seven evaluated loneliness, six measured social support or network, one measured
structural social capital, one measured perceived togetherness, one measured social participation,
one measured social isolation, and three did not have any measurement. Among those that
contained a measure, no universal instrument was used, and there was wide range in the length of
the instruments and the types of questions asked (Appendix F, Table F-2).

14
Loneliness instruments asked about different types of loneliness, including general, social,
and emotional. Social isolation and social support instruments asked about number and role of
relatives and friends, as well as presence and level of engagement with a social support network.
The De Jong Gierveld Loneliness Scale,57
Lubben Social Network Scale,58
and University of
California Los Angeles (UCLA) Loneliness Scale59
were the most commonly used instruments
in this review, with each used in at least two studies. A recent review60
identified 54 instruments
used to measure social relationships in those 65 and older, of which only 5 overlapped with the
13 tools used in our identified studies. This highlights the need to come to a shared
understanding of social isolation and agree upon an appropriate and validated metric in order to
make progress in this field.
Fewer than half of the included studies were rated fair or good quality. The main
methodological issues of these fair- and good-quality studies included differential drop-out rates
between groups, follow-up periods that were too short to show an effect, and not accounting for
confounders, losses to follow-up, or missing data. The majority of studies were poor quality.
These studies similarly had follow-up periods that were too short to show an effect (such as one
study41
of a 3-week intervention that measured changes in quality of life), and did not use
appropriate analyses to control for confounders, losses to follow-up, or missing data. These
studies had additional methodological issues such as failing to use validated measures, not
blinding outcome assessors, not adequately describing the intervention, and having overall drop-
out rates that were above 30 percent. Many of these poor-quality studies also did not have a
concurrent control group. Therefore, it was difficult to determine whether any changes in
outcomes were due to the intervention or a secular trend. Findings from these studies should be
interpreted with caution, but they provide helpful information for stakeholders to get an
understanding of the breadth of interventions that have been delivered to reduce social isolation
and loneliness.
In additional to methodological flaws, most studies were conducted in countries other than
the United States, including Hong Kong, Singapore, Japan, Finland, Italy, Spain, Australia,
Canada, and the UK. These countries vary both in terms of cultural expectations around the
inclusion of older adults in society and the extent to which social programs exist to support the
needs of older adults, so it is unclear whether findings from the studies are generalizable to the
United States.
Research Recommendations
We recommend researchers take the following approaches to improve the quality of studies
and help to fill evidence gaps.
• Be explicit about how their proposed intervention would theoretically impact social
isolation to improve health (e.g., explain how the outcomes would change according to
behavior change theory).
• Collaborate with health systems, payers, and patient advocacy groups to agree upon
standardized definitions and measures for social isolation and loneliness. As mentioned
previously, social isolation is currently measured with myriad constructs and measures,
which complicates the ability to draw conclusions between social isolation and health
outcomes.
• Compare the intervention group with a control group or otherwise control for
confounding variables in order to better determine intervention effectiveness.

15
• Recruit and report results for a diverse population (only one38
of the eight good- or fair-
quality studies reported the ethnicity of its participants) to determine important
population differences.
• Carefully select outcomes depending on the duration and intensity of the intervention to
be studied. For example, for shorter duration interventions of less than a month, consider
focusing on shorter term outcomes such as participant satisfaction with intervention as
opposed to quality of life. For outcomes that involve subscales, report the results of the
complete scale. Consistently report between-group difference-in-difference for outcomes.
• Measure health care utilization outcomes, in addition to health outcomes. Health systems,
payers and other stakeholders are very interested in both health and health care utilization
outcomes to determine the ideal intervention to address social isolation in older adults
with limited resources.
• Conduct longer term interventions and measure longer-term outcomes, including health
care utilization, to assist health care systems in determining where to focus limited
resources. Large, longitudinal, multi-site studies that are randomized at the site rather
than participant level may be needed to capture the effect of real-world implementation
of interventions on important health outcomes such as quality of life and chronic disease
management, as well as utilization outcomes such as emergency department visits and
primary care visits.
• Report all harms for studies, including both serious adverse events (e.g., hospitalization)
and less severe adverse events (e.g., musculoskeletal injuries for physical activity
interventions). Consider other types of study designs such as cohort, case-control, or
cross-sectional to capture information on harms over long periods of time and large
groups of people.61
Conclusion
Health system researchers are just beginning to evaluate the effectiveness of some potentially
promising interventions to address social determinants of health. Through the Centers for
Medicare & Medicaid Services Accountable Communities Model, health systems are evaluating
the health care and utilization effects of identifying and referring patients to address social
determinants of health.62
Preliminary data also suggest that coordinating delivery of social
determinants of health to high-risk patients through clinical and non-clinical care staff may
improve certain health and health care utilization outcomes.63
One health system used peers as
community health workers for Medicare patients and evaluated the effects on health care
utilization outcomes (including emergency department visits, hospital admissions, and annual
wellness visits) as well as patient-centered outcomes (e.g., patient satisfaction).64
In addition, an
academic medical center–led initiative is focusing on how technology can facilitate the health
and independence, and decrease the social isolation, of older adults.65
Another model for
addressing social isolation in people of all ages is a company that facilitates creation of
relationships through exchange of interests and abilities.66
Case management services, such as
those provided by ElderTree, have also been used to address social support and other health
needs of older adults, although that was not the focus of this review.67
Social isolation is a complex construct with an unclear relationship to health outcomes, and
research should attempt to capture this complexity. Particularly when targeting interventions on
health effects, researchers should measure other important personal domains that may be affected
by social isolation and are potential intermediaries to health but go beyond simply social

16
interactions such as personal agency, comfort being alone, and/or self-efficacy. With health
systems attempting multiple innovative interventions for social determinants of health, we
recommend that they rigorously evaluate these interventions and share their data on effectiveness
with other health systems.
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38. Yap AF, Kwan YH, Tan CS, et al. Rhythm-
centred music making in community living elderly: a
randomized pilot study. BMC Complement Altern
Med. 2017 Jun 14;17(1):311. doi: 10.1186/s12906-
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39. Bartsch DA, Rodgers VK, Strong D. Outcomes
of senior reach gatekeeper referrals: comparison of
the Spokane gatekeeper program, Colorado Senior
Reach, and Mid-Kansas Senior Outreach. Care
Manag J. 2013;14(1):11-20. PMID: 23721039.
40. Coll-Planas L, Del Valle Gomez G, Bonilla P, et
al. Promoting social capital to alleviate loneliness and
improve health among older people in Spain. Health
Soc Care Community. 2017 Jan;25(1):145-57. doi:
10.1111/hsc.12284. PMID: 26427604.
41. Gaggioli A, Morganti L, Bonfiglio S, et al.
Intergenerational group reminiscence: A potentially
effective intervention to enhance elderly psychosocial
wellbeing and to improve children's perception of
aging. Educ Gerontol. 2014;40(7):486-98. doi:
doi.org/10.1080/03601277.2013.844042.
42. Gonyea JG, Burnes K. Aging well at home:
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A-1
Appendix A. Full Methods
Literature Search
Our goal was to rapidly identify the most recent (past five years) research on this topic. We
searched for systematic reviews in PubMed, PsycInfo, and Cumulative Index of Nursing and
Allied Health (CINAHL) from January 2013 to May 2018, as well as databases routinely
searched during topic development for the Agency for Healthcare Research and Quality (AHRQ)
Evidence-based Practice Center Program (Cochrane Database of Systematic Reviews, Agency
for Healthcare Research and Quality evidence report and technical assessment portfolio, PubMed
Health, PROSPERO, Veterans Affairs Evidence-based Synthesis Program, Centre for Reviews
and Dissemination [CRD database], Canadian Agency for Drugs and Technologies in Health
[CADTH], Database of promoting health effectiveness reviews [DOPHER], ECRI Institute,
Systematic Reviews Journal, and McMaster Health System Evidence). We selected the four most
recent reviews, reviewed their included studies, and searched for additional primary studies
published in the last two years (January 2016 to April/May 2018) in PubMed, PsycInfo and
CINAHL. The librarian updated the searches in PubMed, PsycINFO, and CINAHL in November
2018 for both systematic reviews and primary studies. A two-year primary study search was
chosen as this was the end date of the search of the systematic review with the most recent,
broadest scope. The complete search strategy is listed in Appendix A.
We also searched for guidelines at UK National Institute for Health and Clinical Excellence
(NICE), American College of Physicians, and World Health Organization, and contacted Edward
R. Roybal Centers for Translation Research in the Behavioral and Social Sciences of Aging and
health systems in the High Value Health Care Collaborative (HVHC) asking if they were
conducting any interventions focused on social isolation in the elderly. None of 13 Roybal
Centers and two HVHCs (Baylor Scott and White, and Intermountain Healthcare) were engaged
in work on social isolation meeting our eligibility criteria and none had published studies to
share but one (Baylor Scott and White) shared a power point highlighting key findings.
Study Selection
We specified and refined our inclusion and exclusion criteria based on the populations,
interventions, comparators, outcomes, timing, and settings (PICOTS) identified for this review
(Table A-1). Due to our rapid timeline, we decided to focus on studies that addressed a broad
population of healthy, community-dwelling older adults and therefore excluded studies that
focused on specific subgroups (e.g., Veterans, indigenous populations, those with specific health
conditions). We also decided to exclude information technology (IT) interventions as we wanted
to focus on interventions that a broad range of partners (e.g., health systems, advocacy groups,
community organizations) could implement. We included all measurements of physical and
mental health outcomes (e.g., we included validated scales for quality of life and self-reported
overall health)
We included systematic reviews if they searched at least two medical databases, pre-defined
their inclusion criteria, and assessed study quality. We initially planned to include all relevant
primary studies from included systematic reviews published within the last 10 years; however
due to the large number of studies retrieved, and our partner’s focus on the most recently
available evidence, we only included studies which were published in the last five years. One
reviewer evaluated titles, abstracts, and full texts of systematic reviews and primary studies

