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Social Connection in Long-Term Care Homes: A Scoping Review of Published Research on the Mental Health Impacts and Potential Strategies During COVID-19

Open AccessPublished:November 26, 2020DOI:https://doi.org/10.1016/j.jamda.2020.11.025

      Abstract

      Objectives

      Good social connection is associated with better health and wellbeing. However, social connection has distinct considerations for people living in long-term care (LTC) homes. The objective of this scoping review was to summarize research literature linking social connection to mental health outcomes, specifically among LTC residents, as well as research to identify strategies to help build and maintain social connection in this population during COVID-19.

      Design

      Scoping review.

      Settings and Participants

      Residents of LTC homes, care homes, and nursing homes.

      Methods

      We searched MEDLINE(R) ALL (Ovid), CINAHL (EBSCO), PsycINFO (Ovid), Scopus, Sociological Abstracts (ProQuest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid), and AgeLine (EBSCO) for research that quantified an aspect of social connection among LTC residents; we limited searches to English-language articles published from database inception to search date (July 2019). For the current analysis, we included studies that reported (1) the association between social connection and a mental health outcome, (2) the association between a modifiable risk factor and social connection, or (3) intervention studies with social connection as an outcome. From studies in (2) and (3), we identified strategies that could be implemented and adapted by LTC residents, families and staff during COVID-19 and included the articles that informed these strategies.

      Results

      We included 133 studies in our review. We found 61 studies that tested the association between social connection and a mental health outcome. We highlighted 12 strategies, informed by 72 observational and intervention studies, that might help LTC residents, families, and staff build and maintain social connection for LTC residents.

      Conclusions and Implications

      Published research conducted among LTC residents has linked good social connection to better mental health outcomes. Observational and intervention studies provide some evidence on approaches to address social connection in this population. Although further research is needed, it does not obviate the need to act given the sudden and severe impact of COVID-19 on social connection in LTC residents.

      Keywords

      Coronavirus (COVID-19) has taken a disproportionate toll on people living in long-term care (LTC) homes. To protect LTC residents from COVID-19 infection, infection control measures have included prohibiting visitors and restricting activities and interactions with other residents and staff in the home. Although these measures may have reduced risk of infection, they have also presented their own health risks through the devastating impact on resident's social connection.
      • Chu C.H.
      • Donato-Woodger S.
      • Dainton C.J.
      Competing crises: COVID-19 countermeasures and social isolation among older adults in long term care.
      ,
      • Stall N.M.
      • Johnstone J.
      • McGeer A.J.
      • et al.
      Finding the right balance: An evidence-informed guidance document to support the re-opening of Canadian nursing homes to family caregivers and visitors during the coronavirus disease 2019 pandemic.
      Social connection is good for health and well-being
      • Holt-Lunstad J.
      • Smith T.B.
      • Baker M.
      • et al.
      Loneliness and social isolation as risk factors for mortality: A meta-analytic review.
      • Kelly M.E.
      • Duff H.
      • Kelly S.
      • et al.
      The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A systematic review.
      • Valtorta N.K.
      • Kanaan M.
      • Gilbody S.
      • et al.
      Loneliness and social isolation as risk factors for coronary heart disease and stroke: Systematic review and meta-analysis of longitudinal observational studies.
      and important to quality of life in LTC homes.
      • Bradshaw S.A.
      • Playford E.D.
      • Riazi A.
      Living well in care homes: A systematic review of qualitative studies.
      • Moyle W.
      • Fetherstonhaugh D.
      • Greben M.
      • et al.
      Influencers on quality of life as reported by people living with dementia in long-term care: A descriptive exploratory approach.
      • Cahill S.
      • Diaz-Ponce A.M.
      “I hate having nobody here. I’d like to know where they all are”: Can qualitative research detect differences in quality of life among nursing home residents with different levels of cognitive impairment?.
      Social connection also has distinct considerations for those living in LTC homes. Most LTC residents are older adults, and many have complex health needs, including sensory, cognitive,
      Ontario Long Term Care Association
      This is long-term care 2018.
      or mobility impairment that can impact social connection.
      • Mick P.
      • Parfyonov M.
      • Wittich W.
      • et al.
      Associations between sensory loss and social networks, participation, support, and loneliness: Analysis of the Canadian Longitudinal Study on Aging.
      • Schroll M.
      • Jónsson P.V.
      • Berg K.
      • et al.
      An international study of social engagement among nursing home residents.
      • Pinquart M.
      • Sörensen S.
      Influences on loneliness in older adults: A meta-analysis.
      For many residents, families play an integral role, including participating in care, representing the resident's perspective and history, and maintaining family connections.
      • Puurveen G.
      • Baumbusch J.
      • Gandhi P.
      From family involvement to family inclusion in nursing home settings: A critical interpretive synthesis.
      ,
      • Bern-Klug M.
      • Forbes-Thompson S.
      Family members' responsibilities to nursing home residents: "She is the only mother I got".
      Within LTC homes, residents share space, have daily interactions with staff and take part in congregate activities. Communities surrounding LTC homes, including volunteers and care professionals, also participate in the lives of many LTC home residents. Taken together, LTC residents are a population with unique needs and opportunities for building and maintaining social connection.
      The current scoping review was undertaken to provide LTC residents, families, and staff with (1) a summary of research evidence linking social connection to mental health outcomes for LTC residents; and (2) strategies they may implement quickly, during COVID-19, to address social connection in this population. These objectives align with the needs of stakeholders representing or supporting LTC as well as COVID-19 research priorities identified internationally.
      • Holmes E.A.
      • O'Connor R.C.
      • Perry V.H.
      • et al.
      Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science.
      ,
      • O'Connor D.B.
      • Aggleton J.P.
      • Chakrabarti B.
      • et al.
      Research priorities for the COVID-19 pandemic and beyond: A call to action for psychological science.

