Isolation

Definition

Isolation in the context of senior health usually refers to social isolation rather than to the medical practice of isolating persons with contagious illnesses. Social isolation has been defined by the Cornell Institute for Translational Research on Aging (CITRA) as “the lack of access to social support and the lack of meaningful social relationships , roles, and activities.” As this definition suggests, social isolation should not be confused with solitude, living by oneself, or loneliness. Solitude refers to being apart from others, whether for a short period of time or longer, and is usually self-chosen. People of all ages often need solitude in order to focus on work or to rest; many believe that solitude is an important precondition for artistic or scientific creativity. Some people may go on periodic religious retreats in order to deepen their spiritual life through a period of solitude; thus it is not being alone in and of itself that defines a person as socially isolated.

With regard to living by oneself, a senior may live alone in a house or apartment and still have frequent contacts with friends and family members or participate in various community activities. Loneliness, on the other hand, is an emotional condition that may affect a person without regard to age or to his or her living situation. Loneliness is usually understood as an internal sense of emptiness or hollowness, of feeling cut off and disconnected from others; it is stronger and more painful than a simple desire for the company of another person. It is thus possible for someone to feel lonely even though they are sharing a household with several other people.

Description

Social isolation in the senior population has become a concern to health care professionals and policy makers since the 1960s, when gerontology (the branch of medicine dealing with older adults) first emerged as a separate specialty. The aging of the so-called baby boomer generation has intensified this concern, particularly because a number of studies have linked social isolation to an increased risk of physical and mental illnesses ranging from heart disease and cancer to depression and panic disorder .

Effects of social isolation

The connections between social isolation and these various diseases and disorders are still not fully understood as of 2008, although there is general agreement that the effects of social isolation depend on the amount of control a senior has over his or her living situation. That is, a senior who is in good physical and mental health and can participate in social activities when they wish to is less likely to feel socially isolated than someone who has mobility problems or is in the early stages of dementia.

One theory maintains that social isolation in and of itself produces stress on the body, leading to a lowkey version of the fight-or-flight reaction that raises the risk of physical illness if it persists for long periods of time. Conversely, social contacts with others supposedly reduce emotional stress and its long-term effects on health. Some animal studies have been cited in support of this theory.

A second theory maintains that social contacts are beneficial to a senior's health because other people influence the senior's attentiveness to self-care and compliance with medical recommendations. Friends and family members can also discourage smoking , excessive drinking, and other behaviors that are harmful to health. A variation on this theory maintains that social contacts improve a senior's access to other sources of companionship or help, such as medical referral networks or support groups of various types, thus multiplying the number of the senior's contacts with others.

Causes of isolation

Most of the research that has been done on social isolation among the elderly has been done among seniors living in large cities rather than in small towns or rural areas. To some extent this focus is the result of the special problems facing seniors in crowded urban areas. A study that was done by CITRA on seniors living in the New York City area identified several causes that contribute to isolation among older adults:

• Demographic changes that have increased the number of seniors living alone. As of the early 2000s, seniors are the age group in the United States most likely to live alone; 28 percent of Americans over 65 live by themselves. Three times as many women as men live alone. Over time, older Americans have becomes less likely to live with a relative other than a spouse—a change brought about by a combination of the rising divorce rate since the 1960s, the baby boomers' preference for smaller families, and increased geographical mobility. Although most seniors have at least one adult child, they may live hundreds of miles away from him or her. While living alone does not indicate by itself that a senior is socially isolated, it is thought to be a risk factor for eventual social isolation.
• Role loss. As a senior gets older, he or she is likely to lose one or more of the roles that connect him or her with others, such as husband or wife, employer or employee, friend or neighbor. It is also harder for seniors to make new friends as their friendship circle is narrowed by death or as former neighbors move away.
• Differences between men and women. Although women are more likely than men to be widowed and not remarry, they are also more likely to maintain social networks as they age. Men tend to rely on their wives to maintain their social networks and may have serious difficulties finding social support after a wife's death. A Swedish study of older men with prostate cancer reported in 2000 that nine out of every 10 patients in the study had only their spouse to confide in, and eight out of every 10 single men had no one they could call on for social support. The authors of the study concluded that gender has to be taken into account in evaluating a senior's social isolation.
• Health problems. Seniors with physical disabilities, cognitive decline, or mood disorders are more vulnerable to social isolation.
• Poverty. Of all seniors living alone and below the poverty line, 34 percent have no contact with friends or neighbors for two weeks at a time, and 20 percent have no phone conversations with friends or family.
• Language difficulties. Some seniors, particularly in large cities, are recent immigrants with poor command of English. A study published in 2007 reported that elderly Chinese in the United States are vulnerable to elder abuse as well as social isolation because of their language difficulties.