A-2
based on predetermined criteria and a 25 percent sample was checked by a second reviewer.
Disagreements were resolved through discussion.
Table A-1. Inclusion and exclusion criteria
Population Include: Older adults (Medicare or retirement age [60 years or older]), community dwelling
Exclude: People less than 60 years of age, exclusively focused on, a single health condition (e.g.
physical or sensory disability, specific mental illness, etc.), non-community dwelling (e.g. nursing
home, institutional setting, etc.), exclusively focused on a specific subpopulation (indigenous
populations, immigrants, veterans, etc.)
Intervention Include: Interventions that target social isolation to improve health outcomes or reduce
unnecessary health care utilization. Examples include volunteerism, programs delivered by peers
or health care practitioners, transportation programs, etc.
Exclude: Case management delivered by a trained health care professional, information
technology (IT) focused interventions, telehealth, interventions not focused on reducing social
isolation, not an intervention, interventions that did not measure impact on health outcomes.
Comparator Include: Any comparator, no comparator
Outcomes Include*
Primary:
• Physical and mental health outcomes (including but not limited to depression, quality of life,
and chronic disease management)
Secondary:
• Social isolation and loneliness
• Health care utilization (including but not limited to Emergency Department visits,
hospitalizations, primary and specialty care appointments)
• Harms (e.g., adverse events, worsening of health or social isolation, costs)
Setting Include: Community settings
Exclude: Low and middle-income countries, skilled nursing facilities, assisted living facilities,
hospitals.
Study
Design
Include: Quantitative or mixed-methods studies including observational studies (we only included
quantitative data)
Exclude: Qualitative studies, single time point studies (i.e., post-intervention survey)
Timing Include: Studies published since 2013
Language Include: English
* Systematic reviews were included if they report any of the primary or secondary outcomes of interest. Primary studies were
only included if they report the primary outcome. PICOTS = population, intervention, comparator, outcomes, time, setting
Data Extraction
For each included study, one investigator extracted information about design, population,
intervention, and outcomes, and a second reviewer reviewed for completeness and accuracy. For
studies that measured multiple, similar, intermediate health outcomes, we prioritized patient-
centered outcomes (e.g., we extracted body mass index and weight but not arm girth or leg girth)
and for mixed methods studies we focused on quantitative outcomes.
For studies with a comparator, only between-group difference-in-differences and p-values
were extracted. For pre-post studies, only pre-post differences and p-values were extracted. We
only extracted these values if the effect was significant (p < 0.05); otherwise, we reported that no
significant effect was seen for that outcome. When studies reported overall results of scales (such
as the SF-36) that also had subscales (such as the SF-36 mental health or physical health), we
limited reporting of results for overall scales, with the exception of when study authors pre-
specified that a subscale was their primary outcome. In these cases, we only reported the
subscale.
We extracted reported measures of social isolation and included measures of social capital,
social networks, social support, and social participation in our construct of social isolation. While

A-3
we initially did not plan to extract this detailed information, we decided it was important to
inform stakeholder decisions by clarifying which interventions have an effect on both social
isolation/loneliness outcomes and health/health care outcomes, either set of outcomes or neither
set of outcomes.
Risk of Bias/Quality Assessment
One reviewer evaluated the quality of each study as good, fair, or poor, using criteria
developed by the U.S. Preventive Services Task Force guidance1
(see Table A-2) and a second
reviewer evaluated a 25 percent sample. Reviewers completed training before assessing risk of
bias to improve inter-rater reliability, including pilot testing the risk of bias tool and pre-
specifying how to rate each criterion as high, unclear, or low risk of bias. Disagreements were
resolved through discussion.
Of note, we considered the presence of a control group when determining overall study
quality since the lack of a control group creates bias by severely limiting the ability to determine
if effects are due to secular trends (e.g., a simultaneously implemented community policy).
Table A-2. Risk of bias criteria based on U.S. Preventive Services Task Force guidance
# Criterion
1 Groups were adequately randomized (RCT only)
2 Allocation was adequately concealed (RCT only)
3 Inclusion and exclusion criteria were consistently used across
groups.
4 Participant characteristics were balanced or there was
adjustment for potential important confounders.
5 Comparable groups were maintained, including low overall
drop-out rate, equal drop-outs between groups, and efforts to
minimize contamination between groups.
6 Interventions were clearly defined, including any co-
interventions.
7 Outcome measurements were used consistently across
groups, explicitly defined, valid and reliable, important,
multiple outcomes were measured, and outcome assessors
were blinded.
8 Followup was equal between groups and long enough for
outcomes to occur.
9 Study conducted appropriate sensitivity analysis or other
statistical adjustment related to confounders,
inclusion/exclusion criteria, losses to follow-up, missing data,
or adherence to intervention, as needed.
Data Synthesis and Analysis
We constructed evidence tables with study characteristics, results, and risk-of-bias ratings for
all included studies and summary tables to highlight the main findings. Given the heterogeneity
of interventions to address social isolation and our partner’s focus on identifying the evidence for
specific interventions, we did not conduct a meta-analysis or use a formal process to grade the
evidence.
Reference for Appendix A
1. Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of
the process. Am J Prev Med. 2001 Apr;20(3 Suppl):21-35. PMID: 11306229.

B-1
Appendix B. Search Strategies
Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R)
Daily and Ovid MEDLINE(R) 1946 to Present
Update Search Date: November 13, 2018
Searched by: Robin Paynter, MLIS
Searches
1 social alienation/ or social Isolation/ or social networking/ or social participation/ or loneliness/ or ((social* adj3
(alienat* or connect* or engag* or exclusion or exclude* or isolat* or network* or participat* or relation* or support*))
or loneliness or lonely or marginal* or solitude or psychosocial or psycho-social or wellbeing or well-being).ti,kf.
2 (aged/ or "Aged, 80 and over"/ or frail elderly/ or (aged or elder* or geriatric* or gerontol* or nonagenarian* or
octogenarian* or older or "oldest old" or senior* or septuagenarian* or sexagenarian* or "very old").ti,kf.) not
(adolescent/ or child/ or child, preschool/ or infant/ or infant, newborn/ or middle aged/ or young adult/ or
(adolescen* or infant* or child or children or "middle aged" or "school-aged" or "young adult*").tw,kf.)
3 and/1-2
4 limit 3 to yr="2013 -Current"
5 limit 4 to english language
6 limit 5 to (meta analysis or systematic reviews)
7 social alienation/ or social Isolation/ or social networking/ or social participation/ or loneliness/ or ((social* adj3
(alienat* or connect* or engag* or exclusion or exclude* or isolat* or network* or participat* or relation* or support*))
or loneliness or lonely or marginal* or solitude or psychosocial or psycho-social or wellbeing or well-being).ti,kf.
8 program evaluation/ or (alleviat* or evaluat* or group or improv* or increas* or initiative* or innovat* or intervention*
or manag* or "patient navigator*" or peer or peers or pilot* or project* or program* or reduc*).ti,kf.
9 1 and 2 and 8
12 remove duplicates from 11
13 12 not 6

B-2
CINAHL Plus with Full Text
Searched by: Information Specialist
# Search Actions
S10 S8 NOT S9
S9 S8 Limiters –
Publication Type:
Case Study,
Commentary,
Editorial, Letter
S8 S7 NOT S3 Limiters –
Published Date:
20160101-20180531;
English Language;
Exclude MEDLINE
records
S7 S1 AND S2 AND S6
S6 (MH "Program Evaluation") OR TI (alleviat* or assess* or change or "community-based"
or evaluat* or decreas* or group or improv* or increas* or initiative* or innovat* or
intervention* or partnering or partnership* or pilot* or project* or program* or reduc*)
S5 S4 NOT S3 Limiters –
Published Date:
20130101-20180531;
English Language;
Exclude MEDLINE
records; Publication
Type: Meta Analysis,
Meta Synthesis,
Systematic Review
S4 S1 AND S2
S3 TI ("care homes" OR carer* OR caregiver* OR "case manag*" OR employe* OR facility
OR facilities OR family OR families OR student* OR prison* OR worker* OR workplace*
OR "residential care" OR "residential setting" OR cancer* OR dementia OR diabetes
OR "hepatitis c" OR HIV OR parkinson* OR psychos?s OR psychotic OR schizophren*
OR app OR apps OR computer* OR Internet OR phone OR online OR videoconferenc*
OR video-conferenc*)
S2 (MH "Aged") OR (MH "Aged, 80 and Over") OR (MH "Frail Elderly") OR (MH "Middle
Age") OR TI ( (aged OR ageing OR aging OR "assisted living" OR "community-dwelling"
OR "community-residing" OR elder* OR geriatric* OR gerontol* OR nonagenarian* OR
octogenarian* OR (older N2 (adult* OR men OR people OR person* OR women)) OR
"oldest old" OR pensioner* OR retired OR retiree* OR retirement OR "senior citizen*"
OR seniors OR septuagenarian* OR sexagenarian* OR "very old") NOT (adolescen*
OR ((college O ...
S1 (MH "Social Isolation") OR (MH "Loneliness") OR (MH "Social Alienation") OR (MH
"Social Participation") OR (MH "Support, Psychosocial") OR (MH "Social Isolation In Old
Age") OR (MH "Loneliness In Old Age") OR (MH "Social Participation In Old Age") OR
TI (((communit* or neighbor* or social*) N3 (alienat* or connect* or cooperat* or engag*
or exchang* or exclusion or exclude* or include* or inclusion or integrat* or interaction*
or involv* or isolat* or network* or participat* or relation* or supp ...

