[Senate Hearing 115-363]
[From the U.S. Government Publishing Office]
S. Hrg. 115-363
AGING WITHOUT COMMUNITY: THE CONSEQUENCES OF ISOLATION AND LONELINESS
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HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
WASHINGTON, DC
__________
APRIL 27, 2017
__________
Serial No. 115-4
Printed for the use of the Special Committee on Aging
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
28-602 PDF WASHINGTON : 2018
SPECIAL COMMITTEE ON AGING
SUSAN M. COLLINS, Maine, Chairman
ORRIN G. HATCH, Utah ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona BILL NELSON, Florida
TIM SCOTT, South Carolina SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina JOE DONNELLY, Indiana
MARCO RUBIO, Florida ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska CATHERINE CORTEZ MASTO, Nevada
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Kevin Kelley, Majority Staff Director
Kate Mevis, Minority Staff Director
CONTENTS
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Page
Opening Statement of Senator Susan M. Collins, Chairman.......... 1
Statement of Senator Robert P. Casey, Jr., Ranking Member........ 2
PANEL OF WITNESSES
Julianne Holt-Lunstad, Ph.D., Professor of Psychology and
Neuroscience, Brigham Young University......................... 5
Lenard W. Kaye, D.S.W., Ph.D., Director, Center on Aging, and
Professor, School of Social Work, University of Maine.......... 7
W. Mark Clark, M.S.W., President and Chief Executive Officer,
Pima Council on Aging.......................................... 9
Rick Creech, Educational Consultant, Pennsylvania Training and
Technical Assistance Network................................... 11
APPENDIX
Prepared Witness Statements
Julianne Holt-Lunstad, Ph.D., Professor of Psychology and
Neuroscience, Brigham Young University......................... 30
Lenard W. Kaye, D.S.W., Ph.D., Director, Center on Aging, and
Professor, School of Social Work, University of Maine.......... 38
W. Mark Clark, M.S.W., President and Chief Executive Officer,
Pima Council on Aging.......................................... 40
Rick Creech, Educational Consultant, Pennsylvania Training and
Technical Assistance Network................................... 45
Additional Statements for the Record
Chelsea Conaboy, Freelance Writer, The Agenda-Politico article,
They're Out There-If We Can Find Them.......................... 50
Dhruv Khullar, M.D., M.P.P., Massachusetts General Hospital and
Harvard Medical School, New York Times Op-Ed, How Social
Isolation Is Killing Us........................................ 52
Meals on Wheels, Statement for the Record........................ 54
AGING WITHOUT COMMUNITY: THE
CONSEQUENCES OF ISOLATION
AND LONELINESS
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THURSDAY, APRIL 27, 2017
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The Committee met, pursuant to notice, at 9:48 a.m., in
Room SD-430, Dirksen Senate Office Building, Hon. Susan M.
Collins (Chairman of the Committee) presiding.
Present: Senators Collins, Flake, Tillis, Fischer, Casey,
Nelson, Gillibrand, Donnelly, Warren, and Cortez Masto.
OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN
The Chairman. The Committee will come to order.
Good morning. Today we are shining a light on a growing
phenomenon: the consequences of isolation and loneliness on
older Americans who are aging without a strong sense of
community. This is the first of a two-part series. In our next
hearing, we will explore solutions that reconnect older people
to communities.
One survey to assess isolation among seniors asks this
question: If you had good news or an interesting story to tell,
do you know someone with whom you could share it? Increasingly,
older Americans are answering this question not with the name
of a relative or a friend, but with the name of their cat or
their dog. While studies have shown that pets can help to
alleviate loneliness, they should not be an individual's only
social contact. In fact, the science is clear that isolation
and loneliness are dangerous to the health of our seniors.
Having friends is as important for good health and well-being
as food and water.
Isolation and loneliness can result in negative mental,
behavioral, and physical health outcomes. Seniors who are
lonely have a 45 percent greater risk of dying. They have a 59
percent greater risk of functional decline, causing
deterioration in their mobility and ability to perform daily
tasks. Isolation and loneliness are associated with higher
rates of heart disease; a weakened immune system; more
depression and anxiety; dementia, including Alzheimer's
disease; and nursing home admissions. Prolonged isolation is
comparable to smoking 15 cigarettes a day. I must say that was
a statistic that really hit home to me.
Older Americans who are isolated or lonely are also more
susceptible to financial scams and elder abuse. Last Congress,
we uncovered the tragic story of a 77-year-old man from Maine
who turned to the Internet for companionship. Lured by scam
artists, he ended up in a European prison as a convicted drug
smuggler. Without the persistent work of this Committee and
diplomatic negotiations, he would still be there today. The
plight of this man and thousands of seniors in his shoes could
have been avoided had he and others not been so susceptible due
to their desire for simple companionship.
A number of risk factors for isolation and loneliness are
age related--including widowhood, chronic health conditions,
and mobility impairments. The size of one's social network also
decreases with age. I have heard seniors in my state compare
this phenomenon to ``watching the world die before you,'' as
they lose more and more of their friends.
Maine is the oldest state in median age, is aging the
fastest, and is among the most rural. An epidemic of loneliness
and isolation is growing, and we face major challenges. Those
who live in Maine year round can be left isolated. Winter can
keep them indoors for long stretches, homes are often far
apart, and transportation is often a barrier.
Established programs such as Meals on Wheels are reaching
seniors in important ways. For many, Meals on Wheels is not
just about food. It is about social sustenance, also. Seniors
look forward to greeting the driver and having a bit of
conversation. That is why I am concerned that the
administration's proposed budget cuts would affect programs
like this one and many others that help keep our seniors
connected. If you look at it, those cuts are really penny wise
and pound foolish, because in the end they are going to cause
more hospitalizations, more nursing home admissions, and poorer
health outcomes.
The fact is the consequences of isolation and loneliness
are severe: negative health outcomes, higher health care costs,
and even death. The root problem is one that we can solve--by
helping seniors keep connected with communities. Just as we did
when we made a national commitment to cut smoking rates in this
country, we should explore approaches to reducing isolation and
loneliness. Each has a real impact on the health and well-being
of our seniors.
I am now pleased to turn to our Ranking Member, Senator
Casey, for his opening statement. Before I do so, however, I
want to extend my thanks to our witnesses for being so flexible
on this hearing. It seemed that every time it was scheduled, we
had something intervene, most recently the briefing at the
White House yesterday on North Korea. So I very much appreciate
your staying over and being with us today.
OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING
MEMBER
Senator Casey. Chairman Collins, thank you very much for
calling this hearing and for your opening statement.
We, of course, want to begin a process today of examining
both social isolation and loneliness. And as the chairman
mentioned, this will be a two-part hearing series. Today we
will focus on loneliness and social isolation, and in two
weeks, we will be able to examine more macro solutions,
focusing on livable communities.
Taken together, these hearings will provide the Committee
with the opportunity to examine the full scope of an issue
facing seniors as well as others across the country.
One of the most searing reminders of this came from a New
York Times op-ed back in December by Dr. Khullar from Harvard
Medical School and Massachusetts General Hospital, entitled
``How Social Isolation Is Killing Us''. He was talking about an
individual that he knew would be dying, and the individual knew
they were dying, he said--and this is the doctor speaking--
``for me the sadness of his death was surpassed only by the
sadness of his solitude.'' And I think that sums it up.
We hope that this hearing, and the series of two hearings,
will inform our engagement on other matters as well that may be
coming before the Senate, like the President's budget request
or potentially an infrastructure package.
You might be asking how those two are related. Well, let me
explain.
Back in March, like a lot of parts of the country, my
hometown of Scranton, in Lackawanna County, was hit hard by a
last gasp of winter with a terrible blizzard. Meals on Wheels,
of course, in that moment became even more important. The
blizzard did not stop Meals on Wheels in northeastern
Pennsylvania. One of the drivers that I met with a couple of
days after he had been out in that snowstorm went to a home in
Lackawanna County to drop off a weekly supply of meals. Upon
arrival, the driver heard the homeowner calling out for help.
This individual had fallen into a snow bank wearing shorts and
just a T-shirt. He had fallen after going outside. That Meals
on Wheels driver saved that man's life that day. There is no
doubt about it.
And when it comes to not only Meals on Wheels but also
other programs, but especially a program like Meals on Wheels,
I think the administration's cuts to that program are
misguided, to say the least.
I believe that Democrats and Republicans can agree on
issues like that. We have a great deal to work together on to
address our Nation's infrastructure in addition to that so that
we have improved accessibility. This would include improving
signage that makes it easier to read. It also includes
constructing curb cut-outs so those who are aging or have
disabilities can continue to get around in their communities;
and, finally, enhancing access to technology and broadband so
that those in rural communities can stay connected to their
loved ones.
I would say parenthetically another story that I read in
Politico talking about loneliness and isolation in rural
America is recommended reading for all of us.
So improvements like the ones I just mentioned will help
individuals venture outside of their homes and into their
communities with success, as well as stay connected to those
who are most important in their lives.
So I look forward to the hearing and discussing the
pressing issues with our witnesses today, who I thank, as well
as the Chair, for being here and for rearranging your
schedules.
Chairman Collins, I am also told in the audience today we
also have the Acting Director of the Administration on
Community Living at the Department of Health and Human
Services, Bob Williams. We want to acknowledge his presence as
well.
Thank you, Madam Chair.
The Chairman. Thank you. We will now turn to our panel of
witnesses.
First I would like to introduce Dr. Julianne Holt-Lunstad.
Dr. Holt-Lunstad is a professor of psychology at Brigham Young
University in Utah and studies the influence of social
relationships on long-term health. Her work has been nationally
and internationally recognized.
Next we are going to be very fortunate to hear from one of
my constituents, Dr. Lenard Kaye. I first met Dr. Kaye some 17
years ago. He is a professor of social work and director of the
Center on Aging at the University of Maine. He is also the
director of the Encore Leadership Corps, a statewide adult
volunteer program that involves older residents in community
service. He, too, is a nationally recognized leader in the
field of health care and aging, and I am delighted that he
could be here to join us today.
I would like to next turn to my colleague Senator Flake to
introduce Mr. Mark Clark.
Senator Flake. Thank you, Madam Chair, and thank you for
being here. And I just wanted to personally welcome Mr. Clark,
an Arizonan traveling here to discuss this important issue of
isolation and innovative programs that your organization has
developed to help combat the issue. Mr. Clark currently serves
as president and chief executive officer of the Pima Council on
Aging as well as grass-roots coordinator for the National
Association of Area Agencies on Aging. He has extensive
experience in administrative advocacy and policy experience
working for a variety of community service organizations in
Tucson. He has also served as a faculty associate with Pima
Community College's Social Services Program and ASU's School of
Social Work.
Welcome, Mr. Clark. Thank you for coming from Arizona. I am
also glad that there is a fellow BYU alumni on the panel as
well.
Thank you, Madam Chair.
The Chairman. Thank you, Senator Flake.
And now I want to once again turn to our Ranking Member,
Senator Casey, to introduce the final witness on this panel.
Senator Casey. Thank you, Madam Chair. I am pleased to
introduce Rick Creech from Harrisburg, Pennsylvania. Rick, I am
going to use some of your own words to describe you. I hope
that is okay.
Rick, in your book you refer to yourself as a ``unicorn,''
and I know we will hear more about that. But we are grateful
that you are here, and I do not think I could have come up with
a single word like that. But I have also read your work. And I
had an opportunity to meet with Rick today, and I have to say
his spirit is inspiring and even magical, your ability to
communicate. And we know that your cerebral palsy does not
define you. Instead, you have defined cerebral palsy in your
own way.
Early on in life, Rick relied upon an alphabet board made
of wood to communicate. Today, using his powered wheelchair and
augmentive communication devices, Rick works at the
Pennsylvania Training and Technical Assistance Network in
Harrisburg. He is an educational consultant providing training
and technical assistance on assistive technology and augmentive
communication and assists schools, providers, parents, and
administrators about how technology can promote inclusion. He
is an author, and he is also a poet.
Rick, I am certain that throughout your life people have
second-guessed your ability. I am sure after today they will
have a different point of view. This panel is excited to hear
your story and hear how you have defied the skeptics and wound
up here before the Special Committee on Aging discussing, among
other things, how technology has enabled you to remain actively
engaged in your community and how your work helps to combat
loneliness and social isolation in others.
Rick, thanks for being here.
The Chairman. Thank you very much, Senator Casey.
We will now turn to our witnesses, starting with Dr. Holt-
Lunstad.
STATEMENT OF JULIANNE HOLT-LUNSTAD, PH.D., PROFESSOR OF
PSYCHOLOGY AND NEUROSCIENCE, BRIGHAM YOUNG UNIVERSITY
Ms. Holt-Lunstad. Thank you, Chairman Collins, Senator
Casey, and members of the Committee, for your interest in
social isolation and loneliness and for the opportunity for me
to present testimony today. My name is Julianne Holt-Lunstad. I
am a professor of psychology and neuroscience at Brigham Young
University, and my research focuses on the influence our social
relationships have on our physical health outcomes. In my
remarks today, I will be talking about the public health
relevance of social isolation and loneliness, including data on
prevalence rates, health and mortality risk, and potential risk
factors.
Being connected to others socially is widely considered a
fundamental human need--crucial to both well-being and
survival. Extreme examples show infants in custodial care who
lack human contact fail to thrive and often die. And, indeed,
social isolation and solitary confinement has been used as a
form of punishment. Yet an increasing portion of the U.S.
population now experiences isolation regularly.
It is estimated that more than 8 million older adults are
affected by isolation. However, if we consider social
connection more comprehensively, this includes the extent to
which relationships are present, can be relied upon, and one's
satisfaction with them. And if we consider this, the prevalence
of adults in the United States may be--or the prevalence of
this may be much larger. So, for instance, a quarter of the
population and 28 percent of older adults live alone, and over
half the U.S. adult population is unmarried. Three in ten
marriages are severely distressed, and the majority of adults
do not participate in social groups. More than a third of older
adults experience frequent and intense loneliness.
There is also evidence that isolation or social
disconnection is increasing. For instance, the average size of
social networks has declined by one-third, and social networks
have become less diverse. Census data also shows trends of
decreasing marriage rates, fewer children per household, and
increased childlessness and living alone.
Taken together with an increasing aging population, smaller
families and greater mobility reduces the ability to draw upon
familial support in times of need and in older age.
To estimate the prevalence--or the influence that this has
on the risk for premature mortality, my colleagues and I have
conducted two meta-analyses. We first examined the social
connections, including a variety of indicators. Cumulative
evidence from 148 studies revealed that greater social
connection is associated with a 50 percent reduced risk of
early death.
The second focused specifically on social deficits,
including social isolation, loneliness, and living alone.
Cumulative evidence from 70 different studies, including over
3.4 million participants, indicates that each of these have
significant and independent effects on mortality risk.
To contextualize this cumulative data on social connections
relative to other leading health indicators, we created Figure
1 (page 37) to benchmark the magnitude of the effect on overall
mortality risk. Despite some variation across social
indicators, there is a consistent and significant effect on
mortality risk, and the magnitude is comparable and in many
cases exceeds that of other well-accepted risk factors,
including smoking up to 15 cigarettes per day, obesity, and air
pollution.
As seen in Figure 2 (page 36), prevalence rates or the
proportion of the population affected are also comparable with
other risk factors that receive considerable attention.
Social isolation has also been linked to a variety of
mental and physical health outcomes. For example, those who are
isolated are at increased risk for depression, cognitive
decline, and dementia.