Social isolation and elder abuse

Social isolation is a concern because of its connection with elder abuse ; social isolation of caregivers as well as the abused elders themselves has been identified as a major risk factor for abuse. Such isolation reduces the likelihood that others will intervene to protect the abused elder. In addition, the senior's fear of the consequences of reporting the abuse reinforces his or her feelings of loneliness and helplessness.

Viewpoints

A number of programs and proposals have been put forward to help seniors deal with social isolation.

Public policy measures

Some public policy measures that have been proposed include making demographic analyses of neighborhoods within large cities and targeting those with a high population of vulnerable seniors (based on the number of seniors living alone and the level of their need for services).

Within the medical profession, some doctors have suggested screening seniors in primary care settings for signs of depression and other mood changes that often indicate social isolation. A common instrument used to screen for depression in seniors is the Geriatric Depression Scale, or GDS, first used in 1983 and translated into many different languages. The short form of the GDS consists of 15 questions with yes/no answers; the longer form has 30 questions. The GDS can be used by a senior's dentist, a visiting nurse, or any health care professional who is concerned about the senior's well-being.

Visitation programs

Volunteer approaches to the issue of social isolation in the senior population often take the form of visitation programs. Some churches and synagogues have groups of lay leaders who visit elderly members on a regular basis; in some cases, youth in the congregation “adopt” seniors and visit them on their birthdays and major religious occasions. In recent years, some colleges and universities have started volunteer programs that pair students with seniors living near the school. Many of these relationships turn into long-term friendships. Some organizations that sponsor intergenerational friendships include Dorot, which serves Jewish seniors in the New York City area, and Little Brothers-Friends of the Elderly (LBFE), a group that was started in France in 1946 by Armand Marquiset (1900–1981), a French nobleman who wanted to relieve the suffering of the elderly after the devastation of World War II. The American branch of LBFE was founded in 1959.

Other approaches

Other approaches that have been used with some success in reducing social isolation among seniors are:

• The formation of hobby groups and other interest groups recruited from neighborhoods where the members will see each other outside the group meetings.
• Programs that have some kind of educational component; this feature appears to increase the members' level of interest in and commitment to the group.
• Internet-based programs. One study done in the Netherlands reported that introducing homebound seniors to the Internet helped alleviate loneliness, with e-mail and online chat groups found to be the seniors' favorite activities.
• Pet therapy. A number of studies have reported that caring for a cat or dog not only relieves loneliness for seniors but also leads to forming new social contacts with other pet owners and keeping more active physically. The Delta Society, a group formed in 1977 to study and encourage the human/animal bond, has several of these studies posted on its website.

KEY TERMS

Gerontology —The branch of medicine that deals with the study of older adults and the aging process.

Loneliness —An internal feeling of hollowness or emptiness combined with a sense of being cut off from or estranged from other people. It can affect people who share a household with others as well as those who live alone.

Solitude —The condition or situation of being apart from other people, whether short-term or long-term. It is often self-chosen for the sake of privacy or to rest or work undisturbed.

It is generally agreed, however, that further research is needed in order to counteract social isolation among seniors more effectively. As of 2008, the approaches that seem to work best are those that target specific groups of seniors with clearly defined needs or interests.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 15, “Social Issues.” Whitehouse Station, NJ: Merck, 2005.