B-3
Ovid PsycINFO 1806 to Present
Searched by: Robin Paynter, MLIS
# Searches
1 Social Isolation/ or Loneliness/ or Social Capital/ or Social Interaction/ or Social Networks/ or Social Support/ or
(((communit* or social*) adj3 (alienat* or connect* or cooperat* or co-operat* or engag* or exchang* or exclusion or
exclude* or include* or inclusion or integrat* or interaction* or involv* or isolat* or network* or participat* or relation*
or support*)) or loneliness or lonely or marginal* or psychosocial* or psycho-social* or "social capital" or solitude or
wellbeing or well-being).ti,id.
2 (Aging/ or Aging in Place/ or Physiological Aging/ or "Aged (Attitudes Toward)"/ or "Aging (Attitudes Toward)"/ or
Geriatric Psychiatry/ or Geriatric Psychotherapy/ or Geriatrics/ or Gerontology/ or Geropsychology/ or Retirement/ or
("360" or "380" or "390").ag. or "2860".cc. or (aged or ageing or aging or "assisted living" or "community-dwelling" or
"community-residing" or elder* or geriatric* or gerontol* or nonagenarian* or octogenarian* or ((old or older) adj2
(adult* or men or people or person* or women)) or "oldest old" or pensioner* or retired or retiree* or retirement or
"senior citizen*" or seniors or septuagenarian* or sexagenarian* or "very old").ti,id.) not (adolescen* or ((college or
men or school or women) adj2 aged) or infant* or child or children or pediatri* or (young adj2 (adult* or men or
women)) or teenage* or youth*).tw,id.
3 and/1-2
6 limit 5 to (meta analysis or systematic reviews)
7 Program Evaluation/ or Mental Health Program Evaluation/ or (alleviat* or assess* or change or "community-based"
or evaluat* or decreas* or group or improv* or increas* or initiative* or innovat* or intervention* or partnering or
partnership* or pilot* or project* or program* or reduc*).ti,id.
8 and/1-2,7
11 limit 10 to ("column/opinion" or "comment/reply" or editorial or letter)
12 10 not 11
13 (carer* or caregiver* or "case manag*" or employe* or family or families or student* or prison* or worker* or
workplace* or cancer* or dementia or diabetes or "hepatitis c" or HIV or parkinson* or psychos?s or psychotic or
schizophren* or app or apps or computer* or Internet or phone or online or videoconferenc* or video-
conferenc*).ti,id.
14 12 not 13
15 limit 14 to case reports
16 14 not 15
17 16 not (case adj1 (report* or study or studies or series)).tw,id.
18 17 not 6

C-1
Appendix C. Study Details
Table C-1. Physical activity interventions
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Population Intervention vs. Comparator Health and Health Care Outcomes
Measured
Effect on Loneliness
and Social Isolation
Effect on Health and
Health Care Outcomes
Chan et. al,
20171
RCT
3 months
Hong Kong, SAR
Study Quality:
Fair
• 48 participants that
were “hidden elderly”
aged 60 and above
that did not engage in
any social activities
• Age range: 66-103;
mean: 77.3
• 24% male
• Race ethnicity: NR
Intervention
• Tai chi qigong group attended
one 60-minute exercise class
twice per week for 3 months.
• The class was held in an elderly
community center and provided
by an experienced tai chi qigong
instructor.
• Participants were instructed to
self-practice tai chi qigong for 30
minutes every day.
• Volunteer “health ambassadors”
aged 55 or above were recruited
and trained for 4 weeks in a
variety of elderly issues before
being assigned to participants to
build peer relationships while
facilitating participation in the
program, additional daily practice
sessions and recording progress.
Comparator
• Usual care, which included
irregular home visits from social
workers ranging from monthly to
quarterly
Data collected at baseline, 3 months
and 6 months:
• Health-related quality of life
[Short Form Health Survey (SF-
12)]
• Mental health status [mental
health inventory (MHI-18)]
• Self-esteem (Rosenberg self-
esteem scale)
At 3 months:
• No significant effect
on loneliness (De
Jong Gierveld
loneliness scale)
on social network
(Lubben social
network scale)
• Total score on social
support (revised
social support
questionnaire) NR
At 6 months:
• Significant
improvement on
loneliness (De
Jong Gierveld
loneliness scale)
(p=0.033)
on social network
(Lubben social
network scale)
• Total score on social
support (revised
social support
questionnaire) NR
At 3 and 6 months:
• Overall health-related
quality of life score
not reported.
on mental health
status or self-esteem
at 3 or 6 months.

C-2
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Kamegaya et al.,
20142
RCT
3 months
Japan
Study Quality:
Fair
• N=52
• Age range: 65-87
years old; mean=74.9
• 9.6% male
Race/ethnicity: NR
• No baseline
loneliness/social
isolation data
Intervention
• Program consisted of physical
activity (walking, stretching and
weights) and leisure activities
(games, crafts, cooking)
• Delivered by health care
professionals including a physical
therapist, occupational therapist,
and public health nurse, and 3-5
senior citizen volunteers for 12
weeks.
• Participants attended the
program for 2-hours once per
week, with 45 minutes devoted to
the exercise program.
• Administered at a community
center
Comparator
• Control group did not participate
in the program
Data collected at baseline and 3
months:
• Subjective quality of life
(satisfaction in daily life)
• Subjective health status (“How is
your health in general?”)
• Cognitive function (Five-Cog
Test)
• Executive function (Wechsler
Digit Symbol Substitution Test
and Yamaguchi Kanji-Symbol
Substitution Test)
• Physical function (grip strength
test, timed up-and-go test, 5-m
maximum walking times test, and
functional reach test) Functional
capacity (Tokyo Metropolitan
Institute of Gerontology Index of
Competence)
• Depressive symptoms (15-item
short version of the Geriatric
Depression Scale)
At three months:
on social support
(Lubben Social
Network Scale
Revised)
At 3 months:
• Subjective quality of
life significantly
improved (F-
value=4.773,
p=.035).
• No significant
improvements seen
on subjective health
status, executive
function, physical
function, functional
capacity, or
depressive
symptoms. Total
score on cognitive
function not reported.

C-3
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Pynnonen et. al,
20183
RCT (treatment
group had choice
of treatment)
6 months
Finland
Study Quality:
Fair
• 223 participants that
all reported feeling
lonely, melancholy, or
depressed mood.
mean age: 77.0
• 24.7% male
• Race/ethnicity: NR
Intervention
• Intervention group participants
could choose to participate in
exercise program group, personal
counseling, or social activity
group.
o The exercise program was
delivered by qualified
instructors at municipal gyms.
Met weekly for 1 hour, for a
total of 19-21 sessions.
o The social activity program
was delivered by health care
university students at a city
library. The social activities
included group discussions,
day-trips, and artistic self-
expression. Met weekly for 2
hours, for 19-21 sessions.
o The personal counseling was
conducted by a rehabilitation
counselor in a health care
center. Attended 4-5
meetings, for 1 hour roughly
every third week.
Comparator
• The control group received one
counseling session prior to
randomization.
• Controls had access to the usual
services offered by the city.
months:
• Depression (Geriatric Depression
Scale short form)
• Melancholy
At 6 and 12 months:
• No significant group
x time effect for
feeling of loneliness
at 6 months or 12
months
• The overall group x
time score for
perceived
togetherness
(Social Provisions
Scale) was not
reported; however,
study authors did
an analysis of
simple effects of
the six subscales,
and social
integration scores
improved in the
intervention group
but not control
group at 6 months.
At 6 months:
on depression or
melancholy.

C-4
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Seino, 20174
Crossover RCT
3 months
Japan
Study Quality:
Fair
• N=77 pre-frail or frail,
community dwelling,
older adults
• Mean age: 74.6
• 69% male
• Loneliness/social
isolation: NR
Intervention
• First three-month period:
Immediate intervention group
(IIG) subjected to intervention
group. Delayed intervention
group (DIG) given no
intervention.
• Second three-month period: Both
groups were crossed over.
• Intervention was a twice weekly
multifactorial intervention (100
min per session) consisting of
resistance exercise (60 min), rest
(10 min) and nutritional or
psychosocial programs (30 min,
each, once every two weeks)
over a three-month period.
• Intervention given in a local
community center by project staff.
Comparators
• Delayed intervention group (DIG)
given no intervention.
Data collected at baseline, 3
months, and 6 months (after cross-
over):
• Frailty (Check-List 15)
Score)
• Dietary variety (Dietary Variety
Score)
• Food frequency (Food frequency
score)
• Health-related quality of life
(Short-Form Health Survey)
• Self-rated health
• Physical functioning (Timed Up
and Go test, maximum gait
speed, usual gait speed, timed-
up-and-go, hand grip strength,
one-legged stance with eyes
open)
• Weight
• Body-mass Index (BMI)
At 3 months:
• Significant
improvement in
structural social
capital (social and
voluntary
activities domain
of Check List for
Vivid Social
Activities) at 3
months (p=0.023)
At 3 months, there were
improvements in:
• Frailty (-0.36, p=
0.024)
• Depression (-0.92, p
= 0.037)
• Dietary variety (0.65,
p =0.034)
• Food frequency (2.2,
p < 0.001)
• Timed Up and Go
(seconds) (-0.25, p =
0.005)
At 3 months, there were
no improvements in:
• Overall health-related
quality of life not
reported.
on self-rated health,
other physical
functioning scores
besides Timed Up
and Go, weight, or
BMI.