Social relationships influence health-related behaviors
such as medication and treatment adherence and have a direct
influence on health-related physiology such as blood pressure,
neuro-endocrine and immune functioning, increasing the
likelihood of the development and progression of a variety of
chronic illnesses.
Risk factors include living alone, being unmarried, no
participation in social groups, fewer friends, and strained
relationships. Retirement and physical impairments, including
reduced mobility and hearing loss, may also increase the risk
for social isolation.
Why is it important among older adults? Chronic exposure to
either protective or risk factors are more pronounced as
individuals age; therefore, we are more likely to see the
effects of lacking social connection in older adults. Further,
there are a number of important life transitions among older
adults that reduce social connection. These include retirement,
widowhood, children leaving home, and age-related health
problems.
Given the incidence of loneliness is known to increase with
age and social networks shrink with age, the prevalence of
loneliness is estimated to increase with increased population
aging.
In conclusion, the World Health Organization explicitly
recognizes the importance of social connections, and many
nations around the world now suggest that we are facing a
loneliness epidemic. The scientific evidence is clear that
social isolation poses a significant risk to both older adults
and public health more generally. The challenge we face now is
what to do about it.
I am very pleased to see that the Committee has recognized
and is bringing attention to this important issue, and I am
happy to assist in advancing an agenda to address social
isolation and loneliness among older adults.
Thank you again for the opportunity to comment, and I
welcome your questions.
The Chairman. Thank you very much.
Dr. Kaye.
STATEMENT OF LENARD W. KAYE, D.S.W., PH.D., DIRECTOR, CENTER ON
AGING, AND PROFESSOR, SCHOOL OF SOCIAL WORK, UNIVERSITY OF
MAINE
Mr. Kaye. Chairperson Collins, Ranking Member Casey, and
members of the Senate Special Committee, thank you so much for
inviting me to be here today. I appreciate it. And I also
applaud your willingness to be addressing what is a very, very
troubling issue but, unfortunately, an under-recognized issue
of the day, and that is social isolation.
As director of the Center on Aging at the University of
Maine, it has become clear to me that aging Mainers across the
oldest and the most rural state in the Nation are a stoic and
fiercely independent lot. But like millions of their
counterparts in other rural states, they may be losing the
battle when it comes to protecting themselves against the
devastating consequences of isolated living and loneliness.
The fact is social isolation is a silent killer, and it is
lethal in its impacts. More Americans are dying of isolation
and loneliness than ever before. The prevalence, in fact, may
be as high as 43 percent if you break out certain subgroups of
older adults who are at particularly high risk. And let me
remind you that risk is high as well for caregivers of older
adults given that when they engage in elder caregiving, as if
it were a career, it can become a very, very isolating
experience.
Perhaps that is why multiple national social work
associations have identified social isolation as one of 12
grand challenges to societal well-being and why AARP, NIH, and,
as you heard, the WHO have also recognized that social
isolation requires it be placed on a high-priority list of
concerns.
I will only add a couple of risk factors that perhaps were
not mentioned as much as they might be. One would be facing
critical life transitions in the lives of older adults, and I
am referring to divorce, death of a spouse, an abrupt
retirement, a health crisis, and even children moving out and
away from under the roof in which older adults live.
Also, I want to highlight the lack of instrumental
supports, and here I am talking about the absence of Internet,
of available transportation, even of telephones in the case of
some older adults who live in extremely rural and even frontier
communities.
The importance of having a social support network cannot be
overstated in this discussion. Family, friends, and neighbors--
what we call ``informal supports''--and professional caregivers
together provide not only social support, but please know they
are socially influential; they create a buffer against stress;
they increase one's access to resources; they can even
stimulate the immune system of older adults. Social
interaction, like a breakthrough medication or balanced low-fat
diet, extends life.
Solutions to preventing social isolation and loneliness are
presenting themselves both locally and nationally and need not
be excessively costly. Many of them simply require that we
mobilize local citizens and existing community organizations.
At the local level, combating social isolation entails
bringing the older adult either out into the community or
bringing the community to them. Area Agencies on Aging remain
one of the first lines of defense, and I will tell you, the
University of Maine, in partnership with the Eastern Area
Agency on Aging, is supporting, for example, a student-led
program called ``Project Generations'' that brings college
students into the homes of older adults for friendly visiting
and lending a helping hand. Programs like this offer students
the opportunity to interact with elders and for older adults to
serve as role models for those younger people as they grow
older themselves.
In at least one Maine community--namely, Augusta--postal
service workers are trained to ask questions of homebound older
adults and to check in on them and ensure their well-being.
Doctors, too, if they so choose, are able to screen for social
isolation during routine doctor's appointments. These solutions
are often called ``sentinel approaches,'' and they provide
gatekeepers--gatekeepers who offer an extra set of eyes and
ears in the community to identify and address social isolation.
Many communities have begun to organize programs as well
where volunteers and law enforcement officers provide regular
calls and wellness checks to older adults who are known to be
frail or homebound. One example is in Franklin County, which
sends sheriff's deputies to regularly check on older adults to
not only help reduce their risk of falling victim to a scam,
but also to increase their social contact and ultimately well-
being.
Creative housing solutions like co-housing where older
adults live with younger adults can also help to combat social
isolation and help create a sense of purpose among both the
young and old.
If you add to that the availability of smart technologies
in those homes, you can further enable regular communication
and contact between older adults and the outside world.
Remember also that information empowers people and that
local informational clearinghouses that keep older adults
informed of services, entitlements, and benefits, and other
programs available to them and their family caregivers, enables
them to more easily stay connected with the world around them.
Several federal programs add to the support infrastructure
available, and I am referring here to the Meals on Wheels
Program. That network reaches 800,000 homebound older adults
across the Nation. They provide not only home-delivered meals,
they also provide socialization. And the Senior Companion
Program--part of the national network of Senior Corps
programs--pairs older adult volunteers with homebound older
adults in their communities for ongoing socialization and
support.
We also know there are ways to prevent social isolation
before it even occurs, and here I am referring to the
importance of encouraging older adults to be involved as
volunteers in their communities through churches and civic
groups, which can be important avenues for ensuring that they
stay healthy but also feel vital and needed by the communities
in which they live. Programs like RSVP, another Senior Corps
program, and Senior Colleges, of which Maine is proud to say we
have 17 such lifelong learning programs, offer older adults
opportunities to meet people and have a purpose.
Older adults residing in small towns and rural communities
may be especially vulnerable to the dangers of isolated living,
but such communities, with relatively modest levels of local
and federal support, can be mobilized to take action against
what, in fact, is the lethal threat to their well-being.
Thank you.
The Chairman. Thank you very much, Dr. Kaye.
Mr. Clark.
STATEMENT OF W. MARK CLARK, M.S.W., PRESIDENT AND CHIEF
EXECUTIVE OFFICER, PIMA COUNCIL ON AGING
Mr. Clark. Good morning. Thank you, Chairman Collins,
Ranking Member Casey, and members of the Aging Committee, for
your interest in this topic and the opportunity to testify
today.
As Senator Flake noted, I have the honor of serving as
president and chief executive officer of Pima Council On Aging,
the Area Agency on Aging serving Pima County, Arizona, since
1976. Area Agencies on Aging, of which there are 622 across the
country, were created by the Older Americans Act in 1973. We
serve as local planning, development, and delivery systems,
providing home and community-based services to older adults so
that they may age successfully with maximum health,
independence, and dignity.
Pima County is roughly the size of the State of Vermont,
and one in four of our residents is age 60 or older. But the
fastest-growing segment of our population is people 85 years of
age and older, up 35 percent in the past decade.
Every four years, we collect information about the issues
of most concern to older adults. Nearly 2,300 people completed
our survey last fall, almost half of whom lived alone. The
ability to continue to live independently in one's own home was
a significant concern of nearly 67 percent of responses. Other
indicators of isolation, such as loss of a spouse, depression,
and anxiety, also appeared as significant issues. Social
isolation itself was cited as a concern by 46 percent of
responses.
While aging at home is cited as a top priority by a
majority of older people and doing so has both emotional and
economic benefits, it can also lead to isolation. And so meal
delivery drivers or direct care workers who come into the home
to drop off lunch or assist with giving a bath, changing
linens, or shopping can become a social network. Such regular
contact can help stave off the depression and ill health
effects that accompany isolation. In fact, these Older
Americans Act home and community-based programs were
intentionally designed to meet those socialization needs, as
well as other needs, including safety, independence, and
nutrition.
As we have heard, the causes of social isolation are many.
What we witness happening is isolation even in the midst of
community. Long-time residents often have no connection to the
younger families in their neighborhoods. People retiring from
other states move to communities like ours and leave behind
their families, friends, and support systems. We have become in
a very real sense communities where the garage door is the
front door, and many come and go without ever seeing neighbors
except through the car window.
Other challenges include isolation from the community by
language or cultural barriers as well as by fear. Many older
people do not reach out for assistance for fear of losing their
ability to remain in their homes. Changes to mobility,
cognitive ability, or health status can cause an individual to
hold back from previously enjoyed social activities. Older
adults in rural areas who can no longer drive are at incredible
risk of physical and social isolation unless transportation
options are available. And as has been noted, acting as a
caregiver can itself also be isolating.
Reaching out to all older people with messages that
resonate and suggestions they will embrace is critical. That is
why we participated in last year's ``Expand Your Circles:
Prevent Isolation and Loneliness As You Age'' campaign, a
national effort of the Federal Eldercare Locator to boost
public awareness and education of social isolation among
seniors.
While PCOA will continue to tackle the problems as best we
can at home in Pima County, we offer several policy
recommendations for consideration by Congress and the
administration.
First, public education needs to be increased. Current
national efforts to raise awareness, assessment, and remedy
should be strengthened and new interventions developed so that
we can elevate the issue with more older adults and their
families. In tandem with national campaigns, local communities
like ours and the aging and community groups that serve them
need effective messages and resources to deploy at the ground
level.
We also believe that all Older Americans Act programs
should be increased in fiscal year 2018. We urge you to pay
particular attention to the Older Americans Act Title III B
Supportive Services, which provides flexible funding for a
range of services from in-home supports to transportation, as
sequestration has eroded III B funding to levels not seen since
before fiscal year 2002.
Programs that get older adults engaged in serving the
community help reduce social isolation for both volunteers and
those they serve, and we support funding the Corporation for
National and Community Service's Senior Corps programs.
Transportation is one of the most pressing needs for all
older adults who are trying to remain at home and in the
community, so we need more investment in affordable, accessible
transportation options.
We also need to create livable communities for all ages.
Although there is much that individuals can and should do to
maximize their independence as they age, public policymakers
make critical decisions about issues such as transportation
systems, housing opportunities, and land-use regulations that
affect whether older adults can live successfully and
productively at home and in their communities.
Finally, the problem of social isolation can be reduced
with better coordination between acute health care systems,
such as hospitals, doctor's offices, and managed care
organizations, and the social and human services systems of
which Area Agencies are a key part.
Thank you again for the opportunity. I look forward to
answering questions.
The Chairman. Thank you, Mr. Clark.
Mr. Creech.
STATEMENT OF RICK CREECH, EDUCATIONAL CONSULTANT, PENNSYLVANIA
TRAINING AND TECHNICAL ASSISTANCE NETWORK
Mr. Creech. Chairwoman Collins, Ranking Member Casey, and
other members of the Committee, thank you for inviting me to
speak today.
There can be no social engagement with others without
interactive communication.
As someone who was born with cerebral palsy and was without
the ability to speak in the accepted way, I grew up lonely and
isolated--except for my parents and grandmothers. It was not
until I received my first vocal output communication device
that people began to realize that they could speak to me and I
could speak to them--well, at least, some people did.
I was born in 1954 in Smithfield, North Carolina. Back then
babies like I was were not expected to live, and if we did
live, we were not expected to be out in public, we were not
expected to be educated, and we were certainly not expected to
become independent adults. However, I had extraordinary parents
who trusted in God, and not in all the doctors, the therapists,
the social workers who said I would never do that, or that, or
certainly not that.
My father told me once--and I never forgot this--that he
wanted me to learn math so that I would be able to manage my
own money. He wanted me to read so that I would be able to read
and understand anything that someone might write about me and
what should be done to and for me. And he wanted me to be able
to communicate so that I could have control over my life.
My parents presumed competence in my ability to learn to do
those things. They insisted that I learn. Boy, did they push
me. When it came to teachers, I would always prefer to have my
mother because with her I could slack some. With my father, the
Baptist preacher, there was no way I could slack. He was more
demanding than God was with Moses.
[Laughter.]
Mr. Creech. However, they taught me that I was competent. I
was competent enough to go beyond their goals--and their
dreams--for me. This is what great parents, great teachers, and
great schools do.
Supporting individuals who need to use AAC is not simple.
The person may want to communicate; however, the person will
have to be taught how to use an augmentative and alternative
communication device for his or her expressive communication.
The vocal-impaired person will not know how, what, when, or why
to express thoughts, feelings, ideas without being encouraged,
without being pushed.
I am speaking from experience. Initiating a conversation
and carrying on a conversation is the hardest thing I do in
life. To put it simply, I am no good at chit-chatting. I
believe that there is an optimal age to learn communication
skills, that age being as young as possible. However, I was 28
when I got my first voice output communication device, and
although I still have deficits, I can expressively communicate
my ideas in conversations.
I had to work extremely hard, and I work long hours to
learn to communicate with an AAC device. I used to read
passages from the Bible and newspapers aloud to practice with
my AAC device. My point is that we cannot provide a person with
assistive technology or AAC and expect people to use it.
I recently got the Amazon Echo to help me to control the
lights in the house. Sometimes I am ready to throw Alexa out
the window, and I will not tell you the names my wife has
called the thing. Amazon Echo is simple compared to AAC
devices. I started telling people many years ago that assistive
technology without training is not assistive.
Even today, as proficient as I am with my AAC device, I
cannot talk to some people because they are too much in a hurry
or too caught up in my Accent1400, saying things such as,
``What can you say?'' ``Can you say my name?'' or they are
hollering at me as if I am deaf, saying, ``it--is--good--to--
meet--you. What--are--you--doing?'' I get tempted to reply,
``Talking to an idiot.''
[Laughter.]
Mr. Creech. But my parents taught me that if you cannot say
something nice, say nothing at all, so I do not.
As I get older, I feel my body slowing down. My bones snap,
crackle, and pop--like Rice Krispies. My muscles hurt. Right
now, I have my best friend and my protector, my wife, but she
is almost my age and has a bad back, arthritis, and diabetes. I
know that I might not always have my wife by my side. One day I
will probably be in the care of a minimum wage worker, who will
have 24 other patients all requiring less time and care than I.
The only way I have to individualize myself to my caretakers
will be through my ability to communicate with them so that
they will be able to see me as a person rather than just
another patient.
Of course, if that does not work, I could always call one
of my three 250-pound sons and say, ``Son, I need help.''
I would like to thank the Committee on Aging for giving me
this opportunity to speak here, although I do not think I am
that old. I would like to thank the Association of Assistive
Technology Programs for sponsoring my trip here. Before I
started working for Pennsylvania Training and Technical
Assistance Network, I worked with Pennsylvania Initiative on
Assistive Technology. I started PIAT's Short Term Loan of
assistive technology to adults nearly 30 years ago, so maybe I
am that old.
The communication device I use, the Accent1400, costs in
the neighborhood of $10,000. It is one of the more
sophisticated AAC devices. However, even simpler augmented
communication devices with speech output cannot be found for
less than $5,000. The AAC devices with eye tracking so that
people can speak with them using only their eyes cost in the
neighborhood of $20,000.