      Methods

      This is a substudy of a larger scoping review,
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      conducted to address a broad set of research questions, with a flexible and iterative approach.
      • Munn Z.
      • Peters M.D.J.
      • Stern C.
      • et al.
      Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach.
      We followed the 6-stage approach
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      ,
      • Levac D.
      • Colquhoun H.
      • O'Brien K.K.
      Scoping studies: Advancing the methodology.
      and report our results in accordance with the PRISMA Extension for Scoping Reviews.
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • et al.
      PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. The PRISMA-ScR Statement.

      Step 1: Identifying the Research Questions

      Our questions were developed to support a rapid knowledge synthesis and mobilization of current evidence on the needs of mental health services, delivery, and related guidelines in the COVID-19 context. Our questions were directed by stakeholders (see Step 6, below):
      • (1)
        What mental health outcomes are associated with social connection for people living in LTC homes?
      • (2)
        What interventions and strategies might support social connection for people living in LTC homes in the context of infectious disease outbreaks like COVID-19?

      Step 2: Searching for Relevant Studies

      We selected studies identified from the larger scoping review whereby published journal articles reporting results of observational and intervention studies were eligible if they reported a quantitative measure of social connection in a population of adult residents of LTC homes.
      We included research on aspects of social integration that have been identified specifically for research in LTC homes,
      • Leedahl S.N.
      • Sellon A.
      • Chapin R.K.
      Assessment of multiple constructs of social integration for older adults living in nursing homes.
      including social networks,
      • Berkman L.F.
      • Glass T.
      • Brissette I.
      • et al.
      From social integration to health: Durkheim in the new millennium.
      social engagement
      • Berkman L.F.
      • Glass T.
      • Brissette I.
      • et al.
      From social integration to health: Durkheim in the new millennium.
      ,
      • Glass T.A.
      • de Leon C.M.
      • Marottoli R.A.
      • et al.
      Population based study of social and productive activities as predictors of survival among elderly Americans.
      and disengagement,
      • Bassuk S.S.
      • Glass T.A.
      • Berkman L.F.
      Social disengagement and incident cognitive decline in community-dwelling elderly persons.
      social support,
      • Berkman L.F.
      • Glass T.
      • Brissette I.
      • et al.
      From social integration to health: Durkheim in the new millennium.
      social isolation,
      • Machielse A.
      The heterogeneity of socially isolated older adults: A social isolation typology.
      and social capital.
      • Leedahl S.N.
      • Sellon A.
      • Chapin R.K.
      Assessment of multiple constructs of social integration for older adults living in nursing homes.
      ,
      • Leedahl S.N.
      • Chapin R.K.
      • Little T.D.
      Multilevel examination of facility characteristics, social integration, and health for older adults living in nursing homes.
      The subjective experience of social integration, including loneliness,
      • De Jong Gierveld J.
      • Van Tilburg T.
      The De Jong Gierveld short scales for emotional and social loneliness: Tested on data from 7 countries in the UN generations and gender surveys.
      perceived isolation
      • Cornwell E.Y.
      • Waite L.J.
      Social disconnectedness, perceived isolation, and health among older adults.
      and social connectedness,
      • O'Rourke H.M.
      • Sidani S.
      Definition, determinants, and outcomes of social connectedness for older adults: A scoping review.
      were also included. Given the diversity of terminology used in this area of research, our search strategy used a broad list of terms.
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      In this article, we refer to all these above-listed concepts collectively as social connection.
      We included studies reporting results specifically for residents of LTC homes, nursing homes or care homes (ie, adults living in residential facilities, whose staff provide help with most or all daily activities and 24-hour care and supervision). These terms reflect differences in terminology between countries, but were chosen for their overlap with the international consensus definition of nursing home.
      • Sanford A.M.
      • Orrell M.
      • Tolson D.
      • et al.
      An international definition for "nursing home".
      We hereafter refer to them collectively as LTC homes.
      To identify studies, we developed a comprehensive search strategy
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      with an experienced information specialist who first conducted the search in MEDLINE(R) ALL (in Ovid, including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily) and then translated it into CINAHL (EBSCO), PsycINFO (Ovid), Scopus, Sociological Abstracts (ProQuest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid), and AgeLine (EBSCO). All searches were conducted from the databases’ inception through to the date the search was executed (July 2019), limited to English language. Covidence (www.covidence.org) and Endnote were used to manage the review process, including the deduplication of database results.
      • Bramer W.M.
      • Giustini D.
      • de Jonge G.B.
      • et al.
      De-duplication of database search results for systematic reviews in EndNote.