C-5
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Tarazona-
Santabalbina,
20165
RCT
6 months
Spain
Study Quality:
Fair
• 100 sedentary,
community-dwelling,
frail older adults
• Mean age: 79.7
(intervention) and 80.3
(control)
• 43.1% male
(intervention) and
49.0% male (control)
• Living alone: 54.9%
(intervention) and 55.1
(control)
Intervention
• Participated in a multicomponent
group exercise program (65
minutes of supervised daily
activities designed to improve
endurance, strength,
coordination, balance, and
flexibility) 5 days per week
• Implemented by 4 physical
therapists and 4 nurses.
• 24 weeks
Comparator
• For 24 weeks, received no
training.
• Attended regular primary care
program at the center.
weeks:
• Quality of life (EuroQol quality of
life-scale [EQ-5D])
• Mental status (Mini-mental State
Examination [MMSE])
• Depression (Yesavage Geriatric
Depression [YGD])
• Number of falls (prior 6 mos.)
• Number of risk factors for falls
(prior 6 mos.)
• Number of voluntary hospital
admissions (prior 6 mos.)
• Number of visits to the
emergency service (prior 6 mos.)
• Number of visits to primary care
center (prior 6 mos.)
• Body mass index (BMI)
• Weight
• Short Physical Performance
Battery (SPPB)
• Physical Performance Test (PPT)
• Physical functioning
(performance in Activities of Daily
Living [Barthel Index],
instrumental Activities of Daily
Living [Lawton and Brody], gait
and balance [Tinetti], timed-up-
and-go, 6-minute-walk test,
Functional Ambulation
Categories [FAC], handgrip
strength
• Frailty (Fried frailty criteria and
Edmonton frailty scale)
• Adverse events
At 24 weeks:
• Social support
(Duke social
support) measured
but p-values NR, so
this outcome
cannot be deemed
statistically
significant.
At 24 weeks:
• No harms reported
• For all measures,
difference-in-
difference could be
calculated but p-value
NR, therefore none of
these outcomes can
be deemed
statistically significant.
Abbreviations: BMI=Body Mass Index; DIG=Delayed Intervention Group; EQ-5D= European Quality of Life-5 Dimensions; FAC=Functional Ambulation Categories; GDS=Geriatric Depression
Scale; IIG=Immediate Intervention Group; MHI-18=Mental Health Inventory-18; MMSE=Mini-mental State Examination; NR=Not Reported; PPT=Physical Performance Test; RCT=Randomized
Controlled Trial; SAR=Special Administrative Region; SPPB=Short Physical Performance Battery; YGD=Yesavage Geriatric Depression.

C-6
Table C-2. Social interventions
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Mountain, 20176
RCT
4 months
UK
Study Quality:
Good
• N=288 participants
with reasonable
cognitive ability from
two UK cities
• Age: 65-92; mean:
72.1
• 31.9% male
• 99.7% Caucasian
• 54.5% living alone
Intervention
• Participants met in groups of up
to 12 once per week and with a
facilitator once a month.
• Meeting topics included
identification of participants’
goals, empowerment through
sharing strengths and skills, and
providing support to enable them
to practice new or neglected
activities independently.
• Facilitators: National Health
Service (NHS) or social care
staff who were provided with
training and supervised by
occupational therapists
• 4-month intervention
Comparator
• Usual care – Accessing health
and social care acute and
community services as
appropriate to meet their needs
Data collected at baseline, 6 and 24
months:
• Mental Health (Short Form Health
Survey [SF-36])
• Depression (Patient Health
Questionnaire [PHQ])
• Quality of life (EQ-5D-3L)
• Self-Efficacy (General Self-
Efficacy Scale [GSE])
• Well-being (Office for National
Statistics [ONS])
At 6 months:
• No significant
effect on
loneliness (De
Jong Gierveld
Loneliness Scale)
At 24 months:
• Significant
improvement on
loneliness (De
Jong Gierveld
Loneliness
Scale) (p=0.026)
At 6 months and 24
months:
on SF-36 mental
health component,
depression scores on
the patient health
questionnaire, quality
of life scores on the
EQ-5D-3L, self-
efficacy, or ONS well-
being measures.

C-7
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Murayama,
20147
Pre-Post
12 months
Japan
Study Quality:
Fair
• N=80 seniors from 3
municipalities
• Mean age: 69.1
• 16.2% male
• 17.5% living alone
Intervention
• Participants attended weekly
training seminars for three
months involving picture book
reading projects. Participants
then worked as book-reading
volunteers for children at
collaborating educational
institutions once every 1-2 week
for 12 months.
• Intervention took place at
Educational centers (mostly
schools)
• Training led by lay people and
project staff
Comparator
• Conventional social activities
Data collected at baseline, either 3 or
9 months (inconsistent in article), 1
year, and 2 years:
Scale-Short Version-Japanese
[GDS-S-J])
• Sense of coherence (13-item
scale measuring
comprehensibility, manageability,
and meaningfulness
All time points:
• Neither loneliness
nor social isolation
were measured.
Group x time effects
• Geriatric depression:
no significant effect
• Sense of coherence:
After finding a
significant (p<.10)
group x time
interaction effect for
sense of coherence,
the study authors
conducted simple
effects analyses and
found the there was a
short-term
improvement in
meaningfulness (one
of three subscales) at
time 1 that was
sustained throughout
the study.

C-8
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Coll-Planas et.
al, 20178
Pre-post
observational
study
15 weeks
Spain
Study Quality:
Poor
• N=38 community-
dwelling participants
that reported feeling
lonely “sometimes,
often or always”
• Age range: 63-89,
mean=77.24
• 5% male
Intervention
• Combined group-based program
with coordinated action
intervention (raising community
awareness, training older people
as volunteers, and building a
team of professionals to design
and conduct the program). The
program included group
discussions of feelings and visits
to community activity centers.
• The program was delivered by 3
nurses and 3 social workers
• 1.5 hours a week for 15 weeks.
• One mixed rural-urban and 2
urban areas in senior centers
and primary care centers
No comparator
Data collected at baseline, unclear
post-test, and 2 years:
• Health related quality of life (SF-
12)
• Self-rated health (excellent or very
good, good, regular, poor)
• Depressive Symptoms (Geriatric
Depression Scale-5)
• Anxiolytic and/or antidepressant
use
• Health service usage (retrieved
from computerized medical
records) including nurse, social
work, and general practitioner
visits for 12 months before
intervention, just after it, and 6
months later.
Post-test and 2 years:
• Significant
improvement in
loneliness (both
feelings and
Gierveld
Loneliness
Scale) and social
participation at
post-test and 2
years (p<.001).
Post-test
• No significant change
in health-related
quality of life, self-
rated health,
depressive
symptoms, anxiolytic
and/or antidepressant
use, all health service
usage other than
nurse visits, in past
12 months, which
increased from 6.65
to 10.42 (p=0.005)
2 years
• No changes in self-
rated health.
• Depressive
symptoms were
significantly
reduced from 2.05 to
1.17 (p=0.032).
• The study does not
report antidepressant
use, anxiolytic use or
number of medical
visits from previous
12 months in follow
up.

C-9
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Gaggioli, et. al,
20149
Pre-post
observational
study
3 weeks
Italy
Study Quality:
Poor
• 32 older adults
recruited from senior
centers in Milan, Italy
• Mean age: 67.53
• Gender: NR
• Loneliness/social
isolation: NR
Intervention
• Reminiscence groups comprised
of 2 older adults and 6-8
students. The older adults were
encouraged to share memories
and promote interaction with the
students.
• Groups were led by a
psychologist
• Groups met once a week for 2
hours, over a period of 3 weeks.
No comparator
Data collected at baseline and week
3:
• Quality of Life (WHOQoL-Old)
• Self-esteem (Rosenberg)
At 3 weeks:
• Overall score on
loneliness (Italian
Loneliness Scale)
NR.
At 3 weeks:
on quality of life or
self-esteem.
Gonyea, 201310
Pre-post
observational
study
9 months
USA
Study Quality:
poor
• N=33 residents
participating in a
community
enhancement
program for seniors
(“Aging Well at Home
Program”).
mean: 81
• 85% Caucasian/white
women
• Within normal
loneliness range for
the age group at
enrollment
• 53% lived alone
Intervention
• 3 parts:
o Community liaison
maintained contact with
participants via phone calls,
home visits, and invitations to
social events.
o “Warm homes” where
participants gathered in
neighbor’s homes for social,
cultural, or recreational
events (e.g. meals, coffee).
o Community forums held to
solicit input from residents in
shaping the program as a
whole.
• Intervention delivered for 9
months
• Delivered in community spaces
and participants homes
No comparator
months:
• 10-item Perceived Stress Scale
(PSS)
• 15-item Geriatric Depression
Scale (GDS) – Short Form
At 9 months:
• No significant
effect on
loneliness at 9
months (20-item
UCLA loneliness
scale, version 3)
At 9 months:
• Perceived stress:
significant
improvement in
intervention group (-
2.23 p<.001)
• Depression: no
significant difference.
Abbreviations: EQ-5D=European Quality of Life-5 Dimensions; GDS=Geriatric Depression Scale; GSE=General Self-Efficacy Scale; NHS=National Health Service; NR=Not Reported; ONS=Office
for National Statistics; PHQ=Patient Health Questionnaire; PSS=Perceived Stress Scale; RCT=Randomized Controlled Trial; SF-36/12=Short Form-36/12; UCLA=University of California Los
Angeles; UK=United Kingdom; USA=United States of America; WHOQoL-Old=World Health Organization Quality of Life-Old.