All of my assistive technology, my AAC device, my van
converted for a powered wheelchair passenger, my smart home
equipment, my powered wheelchair all cost upward of $200,000.
Still, ladies and gentlemen, that is cheap compared with a
lifetime of taking care of me in a nursing facility.
For my work at PaTTAN, Pennsylvania Training and Technical
Assistance Network, I help manage its Assistive Technology
Short-Term Loan Program that provides assistive technology to
school therapists and teachers statewide to try with their
students. Each year the Pennsylvania Department of Education
generously provides around a third of a million dollars for
equipment. To a poor North Carolina country boy, that sounds
like a lot, but we have constant waiting lists of students, and
at the end of every school year, there are requests that I have
to cancel or delay until the next school year because we do not
have enough inventory to meet the requests. These students need
appropriate assistive technology to receive education so that
they can grow to be productive and independent adults who can
be social members of our society.
I want to leave the Committee with this thought: Living
without being able to communicate is like being behind four
glass walls. You are able to see others and people can see you,
but you are ignored, or worse, talked down to, until you stop
remembering who you are and why you are important.
The Chairman. Mr. Creech, forgive me for interrupting you.
I have to go cast a vote just across the hall. I will be right
back. You can continue while I am gone because Senator Tillis
is going to take over temporarily as the Chair of the
Committee. Senator Casey may have to go and cast that vote
also, but I did not want you to think I was one of those idiots
that you talk to.
[Laughter.]
The Chairman. Or that I was disrespectful. And I will
return very quickly. Thank you.
Senator Tillis. [Presiding.] You can continue, Mr. Creech.
Mr. Creech. I have finished.
Senator Tillis. Well, I hope I did not cut you off, but I
am from North Carolina, and it is nice to see another North
Carolinian here before us. Welcome.
I will, acting in the chair, defer to Senator Casey for the
first questions.
Senator Casey. Well, thanks very much. I want to thank our
panel. And, Rick Creech, thank you in particular. I am, of
course, showing deference to Pennsylvania. I am sure the other
witnesses will grant me that privilege, at least for part of
the hearing.
Rick, I will start with you. You mention in your testimony
that your assistive technology keeps you connected to others,
that it combats isolation and allows you to interact with those
around you. You also tell us that for you your technology costs
about $200,000, which is quite an investment. So here is my
question.
First of all, how do you pay for your technology, and what
would life be like without it? That is one question. And maybe
I will continue on so we have it all in one. And since you work
with so many other people who need assistive technology to keep
them connected, how should the Federal Government be supporting
the costs of assistive technology so that others may stay
connected for their communities and live independently?
Mr. Creech. My employer's insurance paid for my powered
wheelchair and my Accent1400, my communication device. That is
one reason that I am not planning on retiring anytime soon,
that and the mortgage on my house.
The Office of Vocational Rehabilitation in Pennsylvania
helped pay for my van conversion. The Office of Vocational
Rehabilitation only will help pay if I am working or I wanted
to work, another reason I am not retiring anytime soon.
My personal care aide, who is not technology but certainly
is assistive, is subsidized by a state program. My smart home
technology I am paying for piece by piece.
One of the biggest breakdowns is in transportation. Too
often paratransit buses are unreliable. I have been told that
drivers can be rude, although I have never experienced that
myself. What I have experienced are vans being late or not
coming; being taken on a 90-minute ride when where I needed to
go was 10 minutes from my home; my powered wheelchair not being
fastened down properly. I absolutely love this one. My van
breaks down, so paratransit is called. Someone tells my wife
that I cannot use paratransit because I am not registered. You
have to register every 6 months. If you do not, you are dropped
from registered users. I guess they figure you are dead.
So my wife says, ``How can I re-register?'' They say first
I will have to get a doctor's note saying that I need
paratransit. Then I will have to go down to the paratransit
office in person to get a photo ID. My wife stopped them right
there and asked, ``How about if I rent a U-Haul trailer, load
my husband and his powered wheelchair in it, and drop him off
at your front door?'' They replied, ``Oh, no, you cannot do
that. It takes 4 to 6 weeks to process his registration and put
him on the schedule.'' My wife hung up.
So the short answer to your question: Get us decent and
reliable transportation.
Senator Casey. Rick, thank you very much for your answers.
I will yield back to Senator Collins, the Chair.
The Chairman. [Presiding.] Thank you very much, and I want
to thank Senator Tillis for taking over the gavel. How did it
feel?
Senator Tillis. It was a tough job.
[Laughter.]
The Chairman. Dr. Holt-Lunstad, I understand that you flew
here directly from a conference in Germany--for which I want to
thank you for making that kind of effort to be with us. I am
curious whether you find that there is a difference between
other countries and our country when it comes to issues related
to isolation and loneliness among our seniors.
Ms. Holt-Lunstad. Thank you. That is a very good question.
So there are a couple of different ways in which we can
approach that. First I will mention that when we look at actual
data from the meta-analysis that we conducted on risk for
mortality, we did not find significant differences across
country of origin. However, I should mention that most of the
data comes from Western nations, and there is less data from
developing nations.
However, we also know that there are some similarities in
terms of other nations that have also in essence called for a
loneliness epidemic, so nations such as Germany, the U.K.,
Australia, North America, and Europe have all reported similar
trends and are considering efforts to alleviate this.
Another way to consider this, though, is also some of the
different norms across nations. So in Western nations, we tend
to value independence. Other nations and cultures tend to value
collectiveness and being part of a group. And our national
value on independence to some extent may come at our detriment
in terms of desire for connecting in older age and the desire
for independence; and that perhaps if we can change some of the
national dialogue around the value of interdependence and
relying upon others as well as being someone to be relied upon,
that could be a potential solution that we could strive for.
The Chairman. Thank you.
Dr. Kaye, you made a very interesting point, and I am
reminded of it by the testimony we have just heard about people
wanting to be independent. Your point focused on the caregivers
and that we have in our state fiercely independent seniors, and
it is not at all uncommon to find a spouse in her 80s taking
care of her husband who may be in his 90s, living down at the
end of a rural road in an old, big farmhouse, and their
children have moved away, their friends have died, they no
longer are well enough to go to church each week, and they
really are cut off.
Could you talk a little bit more about the impact on
caregivers and what we could do to try to assist the caregiver
who may end up being just as isolated as the person for whom
she is caring?
Mr. Kaye. That is a crucially important question, Senator
Collins. The fact is America's families and friends and
neighbors--again, what we call the ``informal support
network''--are unsung heroes. These are the very individuals
who provide the lion's share of care in this country. It is not
doctors or nurses or social workers. They provide supplemental
assistance. But 80 percent or more of care in this country, and
certainly in Maine, is provided by primarily family members,
and they, as I said, are at risk of living isolated lives. They
are also likely to be less healthy than members of the general
population. They themselves are aging. They themselves are
struggling with chronic illnesses and know that the burden they
feel when it comes to caregiving is multidimensional. And so it
is not just a burden on them physically. It is also a burden on
them socially and emotionally and financially.
And so caregiving is dangerous business, especially for
those who are involved in it literally for years at a time. For
them it becomes a career. And for all too many of them, it is
their second or third career, because they are also employed.
And so they are caught between a rock and a hard place. They
need to hold down employment and at the same time manage the
responsibilities of caring for a spouse or a grandparent or
other member of the family.
So caregivers need as much of our attention and support
through a comprehensive network of benefits and entitlements
and programs as older adults themselves.
The Chairman. Thank you. Senator Tammy Baldwin and I have a
bill that we have introduced known as the ``Raise Family
Caregivers Act,'' which we hope we will be able to get through
this session of Congress.
Mr. Kaye. I am aware of that bill, and what is very
inviting and attractive about it, in my view, in particular, is
that it addresses this comprehensively and it aims to establish
a national infrastructure, and it realizes that caregiving
needs responses that are broad-ranging, from information to
respite care to training and preparation to assessment. And
that bill appears to recognize all such needs.
The Chairman. Thank you.
Senator Tillis?
Senator Tillis. Thank you, Madam Chairman.
Mr. Creech, again, thank you. I am from North Carolina. I
am from a different part of the state, but I thank you for
being here.
Mr. Clark, you mentioned Senior Corps earlier. As I
understand Senior Corps, it is primarily focused on 55 and over
adults getting engaged in the community, more or less engaging
them, but the focus is on a younger population, foster
parenting and other kinds of programs. Is that program or other
programs out there focused on engaging seniors to engage with
other seniors?
Mr. Clark. Chairman Collins, Senator Tillis, the Senior
Corps programs, in fact, do focus, several of them, on older
adults. The RSVP program, the historic Retired and Senior
Volunteer Program, the Senior Companion Program, which I
referenced in my written material, is a program where low-
income older adults are actually placed and stipended, but
placed with specific older adults who have support needs. And
so there is a commonality between those two folks who work very
closely together.
So, yes, in fact, the Corporation for National and
Community Service programs do a lot of good for older adults.
Senator Tillis. Mr. Kaye, I think you alluded in your
opening comments to some use of technology. My mother is 84
years old. If it is on C-SPAN, she is probably watching this
right now. My father passed away 20 years ago. She is also one
of the most politically astute people that I know. But we got
her engaged in something as simple as Facebook probably 10
years ago, and it has had a remarkable impact on her feeling
engaged in our daily lives. Sometimes, when somebody engages me
on my Facebook page, she engages a little bit too much.
[Laughter.]
Senator Tillis. She still takes care of her kids. But, you
know, to what extent are best practices arising to where we are
leveraging--you know, there are bad parts to the Internet, but
there are a lot of good uses to connect people when geography--
particularly in my case, six kids spread out all over the
Southeast, the few that live near her. But are there best
practices out there or states that are doing, you know,
particularly better than others that were instructive?
Mr. Kaye. I am so delighted, Senator Tillis, that you
raised the technology question. We in Maine take that very
seriously, and I am pretty proud to tell you the University of
Maine system has a major aging initiative underway, and I am
thinking of other universities--I know for a fact in other
states as well--who have identified and recruited scientists
and researchers who are aiming to put devices and products that
enable older adults to age in place and stay connected and
advance those products on the fast track and get them
commercialized and available. But what we do know is our best
practices need to accompany that process, that the best
technology is going to be that which is responsive to the needs
of the consumer.
We in Maine think that means what we have called ``engaging
older adults in co-design functions''--that is asking consumers
how that product or that device needs to be styled, what design
should it reflect, how much should it cost, where should it be
available for purchase, what should the user interface look
like; that is, is it easily utilized and taken advantage of by
older adults.
And so principles of co-design are driving the research we
are doing at the University of Maine in our aim to put that
technology into the homes on as fast a track as possible.
Senator Tillis. I absolutely believe--I have become just
obsessed with making sure seniors that I interact with spend a
moment to go on Facebook--they probably have family members on
there--to expose them to this interaction tool. And I think the
more that we use these tools to connect people maybe first
through the network, that it will naturally foster
relationships that may result in actual touch and presence,
which is also very important. So I would be interested in
getting any feedback you have on the program in Maine or any
other states.
Dr. Holt-Lunstad, I am going to ask my last question of
you. The health impacts of isolation and loneliness I think are
very compelling. Do you know of any research out there that is
focused on programs that have affected or maybe bent the curve
in a positive direction and, if so, whether or not we have
tried to dollarize them? I think one of the things that we need
to do--and I kind of pound this in a number of our hearings
here, or focus on it--is that we need to understand that, on
the one hand, this is a good thing to do for someone who is
isolated, but at the same time, it is also, I think, a fiscally
sound investment of dollars because it reduces cost of health
and other bad outcomes, whether it is illnesses or similar
things that tend to cost more if we do not invest.
Is there any research out there or information you can
point me to on the subject?
Ms. Holt-Lunstad. Thank you. Yes, so I want to briefly
mention one thing about the technology, and then I will also
talk about effectiveness as well as costs.
One thing that we need to have some caution about in terms
of technology is that we need to recognize that it can be a
tool to bring people together----
Senator Tillis. And it can become isolating.
Ms. Holt-Lunstad. Absolutely. And we really need to do more
research on this and determine to what extent that this can
facilitate social connection versus bringing people apart.
Senator Tillis. That is why I made the point of also using
technology and knowledge of who you are interacting with in
close proximity to ultimately get them to the point to where
there is a human connection or a connection with someone else.
That is why I asked the question earlier.
Ms. Holt-Lunstad. Right, and there are some that are
certainly very concerned about particularly younger generations
that will be our future aging adults, and thus reducing the
ability to connect face to face and may substitute connections,
potentially leading to greater isolation. And so certainly more
attention needs to be paid to that.
In terms of effectiveness, my colleagues and I, we are
currently working on another meta-analysis looking at
interventions and their effectiveness in terms of reducing risk
for mortality. This is currently still in progress, so we do
not--this is not published yet. But what I can tell you from
the preliminary data is that the data is mixed. There are some
interventions that are effective, and there are others that are
not effective. And so we do need to be careful and not assume
that any kind of intervention will be effective.
Senator Tillis. That information--and I have gone way over,
but that information is critically important because it is
instructive to the extent that the federal government gets
involved in funding or promoting any programs that you are
going to be--you are naturally inclined to do it because of the
subject matter, but we want to make sure that we are putting
the limited dollars into the ones that have the most
empirically based--positive results empirically based so that
we--we are going to continue to struggle to have enough money
even for the good ones. What we do not want to do is spread it
out, and I think at the expense of drilling down on ones that
can produce more transformative results.
Thank you, Madam Chair, for indulging me for going over.
And my mother is watching. Hey, Mom.
[Laughter.]
The Chairman. Thank you very much.
Senator Cortez Masto?
Senator Cortez Masto. Thank you.
Thank you all for being here, and this is such an important
topic. I am so happy we are having this conversation. I am from
the State of Nevada and have worked most of my career fighting
against neglect and exploitation for many in our senior
community. And just recently, when I was home over the break, I
had the opportunity to deliver a meal with a Meals on Wheels
driver. I had an incredible conversation, not only with the
Catholic Charities who provides the programs in Nevada for
Meals on Wheels, but also with the driver, as well as the
senior who was the recipient. And one thing I did learn--and we
are talking about this now--is it addresses and helps with the
issue of social isolation and more particularly, medical needs.
The driver that I was riding with actually responded to a
medical need of a senior who had fallen. Thank goodness he
showed up that morning with the meal and was able to help that
individual.
I am curious--and I do not think we have heard it yet
today--are your thoughts on pets and animals, to address
isolation. Is this something that we should be looking at as
well. I know many of the seniors that this gentleman talks with
and delivers Meals on Wheels to, have animals that they treat
just like their children.
And then, more importantly, I think we should be funding
programs like this at the front end. I do not support any cuts
to any funding for Meals on Wheels or any senior programs,
because I think in the long-term it saves dollars for Medicaid,
medical care costs, things that we would be looking at had we
not had these front-end programs.
I'd like your thoughts with respect to animals and
isolation, and front-end programs. How we save money, which is
really what they say, penny wise, pound foolish, if we are
going to go down this path of cutting the funding.
Mr. Kaye. I would like to begin, if I may. There is no
doubt about it that the availability of pets and companion
animals makes an enormous difference in the lives of older
adults. In my experience, in fact, it is those programs that
may be the most popular and most utilized programs offered in
the community through Area Agencies on Aging. Pets are known to
reduce the blood pressure and calm anxiety in older adults. In
fact, more than a few pets are far more popular than many
relatives when it comes----
[Laughter.]