      Step 3: Selecting Studies

      As part of the larger review, in the first and second phase of study selection, 2 reviewers independently screened article titles and abstracts then full articles to identify potentially relevant studies (ie, studies that quantified social connection in an adult population living in LTC homes). In both selection steps, any disagreements were resolved by a third reviewer. For the current subanalysis, 2 reviewers independently analyzed the full-text articles to identify the subset that reported the:
      • (1)
        association between any measure of social connection and a mental health outcome,
      • (2)
        association between a modifiable risk factor(s) and any measure of social connection, or
      • (3)
        results of intervention study (randomized and nonrandomized) whereby the outcome was any measure of social connection.
      We also checked our list against 3 recent systematic reviews of interventions to address social connection in LTC homes.
      • Mikkelsen A.S.B.
      • Petersen S.
      • Dragsted A.C.
      • et al.
      Social interventions targeting social relations among older people at nursing homes: A qualitative synthesized systematic review.
      • Quan N.G.
      • Lohman M.C.
      • Resciniti N.V.
      • et al.
      A systematic review of interventions for loneliness among older adults living in long-term care facilities.
      • Brimelow R.E.
      • Wollin J.A.
      Loneliness in old age: Interventions to curb loneliness in long-term care facilities.
      No formal quality assessment of the studies was undertaken. To be more inclusive of studies of residents with dementia, we included articles that reported social interaction as a measure of social connection, but we did not include measures of social response,
      • Ejaz F.K.
      • Rose M.S.
      • Jones J.
      Restraint removal and changes in social response among nursing home residents.
      social behavior,
      • Smith-Marchese K.
      Effects of participatory music on the reality orientation and sociability of Alzheimer's residents in a long-term-care setting.
      social interest,
      • Sauer P.E.
      • Fopma-Loy J.
      • Kinney J.M.
      • et al.
      "It makes me feel like myself": Person-centered versus traditional visual arts activities for people with dementia.
      social communication (eg, eye contact, facial expressions, body language, etc)
      • Phillips L.J.
      • Reid-Arndt S.A.
      • Pak Y.
      Effects of a creative expression intervention on emotions, communication, and quality of life in persons with dementia.
      or engagement
      • Cohen-Mansfield J.
      • Dakheel-Ali M.
      • Marx M.S.
      Engagement in persons with dementia: The concept and its measurement.
      that was not explicitly characterized as social.

      Step 4: Charting the Data

      Two reviewers then independently extracted data from these studies.
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      We summarized studies according to study characteristics and reported a narrative synthesis and mapping of the results.
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      ,
      • Levac D.
      • Colquhoun H.
      • O'Brien K.K.
      Scoping studies: Advancing the methodology.
      We reported the results in 2 parts, in alignment with the 2 questions guiding the review.