C-10
Table C-3. Arts and recreation interventions
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Yap et al., 201711
Crossover RCT
11 weeks
Singapore
Study Quality:
Fair
• N=31 healthy older
adults (i.e., not on
palliative care or bed-
bound)
• Age: All 65+, Mean
age: 74.65 ± 6.40
years.
• 6% male
• 100% Chinese
Intervention
• Rhythm-centered music making
(RMM).
• All RMM sessions were
facilitated by 3 experienced
instructors. Participants sit in a
circle with one of many
instruments in front of them
(conga, cowbell, Djembe, Ashiko
Tan-tans, Dunun, Shakers, and
wood blocks).
• Total of 10 sessions over 11
weeks, each session 1 hour long
• 54 participants were recruited
with 27 participants in each arm.
Comparator
• In phase 1, group A underwent
the intervention with group B as
the control. In phase 2, group B
underwent the intervention with
group A as the control.
Data collected at baseline, 11
weeks (after intervention)
• Quality of Life (European Quality
of Life-5 Dimensions [EQ-5D])
• Depression (Geriatric
Depression Scale [GDS])
• Sleep Quality (Pittsburg Sleep
Quality Index [PSQI])
At 11 weeks:
• No improvement
in social network
(Lubben Social
Network Scale)
At 11 weeks:
• Linear regression
models found no
significant effect on
quality of life,
depression, or sleep.
• No reported adverse
events.

C-11
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Davidson et. al,
201412
Pre-post
observational
study
8 weeks
Australia
Study Quality:
poor
• All participants were
70 or older, living
independently
• Subgroup 1: n=17
Silver-chain
(recipients of home
care services)
o Age range: NR;
mean age: 79
o 6% male
o Race/ethnicity: NR
• Subgroup 2: n=19
community-based.
o Age range: NR;
mean age=76
o 42% male
• Subgroups were
differentiated by
referral source, but
proceeded through
study as single group
• Both groups had
similar UCLA
loneliness scores
comparable to their
age group
Intervention
• 8 consecutive weekly group
singing sessions lasting 90
minutes
• Sessions were led by an
experienced community
musician at a local community
center
• Both groups received the
intervention together
Comparator
• No control group
Data was collected pre- and post-
intervention (exact timepoint NR)
using:
• Physical and mental health:
Medical Outcomes Study short-
form (SF-36)
• Depression (Geriatric
Depression Scale [GDS])
Survey at the conclusion of
intervention asked participants
about perceived positive
experiences from the intervention.
Participants stated whether these
experiences happened frequently,
infrequently, or never.
Exact timepoint not
reported:
• No significant
change in
loneliness (UCLA
loneliness scale) at
conclusion of
intervention
• 35% of participants
said they made
social contacts
• 71% said they
became a member
of a group.
Exact timepoint not
reported:
• Overall SF-36 scores
not reported.
• Significant increase
in (worsening of)
mean GDS in Silver
Chain group
following
intervention (p=.05),
but not in the
community
participants group.
• 55% reported
frequently
experiencing
increased energy
levels
• 68% reported
frequently
experiencing improved
sense of well-being
• 81% frequently
reported relaxation,
reduced stress
• 64% frequently
reported mental
alertness.

C-12
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Phinney, 201413
Pre-post
observational
3 years
Canada
Study Quality:
poor
• N=51 community
dwelling seniors
mean age: 71 (age
data was only
collected from 24
participants)
• 20% male (n=51)
Intervention
• Subjects participated in weekly
arts sessions, each lasting 2
hours. The program lasted for
three years, and was delivered in
four community centers.
• Intervention delivered in 4
groups, each with diverse
participants: 1 consisted of
Chinese-speaking women, 1
consisted of LGBT seniors, 2
others were social activity groups
• Facilitators: Artists and seniors’
workers based at the community
center.
Comparator
Data collected in first year of
program and approximately 2.5
years later:
• Daily function (OARS-ADL)
• Perceived health status (Single
item perceived overall health)
• Chronic pain (Single item verbal
descriptor scale)
• Depression symptoms (Geriatric
Depression Scale[GDS])
• Self-esteem (Rosenberg Self-
Esteem Scale)
• Morale (Philadelphia Geriatric
Center [PGC] Morale Scale)
• Life satisfaction (Satisfaction
with Life Scale)
• Sense of purpose (Life
engagement test)
At approximately 2.5
years:
• Total score on
community
connections index
not reported.
• No effect on social
support (Multi-
dimensional Scale
of Perceived Social
Support)
At approximately 2.5
years:
• Chronic pain (n =
23): significant
improvement 0.52, p
< .05
• No significant effect on
daily function,
perceived health
status, depression,
self-esteem, morale,
life satisfaction, or
sense of purpose.
Vogelpoel 201414
Pre-post study
12 weeks
UK
Study Quality:
poor
• N=12 sensory
(hearing, vision, or
both) impaired and
socially isolated older
adults
• Participants had a
range of age-related
cognitive, emotional
and physical
impairments, as well
as mobility issues,
within the group.
mean age: over 80
• 25% male
Intervention
• 12-week arts program
• Social prescribed service
commissioned by Voluntary
Action Rotherham, and
coordinated by the national
charity for deafblind people,
Sense.
• The model had three foci:
participation in an arts workshop
program; ongoing individual
assessments of health status;
and ongoing observations of
participant’s health statuses.
• Referrals from GPs to
coordinator at Sense
• Program ran at fully accessible
resource center in central
Rotherham managed by Sense
Comparator
Scales delivered at baseline and 12
weeks:
• Wellbeing (Warwick and
Edinburgh Mental Wellbeing
Scale): a self-reporting measure
completed at the first and last
session
At 12 weeks:
• No quantitative
measurement of
social isolation.
At 12 weeks:
• Mental wellbeing:
Average score
increased from 41 to
47 (n=8) on a scale of
14 to 70 with 3 to 8-
point increase being
meaningful. Not
statistically significant.
No p-value reported.
Abbreviations: EQ-5D=European Quality of Life-5 Dimensions; GDS=Geriatric Depression Scale; GDS-S-J=Geriatric Depression Scale- Short Version- Japan; GP=General Practitioner;
LGBT=Lesbian, Gay, Bisexual, Transgender; NR=Not Reported; OARS-ADL= Older Americans Resources and Services Activities of Daily Living Scale; PGC=Pittsburg Geriatric Center;

C-13
PSQI=Pittsburgh Sleep Quality Index; RCT=Randomized Controlled Trial; RMM=Rhythm-Centered Music Making; SF-36=Short Form-36; UCLA=University of California Los Angeles;
UK=United Kingdom
Table C-4. Health services access interventions
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Bartsch et. al,
201315
Pre-post
observational
study
26-28 months
USA
Study Quality:
Poor
• All participants were
60 or older, living
independently, and
had emotional/
behavioral problems,
poor health, social
isolation, or abuse,
neglect, or substance
abuse problems.
• Colorado group:
n=138
o Mean age: 74.1
years old
o 24.6% male
o Loneliness/social
isolation: NR
• Kansas group: n=190
o Mean age: 74.3
years old
o 30% male
o Loneliness/social
isolation: NR
Intervention
• Each program first trained
community members as
gatekeepers who referred at-risk
seniors to care managers and
mental health professionals, who
recommended mental health,
care management or
information/referral treatments.
• Community interventions were
also provided (strength-based,
recovery treatment, family
support, consultation, advocacy,
coordination and crisis
intervention).
• Gatekeepers were either
traditional (PCPs, adult
protective services, county
human services, etc.) or non-
traditional (restaurant and retail
staff, bus drivers, senior center
staff, etc.)
No comparator
Data collected at baseline, and either
6 months or program discharge,
whichever was earlier. The Colorado
program results were taken from 28
months of operation, while the
Kansas program results were from 26
months. Follow-up at 12 months:
• Geriatric Depression Scale (GDS)
• Self-report surveys regarding
emotional disturbance, cognitive
impairment, and physical
impairment.
12-month follow up:
• Study reports
significant
improvement in
both groups self-
reported measures
of social isolation
but p-value NR.
12-month follow-up:
• GDS (Colorado):
study states this is
significant, but p-
value was NR.
• GDS (Kansas):
significantly more
improvement in
intervention (-3.1, p-
value < .05)
• Study states that all
self-report
measurements
(emotional
disturbance, cognitive
impairment, physical
impairment) for both
Colorado and Kansas
were significantly
improved except for
physical impairment
in Colorado; but p-
values were NR.