Mr. Kaye. [continuing]. To providing support for older
adults in the community. There is no question about it. There
is a natural tie and connection when animals are brought into
assisted living facilities and nursing homes. There is an
immediate response. It is visceral, it is observable. Older
adults are immediately engaged, and it makes it clear and
drives home the point for me that that should be among the
arsenal of programmatic responses that we offer in fighting
against social isolation.
Mr. Clark. Madam Chairman, if I might also, Senator Cortez
Masto, absolutely, pets are important. One of the issues that
we hear about from our Meals on Wheels drivers is the concern
that sometimes our meal recipients are actually feeding their
meals to their pets or sharing their meals with their pets. And
so we are actually working with local pet stores and securing
pet food donations with our animal welfare organizations in the
community and actually exploring ways that we may be able--you
know, with the health requirements and everything, that we may
be able to deliver some pet food at the same time we are
delivering lunch. So it is definitely an issue that we are
concerned about.
We also are working with our older adults between our
social service agencies and our animal welfare agency to try to
develop a notification system, sort of an end-of-life-care plan
for my pets, not when the pets die but what is going to happen
with my pet when I die. And so through end-of-life-care
planning processes, we are working on that as well.
Senator Cortez Masto. Thank you, and I am glad you brought
that up because recognizing that many of the seniors are giving
their food to their pets, the program that I was able to ride
along with started obtaining pet food to also give to the
seniors, and then the driver has little treats that he gives to
the animals when he shows up to deliver the food as well. So I
appreciate that. Thank you so much.
The Chairman. Thank you.
Senator Warren?
Senator Warren. Thank you, Madam Chair.
It is hard to maintain social relationships when you cannot
communicate very well, and a big reason that older adults have
trouble communicating is hearing loss. When people cannot hear,
they do not just drop out of a conversation in a noisy
restaurant. They often drop out of social life altogether.
Research shows that seniors with hearing loss are more likely
to experience loneliness and they score higher on measures of
social isolation, meaning, for example, reporting that they do
not have any close friends, not having anyone to talk over
problems with if they face a difficult situation. And this is a
really big deal on the numbers. More than two-thirds of people
in their 70s have hearing loss, and that figure jumps to 90
percent of people over the age of 80.
So, Dr. Kaye, in your experience studying healthy aging,
does untreated hearing loss play a role in people's ability to
stay active and engaged in their communities?
Mr. Kaye. Of course it does. Senator Warren, it is a
critical issue. Sensory impairment is a frequent and
commonplace chronic impairment, and I would argue that hearing
loss may be the most crucial sensory impairment because, as you
said, it cuts off the ability of one individual to communicate
with another. And the fact is not only is it untreated, but
initially it is undiagnosed. As I understand it, over 9 million
individuals over 65 suffer from hearing loss, and my
understanding is some three out of five of them have not had it
treated, which means they are not taking advantage of the rapid
advance in the quality and the efficacy of hearing aids.
Senator Warren. So let us talk about that for a second,
because there is the good news. The good news is we can treat
hearing loss, and hearing aid technology has just gotten better
and better and better. The bad news is that the vast majority
of people with hearing loss, more than 80 percent according to
the estimates I have read, are not using hearing aids, and one
of the principal reasons is they cannot afford them. Out-of-
pocket costs for a single hearing aid average more than $2,000,
and most people do not need one, they need two.
So the question becomes: Why are hearing aids so expensive?
And the reason in part is because state and federal regulations
restrict this market. They limit competition and channel all of
the business to licensed hearing aid dispensers, even though
evidence shows that with some oversight from the FDA, hearing
aids could be made directly available to consumers in a way
that is safe, effective, and far less costly.
So, Dr. Kaye, let me ask you this one: The National
Academies of Science, Engineering, and Medicine have
recommended changing regulations to permit over-the-counter
sales of hearing aids to bring down prices dramatically. Do you
think this would make a difference for seniors, and
particularly for seniors in rural areas who are closed out of
markets more often?
Mr. Kaye. My knee-jerk reaction is that any policy that
makes devices, technologies, programs, services more readily
available is to be applauded.
Senator Warren. Good.
Mr. Kaye. In rural communities, lack of access is a major
issue. Lack of affordability, of course, is as well.
Senator Warren. Good. Thank you. And if I could ask, Mr.
Creech, you do not use hearing aids, but you do use technology
to help you communicate. Could you just say a brief word about
the importance of access to technology so that you can stay
engaged with your friends and colleagues?
Mr. Creech. If I did not have access to technology, I would
be in a nursing home in my pajamas, being pushed in a manual
wheelchair in front of a television until my brain turned to
mush that not even zombies would eat.
[Laughter.]
Senator Warren. Thank you, Mr. Creech.
Mr. Creech. Assistive technology has to be affordable, and
it is not.
Senator Warren. Yes.
Mr. Creech. I am trying to build a smart home system
through Amazon Echo and my smartphone. I will be paying $30 a
month for three years for the phone; the Amazon Echo, $175. The
Echo Dot, which I will need in every room, is $40 each. A smart
thermostat will be $275 plus installation. Smart keyless lock,
$250. Smart ceiling fans and lights, $400 each. I have not even
checked into smart televisions and appliances. This wonderful
smart home thing holds a lot of promise, but just like any
other assistive technology, people with disabilities cannot
afford this amazing technology without funding assistance. The
cost of not providing assistive technology would be more than
the country could afford in lost productivity, in lost
creativity, in lost humanity, and in increased medical cost, in
increased personal care cost, and in increased cost to family
members who would have to stay home to care for their loved
ones instead of being free to work outside of the home.
Senator Warren. Thank you very much. It is a powerful
statement about the importance of technology. And on hearing
aids, I just want to say they should not be reserved for the
privileged few who can afford $5,000 in order to have some
assistance. I just want to say this is why I have introduced
bipartisan legislation with Senator Grassley, Senator Isakson,
and Senator Hassan that would implement the recommendations of
the National Academies panel and create an FDA-regulated
category of safe and effective over-the-counter hearing aids.
It has been endorsed by the AARP, by the Gerontological Society
of America, and by the American Doctors of Audiology, a leading
group of health practitioners who deal in hearing aids.
One way to tackle the problem of loneliness and isolation
and depression for some older adults is to cut the cost of
hearing aids so they have a chance to participate in
conversations with other people.
Thank you, Madam Chair, and thank you for letting me have a
little extra time.
The Chairman. Thank you.
Mr. Clark, when I was listening to your testimony and read
your written testimony, I was reminded of an important fact,
and that is that we should not only talk about how we can get
services to our seniors but also our seniors have a lot to
offer, and I do not think we should forget that part of the
equation.
I was thinking, when Dr. Kaye was talking about the senior
companion program, for example, and also our Senior Colleges in
Maine, of which there are 17, I think you said, and oftentimes
the courses for those colleges are taught by people who are
retired. So you talked about certain programs, the Aetna model,
for example, that can be useful to change our perception of
seniors as solely needing service but, rather, looking at the
fact that they can serve others, too. And, of course, that is a
wonderful way to end isolation and loneliness. Could you talk a
little bit more about that?
Mr. Clark. Well, at Pima Council on Aging, we have been
working with older adult volunteers for a number of years. We
were one of the original RSVP programs. We are not doing that
program anymore, but we work very collaboratively with the
Senior Corps program, which is the program that Aetna
participated in, which is where older adult volunteers are
paired--they are actually stipended volunteers--with older
adults who need some in-home assistance, and so they both
benefit.
But I also want to reference the Neighbors Care Alliance,
which I also mentioned in my testimony. That is a program that
PCOA began 10, 12 years ago, I think, as part of a compassion
connection grant, and that really is a collection of
neighborhood-based, but also faith communities and a couple of
social service agencies, volunteer organizations like the one
in the neighborhood I live close to, the Old Fort Lowell Live-
at-Home Program. That program is neighbors actually caring for
each other, and so they are driving--and most of them are older
adults who are doing the caring, so they are driving people to
physician appointments; they may be taking people shopping,
stopping by for friendly visiting, or maybe placing a call,
occasionally bringing a meal in if somebody needs one on a
short-term basis, maybe somebody coming in and changing a light
bulb; you know, not so much yard work, maybe once a year sort
of major cleanup. And then another neighbor allows his or her--
his, I think--garage to be used as a durable medical equipment
lending library, so if somebody has a short-term need for a
potty chair or a wheelchair they can get it rather than having
to buy it.
So we have about 15 of those Neighbors Care Alliance
affiliates in the community, and they serve thousands of folks.
We have a little bit of money from our regional transportation
authority for senior volunteer driving, and so we are able to
reimburse their driving volunteers on a per mile basis for the
driving. And driving is a big piece of what those NCA
affiliates do, but they do all those other things. And so it is
a way--we know that people age much more healthfully, if I can
make up a word, if they stay active and involved. And those
kind of programs are really helpful in allowing people to stay
active and involved.
The Chairman. Thank you.
Mr. Creech, first of all, I want to thank you for sharing
your story. In addition to the technology that has been so
important to you and it has allowed you to connect with people
and communicate, are there other steps that you have taken to
overcome isolation?
Mr. Creech. The loneliest time in my life was during
childhood. I had no friends. My outings out of my home was
limited to the churches my father pastored. My days were spent
in my home trying to find ways to fight boredom. I had plenty
of toys; with some I could actually play. I was always able to
bamboozle my parents into letting me have a dog or a cat, the
same way I bamboozled my wife into letting my youngest son have
a dog, and we have had dogs in the house ever since. There was
nothing for me to do except watch TV or read books. I found
that I much preferred my books over TV. Back then, my
communication was limited to the typewriter and an alphabet
board. Have you tried to communicate with someone who used an
alphabet/word board? Most people cannot. My experience has been
after you finish spelling the third word, they forget what was
the first word you spelled. You dare not use words that have
over two syllables else you will completely mess up your
communication partner's mind.
I do not know if you have watched the television show
``Speechless.'' JJ on that show supposedly uses an alphabet/
word board with an optical head pointer, and he is able to
point to a few squares on the board, and his aid comes out with
these correct sentences. That is not how it works in the real
world, folks. When I used an alphabet board, I was lucky to get
three simple words together before blowing the other person's
mind. And what teenager wants to talk with friends through a
grown adult reading over his or her shoulder? I am
flabbergasted every time I see that in the show.
The Chairman. Thank you.
Senator Casey?
Senator Casey. Madam Chair, thanks very much.
Rick, I was thinking as you were giving testimony today and
telling your own story, you know, you said in your testimony,
``I am no good at chit-chatting.'' After all this time, Madam
Chair, chit-chatting is so yesterday, isn't it?
[Laughter.]
Senator Casey. But I have two final questions, two serious
questions that involve, Rick, part of your family's story. You
shared with the Committee that your mother has Alzheimer's
disease. The Committee recently held a hearing on the topic and
continues to advocate for medical research funding that will--
will one day--lead to a cure, for funding to support those who
are caring for family members with Alzheimer's. However, the
disease can also lead to isolation for the individual diagnosed
and their family.
So two questions in one. How has your mother's diagnosis
changed your interaction with her? And has it resulted in any
feelings of isolation for you?
Mr. Creech. This is hard for me to put into words. For 28
years my mom was life. She fed, she dressed, she bathed me. For
28 years, she was the first face I saw in the mornings and the
last face I saw at nights. Ever since she went to a nursing
facility, I have not been able to call her on the phone. This
afternoon, I will be going down to North Carolina to visit mom.
I do not know if she is going to recognize me. This is the
woman who a few years ago gave my wife a box full of old papers
of everything that I had typed since I was 8 years old. I
thought, ``OMG, what other potentially embarrassing things has
she kept?''
[Laughter.]
Mr. Creech. This is the woman who during my first year of
college, because I had gotten a mouthful of mouth ulcers and
could not eat, came and stayed in my dorm for a month and
nursed me back to health so that I would not have to drop out
and go back home.
Mom is not here anymore. What lingers is the shell that
used to contain my precious mother. Mom is gone as certainly as
dad is gone. I feel like a captain of a sailing ship after the
stars have fallen and the sun will not show itself. All I have
is my memory of them and the principles they instilled in me to
guide me through.
Senator Casey. Rick, thank you very much.
Thank you, Madam Chair.
The Chairman. Thank you very much, Senator Casey.
I want to thank all of our witnesses for being here today,
for your patience as we maneuvered the time and date of the
hearing. To my knowledge, this is the first hearing on Capitol
Hill to address the issue of isolation and loneliness among our
seniors, and it is such an important issue when you look at the
impact on our seniors' health and well-being. When I learned
the startling statistic that we heard today from Dr. Holt-
Lunstad about the mortality risk of isolation and loneliness,
something that Dr. Kaye also talked about, it tells us that
this problem is a serious one and it is pervasive, and yet it
has received very little attention outside of the work done by
the experts in the field and in academia.
So one of my hopes today is that we have raised public
awareness of this problem and we can start to explore some of
the creative solutions that you all have talked about, whether
it is greater use of technology or having Meals on Wheels
drivers specifically check on the health of the seniors or
pairing college students and seniors, which I love that
program, Project Generations, that Dr. Kaye has started in
Maine, or helping seniors be of service to others as well. As I
said, I think it is really important that we remember that this
problem can be addressed from both directions in many cases.
And using the resources that we have, we can come up with some
creative solutions to reach out and connect seniors with
communities. ``Connections,'' it seems to me to be the word,
whether you are connected with your family, your neighbor, your
community, your church, your college. That seems to be what
helps to keep people healthy and strong and increases their
well-being.
So now today we have learned a lot about the problem. We
have all heard the phrase that it takes a village to raise a
child. Well, I think the flip side of that is the village can
also care for our seniors, and our seniors need to be an
integral part of that village.
So at our next hearing, we are going to look at some of the
solutions across the country, and I am very proud that my State
of Maine is really leading the way. Dr. Kaye, you get a great
deal of credit for that.
I want to thank our staff for their hard work, all of our
witnesses, and all of the Committee members who are here today.
Many of them had conflicts so could only be here briefly, but
we actually had an excellent turnout, and I think that shows
that people are very interested in this issue.
Committee members will have until Friday, May 5th, to
submit any questions for the record, which we will forward
along to you.
Senator Casey, do you have any closing comments?
Senator Casey. Just briefly. Madam Chair, thank you for
convening the hearing. I want to thank our witnesses for being
with us, Rick especially, and we are grateful for your presence
here and your message.
Despite the challenge of this issue, isolation and
loneliness, we know what works. We know that drop-by programs
work, whether it is Meals on Wheels or some other program.
Group interventions work. And we know, of course, that
assistive technology works. So we are looking forward to more
discussion on these issues and are grateful to have the
opportunity today. Thanks very much.
The Chairman. Thank you, and this hearing is now adjourned.
[Whereupon, at 11:26 a.m., the Committee was adjourned.]
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APPENDIX
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Prepared Witness Statements
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Prepared Statement of Lenard W. Kaye, D.S.W., Ph.D., Director, Center
on Aging, and Professor, School of Social Work, University of Maine
Aging Mainers across the oldest and most rural state in the Nation
are a stoic and fiercely independent lot. But like their millions of
counterparts in other rural states across the Nation, they may be
losing the battle when it comes to protecting themselves against the
devastating consequences of living a socially isolated and lonely life.
Let there be no doubt, social isolation is a killer and more Americans
are living in isolation than ever before. The prevalence may be as high
as 43% among community dwelling older adults. And, the risk is high as
well for caregivers of older adults given that caregiving can be a very
isolating experience. Perhaps that is why the National Association of
Social Workers, the World Health Organization, AARP, and the National
Institutes of Health, among others, have recognized the need to place
social isolation on their lists of major challenges and high priority
threats to societal well-being. It is a perplexing, potentially lethal
problem, impeding a successful and productive old age. The bad news is
that the challenge is perhaps greatest for older adults living in small
towns and rural communities where individuals are separated
geographically, children and grandchildren have often left for the
bright lights of the big cities, and critical community supports are in
short supply.