      Step 5: Collating, Summarizing, and Reporting the Results

      We took an iterative approach to reporting our results. The first author reported consolidated results back to the study team who reviewed the results, suggested refinements, and provided insights on the findings. From the studies identified in criteria (2) and (3) (see Step 3, above), the study team identified strategies that were seen to be potentially quick and relatively low-cost to implement and adapt by LTC residents, families, and staff in the COVID-19 pandemic; the articles informing these strategies were included in our review.

      Step 6: Consulting With Stakeholders

      In our initial protocol,
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      we had described opportunities to present to LTC residents, families, and staff in a LTC home. COVID-19 made these consultations impractical. However, community participation is critical in the COVID-19 context
      • McMahon M.
      • Nadigel J.
      • Thompson E.
      • et al.
      Informing Canada's health system response to COVID-19: Priorities for health services and policy research.
      ; communities can help identify solutions and are well placed to devise collective responses.
      • Marston C.
      • Renedo A.
      • Miles S.
      Community participation is crucial in a pandemic.
      Thus, for this review, we worked with partners from organizations who represent these stakeholder groups: Behavioral Supports Ontario, Family Councils Ontario, and the Ontario Association of Residents’ Councils. These members of our study team were involved in priority-setting (defining the review questions), analyzing data, interpreting and contextualizing the results, and coauthoring the current review and related reports and presentations.

      Results

      Our initial search yielded 20,291 titles, which reduced to 11,653 after deduplication. We distilled this list to 133 articles after full-text review (Figure 1). The characteristics of the included studies are described in Table 1. More than half (n=81; 61%) of the studies were published after 2010. The largest proportion of studies were from North America (n=52; 39%), mostly the United States (n=46). Overall, roughly one-third (n=49; 37%) of studies included fewer than 100 LTC residents in the sample; however, smaller studies made up a larger proportion of intervention studies (n=32; 65%) compared with observational studies in question 1 (n=13; 21%) and question 2 (n=4; 17%). The most commonly investigated aspects of social connection were social engagement (n=41; 31%), social support (n=34; 26%), and loneliness (n=32; 24%), and some studies investigated multiple measures.
      Figure thumbnail gr1
      Fig. 1Flow diagram that describes the flow of information through the review's study search and selection. ∗ Exclusions: social connection assessed but descriptive or psychometric studies or studies with other outcomes (eg, physical health, quality of life, etc).
      Table 1Description of Published Research Articles Included in Scoping Review
      Study CharacteristicsQuestion 1 (N=61)Question 2Total (N=133)
      Observational (N=23)Intervention (N=49)
      n%n%n%n%
      Year of publication
       Pre-199012144865
       1990-19998132912118
       2000-2009162662613273526
       2010-20193659146131638161
      Region
       Asia203331316333929
       Europe11189399182922
       North America2439104318375239
       Other/multiple610146121310
      Study design
       Cross-sectional47772087NANA6750
       Cohort1118313NANA1411
       Other/not stated35003665
       Quasi-experimentalNANANANA29592922
       Randomized controlled trialNANANANA17351713
      Sample size (LTC home residents)
       <100132141732654937
       100-249264352211224232
       250-4991016417361713
       ≥50012201043242418
       Not stated00001211
      Aspect(s) of social connection
      Column percentage adds to more than 100% because some studies investigated multiple aspects of social connection.
       Loneliness111831318373224
       Social capital12000011
       Social engagement233812526124131
       Social interaction6101410201713
       Social isolation00144854
       Social network101600481411
       Social participation00143643
       Social relations005228161310
       Social support2643147143426
       Social withdrawal12291243
      NA, not applicable.
      Column percentage adds to more than 100% because some studies investigated multiple aspects of social connection.

      What Mental Health Outcomes Are Associated With Social Connection for People Living in LTC Homes?