PERIODICALS

Brummett, B. H., D. B. Mark, I. C. Siegler, et al. “Perceived Social Support as a Predictor of Mortality in Coronary Patients: Effects of Smoking, Sedentary Behavior, and Depressive Symptoms.” Psychosomatic Medicine 67 (January-February 2005): 40–45.

Dong, X., M. A. Simon, M. Gorbien, et al. “Loneliness in Older Chinese Adults: A Risk Factor for Elder Mistreatment.” Journal of the American Geriatrics Society 55 (November 2007): 1831–1835.

Fokkema, T., and K. Knipscheer. “Escape Loneliness by Going Digital: A Quantitative and Qualitative Evaluation of a Dutch Experiment in Using ECT to Overcome Loneliness among Older Adults.” Aging and Mental Health 11 (September 2007): 496–504.

Helgason, A. R. et al. “Emotional Isolation: Prevalence and the Effect on Well-Being among 50-80-Year-Old Prostate Cancer Patients.” Scandinavian Journal of Urology and Nephrology 35 (April 2001): 97–101.

Lachs, M. S., and K. Pillemer. “Elder Abuse.” Lancet 364 (October 2-8, 2004): 1263–1272, Raina, P., D. Waltner-Toews, B. Bonnett, et al. “Influence of Companion Animals on the Physical and Psychological Health of Older People: An Analysis of a One Year Longitudinal Study.” Journal of the American Geriatrics Society 47 (March 1999): 323–329.

Sharp, Lisa K., and Martin S. Lipsky. “Screening for Depression across the Lifespan: A Review of Measures for Use in Primary Care Settings.” American Family Physician 66 (September 15, 2002): 1001–1008.

Stratton, D. C., and A. J. Moore. “Fractured Relationships and the Potential for Abuse of Older Men.” Journal of Elder Abuse and Neglect 19 (January-February 2007):75–97.

Wilson, R. S., et al. “Loneliness and Risk of Alzheimer Disease.” Archives of General Psychiatry 64 (February 2007): 234–240.

OTHER

Dutton, Audrey. “Visitation Programs Relieve Isolation of the Elderly.

” Columbia News Service, February 14, 2006. Available online at http://jscms.jrn.columbia.edu/cns/2006-02-14/dutton-visitorsforelderly/ [cited March 5, 2008].

Friedman, Michael B., and Kimberley A. Steinhagen. Issues in Geriatric Mental Health Policy. New York: Geriatric Mental Health Alliance of New York, 2004. Available online in PDF format at http://www.mhawestchester.org/advocates/issuesd1004.pdf [cited March 5, 2008].

Geriatric Depression Scale (GDS). Available online at http://www.stanford.edu/̃yesavage/GDS.html [cited March 5, 2008]. Page contains links to foreign-language as well as the short and long English versions.

Gusmano, Michael K., and Victor G. Rodwin. The Elderly and Social Isolation. Testimony to the New York City Council, February 13, 2006. Available online at http://www.ilcusa.org/media/pdfs/ElderlyandSocialIsolation.pdf [cited March 5, 2008].

ORGANIZATIONS

Cornell Institute for Translational Research on Aging (CITRA), Beebe Hall, Second Floor, Cornell University, Ithaca, NY, 14853, (607) 254 4336, (607) 254 2903, http://www.citra.org/index.php.

Delta Society, 875 124th Avenue NE, Suite 101, Bellevue, WA, 98005, (425) 679-5500, (425) 679-5539, [email protected], http://www.deltasociety.org/index.htm.

Dorot, 171 West 85th Street, New York, NY, 10024, (212) 769-2850, [email protected], http://www.dorotusa.org/site/PageServer?pagename=homepage_DOROT.

Geriatric Mental Health Alliance (MHA) of New York City, 666 Broadway, Suite 200, New York, NY, 10012, (212) 614-5753, http://www.mhawestchester.org/advocates/geriatrichome.asp.

Little Brothers-Friends of the Elderly (LBFE), 28 East Jackson Boulevard, Suite 405, Chicago, IL, 60604, (312) 786-1032, (312) 786-1067, http://www.littlebrothers.org/.

Rebecca J. Frey Ph.D.