C-14
Author, Year
Study Design
Intervention
Duration
Country
Study Quality
Measured
Kim, 201816
Cross-sectional
study of
participants vs.
standby and
post-test survey
of recipients
Unclear
intervention
length
South Korea
Study Quality:
Poor
Cross-sectional study of
those who participated
(healthy older adults that
provided care) for at least
3 months in 2013 vs.
those on standby
• n=12,412 participants
• n=3,307 on standby
• Average age NR, but
all were 65+
• Gender, race, and
loneliness/social
isolation NR.
2014 survey on health
status, subjective health
improvement, and
depression from a
sample of 31,477 of
recipients (vulnerable
older adults that received
care)
• n= 508 survey
participants
• Average age NR, but
all were 65+
• Gender, race, and
loneliness/ social
isolation NR.
Cross-sectional study
Intervention
• Elderly care through the elderly
program (ECEP) – healthy older
adults (participants) provide
emotional and other support for
vulnerable older adults
(recipients) with limited mobility.
• Examples of emotional and other
support include checking on
health status, talking, reading
books, helping with household
chores, taking to medical
appointments and pharmacy
• Healthy older adults are paid.
Comparator
• ECEP standby – elderly people
on standby to become a
participant in the ECEP program
Survey
Intervention is the same as above,
no comparator.
Cross-sectional study, data gathered
on those who participated for five
years in a row:
• Utilization of medical care by
participants and people on
standby
Survey on subjective health condition
completed “during and after”
intervention. Depression survey taken
at one unclear time point:
• Subjective health condition
measured on a 5-point scale
Scale-Korean [SBDS-K])
Data gathered on
those who
participated for five
years in a row:
• Results for neither
loneliness nor
social isolation
were reported.
Data gathered on those
who participated for five
years in a row:
Cross-sectional study
• Fewer
hospitalization days
among intervention
than standby group
(2.24 days, p <
0.0001)
• No significant
difference between
intervention and
standby groups for
changes in medical
care days, outpatient
days, or medication
prescription days.
Timepoint at which the
survey was conducted is
unclear:
Survey
• Significant effect on
subjective health
condition (0.28, p <
0.0001) but no
information on
whether that’s an
improvement.
• Mean score of 7.70
from the short form of
the Geriatric
Depression Scale (not
clear whether this is
during or after
intervention)
ECEP = Elderly Care Through the Elderly Program; GDS = Geriatric Depression Scale; NR = Not Reported; PCP = Primary Care Physician; SBDS-K = Geriatric Depression Scale-Korean; USA =
United States of America.

C-15
References for Appendix C
1. Chan AW, Yu DS, Choi KC. Effects of tai
chi qigong on psychosocial well-being
among hidden elderly, using elderly
neighborhood volunteer approach: a pilot
randomized controlled trial. Clin Interv
Aging. 2017;12:85-96. doi:
10.2147/cia.s124604. PMID: 28115837.
2. Kamegaya T, Araki Y, Kigure H, et al.
Twelve-week physical and leisure activity
programme improved cognitive function in
community-dwelling elderly subjects: a
randomized controlled trial.
Psychogeriatrics. 2014 Mar;14(1):47-54.
doi: 10.1111/psyg.12038. PMID: 24528600.
3. Pynnonen K, Tormakangas T, Rantanen T,
et al. Effect of a social intervention of
choice vs. control on depressive symptoms,
melancholy, feeling of loneliness, and
perceived togetherness in older Finnish
people: a randomized controlled trial. Aging
10.1080/13607863.2016.1232367. PMID:
27657351.
4. Seino S, Nishi M, Murayama H, et al.
Effects of a multifactorial intervention
comprising resistance exercise, nutritional
and psychosocial programs on frailty and
functional health in community-dwelling
older adults: A randomized, controlled,
cross-over trial. Geriatr Gerontol Int. 2017
Nov;17(11):2034-45. doi:
10.1111/ggi.13016. PMID: 28393440.
5. Tarazona-Santabalbina FJ, Gomez-Cabrera
MC, Perez-Ros P, et al. A Multicomponent
Exercise Intervention that Reverses Frailty
and Improves Cognition, Emotion, and
Social Networking in the Community-
Dwelling Frail Elderly: A Randomized
Clinical Trial. J Am Med Dir Assoc. 2016
May 1;17(5):426-33. doi:
10.1016/j.jamda.2016.01.019. PMID:
26947059.
preventative lifestyle intervention for older
adults (lifestyle matters): a randomised
controlled trial. Age Ageing. 2017 Jul
1;46(4):627-34. doi: 10.1093/ageing/afx021.
PMID: 28338849.
7. Murayama Y, Ohba H, Yasunaga M, et al.
The effect of intergenerational programs on
the mental health of elderly adults. Aging
Ment Health. 2015;19(4):306-14. doi:
10.1080/13607863.2014.933309. PMID:
25010219.
8. Coll-Planas L, Del Valle Gomez G, Bonilla
P, et al. Promoting social capital to alleviate
loneliness and improve health among older
people in Spain. Health Soc Care
Community. 2017 Jan;25(1):145-57. doi:
10.1111/hsc.12284. PMID: 26427604.
Intergenerational group reminiscence: A
potentially effective intervention to enhance
elderly psychosocial wellbeing and to
improve children's perception of aging.
Educ Gerontol. 2014;40(7):486-98. doi:
doi.org/10.1080/03601277.2013.844042.
evaluation of a neighborhood-based pilot
project to “put connection back into
community”. J Hous Elderly.
2013;27(4):333-47. doi:
doi.org/10.1080/02763893.2013.813425.
centred music making in community living
elderly: a randomized pilot study. BMC
Complement Altern Med. 2017 Jun
14;17(1):311. doi: 10.1186/s12906-017-
1825-x. PMID: 28615007.
12. Davidson JW, McNamara B, Rosenwax L,
et al. Evaluating the potential of group
singing to enhance the well‐being of older
people. Australas J Ageing. 2014;33(2):99-
104. doi: DOI: 10.1111/j.1741-
6612.2012.00645.x. PMID: 24520864.
13. Phinney A, Moody EM, Small JA. The
Effect of a Community-Engaged Arts
Program on Older Adults' Well-being. Can J
Aging. 2014 Sep;33(3):336-45. doi:
10.1017/s071498081400018x. PMID:
25110936.
14. Vogelpoel N, Jarrold K. Social prescription
and the role of participatory arts
programmes for older people with sensory
impairments. J Integr Care. 2014;22(2):39-
50. doi: doi.org/10.1108/JICA-01-2014-
0002.

C-16
15. Bartsch DA, Rodgers VK, Strong D.
Outcomes of senior reach gatekeeper
referrals: comparison of the Spokane
gatekeeper program, Colorado Senior
Reach, and Mid-Kansas Senior Outreach.
Care Manag J. 2013;14(1):11-20. PMID:
23721039.
16. Kim YE, Hong SW. Health-Related Effects
of the Elderly Care Program.
2018;2018:7121037. doi:
10.1155/2018/7121037. PMID: 29888273.

Appendix D. Poor-Quality Studies
Table D-1. Selected intervention characteristics and outcomes data for poor-quality studies
Type of
Intervention
(Health Effect)
Study
Information
Description of
Intervention
Duration &
Intensity
Staffing
Requirements
Effect on
SI/Loneliness Effect on Health/Health Care
(+)
Coll-Planas, 2017
1
Pre-post n=38
Mean age: 77
Poor quality
Group discussions on
feelings & visits to
community centers
(D) 15 weeks**
(I) 1.5
hrs/week††
Professional
(nurses & social
workers)
Decreased
loneliness
(post-test & 2 yr)
Improved depression at 2 yrs but not
post-test. More nurse visits but no
difference in GP or social work visits or
prescription use (post-test). No effect
on health-related QoL or
self-rated health (post-test & 2 yr).
(+)
Gonyea, 2013
2
Pre-post n=33
Mean age: 81
Poor quality
Phone calls, home visits,
and social engagement
(D) 9 months***
(I) NR
Lay person
No effect on
loneliness (9 mo)
Improvements in perceived stress (9
mo). No effect on depression (9 mo).
(+)
Phinney, 2014
3
Pre-post n=51
Mean age: 71
Poor quality
Art projects
(D) 3 years***
(I) 2 hrs
1x/week††
Lay person
No effect on social
support (2.5 yrs)
Improvements in chronic pain (2.5
yr). No effect on daily function,
perceived health status,
depression or self-esteem (2.5 yr).
(+)
Bartsch, 20134
Pre-post
n=328
Mean age: 74
Poor quality
Training community
members and elder
service providers to
recognize
at-risk elders and provide
referrals to services
(D) 26-28
months***
(I) NR
Professional & lay
person
NR Improved depression (12 mos)
(+)
Kim, 20185
Cross-
sectional
w/ survey
n=12,412
Age: 65+
Poor quality
Peers checking on health,
helping with chores &
transportation, and social
engagement
(D) NR
(I) NR
Lay person NR
Fewer hospital days, but no
difference in medical care
days, outpatient days, or
medication prescription days
(-)
Gaggioli, 20146
Pre-post n=32
Mean age: 68
Poor quality
Share memories and
promote interactions
between elders and youth
(D) 3 weeks*
(I) 2hrs
1x/week††
Professional
(psychologist)
NR
No effect on quality of life or self-
esteem (3 weeks)
(-)
Davidson, 20147
Pre-post n=36
Mean age: 78
Poor quality
Singing sessions
(D) 8 weeks**
(I) 1 hour 30
min 1x/week††
Lay person
No effect on
loneliness (8 weeks)
Worsened depression (8 weeks)
(=)
Vogelpoel, 20148
Pre-post n=12
Mean age: 80+
Poor quality
Art projects
(D) 12 weeks**
(I) NR
Professional (GP
referred) & lay
person
NR NR
(+) = studies that had a positive effect on health/health care utilization outcomes; (-) = studies that had no effect; (=) = studies for which there was insufficient information to make a
determination; = Social; = Arts and recreation; = Health access; (D) = Duration of intervention; (I) = Intensity of intervention; (NR) = No results; (QoL) = Quality of life;
(GP) = General practitioner; (SI) = Social Isolation; * = Low duration; ** = Medium duration; *** = High duration; † = Low intensity; †† = Medium intensity; ††† = High intensity