I've come to realize that stoicism and a fiercely independent
spirit can be overrated qualities and not always something to aspire
to. Not when we learn that such individuals are at higher risk of
living social isolated and lonely lives which, in turn, research
confirms, will place them at higher risk of a variety of poor outcomes
including disability, high rates of mortality and morbidity, dementias,
hospitalizations, falls, not surviving natural disasters, poor health
practices, psychological distress, neglect and exploitation, lower
self-reported health and well-being, and even the common cold.
Who is at greatest risk? That would be LGBT older adults, those
with physical, sensory, and functional impairments, who live alone, are
80 years of age and older, are geographically isolated, living on
limited income, lacking instrumental supports (access to
transportation, the Internet, telephones, etc.), with poor mental
health, weak social networks, and facing critical life transitions
(i.e., divorce, death of a spouse, an abrupt retirement, a health
crisis, children moving out, etc.).
The importance of having available a social network cannot be
overstated in guarding against social isolation. Family, friends,
neighbors, and professional caregivers provide social support, social
influence, create a buffer against stress, increase your access to
resources, and can even stimulate your immune system.
Local Solutions That Make a Difference
Solutions to preventing social isolation and loneliness are
presenting themselves both locally and nationally and need not be
excessively costly. We do, however, need to remain vigilant and
especially mindful of those conditions that put older adults at risk.
The University of Maine Center on Aging recently gathered 200
professionals and community members together at a conference to discuss
older adult social isolation. Their front-line experience suggests
additional factors can increase the risk of social isolation including
ageist views and stigma about aging, a lack of transportation to get
older adults out into the community, lack of access to technology which
could bridge communication gaps with loved ones, poor health,
alcoholism, and increasing lifespans which mean that many older adults
outlive their friends and family. Responding to these challenges, the
University of Maine has identified aging research as an emerging area
of excellence and is especially encouraging its scientists to focus on
developing user friendly, accessible, and affordable technologies that
will keep older adults safe, secure, and mobile not only in their
homes, but in their communities.
At the local level, combating social isolation entails bringing the
older adult out into the community or otherwise bringing the community
to them. The University of Maine in partnership with the Eastern Area
Agency on Aging, is supporting a student-led program, Project
Generations, that brings college students into the homes of local older
adults for friendly visiting and lending a helping hand. Programs like
this offer students the opportunity to interact with and learn from
older adults while providing elders with a much needed source of
support.
In at least one Maine community (Augusta), postal service workers
are trained to ask questions of homebound older adults to check in on
them and ensure their well-being. Doctors, too, if they choose, are
able to screen for social isolation during routine doctor's
appointments. These solutions, often termed sentinel approaches,
provide an extra set of eyes and ears in the community to identify and
address social isolation through screening and referral.
Many communities have begun to organize programs where volunteers
and law enforcement officers provide regular calls and wellness checks
to older adults who are known to be frail, homebound, and isolated. One
such program in Franklin County, Maine, sends sheriff's deputies to
regularly check in on older adults to not only help reduce the risk
that an older adult would fall victim to a scam, but also to increase
social contact and well-being for the older adult.
Creative housing solutions like co-housing where older adults live
with younger adults can also help to combat social isolation and help
to create a sense of purpose among older adults.
Several federal programs are providing lifelines to older adults
who are homebound including the Meals on Wheels Program, a network that
reaches over 800,000 homebound older adults across the Nation,
providing not only home-delivered meals but also socialization. The
Senior Companion Program, (part of the national network of Senior Corps
programs), pairs older adult volunteers with homebound older adults in
their communities for ongoing socialization and support. One such
Senior Companion volunteer shared a story of Mrs. C, a woman whom she
visits, and how she supported Mrs. C after the death of her husband.
The loss of a spouse is a particularly critical time for supporting
older adults and ensuring that they do not become shut off from those
around them:
``Mrs. C experienced the loss of her husband after a long
terminal illness. Having devoted her life to the continuous
care of Mr. C, she was left without purpose in her life. Mrs. C
had no family in this area and felt completely alone. As her
Senior Companion, I was able to assist her through arrangements
to be made for Mr. C's cremation and celebration of life. Other
difficult areas included finances, health, and well-being. It
has been nearly two years since the passing of Mr. C. With
continuous compassion and understanding, I have been able to
help Mrs. C connect again to the world around her. She has made
great progress spiritually, emotionally and with socialization.
As a Senior Companion, I am always at hand for comfort and
support or simply just to listen.''
We also know there are ways to prevent social isolation before it
occurs. Encouraging older adults to be involved in their communities
through churches, civic groups, and volunteer roles can be important
avenues for ensuring that older adults stay healthy and connected to
the world around them. Programs like Retired and Senior Volunteer
Program (RSVP) and Senior College offer older adults opportunities for
meeting new people and learning new skills.
Dr. Kelley Strout at the University of Maine has developed a pilot
program called GROW which sets up garden beds at low-income congregate
housing sites. Originally intended to increase the consumption of
healthy foods, the program also increased social ties between residents
who would not have otherwise interacted and formed friendships despite
living within the same housing complex. There are numerous examples of
programs like this throughout the country that provide an outlet for
older adults to naturally connect with others.
Summary of the State of Current Research
There is still significant progress to be made in determining what
works for helping to reduce social isolation. Lack of rigor in studies
of interventions aimed at reducing loneliness make it difficult to
evaluate some of these strategies.
Due to the various life events that can trigger social isolation,
from death of a significant other, to loss of transportation, to health
decline, effective interventions will need to be diverse and they will
need to be tailored to the personal circumstances of the isolated
individual.
AARP's Framework for Isolation in Adults Over 50 states that
``Reviews support that effective interventions target specific groups,
use representative samples of their target population, use more than
one method of intervention (target more than one aspect), allow
participants an element of control, include individual participation in
intervention planning, and have facilitators who have adequate training
and resources.''
Other Community-Level Strategies
The Maine Health Access Foundation has initiated a significant
grant program in the State of Maine called ``Thriving in Place'' which
supports individuals with chronic conditions and disabilities in
remaining in their homes as they age. Although the activities being
undertaken to support aging-in-place are diverse, reducing isolation is
a key component of Thriving in Place activities. In a review of
Thriving in Place initiatives in the state, project evaluators
identified promising strategies and lessons learned related to reducing
isolation that were emerging from these community change efforts. These
include the importance of developing systems of care whereby people who
may have contact with isolated older adults, such as EMTs, Meals on
Wheels drivers, and other individuals who are knowledgeable enough
about community resources and referral processes, can act as
gatekeepers and key points of access to supportive services which can
reduce isolation and meet other needs.
Another finding was that services promoting older adult well-being
have added benefits in reducing social isolation. Examples include
morning check-in calls from law enforcement programs, which often have
a primary stated purpose of ensuring physical safety for homebound
adults. This finding has been borne out in conversations conducted by
the Center on Aging with coordinators of check-in programs who have
indicated that participants have become less isolated due to these
brief daily contacts. Additionally, through a research partnership with
a local Village to Village model organization, At Home Downeast,
interviews with volunteer drivers have indicated that volunteer
provided rides to health and non-health related destinations serve also
as an opportunity for members of the Village to receive much need
social contact.
AARP's Age-Friendly community initiative is another community-level
strategy for supporting aging-in-place and reducing social isolation.
Like the Thriving in Place initiative, it examines aging-in-place
holistically through a framework called the ``eight domains'' that
contribute to a livable and age-friendly community including:
Outdoor Spaces and Buildings
Transportation
Housing
Social Participation
Respect and Social Inclusion
Communication and Information
Community and Health Services, and
Civic Participation and Employment
Although all domains have implications for reducing isolation and
loneliness, two of the eight domains are particularly important: Social
Participation, and Respect and Social Inclusion. Key elements of these
domains that can impact social isolation are ensuring accessibility of
local gatherings in terms of transportation, affordability, and
physical accessibility; ensuring that outreach for events in a
community are targeted at those at risk of isolation, and combating
negative stereotypes of aging individuals.
We should not minimize the lessons learned from the age-friendly
community movement in terms of what individual towns and communities
can be encouraged to do to reduce the risk of social isolation among
its older citizens, and all its citizens for that matter. The
University of Maine Center on Aging recently conducted a series of
community focus groups with citizens of Bangor, ME and discovered the
following high priority action steps that can be taken to fight
isolation, include: developing and maintaining robust transportation
programs geared to meeting the needs of older adults, making the
community walkable, offering senior center/community center
programming, ensuring that outdoor spaces and buildings are accessible,
maintaining opportunities for meaningful volunteer and civic
engagement, and establishing a more comprehensive and timely
informational clearinghouse that reaches elders and their caregivers
with available resources and programs. I'm proud to say that Maine
leads the Nation in the number of towns and communities that have
formally joined the age friendly community movement--some 35 of the 163
such communities across the U.S.
Older adults residing in small towns and rural communities may be
especially vulnerable to the dangers of isolated living, but such
communities, with modest levels of support, can be mobilized to take
action against this threat to well-being in later life.
__________
Prepared Statement of W. Mark Clark, M.S.W., President and CEO, Pima
Council On Aging
Good afternoon. Thank you, Chairman Collins, Ranking Member Casey
and members of the Aging Committee, for the opportunity to testify
today on the problem of social isolation and loneliness among older
adults.
My name is W. Mark Clark and I have the honor of serving as
President and CEO of Pima Council On Aging, the Area Agency on Aging
serving Pima County, Arizona. Since 1967, Pima Council On Aging (PCOA)
has identified the needs of older adults in our planning and service
area, and responded to those needs with community-based programs and
services. In our role as the Area Agency on Aging for Arizona Region
II, PCOA has served generations of older adults and their families in
communities across Pima County, through planning, advocacy and
providing and contracting for services. Area Agencies on Aging, of
which there are 622 across the country, were created by the Older
Americans Act in 1973 to serve as the local planning, development and
delivery system providing home and community-based services to older
adults so that they may age successfully with maximum health,
independence and dignity.
The Aging of Pima County
Pima County is home to the city of Tucson, the second-largest metro
area in Arizona. Because of our mild winters, thriving hospitality
industry, natural desert beauty and relatively low cost of living,
Tucson and other parts of Pima County are primary destinations for new
retirees and older winter visitors, contributing to it being among the
fastest aging regions in the Nation. Pima County covers 9,184 square
miles--roughly the size of the State of Vermont--and is home to more
than 248,000 people who are 60 years of age or older. That means one in
four County residents is age 60 or older today. The population growth
among those under 50 years old has remained stagnant in the last 5
years in the County, while the population in their 60's grew by 16%.
The fastest growing segment of the population were people over 85,
which has increased by an astonishing 35% in the past decade. We are
not alone in these remarkable numbers--while Arizona is one of the most
rapidly aging states, every single state in the Union is growing older
as the baby boomers age and people live longer. By 2030, one in five
Americans will be age 65 or older.
PCOA's Role in the Community
Pima Council On Aging's 50 year history of supporting older adults
in their homes and communities means we are one of the nation's
longest-serving providers of the critical home and community-based
services that are the mandate of every Area Agency on Aging. In fact,
we began providing these vital supportive services even before Area
Agencies on Aging were formally established in the 1973 reauthorization
of the Older Americans Act.
Today this coordinated system of services provides supportive
programs including home-delivered meals, congregate meals and
socialization, transportation, in-home care, home repair and
adaptations, legal services, evidence-based health promotion programs,
and assistance for family caregivers. The federal dollars we receive
through the Older Americans Act are the foundation of this system, as
we leverage state and local dollars to increase our ability to meet the
need and help older adults meet their goals of aging at home and in the
community, remaining healthy, and retaining their independence for as
long as possible. To accomplish these lofty goals, we work in
partnership with approximately two dozen service provider partners to
provide an array of services, programs and options for older adults, as
well their caregivers.
But to stay healthy and to age well, older adults need to remain
engaged. The home-and-community-based services we offer, such as home-
delivered meals through the Pima Meals on Wheels program, senior lunch
programs, senior center programming and in-home services, increase or
maintain self-sufficiency and independence and reduce social isolation
for the people we serve. In our last fiscal year, PCOA delivered just
shy of 204,000 meals, utilizing 20 routes to cover metro Tucson--and
the outlying rural communities where people are at even greater risks
for isolation--to nearly 1,500 individuals who are homebound, unable to
prepare a nutritious meal because of health or physical limitations and
have no one to assist them. For many, the driver who delivers their
meals may be the only person they see regularly during the week. It is
not uncommon for our delivery drivers to find people who have been
experiencing medical emergencies for a day or longer, and have to
provide crisis assistance.
In collaboration with our community partners, PCOA also provides
nutrition programs in community settings, and these congregate meals
have, since inception, had a twin goal of enhancing seniors' nutrition
and encouraging socialization. We served nearly 87,000 meals through
lunch programs to around 2,000 older adults at our network of 13
community and neighborhood-based centers; 91% of them tell us that the
program gives them someone to talk to each day. The majority of our
home-delivered meal clients live alone (67%) and all are frail or
disabled. More than half (55%) of congregate meal participants live
alone, and nearly 30% are frail or disabled. Our home-and-community-
based system of services known as the Community Services System
includes not only these two types of meals programs, but also other
supports and services that allow people unable to perform basic tasks
of daily living for themselves to remain living in their own homes.
Common in-home services include homemaker services (laundry, cleaning),
personal care services (bathing, dressing) and personal safety systems,
while community supports include transportation, legal services and
caregiver supports.
Social Isolation Harms Health, Independence
Data from our local communities tell us that social isolation and
related factors significantly impact the lives of our older friends and
neighbors, which is validated by national data and emerging research on
the significant negative health effects of becoming isolated or lonely.
In our role as the Area Agency on Aging, since 1975 PCOA has conducted
the only community needs assessment of its kind to identify the needs
of older adults age 60 and older. Every three to 4 years, PCOA collects
information about the issues of most concern to older adults in our
communities through a written survey, public listening sessions and
focus groups with professionals in the field. Through our most recent
community needs assessment process in the fall of 2016, nearly 2,300
seniors completed surveys in English and in Spanish, with nearly half
of those respondents reporting they lived alone. The second-highest
ranking concern for older people in our community, only slightly
outranked by falls and fear of falling, was being able to continue
living independently in their own homes. Remaining independent and
aging in place was expressed as an issue of some or serious concern by
nearly 67% of the people we surveyed. Other significant concerns
included loss of a spouse, depression, mental health issues and related
indicators of isolation, as well as social isolation itself, which was
specifically cited as an issue by 46% of respondents.
While aging at home is cited as a top priority by a majority of
older people, and doing so has both emotional and economic benefits,
aging in place at home can also lead to isolation. As socialization
that occurs naturally throughout much of adult life through work,
raising children, volunteerism, and connection to family wanes in one's
life, without opportunities to build new social networks, including
having the health and mobility to do so, living independently can lead
to that person becoming nearly entirely isolated over time. And so,
Area Agency on Aging funded service providers, such as meal delivery
drivers or the direct care workers who come into the home to assist
with giving a bath, changing linens and shopping, become their social
network, providing not only services that allow the person to remain in
their home, but also regular contact that can help to stave off the
depression and ill health effects that accompany isolation.