Isolation

Definition

Isolation refers to the precautions that are taken in the hospital to prevent the spread of an infectious agent from an infected or colonized patient to susceptible persons.

Purpose

Isolation practices are designed to minimize the transmission of infection in the hospital, using current understanding of the way infections can transmit. Isolation should be done in a user friendly, well-accepted, inexpensive way that interferes as little as possible with patient care, minimizes patient discomfort, and avoids unnecessary use.

Precautions

The type of precautions used should be viewed as a flexible scale that may range from the least to the most demanding methods of prevention. These methods should always take into account that differences exist in the way that diseases are spread. Recognition and understanding of these differences will avoid use of insufficient or unnecessary interventions.

Description

Isolation practices can include placement in a private room or with a select roommate, the use of protective barriers such as masks, gowns and gloves, a special emphasis on handwashing (which is always very important), and special handling of contaminated articles. Because of the differences among infectious diseases, more than one of these precautions may be necessary to prevent spread of some diseases but may not be necessary for others.

The Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control Practice Advisory Committee (HICPAC) have led the way in defining the guidelines for hospital-based infection precautions. The most current system recommended for use in hospitals consists of two levels of precautions. The first level is Standard Precautions which apply to all patients at all times because signs and symptoms of infection are not always obvious and therefore may unknowingly pose a risk for a susceptible person. The second level is known as Transmission-Based Precautions which are intended for individuals who have a known or suspected infection with certain organisms.

Frequently, patients are admitted to the hospital without a definite diagnosis, but with clues to suggest an infection. These patients should be isolated with the appropriate precautions until a definite diagnosis is made.

Standard Precautions

Standard Precautions define all the steps that should be taken to prevent spread of infection from person to person when there is an anticipated contact with:

• Blood
• Body fluids
• Secretions, such as phlegm
• Excretions, such as urine and feces (not including sweat) whether or not they contain visible blood
• Nonintact skin, such as an open wound
• Mucous membranes, such as the mouth cavity.

Standard Precautions includes the use of one or combinations of the following practices. The level of use will always depend on the anticipated contact with the patient:

• Handwashing, the most important infection control method
• Use of latex or other protective gloves
• Masks, eye protection and/or face shield
• Gowns
• Proper handling of soiled patient care equipment
• Proper environmental cleaning
• Minimal handling of soiled linen
• Proper disposal of needles and other sharp equipment such as scalpels
• Placement in a private room for patients who cannot maintain appropriate cleanliness or contain body fluids.

Transmission Based Precautions

Transmission Based Precautions may be needed in addition to Standard Precautions for selected patients who are known or suspected to harbor certain infections. These precautions are divided into three categories that reflect the differences in the way infections are transmitted. Some diseases may require more than one isolation category.

AIRBORNE PRECAUTIONS. Airborne Precautions prevent diseases that are transmitted by minute particles called droplet nuclei or contaminated dust particles. These particles, because of their size, can remain suspended in the air for long periods of time; even after the infected person has left the room. Some examples of diseases requiring these precautions are tuberculosis, measles, and chickenpox.

A patient needing Airborne Precautions should be assigned to a private room with special ventilation requirements. The door to this room must be closed at all possible times. If a patient must move from the isolation room to another area of the hospital, the patient should be wearing a mask during the transport. Anyone entering the isolation room to provide care to the patient must wear a special mask called a respirator.

DROPLET PRECAUTIONS. Droplet Precautions prevent the spread of organisms that travel on particles much larger than the droplet nuclei. These particles do not spend much time suspended in the air, and usually do not travel beyond a several foot range from the patient. These particles are produced when a patient coughs, talks, or sneezes. Examples of disease requiring droplet precautions are meningococcal meningitis (a serious bacterial infection of the lining of the brain), influenza, mumps, and German measles (rubella ).

Patients who require Droplet Precautions should be placed in a private room or with a roommate who is infected with the same organism. The door to the room may remain open. Health care workers will need to wear masks within 3 ft of the patient. Patients moving about the hospital away from the isolation room should wear a mask.