D-2
References for Appendix D
10.1111/hsc.12284. PMID: 26427604.
2013;27(4):333-47. doi:
doi.org/10.1080/02763893.2013.813425.
Aging. 2014 Sep;33(3):336-45. doi:
10.1017/s071498081400018x. PMID:
25110936.
Care Manag J. 2013;14(1):11-20. PMID:
23721039.
5. Kim YE, Hong SW. Health-Related Effects
of the Elderly Care Program.
2018;2018:7121037. doi:
10.1155/2018/7121037. PMID: 29888273.
doi.org/10.1080/03601277.2013.844042
104. doi: DOI: 10.1111/j.1741-
6612.2012.00645.x. PMID: 24520864.
8. Vogelpoel N, Jarrold K. Social prescription
and the role of participatory arts
programmes for older people with sensory
impairments. J Integr Care. 2014;22(2):39-
50. doi: doi.org/10.1108/JICA-01-2014-
0002.

E-1
Appendix E. Characteristics of Interventions in Fair- to Good-Quality Studies
Table E-1. Characteristics of studies that had a positive effect on either SI/loneliness or health/healthcare utilization outcomes
Author, Year Type of
Intervention
Health care provider involved? Duration of intervention Intensity of intervention
Kamegaya 2014 Physical activity Yes (PT, OT, and public health
nurse)
3 months (med duration) 2 hours 1x/week (med intensity)
Seino 2017 Physical activity No 3 months (med duration) 1 hour 40 mins 2x/week (high intensity)
Chan 2017 Physical activity Yes (nurse and social worker) 3 months (med duration) 1 hour 2x/week (high intensity)
Mountain 2017 Social Yes (NHS or social care staff) 4 months (med duration) 1x a week with group and 1x a month with
facilitator (high intensity)
Total 75% were physical
activity
interventions
75% had provider involved,
25% did not
100% were medium duration 75% were high intensity, 25% were medium
intensity
Table E-2. Characteristics of studies that had no effect on either SI/loneliness or health/healthcare utilization outcomes
Intervention
Pynnonen 2018 Physical activity Yes (rehabilitation counselor) 15-21 weeks (med duration) Max 2 hours 1x/week
Min 1 hour 1x/3 weeks (medium-low intensity)
Murayama 2015 Social No 1 year (high duration) 1x every 1-2 weeks (medium-low intensity)
Yap 2017 Arts and recreation No 11 weeks (med duration) 1 hour/10 sessions (low intensity)
Total 33% were physical
activity, 33% were
social, 33% were
arts & recreation
interventions
33% had provider involved,
66% did not.
66% were medium duration,
33% were high duration
66% were medium-low intensity, 33% were
low intensity
Table E-3. Characteristics of studies for which the effect on SI/loneliness or health/healthcare utilization outcomes could not be determined
Intervention
Tarazona-
Santabalbina 2016
Physical activity Yes (PT and nurse) 6 months (high duration) 1 hour 5 min 5x/week (high intensity)
CND = Could Not Determine; NHS = National Health Service; OT = Occupational Therapist; PA = Physical Activity; PT = Physical Therapist; SI=Social Isolation

F-1
Appendix F. Social Isolation and Loneliness
Definitions and Measures
Table F-1. Definitions of social isolation and loneliness
Institution Definitions
National Health Service –
Centre for Reviews and
Dissemination1
Social isolation: The lack of social contact or support1
Loneliness: The feeling of being alone or isolated1
Review Definitions
Gardiner et al, 20182
Social isolation: The objective absence or paucity of contacts and interactions between a
person and a social network.3
Loneliness: A subjective feeling state of being alone, separated or apart from others, and has
been conceptualized as an imbalance between desired social contacts and actual social
contacts.4,5
Poscia et al, 20186
Social isolation: An objective lack of meaningful and sustained communication.6
Loneliness: The way people perceive and experience the lack of interaction.6
Shvedko et al, 20187
Social isolation: A state in which the individual lacks a sense of belonging socially, lacks
engagement with others, has a minimal number of social contacts, and they are deficient in
fulfilling and quality relationships.8
Loneliness: A discrepancy between a person's desired and actual social relationships.9
Ronzi et al, 201810 (Social isolation and loneliness not measured)
Social inclusion: Has explicit links with concepts such as equality, human rights and social
cohesion, and it has focused on barriers that prevent people from participating meaningfully
in society.11
Table F-2. Measures of social isolation and loneliness
Study Construct: Measure Measure Explanation/Questions
Seino, 201712
• Structural social
capital: Check List for
Vivid Social
Activities13
– “social
participation and
voluntary activities”
domain
Check List for Vivid Social Activities13
• Unable to find original checklist and unable to find full-text of the study
which validated the measure.

F-2
Chan, 201714
• Social network:
Lubben Social
Network Scale-615
• Loneliness: De Jong
Gierveld Loneliness
Scale16
• Social support:
Revised Social
Support
Questionnaire (also
known as the SSQ6)17
Lubben Social Network Scale-615
• Measures social isolation by measuring frequency, size, and closeness of
contacts of the respondent’s social network by assessing the perceived
level of support they get from friends and families.
• Scoring is as follows: 0=none; 1-one; 2=two; 3=three or four; 4=five thru
eight; 5=nine or more. Total scores from 0-30 with higher scores indicating
larger social networks
• Three questions on family, and 3 on friends. Questions are framed the
same way across family/ friends.
• Scale questions:
o How many relatives/friends do you see or hear from at least once a
month?
o How many relatives/friends do you feel at ease with that you can talk
about private matters?
o How many relatives/friends do you feel close to such that you could call
on them for help?
De Jong Gierveld Loneliness Scale16
• Measures emotional and social loneliness.
• Six statements, three measuring emotional loneliness and three measuring
social loneliness, each with three choices including yes, more or less, and
no. Scores range from 0-6, with 6 indicating higher loneliness.
• Emotional loneliness statements:
o “I experience a general sense of emptiness”; “I miss having people
around me”; and “I often feel rejected”
• Social loneliness statements:
o “There are plenty of people I can rely on when I have problems”; “There
are many people I can trust completely”; and “There are enough people
I feel close to.”
Revised Social Support Questionnaire (SSQ6)17
• Six-item measure of social support wherein respondents indicate the
number of people they feel they have available to provide support in six
areas:
o “Who can you count on when you need help?”
o “Whom can you really count on to help you feel more relaxed when you
are under pressure or tense?”
o “Who accepts you totally, including both your worse and best points?”
o “Who can you really count on to care about you, regardless of what is
happening to you?”
o “Who can you really count on to help you feel better when you are
feeling generally down in the dumps?”
o “Who can you count on to console you when you are very upset?”
• Each question has a follow up scale regarding how satisfied the
respondent is with support given in each area.
Pynnonen,
201818
• Loneliness:
developed their own
measure
• Perceived
togetherness: Social
Provisions Scale19
Measure for loneliness
• Participants were asked “Do you feel lonely?’
• Answer options were: very rarely or never, sometimes, and often or almost
always
Social Provisions Scale19
• 24-statement scale, split into six dimensions: attachment, social integration,
reliable alliance, guidance, opportunity for nurturance, and reassurance of
worth
• Scale from 1 (strongly disagree) to 4 (strongly agree). Larger final score
indicates greater degree of perceived support.
• Examples of statements include: “There are people I know will help me if I
really need it”; “I have close relationships that make me feel good”; and “I
feel a strong emotional tie with at least one other person.”