      We identified 61 studies that tested the association between social connection and mental health outcomes. The most commonly investigated aspects of social connection were social support (n=26; 43%), social engagement (n= 23; 38%), loneliness (n= 11; 18%), and social network (n=10; 16%). We categorized these studies according to the reported mental health outcomes: depression; responsive behaviors; mood, affect, and emotions; anxiety; medication use; cognitive decline; death anxiety; boredom; suicidal thoughts; psychiatric morbidity; and daily crying (see Table 2 and Supplementary Table 1)—although we acknowledge overlap between these categories.
      Table 2Summary of Studies Included in Question 1, Total Number of Studies Included and Number of Studies With Statistical Evidence of Positive Impact of 1 (or More) Measures of Social Connection on the Mental Health Outcome
      Mental Health OutcomeNumber of Studies Reporting
      Mental Health OutcomePositive Impact of Social Connection
      Where studies report unadjusted and adjusted estimates, classified by adjusted estimates; where studies report cross-sectional and longitudinal analyses, classified by longitudinal analysis.
      Depression3528
      Responsive behaviors97
      Mood, affect, and emotions87
      Anxiety32
      Medication use30
      Cognitive decline22
      Death anxiety22
      Boredom22
      Suicidal thoughts22
      Psychiatric morbidity11
      Daily crying11
      Some studies included multiple outcomes; total does not reflect number of studies included in review.
      Where studies report unadjusted and adjusted estimates, classified by adjusted estimates; where studies report cross-sectional and longitudinal analyses, classified by longitudinal analysis.

      Depression

      There were 35 studies that tested the association between social connection and depression. Most (n=28) of the studies were cross-sectional. Better social connection was associated with less depression in 28 studies.
      • Ahmed D.
      • El Shair I.H.
      • Taher E.
      • et al.
      Prevalence and predictors of depression and anxiety among the elderly population living in geriatric homes in Cairo.
      • Chau R.
      • Kissane D.W.
      • Davison T.E.
      Risk factors for depression in long-term care: A prospective observational cohort study.
      • Cheng S.T.
      • Lee C.K.
      • Chow P.K.
      Social support and psychological well-being of nursing home residents in Hong Kong.
      • Drageset J.
      • Eide G.E.
      • Ranhoff A.H.
      Anxiety and depression among nursing home residents without cognitive impairment.
      • Farber H.J.
      • Brod M.
      • Feinbloom R.I.
      Primary family contacts and emotional health in the institutionalized elderly.
      • Fessman N.
      • Lester D.
      Loneliness and depression among elderly nursing home patients.
      • Gan P.
      • Xie Y.
      • Duan W.
      • et al.
      Rumination and loneliness independently predict six-month later depression symptoms among Chinese elderly in nursing homes.
      • Hjaltadóttir I.
      • Ekwall A.K.
      • Nyberg P.
      • et al.
      Quality of care in Icelandic nursing homes measured with Minimum Data Set quality indicators: Retrospective analysis of nursing home data over 7 years.
      • Hollinger-Smith L.
      • Buschmann M.
      Failure to thrive syndrome: Predicting elderly nursing home residents at risk.
      • Hsu Y.C.
      • Wright C.L.
      The association between participation in social activity and depressive symptoms in institutionalized elders in Taiwan.
      • Jongenelis K.
      • Pot A.
      • Eisses A.
      • et al.
      Prevalence and risk indicators of depression in elderly nursing home patients: The AGED study.
      • Kim O.
      • Byeon Y.
      • Kim J.
      • et al.
      Loneliness, depression and health status of the institutionalized elderly in Korea and Japan.
      • Krohn B.
      • Bergman-Evans B.
      • Mezey M.
      Research brief. An exploration of emotional health in nursing home residents: making the pieces fit.
      • Kwok S.Y.
      • Yeung D.Y.
      • Chung A.
      The moderating role of perceived social support on the relationship between physical functional impairment and depressive symptoms among Chinese nursing home elderly in Hong Kong.
      • Lin P.C.
      • Wang H.H.
      • Huang H.T.
      Depressive symptoms among older residents at nursing homes in Taiwan.
      • Leedahl S.N.
      • Chapin R.K.
      • Little T.D.
      Multilevel examination of facility characteristics, social integration, and health for older adults living in nursing homes.
      • Lou V.W.Q.
      • Chi I.
      • Kwan C.W.
      • et al.
      Trajectories of social engagement and depressive symptoms among long-term care facility residents in Hong Kong.
      • Nikmat A.W.
      • Hashim N.A.
      • Omar S.A.
      • et al.
      Depression and loneliness/social isolation among patients with cognitive impairment in nursing home.
      • Patra P.
      • Alikari V.
      • Fradelos E.C.
      • et al.
      Assessment of depression in elderly. Is perceived social support related? A nursing home study: Depression and social support in elderly.
      • Somporn D.
      • Neeser K.J.
      • Iamsupasit S.
      Factors influencing depression among elderly in Ban Bangkhae nursing homes, Bangkok, Thailand after flooding.
      • Tank Buschmann M.
      Hollinger, LM. Influence of social support and control on depression in the elderly.
      • Tiong W.W.
      • Yap P.
      • Koh G.C.H.
      • et al.
      Prevalence and risk factors of depression in the elderly nursing home residents in Singapore.
      • Tosangwarn S.
      • Clissett P.
      • Blake H.
      Predictors of depressive symptoms in older adults living in care homes in Thailand.
      • Tsai Y.F.
      • Chung J.W.Y.
      • Wong T.K.S.
      • et al.
      Comparison of the prevalence and risk factors for depressive symptoms among elderly nursing home residents in Taiwan and Hong Kong.
      • Tu Y.Y.
      • Lai Y.L.
      • Shin S.C.
      • et al.
      Factors associated with depressive mood in the elderly residing at the long-term care facilities.
      • Yeung J.W.K.
      • Ching K.L.Y.
      • Chung A.
      Correlates and prevalence of depression in Chinese residents of nursing homes in Hong Kong and implications for services and intervention policies.
      • Zhao X.
      • Zhang D.
      • Wu M.
      • et al.
      Loneliness and depression symptoms among the elderly in nursing homes: A moderated mediation model of resilience and social support.
      • McCurren C.
      • Dowe D.
      • Rattle D.
      • et al.
      Depression among nursing home elders: testing an intervention strategy.
      One study showed a cross-sectional association at baseline but not in the longitudinal (1-month follow-up) analysis.
      • Kroemeke A.
      • Gruszczynska E.
      Well-being and institutional care in older adults: Cross-sectional and time effects of provided and received support.
      Five studies did not find statistically significant associations,
      • de Guzman A.B.
      • Jurado J.B.N.
      • Juson A.J.A.
      Examining the structural relationship of chronic illness, physical function, life satisfaction, and social support in the development of depression among Filipino elderly in institutionalized settings.
      • Potter R.
      • Sheehan B.
      • Cain R.
      • et al.
      The impact of the physical environment on depressive symptoms of older residents living in care homes: A mixed methods study.
      • Pramesona B.A.
      • Taneepanichskul S.
      Prevalence and risk factors of depression among Indonesian elderly: A nursing home-based cross-sectional study.
      • Segal D.L.
      Relationships of assertiveness, depression, and social support among older nursing home residents.
      • Van Beek A.P.A.
      • Frijters D.H.M.
      • Wagner C.
      • et al.
      Social engagement and depressive symptoms of elderly residents with dementia: A cross-sectional study of 37 long-term care units.
      and 1 found social support was associated with increased depression among new nursing home residents.
      • Keister K.J.
      Predictors of self-assessed health, anxiety, and depressive symptoms in nursing home residents at week 1 postrelocation.

