Quality of Life Research

https://doi.org/10.1007/s11136-020-02493-7

Factors associated with social isolation in community‑dwelling older

adults: a cross‑sectional study
Reshma A. Merchant1,3   · Shumei Germaine Liu1 · Jia Yi Lim3 · Xiaoxi Fu1 · Yiong Huak Chan2

Accepted: 26 March 2020

© Springer Nature Switzerland AG 2020

Abstract
Purpose  Social isolation in older adults is a major public health problem and associated with increased morbidity and mor-
tality. There are limited data on the association between social isolation and physical function including gait speed. Hence,
this study is to determine the prevalence of social isolation and its association with gait speed, frailty, cognition, depression
and comorbidities amongst community-dwelling older adults.
Methods  Social isolation, depression, frailty and perceived general health were assessed using 6-item Lubben Social Network
Scale (LSNS-6), Geriatric Depression Scale (GDS), FRAIL scale and EuroQol EQ-5D-5L questionnaire which includes EQ
Visual Analogue Scale (EQ-VAS), respectively. Cognition was assessed using the Chinese Mini Mental State Examination
(cMMSE), while physical performance test included gait speed and short physical performance battery test. Binary logistic
regression was performed to determine the influence of socio-demographic, medical, functional and cognitive variables on
social isolation.
Results  Out of 202 participants, 27.7% were robust, 66.8% of participants were pre-frail, and 5.4% of participants were
frail. Almost half (45.5%, n = 92) of the participants were found to be at risk of social isolation. A poor social network was
negatively associated with mean gait speed (OR = 0.674, CI 0.464–0.979, p = 0.039), EQ-VAS (OR = 0.561, CI 0.390–0.806,
p < 0.01) and cMMSE (OR = 0.630, 95% CI 0.413–0.960, p = 0.032).
Conclusion  Almost half of older adults in the community are at risk of social isolation with a very significant association
with gait speed, cMMSE and EQ-VAS scores.

Keywords  Social isolation · Older adults · Gait speed · Quality of life

Introduction 65 years and above in Singapore accounts for 13.7% of the

The world’s population is ageing especially in Asia where
the number of persons aged 60 years and older is grow-
ing faster than all younger age group [1]. Older adults aged
Electronic supplementary material  The online version of this
article (https​://doi.org/10.1007/s1113​6-020-02493​-7) contains
supplementary material, which is available to authorized users.
* Reshma A. Merchant
reshmaa@nuhs.edu.sg
1
Division of Geriatric Medicine, Department of Medicine,
National University Hospital, 1E Kent Ridge Road,
Singapore 119228, Singapore
2
Biostatistics Unit, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
3
Department of Medicine, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
total population, and will double by 2030 [2]. Singapore is
ranked third in global life expectancy ranking [3]. Commu-
nities that facilitate healthy ageing in place are increasingly
relevant in meeting these needs, especially with a growing
trend of older adults preferring to live in their own homes
and communities, even if this means living alone [4, 5].
In addition to being healthy and enabling an individual to
age in place, strong social networks have a direct impact on
health and well-being, with studies showing an association
with increased quality of life [6] and a protective effect on
cognition and the development of dementia [7]. Conversely,
social isolation in older adults has been shown to increase
hospital readmission, disease morbidity and mortality rates
[8, 9]. It has been debated that effect of social isolation on
mortality is comparable to quitting smoking and exceeds
many well-known risk factors such as obesity and physi-
cal inactivity [10]. Older adults are particularly at risk for