CONTACT PRECAUTIONS. Contact Precautions prevent spread of organisms from an infected patient through direct (touching the patient) or indirect (touching surfaces or objects that that been in contact with the patient) contact. Examples of patients who might be placed in Contact Precautions are those infected with:

• Antibiotic-resistant bacteria
• Hepatitis A
• Scabies
• Impetigo
• Lice.

This type of precaution requires the patient to be placed in a private room or with a roommate who has the same infection. Health care workers should wear gloves when entering the room. They should change their gloves if they touch material that contains large volumes of organisms such as soiled dressings. Prior to leaving the room, health care workers should remove the gloves and wash their hands with medicated soap. In addition, they may need to wear protective gowns if there is a chance of contact with potentially infective materials such as diarrhea or wound drainage that cannot be contained or if there is likely to be extensive contact with the patient or environment.

Patient care items, such as a stethoscope, that are used for a patient in Contact Precautions should not be shared with other patients unless they are properly cleaned and disinfected before reuse. Patients should leave the isolation room infrequently.

Resources

BOOKS

Edmond, M. "Isolation." In A Practical Handbook for Hospital Epidemiologists, edited by L. A. Herwaldt and M. D. Decker. Thorofare, NJ: Slack Inc., 1998.

KEY TERMS

Colonized— This occurs when a microorganism is found on or in a person without causing a disease.

Disinfected— Decreased the number of microorganisms on or in an object.

Latex— A rubber material which gloves and condoms are made from.

Phlegm— Another word for sputum; material coughed up from a person's airways.

Stethoscope— A medical instrument for listening to a patient's heart and lungs.

389. Isolation (See also Imprisonment, Remoteness.)

1. Alcatraz Island “The Rock”; former federal prison in San Francisco Bay. [Am. Hist.: Flexner, 218]
2. Alison’s House reclusive woman guards secrets and poems of her dead sister. [Am. Drama: Glaspel Alison’s House in Sobel, 18]
3. Aschenbach, Gustave von spiritual and emotional solitude combine in writer’s deterioration. [Ger. Lit.: Death in Venice ]
4. Count of Monte Cristo Edmond Dantès imprisoned in the dungeons of Château D’If for 14 years. [Fr. Lit.: The Count of Monte Cristo, Magill I, 158–160]
5. Crusoe, Robinson man marooned on a desert island for 24 years. [Brit. Lit.: Robinson Crusoe, Magill I, 839–841]
6. Dickinson, Emily (1830–1886) secluded within the walls of her father’s house. [Am. Lit.: Hart, 224]
7. Hermit Kingdom Korea, when it alienated itself from all but China (c. 1637—c. 1876). [Korean Hist.: NCE, 1233]
8. Iron Curtain political and ideological barrier of secrecy concealing Eastern bloc. [Eur. Hist.: Brewer Dictionary, 490]
9. Magic Mountain, The suspended in time, which exists in flat world below. [Ger. Lit.: The Magic Mountain, Magill I, 545–547]
10. Man Without a Country, The story of man exiled from homeland. [Am. Lit.: The Man Without a Country, Magill I, 553–557]
11. Olivia “abjured the company and sight of men.” [Br. Lit.: Twelfth Night ]
12. prisoner of Chillon cast into a lightless dungeon and chained there for countless years. [Br. Lit.: Byron The Prisoner of Chillon in Benét, 817]
13. Selkirk, Alexander (1676–1721) marooned on Pacific island; thought to be prototype of Robinson Crusoe. [Scot. Hist.: EB, IX: 45]
14. Sleepy Hollow out-of-the-way, old-world village on Hudson. [Am. Lit.: “Legend of Sleepy Hollow” in Benét, 575]
15. Stylites medieval ascetics; resided atop pillars. [Christian Hist.: Brewer Dictionary, 1045]
16. Stylites, St. Simeon lived 36 years on platform atop pillar. [Christian Hagiog.: Attwater, 309]

ISOLATION

"Isolation" is the defense mechanism characteristic of obsessional neurosis. The links of a thought, idea, impression, or feeling with other thoughts or behaviors are broken by means of pauses, rituals, magical formulas, or other such devices.