      Responsive Behaviors

      Nine studies tested the association between social connection and responsive behaviors, typically reporting physical and verbal expression outcomes. Six studies found that social connection was associated with a decrease in some responsive behaviors,
      • Hjaltadóttir I.
      • Ekwall A.K.
      • Nyberg P.
      • et al.
      Quality of care in Icelandic nursing homes measured with Minimum Data Set quality indicators: Retrospective analysis of nursing home data over 7 years.
      ,
      • Chen Y.L.
      • Ryden M.B.
      • Feldt K.
      • et al.
      The relationship between social interaction and characteristics of aggressive, cognitively impaired nursing home residents.
      • Cohen-Mansfield J.
      • Werner P.
      • Marx M.S.
      Screaming in nursing home residents.
      • Draper B.
      • Snowdon J.
      • Meares S.
      • et al.
      Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior.
      • Cohen-Mansfield J.
      • Marx M.S.
      The social network of the agitated nursing home resident.
      • Marx M.S.
      • Cohen-Mansfield J.
      • Werner P.
      A profile of the aggressive nursing home resident.
      but one study found number of family visits was not associated with agitation
      • Livingston G.
      • Barber J.
      • Marston L.
      • et al.
      Prevalence of and associations with agitation in residents with dementia living in care homes: MARQUE cross-sectional study.
      and another found high social interaction was associated with increased agitation.
      • Kolanowski A.
      • Litaker M.
      Social interaction, premorbid personality, and agitation in nursing home residents with dementia.
      One study found that social engagement was associated with a decrease in responsive behavior only among residents without dementia.
      • Choi H.
      • Jung Y.I.
      • Kim H.
      Factors related to aggressive behaviors among older adults in nursing homes of Korea: A cross-sectional survey study.