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social isolation and poor social network due to retirement,
mobility limitation, age related physiological changes such
as vision and hearing impairments and increasing ill health.
International institutions such as World Health Organization
(WHO) have flagged social isolation as a key social and pol-
icy issue for ageing [11, 12]. There are numerous initiatives
in place to address social isolation, and many countries are
now looking into the age-friendly cities (AFC) and commu-
nities movement promoted by WHO. Such AFCs are adapted
in various ways, for example, built-environment, to support
the daily needs of the ageing population while promoting
active ageing [13].
Social isolation and loneliness while related are two
separate constructs. Social isolation can be defined objec-
tively as having either reduced number of social contacts
and frequency of interactions or subjectively as feeling iso-
lated or low quality interactions. Loneliness is a state of
emotion which is evaluated subjectively [14] and can result
from perceived social isolation [15, 16]. A myriad of fac-
tors have been found to be associated with social isolation
in old age; these includes low socioeconomic status [17],
poor health status [18], impaired mobility [19, 20] as well as
cognitive function [21, 22]. Amongst these factors, decline
in gait speed has been found to be reversible by commonly
used exercise interventions [23]. While there have been
an increasing number of studies looking at social isola-
tion in older adults, there are limited data on association
with physical measures including gait speed, frailty, medi-
cal comorbidities and cognition. This cross-sectional study
aims to determine the prevalence of social isolation amongst
community-dwelling older adults and its association with
physical function including gait speed and frailty, cogni-
tion and comorbidities. Identifying such associations is of
high importance for preventive measures to be implemented
before other health aspects are implicated.
Methods
An observational cross-sectional study was performed of
community-dwelling older adults aged 60 years and older.
Recruitment of the seniors took place between August
2017 and December 2018 through network of grassroots
volunteers, senior activity centres and words of peers who
attended the screening program intended to identify sen-
iors at risk, e.g. pre-frail, frail and those with cognitive
impairment.
The screening consisted of an interview questionnaire
and physical performance test. The interview questionnaire
included questions on socio-demographics, physical activ-
ity, frailty using the FRAIL (Fatigue, Resistance, Ambu-
lation, Illness, and Loss of Weight) scale [24], functional
status, chronic diseases, polypharmacy and social isolation
13
Quality of Life Research
using the Lubben Social Network Scale (LSNS-6). Func-
tional status was assessed using the Lawton IADL Scale [25]
and perceived general health was assessed using EuroQol
EQ-5D-5L questionnaire which comprises the EQ-5D-5L
descriptive system and EQ Visual Analogue Scale (EQ-
VAS) [26–28].
The 5-item FRAIL scale [24] has been extensively vali-
dated locally and in numerous populations across various
continents and in different settings [29, 30]. The FRAIL
scale is comparable in terms of function with the multidi-
mensional deficit accumulation frailty index in predicting
physical limitations and mortality [31]. The scores range
from 0 to 5, where scores of 3–5 represent frail and 1–2 pre-
frail. Fear of falling (FOF) was identified by asking “Are you
afraid of falling?’ [32]. For those who replied yes, they were
asked to choose between somewhat or very much afraid of
falling. Depression was assessed using the Geriatric Depres-
sion Scale (GDS) and cognition was assessed using the Chi-
nese Mini Mental State Examination (cMMSE).
The only dependent variable, risk of social isolation, was
measured using the 6-item Lubben Social Network Scale
(LSNS-6). LSNS-6 is a brief, validated instrument devel-
oped to measure social isolation in older adults including
size, closeness and frequency of contact with friends and
family members and correlates with self-perceived health
and physical activity limitations [33]. The total scale score
ranges from 0 to 30 obtained by summing the six items and
a score below 12 suggests at risk of social isolation. LSNS-6
has been validated in Asian populations including Malaysia,
China, Japan and Korea [15, 34].
Following the interview, participants were invited to take
part in several physical performance tests which were admin-
istered by trained staff. These tests were carried out in the
neighbourhood community centre or senior activity centres.
Physical performance screening included body mass index
(BMI), 10 m gait speed with 1 m acceleration and decelera-
tion, body mass index, Snellen test over 3 m (impairment if
at least one eye was worse than 6/18) and Short Performance
Physical Battery (SPPB) Test.
All statistical analyses were carried out using IBM
SPSS Statistics 25.0. Descriptive statistics for numerical
variables were presented as mean and standard deviations,
and frequencies and percentages for categorical variables.
Mann–Whitney U test (for quantitative) and chi-square test
(categorical) were used to test for significant differences in
demographics and health characteristics between those who
are at risk of social isolation and those who are not. Principle
components (PCA) were derived for these medical, func-
tional and cognitive variables (number of chronic disease,
cMMSE score, balance score, chair stand score, mean gait
speed, GDS score and perceived health rating) to resolve
multi-collinearity issues (which will dilute the significance
of the variables) by creating uncorrelated surrogate variables
Quality of Life Research