Yet not every senior needs those particular programs, so how do we
do our part to combat and respond to social isolation among a broader
aging population in our community?
First, we have to understand the causes of the problem. What we as
service providers witness happening in our society is isolation even in
the midst of community. People are aging in place in many of our older
neighborhoods, while the composition of those neighborhoods has changed
to younger families with whom they have no connection, so they no
longer know their neighbors. Our communities continue to see a decades-
long influx of retired people from other states who have left behind
their families, friends, and support systems. Depending on the area
they move to, the social opportunities that are available, and their
ability to navigate the community, they may or may not start rebuilding
a social network in their new community. Living in gated communities
often leads to isolation among a relatively homogeneous group of
people. We have turned into communities where the front door is the
garage door and that for many, especially those without small children,
it is possible to come and go without ever seeing neighbors except
through the car window. We also noted that for some of our longtime
retirement communities like Green Valley, a community of about 22,000
people 20 miles outside of Tucson where individuals aged 85 years and
older make up more than 10% of the population, those who moved there in
the early years of their retirements have often outlived their savings
and their vitality. We hear stories about the fact that since the home
owners' associations maintain the exteriors of the housing units and
landscaping, hidden behind a facade of normalcy is the despair that
exists inside where people simply can't take care of themselves and
don't reach out to others.
These community patterns and structural challenges contribute
greatly to the problem of social isolation, but there are other
challenges we see regularly too, including seniors isolated from the
community by language or culture barriers, as well as by fear. Living
alone with increasing frailty can be terrifying, and it's easy for
these vulnerable older adults to stay inside and resist asking for
help. And, given the prevalence of elder abuse and the perception of
crime and violence, we understand their caution. Many older people
don't reach out for assistance for fear of losing their ability to
remain in their homes.
Finally, we know that there are other risk factors that put some
older adults at greater risk for having their health compromised by
increasing isolation. Changes to mobility, cognitive ability, or health
status, which happen frequently in the lives of older adults, can cause
an individual to hold back from previously enjoyed social activities.
Older adults in rural areas who can no longer drive are at incredible
risk of physical, and thus social isolation, unless other
transportation options are available. The loss of a spouse or a new,
difficult role as a family caregiver may also lead to a withdrawing
from the community at a time when more engagement is needed the most.
Solutions to Reach and Engage Isolated or At-Risk Seniors
Reaching out to all older people with messages that resonate and
suggestions they will embrace is critical. That's why we participated
in last year's ``Expand Your Circles: Prevent Isolation and Loneliness
As You Age'' campaign, a national effort of the Federal Eldercare
Locator (Endnote 1) to provide a new consumer awareness tool to boost
public awareness and education of social isolation among seniors.
Funded by the Administration for Community Living and in partnership
with AARP Foundation and its' social isolation reduction online
platform, Connect2Affect (Endnote 2), the National Association of Area
Agencies (n4a), which operates the ACL-funded Eldercare Locator and of
which we are a member, created a simple, consumer-friendly brochure on
the problem of social isolation, risk factors, negative health
consequences and a self-assessment checklist. The campaign provided
additional materials for aging providers to ensure that the national
effort's leveraged media attention was mirrored locally across the
country. Like our Area Agency on Aging peers around the Nation, we
found the new brochure a great tool and resource to raise the issue
locally.
In addition to sharing the resource itself, a member of our staff
devoted her monthly column in the Arizona Daily Star, the second-
largest newspaper in the state, to the issue, reaching 200,000 print
and online readers with specific tips to stay engaged, access supports
and services and reduce isolation. We saw a significant boost in calls
coming into PCOA the day the story ran and for the next few days.
To supplement and build upon our core Older Americans Act services,
Pima Council On Aging developed the Neighbors Care Alliance to
encourage neighbors to reach out to one another and formally organize
volunteers who could provide transportation, friendly visits and calls,
meals, and run errands. These include many of the top concerns and
unmet needs voiced by our community in prior-year surveys of the most
pressing issues facing older adults. The 15 active Neighbors Care
Programs and their 120 partners are dedicated to helping their aging
neighbors remain independent, safe, and less isolated in their homes
for as long as possible. Our communities need to continue to seek
innovative, often low-cost, neighborhood-based solutions such as this
effort to address the challenges of aging in our society.
We have seen first-hand how social isolation impacts quality of
life and overall well-being, and the dramatic effects that breaking
down that isolation can have in people's lives. I'm reminded of Edna, a
woman in her late 60's, who lived alone, suffered from multiple chronic
health conditions and depression, and received several services from us
including home-delivered meals, housekeeping help and grocery shopping
assistance. She rarely left her home. Her concerned case manager
suggested that she consider volunteering through the Corporation for
National and Community Service funded Senior Companion Program, which
at the time had recently been brought to Pima County by community
partner, Our Family Services. Over time, Edna began volunteering to
offer companionship to other isolated older adults receiving in-home
services from us, and within a year, she discontinued most of her own
services because she simply no longer needed them. She said that going
to visit with older people in the community every day and a newfound
sense of purpose had led her to getting around better and doing more
than she had in a long time. Edna volunteered as a Senior Companion and
benefited from the boost in vitality that social interaction gave her
for 8 years, contributing significantly to her ability to maintain
independent living and her overall quality of life.
In the course of five decades of service to older people and their
families, Pima Council On Aging has recognized that social isolation is
an issue that not only requires intervention to improve overall health
and well-being, it demands prevention, as well. Encouraging people as
they age to engage in continuing health-related education,
volunteerism, and community engagement are critical to reducing
systemic social isolation in later years. And so, our challenge as a
society becomes not only continuing to provide and expand critical home
and community-based supports and services that ensure safety and
promote independence like those supported by the Older Americans Act,
but also to break down systemic barriers to lifelong good physical and
mental health and meaningful engagement. It is our role as an Area
Agency on Aging to both find ways to reduce social isolation for older
people like Edna, forestalling the need for deeper interventions, and
to ensure that those interventions are in place and adequate for those
who eventually need them.
Policy Recommendations
Unfortunately, the problem of social isolation is widespread and
knows no race, gender, income or geographic boundaries. According to
our national association, n4a, our fellow Area Agencies on Aging share
our concern, our willingness to respond and our desire to see greater
awareness and resources deployed to address this problem that, with a
nation that's aging as fast as ours is, cannot be ignored.
While PCOA will continue to tackle the problem as best we can at
home in Pima County, we offer several policy recommendations for
consideration by Congress and the Administration.
1. Increase Public Education
Current national efforts to raise awareness, assessment and remedy
should be strengthened and new interventions developed. Our agency
knows what to look for and how to respond, but we don't have the
capacity to serve every older person in Pima County. The issue needs to
be elevated so that more older adults and their families understand
that social isolation is a public health issue and should not go
unaddressed. In tandem with national campaigns, local communities like
ours and the aging and community groups who serve it need effective
messages and resources to deploy at the ground level. The Eldercare
Locator and Connect2Affect campaigns have been extremely helpful but we
need more national emphasis on this critical issue.
2. Expand Services that Promote Health, Engagement, Aging
at Home and in the Community
As our population ages, it's essential that life-saving,
independence-maintaining and isolation-reducing home and community-
based services are expanded to meet the incredibly growing need. The
Older Americans Act's critical services and supports must grow as we
adjust to this age wave. If we don't meet the need, many older
Americans will lose their independence and health, resulting in higher
costs for taxpayers in the form of increased Medicaid nursing home
costs and avoidable Medicare expenditures. PCOA believes that all Older
Americans Act (OAA) programs should be increased in FY 2018. OAA Title
III B Supportive Services--which provides flexible funding for a range
of services from in-home supports to transportation--needs particular
attention, as sequestration and other budget cuts have reduced it to
spending levels not seen since before FY 2002, 15 years ago! This same
title supports Area Agencies on Aging information and referral (I&R)
efforts, so that consumers have someone to call for information on and
access to aging services in that community. While the OAA meals
programs of Title III C Nutrition have seen restoration from
sequestration, much more needs to be done to meet growing community
need now and in the future.
As Edna's story showed, programs that get older adults engaged in
serving the community help reduce social isolation for both volunteers
and those they serve. We support funding for the Corporation for
National and Community Service's Senior Corps programs, which are
specifically designed to engage and serve older adults.
Transportation is one of the most pressing needs for all older
adults who are trying to remain at home and in the community--
especially those who are isolated, and yet it can be difficult to find
reliable, accessible, and affordable options to get to the doctor, the
grocery store, religious services, or social events--all of which are
critical to staying healthy and independent and prevent isolation.
Lawmakers must invest in federal, state and local programs that create
a wider array of affordable, accessible transportation options.
3. Build Livable Communities for All Ages
As the population of older adults grows so does the desire and need
for communities to support people of all ages to ensure that they can
grow up and grow old with maximum independence, safety, and well-being.
Although there is much that individuals can and should do to maximize
their independence as they age, public policymakers make critical
decisions about issues such as transportation systems, housing
opportunities and land-use regulations that affect whether older adults
can live successfully and productively at home and in their community.
That's why Tucson, through the leadership of Mayor Jonathan Rothschild
and Council Member Steve Kozachik, recently joined the World Health
Organization (WHO)/AARP Age-Friendly Communities List, as the 144th
city in the Nation to join; we are currently deeply involved in the
planning work to make our community even more age-friendly.
Federal leadership in livable and sustainable communities is
vitally needed, yet federal investments in promoting sustainable and
livable communities has lagged significantly since 2010. In the
meantime, states and local governments tasked with developing and
implementing broad long-term community infrastructure and service
systems have increasingly recognized the value of ensuring that these
systems meet the needs of the ever-growing aging population. These
community efforts will only be cost-effective and efficient if they
reflect our aging reality. This means directing a portion of any new
infrastructure spending to community agencies and nonprofit
organizations by encouraging states and local governments to embrace
livable-communities-for-all-ages principles and make them central to
the core work of all government departments.
The more livable a community is, the easier it will be to prevent
isolation among older adults. If seniors have appropriate housing
options, can get around smoothly and safely, are tapped as a resource,
and are vital to the life of the community, it will do a great deal to
prevent social isolation and loneliness.
4. Create Stronger Connections Between Health Care Systems
and Community Systems
The problem of social isolation can also be reduced with better
coordination between acute health care systems (hospitals, doctor's
offices, managed care organizations) and the social and human services
systems. According to the Robert Wood Johnson Foundation, nearly 90
percent of physicians indicated they see their patients' need for
social supports, but unfortunately 80 percent of doctors said they do
not fully know how to link patients to these networks. Clearly, there
is still a wide gap to bridge between these very different social
services and medical systems, and it is imperative that new
intersections, partnerships and coordination processes are created
rather than allowing the medicalization of social services, which will
undoubtedly lead to higher costs and reduced consumer satisfaction.
This list is just a great starting point for a longer list of
policy prescriptions that this Committee and all of us who care about
older adults should develop; we know there's more to be done.
I thank you for shining a spotlight on this critical issue and for
inviting me here to share Pima Council On Aging's perspective, and I
look forward to taking any questions you may have.
Endnotes
1. The Eldercare Locator is the only national information and
referral resource to provide support to consumers seeking assistance
across the spectrum of issues affecting older Americans. The Locator
was established and is funded by the U.S. Administration on Aging, part
of the Administration for Community Living, and is administered by the
National Association of Area Agencies on Aging (n4a). Through its
National Call Center (1-800-677-1116), which operates 5 days a week
from 9 o'clock a.m. to 8 o'clock p.m. ET, and website
(www.eldercare.gov), the Locator serves as a trusted gateway for older
adults and caregivers searching for information and resources which can
be crucial to their health, well-being and independence.
2. Because the issue of social isolation is so complex, AARP
Foundation spearheaded Connect2Affect to seek out solutions. Through
research and innovative efforts, the AARP Foundation and its partners
are working to create a deeper understanding of loneliness and
isolation, draw crucial attention to the issue, and catalyze action to
end social isolation among older adults. The goal of Connect2Affect is
to create a network of resources that meets the needs of anyone who is
isolated or lonely, and that helps build the social connections older
adults need to thrive. Website www.connect2affect.org.
__________
Prepared Statement of Rick Creech, Educational Consultant, Pennsylvania
Training and Technical Assistance Network
Chairwoman Collins, Ranking Member Casey, and other members of the
Committee, thank you for inviting me to speak before you today.
There can be no social engagement with others without interactive
communication.
As someone who was born with cerebral palsy and was without the
ability to speak in the accepted way, I grew up lonely and isolated--
except for my parents and grandmothers. It was not until I received my
first vocal output communication device that people began to know that
they could speak to me and I could speak to them, well, at least, some
people did.
I was born in 1954 in Smithfield, North Carolina. Back then babies
like I was were not expected to live, and if we did live, we were not
expected to be out in public, we were not expected to be educated, and
we were certainly not expected to become independent adults. However, I
had extraordinary parents who trusted in God, and not in all the
doctors, the therapists, the social workers who said I would never do
that, or that, or certainly--not that.
My father told me once, and I never forgot this, that he wanted me
to learn math, so that I would be able to manage my own money. He
wanted me to read, so that I would be able to read and understand
anything that someone might write about me, and what should be done to,
and for me. And he wanted me to be able to communicate, so that I could
have control over my life.
My parents presumed competence in my ability to learn to do those
things. They insisted that I learn. Boy, did they push me. When it came
to teachers, I would always prefer to have my mother because with her,
I could slack some. With my father, the Baptist preacher, there was no
way I could slack. He was more demanding than God was with Moses.
However, they taught me that I was competent. I was competent enough to
go beyond their goals--and their dreams--for me. This is what great
parents, great teachers, and great schools do.
Supporting individuals who need to use AAC is not simple. The
person may want to communicate, however, the person will have to be
taught how to use an augmentative and alternative communication device
for his or her expressive communication. The vocal impaired person will
not know how, what, when, or why to express thoughts, feelings, ideas
without being encouraged, without being pushed.
I am speaking from experience. Initiating a conversation and
carrying on a conversation is the hardest thing I do in life. To put it
simply, I am no good at chit-chatting. I believe that there is an
optimal age to learn communication skills. That age being as young as
possible. However, I was 28 when I got my first voice output
communication device, and, although I still have deficits, I can
expressively communicate my ideas in conversations.
I had to work extremely hard, and I work long hours to learn to
communicate with an AAC device. I used to read passages from the Bible
and newspapers aloud to practice with my AAC device. My point is that
we cannot provide a person with assistive technology or AAC, and expect
people to use it.
I recently got the Amazon echo to help me to control the lights in
the house. Sometimes I am ready to throw Alexa out the window, and I
will not tell you the names my wife has called the thing. Amazon Echo
is simple compared to AAC devices. I started telling people many years
ago that assistive technology without training is not assistive.
Even today, as proficient as I am with my AAC device, I cannot talk
to some people because they are too much in a hurry, or too caught up
in my Accent1400, saying things such as, what can you say?, can you say
my name?, or they are hollering at me as if I'm deaf, saying ``it-is-
good-to-meet-you, what-are-you-doing?'' I get tempted to reply,
``talking to an idiot'', but my parents taught me that if you cannot
say something nice, say nothing at all, so I don't.
As I get older, I feel my body slowing down. My bones snap, crackle
and pop--like Rice Crispies. My muscles hurt. Right now, I have my best
friend and my protector, my wife, but she is almost my age and has a
bad back, arthritis, and diabetes. I know that I might not always have
my wife by my side. One day I will probably be in the care of a minimum
wage worker, who will have 24 other patients all requiring less time
and care than I. The only way I have to individualize myself to my care
takers will be through my ability to communicate with them, so that
they will be able to see me as a person rather than just another
patient.
