The Face of God Revealed.

Many years have passed since I visited Donny in the hospital, where he was admitted with a newly diagnosed and terminal lung cancer. Despite years of separation, his wife Rose took him back into her home and cared for Donny at the end of his life. In the months after his death, I learned more about their relationship; Donny's drinking and infidelities, the emotional and verbal abuse that Rose put up with. At the end of one office visit, I was incredulous in silent amazement and asked her, "Why did you do it?" Rose looked at me and simply said, "Because he was one of us; because he was family." As she repeated this, I saw the face of God gazing at me. Well before caring for Donny and Rose, a spiritual director encouraged me to work on describing my image of God. It was an arid time and place on my interior journey and the activity felt forced and inauthentic. Although Rose died more than 5 years ago, I still think of her and reflect on my life as a physician practicing in the shadow of the COVID-19 pandemic. As she looks at me, my uncertainties scatter and her image draws down and stirs divine wellsprings in me.

Addressing Loneliness and Social Isolation in Older Adults

The incidence of cardiovascular disease and mental health disorders is significantly increased, and socially isolated individuals report a higher prevalence of tobacco product usage and other deleterious health behaviors.1,3,5,7 Individuals who are socially isolated and/or lonely also report higher rates of health service utilization that may be because of greater disease occurrence and/or increased outreach provided by health service agencies.1 Nevertheless, these individuals report decreased adherence with medical advice.3,8 IDENTIFYING LONELINESS AND SOCIAL ISOLATION Family physicians recognize the importance of loneliness as a condition that affects their patients but are often limited in their ability to reliably identify affected patients.9 The U.S. Preventive Services Task Force does not have a recommendation about screening for loneliness and social isolation;however, a recent report from the National Academy of Medicine provides guidance.1 Universal screening is not currently indicated because of the paucity of evidence-based interventions;however, physicians may consider assessments using validated tools, such as the Berkman-Syme10 or UCLA Loneliness Scale.1,11 Screening may be indicated in at-risk patients, for example, in those who have experienced a challenging life event such as the loss of a loved one, those who disclose limited social networks, or those who have frequent health care use.1 When patients at risk have been identified, physicians should consider discussing the adverse health outcomes associated with social isolation and loneliness with their patients and caregivers and investigate for underlying health or functional limitations that may be contributing factors.1 There is growing interest in information technology as a platform for assessing social isolation and loneliness.1 Several technologies are being explored as tools to identify or predict patterns of social isolation, including home-based activity monitoring, tracking of online and electronic usage patterns, and wearable devices that record sleep and physical activity.1 STRATEGIES TO MITIGATE LONELINESS AND SOCIAL ISOLATION There is currently limited evidence to support specific interventions to mitigate the health effects of social isolation and loneliness. The recent National Academy of Medicine report also noted the limited evidence base supporting interventions;however, the report provided approaches that could be implemented by family physicians caring for patients who are experiencing social isolation and loneliness.1 Social prescribing is an approach involving the activities that health care professionals can suggest to link patients with nonclinical support services, which are often found in the community.1 Primary care physicians can implement social prescribing in multiple ways, including a direct referral to community-based agencies through the use of a practice-based care manager for assessing needs and tailoring the referral or by providing access to a directory of support services for patients and family caregivers.1 Peer support groups, particularly for patients with a shared illness or condition, have an extensive evidence base in chronic disease self-management and may benefit those who are socially isolated or lonely.1,14 Although cognitive behavior therapy and interpersonal psychotherapy have the potential to mitigate the negative perceptions of social interactions, the evidence demonstrating effectiveness is limited.1 In addition to its role in assessment, information technology may offer new tools to deliver individual or group interventions to this population.1 Social media virtual communities and video-assisted friendly visits are among these intervention strategies that are currently being researched.1 The National Academy of Medicine recommends that physicians, clinical practices, and health care systems partner with community-based providers to promote care that includes and facilitates the use of tailored social services in addressing social isolation and loneliness in older adults.1 Many countries, having identified the public health implications of social isolation and loneliness, have launched initiatives to support systems-level interventions, and regional organizations have created directories of resources (Table 2). [...]screening for comorbid mood disorders may provide an opportunity to offer a more directed intervention, such as cognitive behavior therapy.