to be used together with socio-demographic in the binary
logistic regression to determine their influence on social
isolation in three models. Statistical significance was set at
p < 0.05.
Ethics approval was obtained from Domain-Specific
Review Board of National Healthcare Group, Singapore.
All participants provided signed consent.
Results
A total of 202 community-dwelling older adults partici-
pated in the study. As shown in Table 1, 158 (78.2%) of the
participants were female. The mean age of participants was
74.1 years. Participants reported an average of five years
of education and approximately one in every five partici-
pants (18.8%) was living alone. Most of the participants in
this study were pre-frail (66.8%, n = 135) or robust (27.7%,
n = 56), with only 5.4% (n = 11) of participants being frail.
About one in four had a lot of fear for fall (26.7%), seven in
ten (67.5%, n = 131) participants had vision impairment and
one in ten had at least two IADL impairment.
Almost one in two (45.5%) participants were found
to be at risk of social isolation. Individual responses to
LSNS-6 are shown in Annex 1. Three quarter (75.3%)
of older adults hear from three or more friends a month
but 47.0% (n = 95) and 46.0% (n = 93) do not have any
friends they feel at ease to talk about personal matters
or help them in difficulty, respectively. Significant differ-
ences between those at risk and not at risk of social isola-
tion were only found for years of education and having at
least two IADL impairment. There was a non-significantly
higher prevalence of fear of falling in the older adults at
risk of social isolation,
Tables 2 and 3 show factors associated with risk of
social isolation. After adjusting for participants’ charac-
teristics in Table 1 and confounding factors in Table 2, gait
speed, cMMSE and EQ-VAS scores in Model 3 which had
a marginal good fit with p = 0.078 (chi-sq = 12.1, df = 8)
remained significantly associated with risk of social iso-
lation. Older adults with slower gait speed were at 1.5
times risk of social isolation (adjusted OR = 0.674, CI
0.464–0.979) while those with lower EQ-VAS scores were
at 1.8 times risk (adjusted OR = 0.561, CI 0.390–0.806).
Those with lower cMMSE scores have 37% increased like-
lihood of being at risk of social isolation. For functional
status, while non-significant, those at risk of social isola-
tion had lower balance and chair stand scores.

Table 1  Characteristics of All Not at risk of social At risk of social p value#

participants n = 202 isolation isolation
n = 110 (54.5%) n = 92 (45.5%)

Gender (female) 158 (78.2) 86 (78.2) 72 (78.3) 0.989

Age 74.1 ± 7.9 73.4 ± 7.9 75.0 ± 7.9 0.226
BMI 24.0 ± 4.3 24.3 ± 4.4 23.6 ± 4.2 0.250
Ethnicity* 0.668
 Chinese 181 (89.6) 97 (88.2) 84 (91.3)
 Malay 17 (8.4) 11 (10.0) 6 (6.5)
 Indian 4 (2.0) 2 (1.8) 2 (2.2)  < 0.01
Years of education 5.0 ± 4.5 5.7 ± 4.6 4.1 ± 4.2
Frailty status 0.444
 Robust 56 (27.7) 32 (29.1) 24 (26.1)
 Pre-frail 135 (66.8) 74 (67.3) 61 (66.3)
 Frail 11 (5.4) 4 (3.6) 7 (7.6)
A lot fear of falling 54 (26.7) 23 (20.9) 31 (33.7) 0.124
Living alone 38 (18.8) 19 (17.3) 19 (20.7) 0.224
Vision impairment 131 (67.5) 70 (64.2) 61 (71.8) 0.266
At least two IADL impairment 19 (9.4) 4 (4.5) 14 (15.2) 0.010

Bold indicates p < 0.05

SD standard deviation
IADL Instrumental Activities of Daily Living
Values are n (%), otherwise mean ± SD
*Ethnicity was self-reported

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 Quality of Life Research

Table 2  Unadjusted and adjusted odds ratio for factors associated with risk of social isolation
Factors All Not at risk of social At risk of social Unadjusted Model ­1+
n = 202 isolation isolation OR (95% CI)
n = 110 n = 92 p value