Of course, if that does not work, I could always call one of my
three 250 pound sons, and say, son, I need help.
I would like to thank the Committee on Aging, for giving me this
opportunity to speak here, although I do not think I am that old. I
would like to thank the Association of Assistive Technology Programs
for sponsoring my trip here. Before I started working for Pennsylvania
Training and Technical Assistance Network, I worked with Pennsylvania
Initiative on Assistive Technology. I started PIAT's Short Term Loan of
assistive technology to adults nearly 30 years ago, so, maybe I am that
old.
The communication device I use, the Accent1400, costs in the
neighborhood of $10,000. It is one of the more sophisticated AAC
devices. However, even simpler augmented communication devices with
speech output cannot be found for less than five thousand dollars. The
AAC devices with eye tracking, so that people can speak with them using
only their eyes, cost in the neighborhood of $20,000.
All of assistive technology, my AAC, my van converted for a powered
wheelchair passenger, my smart home equipment, all cost upward of
$200,000. Still, ladies and gentlemen, that is cheap, compared with a
life time, of taking caring of me in a nursing facility.
For my work at PaTTAN, Pennsylvania Training and Technical
Assistance Network, I help managed its Short Term Loan of assistive
technology program that provides assistive technology to school
therapists and teachers statewide, to try with their students. Each
year the Pennsylvania Department of Education generously provides
around a third of a million dollars for equipment. To a poor North
Carolina country boy, that sounds like a lot, but we have constant
waiting lists of students, and at the end of every year, there are
requests that I have to cancel or delay until next school year because
we don't have enough inventory to meet the requests. These students
needs appropriate assistive technology to receive education so that
they can grow to be productive and independent adults, who can be
social members of our society.
I want to leave the committee with this thought. Living without
being able to communicate, is like being behind four glass walls. You
are able to see others, and people can see you, but you are ignored, or
worse, talked down to, until you stop remembering who you are and why
you are important.
Thank you, have a blessed day.
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Additional Statements for the Record
=======================================================================
Chelsea Conaboy, Freelance Writer
The Agenda-Politico, 04/12/2017
They're Out There-If We Can Find Them
In rural America, social isolation isn't just a private woe. It's
increasingly seen as a public health crisis, with new ideas for
tackling it.
FRIENDSHIP, Maine--Robin Overlock worries about Elizabeth Brown.
That's his job.
The retired paramedic checks in frequently with Brown, 94, who
lives in the same farmhouse in rural Maine where she's lived since
1940, where she raised sheep and her four children as well as cared for
her own mother for the last two decades of her life. The white
clapboards have weathered to gray and the barn, the sheep long gone, is
beginning to collapse in on itself.
Congestive heart failure and a stroke, plus other consequences of
aging, have left Brown housebound and largely confined to a recliner,
watching TV to pass the time or talking by phone with friends or her
oldest son, who lives about 100 miles away and has health issues of his
own. Brown hasn't seen her son in more than a year, she said; her other
children are dead or estranged. Overlock, who works for a small startup
that helps low-income seniors stay in their homes, has become the
person in her life who monitors her swollen legs for infection.
As he drives toward Brown's home, on a finger of land bordering
Muscongus Bay, Overlock passes houses with logging equipment parked in
the driveway or lobster traps stacked outside. Some, like Brown's home,
show signs of neglect, and Overlock worries that the people who live in
them also might be elderly and isolated.
``They're out there,'' he said, pointing out the windshield toward
rolling hills that lead quickly to the bay and the Atlantic Ocean. ``If
we can find them, help them, keep them safe . . . ''
Overlock is part of a vanguard of health care workers tackling what
researchers say is a growing health risk: social isolation. Researchers
increasingly are convinced that living alone and losing contact with
family and friends can be as much a threat to people's health as more
physiological factors, like high blood pressure or obesity.
And the problem is set to get worse in coming decades. Baby
boomers, who had fewer children than previous generations, are living
longer, often with chronic diseases that can reduce their mobility.
Family networks that traditionally cared for older generations are more
dispersed or have unraveled altogether. The trend is already acute in
rural regions like those in Maine hard hit by the collapse of the paper
industry and other manufacturing losses, where young people continue to
leave for jobs to the South.
Social isolation is not only unpleasant; it can be deadly. Someone
who lacks social relationships has the same risk for early death as
someone who is severely obese, according to a 2015 analysis by
researchers at Brigham Young University. The feeling of loneliness, or
a person's perception of being isolated, has been linked to higher
blood pressure and cognitive decline. Taken together, social isolation
and loneliness were associated with a 29 percent increased risk for
coronary heart disease and a 32 percent increased risk for stroke,
according to another large-scale analysis led by researchers at the
University of York in Great Britain.
Just how isolation erodes health is a matter of some speculation.
Scientists have long thought that interaction with others is beneficial
because of ``social control.'' Friends and family members prop each
other up, encouraging good behavior and healthy habits. When those
relationships break down, so can a person's health.
But in recent years, research has found that something more is at
work: Loneliness, often thought of as a matter of the heart, may
actually change the brain. The authors of a 2015 paper published in the
Annual Review of Psychology theorize that chronic loneliness increases
activity in a network of glands that control stress responses and
create an inflammatory effect that raises the risk for chronic
illnesses.
The reason for this may be a product of evolution. Loneliness may
be meant to motivate us, when a spouse dies or when we move to a new
city, to seek out new connections that can sustain us physically and
emotionally. But when a person can't act on the feeling in a way that
resolves it, loneliness can make people more sensitive to threats and
less likely to seek out meaningful relationships for fear of negative
consequences.
``We aren't, by our evolution, designed to be solitary survivors,''
said Louise Hawkley, who studies social relationships at NORC, an
independent research organization at the University of Chicago. ``We
need to have others around us.''
When Sandra Lane, 79, was growing up in Bristol, Maine, where the
local newspaper regularly printed the names of people in the hospital
so friends and neighbors could call, an elderly aunt lived next door.
Afraid of thunderstorms, the aunt would pull on rubber boots and run to
Lane's family home to wait out each squall.
Lane now lives with her husband, Russell, 85, a former lighthouse
keeper and lobsterman disabled by post-traumatic stress disorder and
depression, in a home they built down a rutted gravel road on a remote
pond. More homes have been built nearby in the years since, but most
are seasonal. When a blizzard comes during the quiet winter months,
Lane said, she feels so isolated ``I almost go crazy.''
The Lanes, whose son moved back to Maine from Pennsylvania to help
care for them, are working with Overlock through Access Health, a
nonprofit launched this year by their longtime doctor, Allan ``Chip''
Teel, who regularly performed house calls before he closed his
practice. Now Teel is working with a local hospital group to pair video
calls from a doctor with home visits and phone calls from people like
Overlock, who not only checks on medical issues but listens to his
patients' stories, takes out their trash, or couriers a broken hearing
aid across the state for a speedy repair. When he called recently and
learned Russell Lane was having hallucinations, he took quick action to
get Teel on the phone to adjust his medication. The aim of Access
Health is to restore some of the attention that a ``country doctor''
once provided, Overlock said, as well as provide a small sense of
community.
Nearly half of Mainers 65 and older--about 46 percent--live alone,
slightly higher than the national rate, according to 2015 U.S. Census
data; fewer than one-third lived alone in 1990. Older adults who are
lonely are less likely to be married and more likely to have annual
household income of $25,000 or less, according to a report conducted
for the AARP Foundation by Hawkley and others at NORC using 2010 data.
Experts say shifts in family dynamics have compounded other factors
that are part of rural life that contribute to isolation, including
poor public transportation and long travel times to grocery stores,
doctors, community centers or even neighbors' homes.
It used to be that grandparents ``moved into the spare room, and
they were there until they left--until they died, I'll be blunt--and
that was part of life's lesson,'' Overlock said. ``In today's society,
we all are busy. We all have careers, and we move around.'' Access
Health, he said, is taking ``a step to be a surrogate.''
The reach of Access Health, which will cost about $99 a month per
patient when the program is fully rolled out, is relatively small.
Overlock serves 12 patients now, though Teel hopes each of the
program's health advocates eventually will serve up to 100 people. The
need is great.
That's apparent in the hospital emergency department in Augusta,
the state capital, where Rob Boudewijn works as a physician's
assistant. About once or twice a week, he admits a patient who has no
acute diagnosis but who lacks the support at home to manage ongoing
chronic conditions, such as lung disease and obesity, or simple
frailty. ``Social admissions,'' a frowned-upon reality in many
hospitals, allow social workers time to contact family members or to
enroll a patient in support services. Sometimes, Boudewijn said, a
patient will come to the emergency department showing signs of
dementia. Then they spend time with nurses and doctors, just connecting
with other people, and their whole disposition changes.
In those patients, he said, he can see the harmful effects of
social isolation. ``Everybody likes to feel worthwhile.''
Oxford County, A paper-making region stretching along much of
Maine's border with New Hampshire, was named the state's least healthy
county by a Robert Wood Johnson Foundation analysis in 2010. That
prompted a broad group of public health organizations and community
groups to undertake a years-long assessment, looking at the root causes
of the county's poor health. They eventually settled not on access to
healthy food or exercise or even poverty but on something deeper:
disconnection, a feeling of being undervalued, and social isolation.
``Everything we have done since then has been with an eye toward .
. . reducing that root cause,'' said Jim Douglas, director of Healthy
Oxford Hills, a public health program of the local hospital that
facilitated the process.
But what to do about it? While research has made progress in
identifying the problem, solutions remain few and far between.
Some studies have found that targeted psychotherapy can help people
cope with loneliness in older age. That is unlikely to be a widely
adopted strategy in rural communities with limited resources. In the
meantime, countless social service agencies are working, much like
Overlock, to address the needs of isolated individuals by providing in-
home support, meal delivery, transportation or group activities.
However, many lack the resources for rigorous research necessary to
persuade policymakers to invest in their work.
Oxford has come up with a few local initiatives. A plan to expand
community gardens became a means of teaching young people leadership
skills. A group concerned about the opioid crisis organized a
``recovery rally'' in one town and put together a how-to to help other
towns do the same. Others organized community conversations about
broadband internet access to improve lobbying for its expansion, an
important step for job growth and the use of telemedicine.
``It's a very long-term strategy,'' Douglas said. ``This is not
something we're expecting to be able to point to in two, three, even
seven years and say, `This happened because of that.' It's really a
long-term investment in the county-wide community.''
Julianne Holt-Lunstad, a health psychologist at Brigham Young
University and lead author on the 2015 mortality analysis, said
reducing social isolation on a national level likely will require
something bigger, a societal change prompted by something like the
public health campaigns that altered public perception of tobacco use
and dramatically reduced smoking rates over the past four decades.
A few efforts are getting underway. In December, the AARP
Foundation launched Connect2Affect.org, a website aimed at raising
awareness of social isolation as a major determinant of health. It
includes links to research and a searchable data base of local and
national resources. President Lisa Marsh Ryerson said she hopes it will
help inspire more communities to take a broad-based look at how to
improve health generally while putting isolation front and center.
``The reality is that social isolation cuts across the lifespan,''
she said.
John Gale, a researcher at the University of Southern Maine's
Muskie School of Public Service who grew up working on his
grandparents' Maine farm and is a national expert on behavioral health
in rural communities, said the answer lies in finding new ways to
rebuild the community fabric lost over the years. Such efforts, he
said, don't need scientific proof.
``The fact that someone is living out on a farm in the middle of
nowhere, can't get enough food . . . that seems to be a problem in and
of itself,'' Gale said. ``We all fall into the trap of wanting an
evidence base, but sometimes, at the end of the day, [it's about] doing
the right thing. We have to get started.''
Which is where people like Overlock come in. During his visit,
Brown reminisced about the days when televisions first arrived in town
and she served as a member of the Friendship Women's Ambulance Corps.
As she sat in her recliner in what used to be the dining room, where
she spends her days and nights, Overlock checked on her legs, swollen
enough that she could be admitted to the hospital. But she won't go.
``This is my life,'' she said, sweeping her arms across her lap and
over side tables overflowing with newspapers and letters, cans of food
for her white-pawed Miss Alley Cat, and a television remote. ``This
room is my life.''
Chelsea Conaboy is a freelance writer focused on health care and was
features editor at the Portland Press Herald in Maine when this article
was published.
__________
Dhruv Khullar, M.D., M.P.P., Massachusetts General Hospital
and Harvard Medical School
New York Times Op-Ed, 12/22/2016
How Social Isolation Is Killing Us
My patient and I both knew he was dying.
Not the long kind of dying that stretches on for months or years.
He would die today. Maybe tomorrow. And if not tomorrow, the next day.
Was there someone I should call? Someone he wanted to see?
Not a one, he told me. No immediate family. No close friends. He
had a niece down South, maybe, but they hadn't spoken in years.
For me, the sadness of his death was surpassed only by the sadness
of his solitude. I wondered whether his isolation was a driving force
of his premature death, not just an unhappy circumstance.
Every day I see variations at both the beginning and end of life: a
young man abandoned by friends as he struggles with opioid addiction;
an older woman getting by on tea and toast, living in filth, no longer
able to clean her cluttered apartment. In these moments, it seems the
only thing worse than suffering a serious illness is suffering it
alone.
Social isolation is a growing epidemic--one that's increasingly
recognized as having dire physical, mental and emotional consequences.
Since the 1980's, the percentage of American adults who say they're
lonely has doubled from 20 percent to 40 percent.
About one-third of Americans older than 65 now live alone, and half
of those over 85 do. People in poorer health--especially those with
mood disorders like anxiety and depression--are more likely to feel
lonely. Those without a college education are the least likely to have
someone they can talk to about important personal matters.
A wave of new research suggests social separation is bad for us.
Individuals with less social connection have disrupted sleep patterns,
altered immune systems, more inflammation and higher levels of stress
hormones. One recent study found that isolation increases the risk of
heart disease by 29 percent and stroke by 32 percent.
Another analysis that pooled data from 70 studies and 3.4 million
people found that socially isolated individuals had a 30 percent higher
risk of dying in the next seven years, and that this effect was largest
in middle age.
Loneliness can accelerate cognitive decline in older adults, and
isolated individuals are twice as likely to die prematurely as those
with more robust social interactions. These effects start early:
Socially isolated children have significantly poorer health 20 years
later, even after controlling for other factors. All told, loneliness
is as important a risk factor for early death as obesity and smoking.
The evidence on social isolation is clear. What to do about it is
less so.
Loneliness is an especially tricky problem because accepting and
declaring our loneliness carries profound stigma. Admitting we're
lonely can feel as if we're admitting we've failed in life's most
fundamental domains: belonging, love, attachment. It attacks our basic
instincts to save face, and makes it hard to ask for help.
I see this most acutely during the holidays when I care for
hospitalized patients, some connected to I.V. poles in barren rooms
devoid of family or friends--their aloneness amplified by cheerful
Christmas movies playing on wall-mounted televisions. And hospitalized
or not, many people report feeling lonelier, more depressed and less
satisfied with life during the holiday season.
New research suggests that loneliness is not necessarily the result
of poor social skills or lack of social support, but can be caused in
part by unusual sensitivity to social cues. Lonely people are more
likely to perceive ambiguous social cues negatively, and enter a self-
preservation mind-set--worsening the problem. In this way, loneliness
can be contagious: When one person becomes lonely, he withdraws from
his social circle and causes others to do the same.