F-3
Tarazona-
Santabalbina,
201620
• Social support: Duke
Social Support Index.
(NOTE: The study
was non-specific.
They state they used
“Duke Social Support”
with no associated
reference. There is no
tool by this name.
There is the Duke
Social Support
Index,21
and an
abbreviated version of
this tool. We provide
information on the
most current version
when the study came
out: the DSSI-10.22
)
Duke Social Support Index-1022
• Originally 35 items long, this index was reworked in 2013, and the current
10-item assessment, which measures social support, has two subscales:
social interaction and subjective social satisfaction. Higher scores indicate
more social support
• Example questions in the social interaction subscale include: “What is the
number of times in the past week spent with someone not living with you?”
and “What is the number of times in the past week you talked with
friends/relatives on the telephone?”
• Example questions in the social support subscale include: “Do you feel
useful to your family and friends?” and “Can you talk about your deepest
problems?”
Kamegaya,
201423
• Social support:
Lubben Social
Network Scale
Revised15
• See “Lubben Social Network Scale-6” under Chan, 2017
Mountain,
201724
Gierveld Loneliness
Scale16
• See “De Jong Gierveld Loneliness Scale” under Chan, 2017
Gonyea,
201325
• Loneliness: UCLA
Loneliness Scale
Version 326
UCLA Loneliness Scale Version 326
• 20-question tool used to assess subjective feelings of loneliness or social
isolation. All questions are framed using “how often do you feel…” and
choices include never, rarely, sometimes, and often. Scores range from 20
to 80, with a higher score indicating greater loneliness.
• Examples of questions include: “How often do you feel a lack on
companionship?”; “How often do you feel left out?”; and “How often do you
feel isolated from others?”
Coll-Planas,
201727
Gierveld Loneliness
Scale16
• Social support (as
cognitive aspect of
social capital): Social
Resources Inventory
in Older Adults
• Social participation
(as structural aspect
of social capital):
Subjective Social
Participation Index28
• See “De Jong Gierveld Loneliness Scale” under Chan, 2017
Social Resources Inventory in Older Adults
• Unable to find inventory and unable to find full-text of the study which
validated the measure.
Subjective Social Participation Index28
• Of note, we could only find this scale in Spanish. We used Google
Translate to translate the scale into English, so some questions may not
translate perfectly.
• This 15-question scale is broken into three “Factors” – perception of social
support, use of new technologies, and index of subjective social
participation.
• This study used to the four questions asked in the social participation
factor:
o During the week and on weekends do you call other people to go
outside?
o Do you find it easy to make friends?
o Do you go to any park, association, home of the pensioner (retirement
home) where you relate to other elders?
o Do you like to participate in leisure activities that are organized in your
neighborhood/town?
• Answers to these four questions are always=0, sometimes=1, or never=2.
Low scores indicate increased social participation.

F-4
Gaggioli,
201429
• Loneliness: Italian
Loneliness Scale30
Italian Loneliness Scale30
• This 18-item scale is broken into three subscales: emotional loneliness,
social loneliness, and general loneliness. Questions are answered on a 4-
point Likert-type scale (ranging from 1=never to 4=always).
• The emotional loneliness subscale has six negative statements, including
“Often I feel rejected,” and “I miss having people around.”
• The social loneliness subscale has five positive statements such as “There
are enough people that I feel close to,” and “I can call on my friends
whenever I need them.”
• The general loneliness subscale has seven negative statements such as “I
feel left out,” and “People are around me but not with me.”
Yap, 201731
• Social network:
Lubben Social
Network Scale-615
• See “Lubben Social Network Scale-6” under Chan, 2017
Phinney,
201432
• Social support:
Multidimensional
Scale of Perceived
Social Support33
Multidimensional Scale of Perceived Social Support33
• This 12-item scale is broken into three factor groups (source of social
support): family, friends, and significant other. This scale is scored on a 1
(very strongly disagree) to 7 (very strongly agree) Likert-type scale. Four is
neutral. Higher scores indicate high levels of social support.
• Statements in the family factor group include: “My family really tries to help
me”; “I get the emotional help and support I need from my family”; “I can
talk about my problems with my family”; and “My family is willing to help me
make decisions.”
• Statements in the friend factor group include: “My friends really try to help
me”; “I can count on my friends when things go wrong”; “I have friends with
whom I can share my joys and sorrows”; “I can talk about my problems with
my friends.”
• Statements in the significant other factor group include: “There is a special
person who is around when I am in need”; “There is a special person with
whom I can share my joys and sorrows”; “I have a special person who is a
real source of comfort to me”; and “There is a special person in my life who
cares about my feelings.”
Davidson,
201434
• Loneliness: UCLA
Loneliness Scale
Version 326
UCLA Loneliness Scale Version 326
• See “UCLA Loneliness Scale Version 3” under Gonyea, 2013
Bartsch,
201335
• Social isolation:
developed own
survey, called the
“Care Manager
Survey”
Care Manager Survey
• This survey was given at intake and discharge for all clients.
• The survey measured five potential isolators: emotional disturbance,
cognitive impairment, social isolation, physical impairment, and economic
disadvantage.
• The scoring for each isolator is as follows: 0 for no problem with the isolator
to 4 for a major problem with the isolator.
Studies that did not measure social isolation or loneliness: Murayama, 2014; Vogelpoel, 2014;
Kim, 2018.
References for Appendix F
1. Interventions for loneliness and social
isolation National Institute for Health
Research. The University of York Centre for
Reviews and Dissemination. 2014.
2. Gardiner C, Geldenhuys G, Gott M.
Interventions to reduce social isolation and
loneliness among older people: an
integrative review. Health Soc Care
Community. 2018 Mar;26(2):147-57. doi:
10.1111/hsc.12367. PMID: 27413007.
3. Gardner I, Brooke E, Ozanne E, et al.
Improving social networks, a research
report: Improving health and social isolation
in the Australian veteran community.
Lincoln Gerontology Centre, La Trobe
University, Melbourne. 1999.
4. Weiss RS. Loneliness: The Experience of
Emotional and Social Isolation. Cambridge,
MA: MIT Press; 1973.

F-5
5. Ernst JM, Cacioppo JT. Lonely hearts:
psychological perspectives on loneliness.
Appl Prev Psychol. 1999;8(1):1-22. doi:
10.1016/S0962-1849(99)80008-0.
6. Poscia A, Stojanovic J, La Milia DI, et al.
Interventions targeting loneliness and social
isolation among the older people: An update
systematic review. Exp Gerontol. 2018
Feb;102:133-44. doi:
10.1016/j.exger.2017.11.017. PMID:
29199121.
7. Shvedko A, Whittaker AC, Thompson JL, et
al. Physical activity interventions for
treatment of social isolation, loneliness or
low social support in older adults: A
systematic review and meta-analysis of
randomised controlled trials. Psychol Sport
Exerc. 2018. doi:
doi.org/10.1016/j.psychsport.2017.10.003.
8. Nicholson NR. A review of social isolation:
an important but underassessed condition in
older adults. . J Prim Prev. 2012;33:137-52.
doi: http://dx.doi.org/10.1007/s10935-012-
0271-2.
9. Russell D, Peplau LA, Cutrona CE. The
revised UCLA Loneliness Scale: Concurrent
and discriminant validity evidence. J Pers
Soc Psychol. 1980;39(3):472-80.
10. Ronzi S, Orton L, Pope D, et al. What is the
impact on health and wellbeing of
interventions that foster respect and social
inclusion in community-residing older
adults? A systematic review of quantitative
and qualitative studies. Syst Rev. 2018 Jan
30;7(1):26. doi: 10.1186/s13643-018-0680-
2. PMID: 29382375.
11. Angus J, Reeve P. Ageism: a threat to
"aging well" in the 21st century. J Appl
Gerontol. 2006;25:137-52. doi:
https://doi.org/10.1177/0733464805285745.
12. Seino S, Nishi M, Murayama H, et al.
Effects of a multifactorial intervention
comprising resistance exercise, nutritional
and psychosocial programs on frailty and
functional health in community-dwelling
older adults: A randomized, controlled,
cross-over trial. Geriatr Gerontol Int. 2017
Nov;17(11):2034-45. doi:
10.1111/ggi.13016. PMID: 28393440.
13. Takahashi M, Shibazaki S, Hashimoto S, et
al. Evaluation of social activities of the
elderly in 27 regions with use of the 'check
list for vivid social activities'. Nihon Koshu
Eisei Zasshi. 2000;47(11):936-44. PMID:
11187810.
14. Chan AW, Yu DS, Choi KC. Effects of tai
chi qigong on psychosocial well-being
among hidden elderly, using elderly
neighborhood volunteer approach: a pilot
randomized controlled trial. Clin Interv
Aging. 2017;12:85-96. doi:
10.2147/cia.s124604. PMID: 28115837.
15. 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. 2006
Aug;46(4):503-13. PMID: 16921004.
16. Gierveld JDJ, Tilburg TV. A 6-item scale
for overall, emotional, and social loneliness:
Confirmatory tests on survey data. Res
Aging. 2006;28(5):582-98. doi:
doi.org/10.1177/0164027506289723.
17. Sarason IG, Sarason BR, Shearin EN, et al.
A Brief Measure of Social Support: Practical
and Theoretical Implications. Journal of
Social and Personal Relationships.
1987;4(4):497-510. doi:
10.1177/0265407587044007.
18. Pynnonen K, Tormakangas T, Rantanen T,
et al. Effect of a social intervention of
choice vs. control on depressive symptoms,
melancholy, feeling of loneliness, and
perceived togetherness in older Finnish
people: a randomized controlled trial. Aging
10.1080/13607863.2016.1232367. PMID:
27657351.
19. Cutrona C, Russell D. The Provisions of
Social Relationships and Adaptation to
Stress. Vol. 1. 1983:37-67.
20. Tarazona-Santabalbina FJ, Gomez-Cabrera
MC, Perez-Ros P, et al. A Multicomponent
Exercise Intervention that Reverses Frailty
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