Gait speed 1.14 ± 0.3 1.21 ± 0.3 1.07 ± 0.28 0.172 (0.061–0.488) 0.256 (0.073–0.904)

p < 0.01 p = 0.034
SPPB Balance score 3.4 ± 1.0 3.5 ± 0.8 3.2 ± 1.1 0.732 (0.543–0.988) 0.859 (0.598–1.235)
p = 0.041 p = 0.413
SPPB Chair stand score 2.9 ± 1.2 3.1 ± 1.2 2.7 ± 1.3 0.772 (0.613–0.973) 0.871 (0.667–1.136)
p = 0.028 p = 0.307
cMMSE score 25.5 ± 3.7 26.2 ± 3.1 24.7 ± 4.1 0.886 (0.815–0.962) 0.884 (0.792–0.987)
p < 0.01 p = 0.028
GDS 1.7 ± 1.9 1.6 ± 2.0 1.8 ± 1.7 1.069 (0.920–1.242) 1.014 (0.856–1.201)
p = 0.385 p = 0.874
EQ-VAS 72.1 ± 15.2 75.6 ± 12.7 67.9 ± 16.9 0.966 (0.947–0.985) 0.965 (0.943–0.987)
p < 0.01 p < 0.01
Number of chronic diseases 1.6 ± 1.3 1.4 ± 1.1 1.8 ± 1.4 1.209 (0.969–1.507) 1.215 (0.957–1.542)
p = 0.092 p = 0.110

Bold indicates p < 0.05

GDS Geriatric Depression Score, SPPB Short Physical Performance Battery Test, cMMSE Chinese Mini Mental State Examination
Values are mean ± SD
+
 Odd ratios adjusted for variables in Table 1

Table 3  Adjusted odds ratio for factors associated with risk of social 26.2 to 49.8% [15, 35, 36]. Almost half of the older adults
isolation felt they had no friends they could talk about personal
Factors Model ­2* Model ­3^ matters (47.0%) with or help them in difficulty (46.0%).
Older adults with declining function tend to rely more on
Gait speed 0.672 (0.493–0.917) 0.674 (0.464–0.979) friends, family and society for support where meaningful
p = 0.012 p = 0.039
social contact is an important aspect of well-being and
SPPB Balance 0.866 (0.638–1.174) 0.874 (0.608–1.252)
p = 0.353 p = 0.460 ageing well [37].
SPPB Chair stand 0.837 (0.618–1.132) 0.892 (0.635–1.251) Data from this study indicate a strong association
p = 0.248 p = 0.507 between social isolation and gait speed. Slow gait speed
cMMSE score 0.625 (0.453–0.863) 0.630 (0.413–0.960) is a well-recognised predictor of poor clinical outcomes
p < 0.01 p = 0.032 in community-dwelling older adults [38, 39]. Gait speed
GDS mean 1.105 (0.819–1.490) 01.004 (0.721–1.397) is also a useful diagnostic tool for sarcopenia and frailty
p = 0.516 p = 0.983
[40]. Older adults who are able to ambulate more easily
EQ-VAS 0.594 (0.434–0.814) 0.561 (0.390–0.806)
in the community have more opportunity to engage with
p < 0.01 p < 0.01
friends and family [41]. A recent study published reported
Number of chronic 1.272 (0.940–1.720) 1.304 (0.949–1.793)
diseases p = 0.119 p = 0.102 that social isolation was associated with a decrease in gait
speed after 6 years, especially in participants from a lower
Bold indicates p < 0.05 social economic class [42]. Data from the same study of
*Model 2 adjusts each factor for the remaining factors within the 2817 older adults aged > 60 also showed that adults with
table
^
loneliness were more likely to become frail over time [43].
 Model 3 adjusts each factor for the remaining factors within the table
Although non-significant, our study did show a higher
as well as participants’ characteristics from Table 1
prevalence of frailty in those at risk of social isolation.
While interventions to reduce social isolation and lone-
Discussion liness including senior clubs, befriending initiatives and
psychosocial group have produced mixed results [44–48],
Findings from this study suggest that nearly one in every a recent intervention on membership of a fitness program
two community-dwelling older adults (45.5%) is at risk of did show reduction in social isolation and loneliness [49]
social isolation. The prevalence is similar to many other which further supports impact of function on social isola-
countries depending on the definition used ranging from tion. The importance of planning for appropriate physical
environments and age-friendly communities in developing