In "The Neuro-Psychoses of Defense," Freud conceived of defense, in hysteria as well as in phobias and obsessions, as a form of isolation: "defense against the incompatible idea [is] effected by separating it from its affect; the idea itself [remains] in consciousness, even though weakened and isolated" (1894a, p. 58).

In the case of the "Rat Man," Freud wrote suggestively of "isolation" though still without naming it as a specific neurotic defense mechanism. He wrote that, in contradistinction to hysteria, in which amnesia attests to a successful repression, obsessional neurosis reveals that "[t]he infantile preconditions of the neurosis may be overtaken by amnesia, though this is often an incomplete one. . . . The trauma, instead of being forgotten, is deprived of its affective cathexis; so that what remains in consciousness is nothing but its ideational content, which is perfectly colourless and is judged to be unimportant" (Freud 1909d, pp. 105-106). Thus, in obsessional neurosis, "patients will endeavour to 'isolate ' all such protective acts from other things" (p. 243).

In Inhibitions, Symptoms and Anxiety (1926d), Freud returned to the analysis of isolation as a defense mechanism in obsessional neurosis—a view that Anna Freud would further develop in 1936—and he emphasized how isolation involves the "the taboo on touching" to the extent that it involves "removing the possibility of contact; it is a method of withdrawing a thing from being touched in any way. And when a neurotic isolates an impression or an activity by interpolating an interval, he is letting it be understood symbolically that he will not allow his thoughts about that impression or activity to come into associative contact with other thoughts" (pp. 121-122).

Elsa Schmid-Kitsikis

See also: Defense mechanisms; Ego and the Mechanisms of Defence, The ; Inhibitions, Symptoms and Anxiety ; Neurotic defenses; Obsessional neurosis.

Bibliography

Freud, Anna. (1966). The ego and the mechanisms of defence. New York: International Universities Press.

Freud. Sigmund. (1894a). The neuro-psychoses of defence. SE 3: 41-61.

——. (1909d). Notes upon a case of obsessional neurosis. SE 10: 151-318.

——. (1926d). Inhibitions, symptoms and anxiety. SE 20: 75-172.

ISOLATION

In epidemiology isolation refers to a procedure used in communicable disease control. It consists of a separation of cases (persons or animals) for a disease's period of communicability. The cases are isolated in a specific location and under conditions that minimize the risk of direct or indirect transmission of the infectious agents to those who may be susceptible. The American Public Health Association's Control of Communicable Diseases Manual, 17th edition, recommends "universal precautions" to prevent the transmission of blood-borne agents and strict hygienic measures such as thorough hand washing after attending to infectious cases and disinfection of articles that have been in contact with infectious cases.

The Centers for Disease Control's Guidelines for Isolation Precautions in Hospitals identifies several categories of isolation that are appropriate according to the mode of transmission of the infectious agent. Strict isolation is used for highly contagious or virulent infections in which the agent may be spread by direct contact or droplet. Procedures include segregation in a private room; use of gowns, masks, and gloves; and sometimes special ventilation. Contact isolation is used for less dangerous conditions spread by direct contact. Measures similar to strict isolation are employed, but more than one person may share a room and sometimes barrier nursing suffices. Respiratory isolation is used to prevent airborne transmission of infectious agents—it resembles contact isolation in that infectious patients may share a room. Tuberculosis isolation is used for patients known or suspected to be excreting tubercle bacilli in sputum. A private room with the door closed is required, as well as the same procedures used for contact and respiratory isolation and the use of respirator-type masks by all who enter the room. Gowns are used but gloves are unnecessary. Enteric precautions are used when the infectious agent is transmitted in feces. These precautions resemble contact isolation and include particular care in sanitary disposal of feces. Drainage/secretion precautions are used when patients are discharging purulent material, such as that from an abscess or other infected body site. A private room is not necessary, and gowns and gloves are indicated if attendants have to touch contaminated material.

John M. Last

(see also: Barrier Nursing; Communicable Disease Control; Nosocomial Infections; Quarantine; Universal Precautions )