Dr. John Cacioppo, a psychology professor at the University of
Chicago, has tested various approaches to treat loneliness. His work
has found that the most effective interventions focus on addressing
``maladaptive social cognition''--that is, helping people re-examine
how they interact with others and perceive social cues. He is
collaborating with the United States military to explore how social
cognition training can help soldiers feel less isolated while deployed
and after returning home.
The loneliness of older adults has different roots--often resulting
from family members moving away and close friends passing away. As one
senior put it, ``Your world dies before you do.''
Ideally, experts say, neighborhoods and communities would keep an
eye out for such older people and take steps to reduce social
isolation. Ensuring they have easy access to transportation, through
discounted bus passes or special transport services, can help maintain
social connections.
Religious older people should be encouraged to continue regular
attendance at services and may benefit from a sense of spirituality and
community, as well as the watchful eye of fellow churchgoers. Those
capable of caring for an animal might enjoy the companionship of a pet.
And loved ones living far away from a parent or grandparent could ask a
neighbor to check in periodically.
But more structured programs are arising, too. For example, Dr.
Paul Tang of the Palo Alto Medical Foundation started a program called
linkAges, a cross-generational service exchange inspired by the idea
that everyone has something to offer.
The program works by allowing members to post online something they
want help with: guitar lessons, a Scrabble partner, a ride to the
doctor's office. Others can then volunteer their time and skills to
fill these needs and ``bank'' hours for when they need something
themselves.
``In America, you almost need an excuse for knocking on a
neighbor's door,'' Dr. Tang told me. ``We want to break down those
barriers.''
For example, a college student might see a post from an older man
who needs help gardening. She helps him plant a row of flowers and
``banks'' two hours in the process. A few months later, when she wants
to cook a Malaysian meal for her boyfriend, a retired chef comes by to
give her cooking lessons.
``You don't need a playmate every day,'' Dr. Tang said. ``But
knowing you're valued and a contributing member of society is
incredibly reaffirming.''
The program now has hundreds of members in California and plans to
expand to other areas of the country.
``We in the medical community have to ask ourselves: Are we
controlling blood pressure or improving health and well-being?'' Dr.
Tang said. ``I think you have to do the latter to do the former.''
A great paradox of our hyper-connected digital age is that we seem
to be drifting apart. Increasingly, however, research confirms our
deepest intuition: Human connection lies at the heart of human well-
being. It's up to all of us--doctors, patients, neighborhoods and
communities--to maintain bonds where they're fading, and create ones
where they haven't existed.
Correction: December 24, 2016
An Upshot article on Thursday about the health risks of social
isolation misstated the purpose of a grant by the Robert Wood Johnson
Foundation to a program, linkAges, dedicated to fighting the problem.
The grant to linkAges was for testing a new project connected to the
program; it was not meant to help linkAges expand across other areas of
the country.
Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts
General Hospital and Harvard Medical School.
__________
Meals on Wheels
Additional Statement for the Record
Chairman Collins, Ranking Member Casey and Members of the
Committee:
We first want to commend you for your bipartisan leadership and
commitment to improving the lives of, and protections for, our nation's
older adults. Second, we want to express our appreciation to you for
holding this important hearing and bringing to light the serious issue
of social isolation and loneliness among this population. Meals on
Wheels of America is grateful for the opportunity to submit this
statement for the record and eager to work with you as we continue to
seek solutions to address the growing problems of senior hunger and
isolation. We offer our perspectives on the risks and consequences of
social isolation and loneliness as they relate to the individuals
served through Meals on Wheels, as well as our thoughts about how this
nationwide network is delivering a cost-effective and vital
intervention for America's most at-risk seniors every day.
In a recent speech to healthcare journalists, Ellie Hollander, our
President and CEO, highlighted an alarming statistic originally
presented by Dr. Julianne Holt-Lunstad, both a leader in loneliness
research and a witness at the hearing, that the effects of loneliness
and isolation are comparable to the impact of well-known risk factors
such as obesity and substance abuse, and are the equivalent of smoking
15 cigarettes a day. Loneliness is prevalent among older adults, and
the statistic of one in three older adults over the age of 60
experiencing loneliness is thought to be an underestimate, as witness
Dr. Lenard Kaye presented in his testimony. We echo Dr. Holt-Lunstad's
assertion that senior social isolation and loneliness is an epidemic
and a growing public health concern amidst demographic, geographic and
societal shifts toward smaller, more isolated families.
The factors that make older adults more susceptible to social
isolation and loneliness are commonly found among individuals receiving
Meals on Wheels. According to AARP Foundation's Isolation Framework,
living alone, having lower incomes, and having more physical
impairments make already vulnerable older adults susceptible to
loneliness. Data from the Administration for Community Living's State
Program Reports and National Survey of Older Americans Act (OAA)
Participants indicates that seniors receiving meals at home and in
congregate settings, such as senior centers, are primarily women, age
75 or older, who live alone, have multiple chronic conditions, take six
or more medications daily and are functionally impaired. Significant
numbers of OAA meal recipients are also impoverished, live in rural
areas and belong to a minority group, making them more at-risk for
social isolation and loneliness.
Findings from a 2015 study entitled More Than a Meal, conducted by
our organization in conjunction with Brown University and AARP
Foundation, found that those receiving and/or requesting Meals on
Wheels services are significantly more vulnerable compared to a
nationally representative sample of comparably-aged Americans.
Specifically, seniors who are on Meals on Wheels waiting lists were
significantly more likely to:
Report poorer self-rated health (71% vs. 26%)
Screen positive for depression (28% vs. 14%) and anxiety
(31% vs. 16%)
Report recent falls (27% vs. 10%) and fear of falling
(79% vs. 42%) that limited their ability to stay active
Moreover, functional impairment is not just a risk factor but also
a consequence of social isolation and loneliness (Luo, Hawkley, Waite,
& Caccioppo, 2012), along with mortality and chronic illnesses like
cardiovascular disease (Holt-Lunstad & Smith, 2016). The good news,
however, is that Congress' foresight 45 years ago to authorize a
nutrition program demonstration for older adults in the greatest
economic and social need has since grown into a highly effective
community-based, nationwide network of 5,000 senior nutrition programs
(e.g., Meals on Wheels). Today this network is successfully fulfilling
its purposes outlined in the OAA and carrying out what it was intended
and designed to do by:
Reducing hunger and food insecurity among older
individuals
Promoting socialization of older individuals
Promoting the health and well-being of older individuals
Delaying adverse health conditions for older individuals
Delivering More Than Meals
During the hearing, Senators drew from their own experiences of
delivering Meals on Wheels and shared compelling testimonials from
constituents about how volunteer drivers often identify medical issues
before they became serious problems. It was also noted that Meals on
Wheels provides opportunities for meaningful social engagement among a
particularly vulnerable older adult population. In his testimony, Mark
Clark, Director of Pima Council on Aging and Member of Meals on Wheels
America, reiterated anecdotal evidence that Meals on Wheels volunteers
can become important members of seniors' social networks, helping to
deter loneliness. Below are some additional quotes gathered from recent
news articles or were shared with our organization that illustrate the
social benefits of Meals on Wheels services, as told by older adults
receiving Meals on Wheels or family members or local programs:
Meals on Wheels delivers more than food; they deliver
companionship and friendship five days a week. I think that's vital for
people who are shut-ins or semi-shut-ins. That's our visitor. Food and
friendship and pleasantness. It's more than food.
I am served nourishing meals and enjoy being able to eat
with friends. Socialization is almost as important as the food.
We hear story after story of people who are hungry and
have nobody to help. Often times, our clients tell us that the driver
is the only person they see throughout the week. It breaks my heart to
think about the number of people who are on our waiting list because we
don't have the funding to feed them.
I have a reason to live now. I need to be up and dressed
in time to greet my Meals on Wheels delivery person when they arrive.
Both my mother and father were fortunate to be able to
receive this service starting on 2012 until my mother's death at age 85
in 2014 . . . my father still enjoys this service today at 88 years
old. Not only does the service provide him with a good nutritious meal
but the added benefit of having the delivery person touch basis with
him is a blessing.
Along with compelling personal stories of the health benefits of
Meals on Wheels, the same More Than a Meal study referenced above found
that seniors who received daily home-delivered meals (the traditional
Meals on Wheels model of a daily, home-delivered meal, friendly visit
and safety check), experienced the greatest improvements in health and
quality of life. Specifically, between baseline and follow-up, seniors
receiving daily home-delivered meals were more likely to report or
exhibit:
Improvements in mental health (i.e., levels of anxiety)
Improvements in self-rated health
Reductions in the rate of falls and the fear of falling
Reductions in hospitalizations
Improvements in feelings of isolation and loneliness
Decreases in worry about being able to remain in home
Meals on Wheels can be used to reduce the social isolation that
occurs due to functional decline and also help prevent costly
hospitalizations and nursing home placement (Valtorta & Hanratty, 2012)
that, in and of themselves, lead to social isolation. In addition to
being a preventative measure for emergency department visits and
hospital admissions, Meals on Wheels is also a proven way to reduce
readmissions to the hospital and other post-discharge costs. Based on
the results of a pilot for a five-year program that eventually spanned
36 states and more than 135,000 Medicare Advantage beneficiaries, post-
discharge costs were reduced by one-third on average per patient who
was served by Meals on Wheels, as compared to those who did not
participate. Furthermore, several other pilot projects showed seniors
receiving short-term nutrition interventions from Meals on Wheels post-
hospital discharge, ranging from a daily hot meal to a combination of
different meal types (i.e., lunch, dinner, snack, hot or frozen meals),
resulted in readmission rates of 6%-7% as compared to national 30-day
readmission rates of 15%-34%.
As noted above, Meals on Wheels programs deliver so much more than
nutritious meals to the seniors they serve. Many programs are providing
social isolation interventions beyond the daily visit and safety check.
In his testimony, Dr. Kaye summarized AARP's Framework for Isolation in
Adults Over 50, highlighting the importance of drawing on multiple
methods of intervention. Below are some examples of creative
interventions currently being used by Meals on Wheels programs to
address social isolation and loneliness among their clients:
Many Meals on Wheels programs across the country are
offering extended or follow-up visits with clients beyond the mealtime
delivery. Others conduct regular wellness checks that incorporate
casual conversation, and still others have volunteer befriending or
friendly visitor programs to accompany home-delivered meal services.
The efficacy of these types of interventions is supported by research
which finds that the addition of volunteer visitors to planned
homemaking and nursing care made a difference for elderly in the
community (MacIntyre, 1999).
Numerous Meals on Wheels programs across the country are
helping to support older adults with pets by also delivering pet food
along with the seniors' meals. As noted by Senator Cortez Masto and Dr.
Kaye, pets can alleviate social isolation, feelings of loneliness and
doctor visits among older adults, especially among individuals who live
alone (Stanley et al., 2014).
Dr. Kaye discussed the importance of technology as a
potentially powerful tool for connecting socially isolated older adults
and introduced the University of Maine's initiative to develop these
tools. Some Meals on Wheels programs are, in fact, partnering with
businesses and other local community organizations to install
technologies in clients' homes that would help facilitate both social
connections and telehealth. Although leading to some positive outcomes,
we must also reiterate Dr. Holt-Lunstad's caution that more research is
necessary to better understand which interventions are most effective
and under what conditions, as we do not fully understand the adverse
effects of some of these newer technologies (Chen et al., 2016).
An important strategy for addressing social isolation is
getting homebound seniors out into their communities. One particularly
innovative and exciting program called ``Outings to Your Taste'' took
older adults receiving home-delivered meals to a restaurant of their
choosing. The program seemed to attract socio-demographically diverse
clients, and older adults who participated seemed satisfied with the
endeavor (Richard et al., 2000).
In a multifaceted approach to addressing both social
isolation and health, one initiative trained Meals on Wheels volunteers
in health literacy coaching (Rubin et al., 2013). Loneliness has been
associated with poor health behaviors, which adversely impacts health
outcomes. This type of intervention also appeals to the call for more
preventative work in the areas of both health and social isolation
(Nicholson, 2012).
Challenges Holding Meals on Wheels Back
As outlined throughout this statement, Meals on Wheels programs are
already doing much to address the issues of isolation among the
nation's elderly, but more can and should be done. The issues of senior
isolation and hunger is grave and growing, with 1 in 4 seniors living
alone and 1 in 6 struggling with hunger, a 65% increase since the start
of the recession in 2007. Federal funding through the OAA has not kept
pace with either inflation or need, and the network overall is serving
23 million fewer meals today than we were in 2005. In 2014, funding
provided through the OAA supported the provision of meals to 2.4
million seniors, yet there are millions more in need. In fact, a 2015
Government Accountability Office report found that about 83% of food
insecure seniors and 83% of physically impaired seniors did not receive
meals [through the OAA], but likely needed them. This gap, coupled with
an increasing demand as the senior population grows at an unprecedented
pace, portends a serious national dilemma. With this backdrop, we urge
your consideration of the following policy priorities:
1. Fund, Protect and Strengthen the Older Americans Act
Nutrition Program
The OAA has been the primary piece of federal legislation
supporting social and nutrition services to Americans age 60 and older
since 1965. In 2014, the last year for which data exists, the OAA
enabled 218 million meals to be provided to 2.4 million seniors.
Despite the longstanding bipartisan, bicameral support for the Act, it
remains woefully underfunded. As such, we ask Congress to:
Provide, at a minimum, a total of $874.6 million for all
three nutrition programs authorized under the OAA (Congregate Nutrition
Program, Home-Delivered Nutrition Program and the Nutrition Services
Incentive Program) in FY 2018. Current funding is $36.8 million below
the levels authorized under the Older Americans Act Reauthorization Act
and unanimously passed by Congress last year.
End sequestration for FY 2018 and beyond and replace it
with a balanced plan. OAA programs, among others, were hit hard by the
unnecessary and harsh cuts in 2013 and waiting lists for Meals on
Wheels continue to climb in every state.
2. Modify Medicare and Medicaid plans, as recommended by
the National Commission on Hunger, to improve
nutrition assistance options for our most
vulnerable
The health consequences of inadequate nutrition are particularly
severe for seniors. Proper nutrition, on the other hand, averts
unnecessary visits to the emergency room, reduces falls, admissions and
re-admissions to hospitals, saving substantial Medicare and Medicaid
expenditures. It is notable that a senior can receive Meals on Wheels
for an entire year for about the same cost of 1 day in the hospital or
10 days in a nursing home. Accordingly, we recommend the following:
Expand Medicare managed care plans to include coverage
for home-delivered meals prepared and delivered by a private nonprofit
for seniors with physician recommendation.
Expand Medicaid managed care plans to include coverage,
with a physician recommendation, for home-delivered meals prepared and
delivered by a private nonprofit for individuals who are too young for
Medicare, but who are at serious medical risk or have a disability.
Allow doctors to write billable Medicare and Medicaid
``prescriptions'' for nutritious and medically appropriate meals
prepared and delivered by a private nonprofit for individuals prior to
being discharged from a hospital.
Across the nation, we already see some outstanding initiatives to
address social inclusion through Meals on Wheels services, but more
systematic research and evaluation is necessary. In this effort, Meals
on Wheels is beginning a research project that will test the effects of
various types of loneliness interventions, including those that are
technology-based, employed through Meals on Wheels programs. We again
applaud Chairman Collins and Ranking Member Casey for holding the first
congressional hearing on social isolation and loneliness among older
adults. We cannot emphasize enough the timeliness of raising public
awareness on this hidden issue.
We look forward to working with every Member of the Committee to
advance this agenda and ultimately, to not only eradicate senior hunger
in our country, but also to make sure no older adult feels alone or
left behind. We hope this information has been instructive and are
pleased to offer our assistance and expertise at any time.
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