13
Quality of Life Research
social networks and reducing the risk of social isolation
cannot be understated [50].
Older adults at risk of being socially isolated had sig-
nificantly poorer scores on the self-rated EQ-VAS scale of
general health. This corroborates the observation of Coyle
and Dugan (2012) where the likelihood of rating one’s health
as fair/poor was as high as 39% for those who scored higher
on the social isolation scale. Similar relationship was also
documented in other studies [15, 51, 52]. Social isolation
increases the risk of being diagnosed with chronic illness
[53]. In our study, older adults at risk of social isolation did
have a slightly higher numbers of chronic diseases although
it did not reach a significant level. The association between
social isolation and poor health is consistent with available
literature across various adult age groups, including a meta-
analysis of 148 studies where participants with stronger
social networks were shown to have a 50% increased likeli-
hood of survival [10] and a systematic review of 128 papers
[45] which showed that increased social isolation is con-
sistently associated with poor cardiovascular health. The
mechanisms and causal links through which increased dis-
ease morbidity is associated with poorer social networks is,
however, still being investigated, with suggestions that this
could be due to loneliness and depression.
There is evidence linking social isolation with cognition
in later life [22, 34, 54, 55]. Our study also showed an over-
all lower cMMSE scores in those at risk of social isolation.
Most of the evidence above was in longitudinal follow-up
studies. Slow gait speed in those with mild cognitive impair-
ment which is better known as Motoric Cognitive Risk Syn-
drome (MCR) is also a predictor of incident dementia in
later life [56].
There was non-significant difference between the GDS
mean scores amongst those at risk and not at risk of social
isolation. This could be due to the overall prevalence of
depression amongst older adults in Singapore being low at
5% [57]. Many studies on the contrary have reported asso-
ciation of social isolation with depression [58, 59].
The findings from this study are important for Age
Friendly Community Planning Committee, social and
healthcare policy makers to create supportive and acces-
sible environments, public awareness, educational program
and effective intervention. While the other associations were
not significant, longitudinal studies did highlight the adverse
consequences of social isolation including increased health-
care utilization, depression and dementia [7].
While this study represents overall community-dwelling
older adults, there are several minor limitations in this study.
First, the study population involved a group of community-
dwelling older adults who likely had pre-existing contacts
with grassroots organisations, senior activity centres or a net-
work of friends that enabled them to learn about participa-
tion in the study. This could lead to an under-representation
of community-dwelling older adults who lack these social
connections, suggesting that the prevalence of older adults
with a poor social network could be even higher. Second, the
cross-sectional nature of this study excludes the analysis of
causal relationships between social isolation and other physi-
cal and social participant characteristics. As such, whether
the association between gait speed and social isolation is
bi-directional is unclear. Third, the gender ratio in this study
population was skewed towards the female gender, with 4
female participants for every 1 male participant. Previous
studies suggest that men are more likely to be socially iso-
lated compared to women [60], suggesting again that the
prevalence of socially isolated older adults is likely to be
higher than amongst our population.
Opportunities for further research include other factors
that have not been discussed in this study, such as subjective
measures of loneliness, nutritional status and implications
on physical health including rate of hospital readmissions
and healthcare utilization. In addition to identifying individ-
ual characteristics associated with social isolation in older
adults, further research is needed to understand broader bar-
riers to fostering a good social network, such as financial or
environmental constraints including monetary concerns or
a lack of physical spaces to interact with friends or family.
This would be important in aiding efforts at a population-
based level to improve access to good social networks for
older adults.
Conclusion
Social isolation is associated with many adverse outcomes
including dementia, poor mobility, disease morbidity and
mortality. Almost half of older adults in the community are
at risk of social isolation with a very significant association
with gait speed, cMMSE and EQ-VAS scores. Those at risk
had overall lower education attainment and higher preva-
lence of at least two IADL impairment. The findings from
this study are useful for future Age Friendly Community
Planning Committee, and policy makers to create supportive
and accessible environments, and build a sustainable com-
munity health ecosystem. The impact of functional screen-
ing with necessary interventions and enabling environment
on social isolation needs to be studied in a larger population
[57].
Funding  Ministry of Health, Singapore.
Compliance with ethical standards 
Conflict of interest  The authors declare no conflict of interest.
13
 Quality of Life Research

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