      Mood, Affect, and Emotions

      Eight studies tested the association between social connection and mood, affect, and emotion outcomes. All provide some evidence that social connection was associated with better mood, affect, and emotions
      • Cheng S.T.
      • Lee C.K.
      • Chow P.K.
      Social support and psychological well-being of nursing home residents in Hong Kong.
      ,
      • Beerens H.C.
      • Zwakhalen S.M.
      • Verbeek H.
      • et al.
      The relation between mood, activity, and interaction in long-term dementia care.
      • Gilbart E.E.
      • Hirdes J.P.
      Stress, social engagement and psychological well-being in institutional settings: Evidence based on the Minimum Data Set 2.0.
      • Jao Y.L.
      • Loken E.
      • MacAndrew M.
      • et al.
      Association between social interaction and affect in nursing home residents with dementia.
      • Lee K.H.
      • Boltz M.
      • Lee H.
      • et al.
      Does social interaction matter psychological well-being in persons with dementia?.
      • Sherer M.
      Interactions with friends in a nursing home and residents' morale.
      • Cohen-Mansfield J.
      • Marx M.S.
      Pain and depression in the nursing home: Corroborating results.
      although one study showed cross-sectional associations at baseline did not extend to longitudinal analysis (with 1-month follow-up)
      • Kroemeke A.
      • Gruszczynska E.
      Well-being and institutional care in older adults: Cross-sectional and time effects of provided and received support.
      and 2 studies reported that, among residents with dementia, social interaction was associated with both positive and negative affect
      • Jao Y.L.
      • Loken E.
      • MacAndrew M.
      • et al.
      Association between social interaction and affect in nursing home residents with dementia.
      and expressions (and the quality of interaction, positive, negative or neutral, may differentiate positive and negative expressions).
      • Lee K.H.
      • Boltz M.
      • Lee H.
      • et al.
      Does social interaction matter psychological well-being in persons with dementia?.

      Anxiety

      Three cross-sectional studies tested the association between social connection and anxiety. Two studies reported that better social connection was associated with less anxiety,
      • Ahmed D.
      • El Shair I.H.
      • Taher E.
      • et al.
      Prevalence and predictors of depression and anxiety among the elderly population living in geriatric homes in Cairo.
      ,
      • Drageset J.
      • Eide G.E.
      • Ranhoff A.H.
      Anxiety and depression among nursing home residents without cognitive impairment.
      whereas 1 study of new residents found that higher informational social support was associated with more anxiety.
      • Keister K.J.
      Predictors of self-assessed health, anxiety, and depressive symptoms in nursing home residents at week 1 postrelocation.

      Cognitive Decline

      Two cohort studies, both using data from the Resident Assessment Instrument (RAI), tested the association between social engagement and cognitive performance; both found that more social engagement was associated with less cognitive decline.
      • Freeman S.
      • Spirgiene L.
      • Martin-Khan M.
      • et al.
      Relationship between restraint use, engagement in social activity, and decline in cognitive status among residents newly admitted to long-term care facilities.
      ,
      • Yukari Y.
      • Denkinger M.D.
      • Onder G.
      • et al.
      Dual sensory impairment and cognitive decline: The results from the Shelter Study.

      Other Mental Health Outcomes

      Three studies used RAI data to test the association between social engagement and (antipsychotic or hypnotic) medication use but produced mixed results.
      • Hjaltadóttir I.
      • Ekwall A.K.
      • Nyberg P.
      • et al.
      Quality of care in Icelandic nursing homes measured with Minimum Data Set quality indicators: Retrospective analysis of nursing home data over 7 years.
      ,
      • Foebel A.
      • Ballokova A.
      • Wellens N.I.
      • et al.
      A retrospective, longitudinal study of factors associated with new antipsychotic medication use among recently admitted long-term care residents.
      ,
      • Saleh N.
      • Penning M.
      • Cloutier D.
      • et al.
      Social engagement and antipsychotic use in addressing the behavioral and psychological symptoms of dementia in long-term care facilities.
      Two cross-sectional studies reported associations between social support and lower death anxiety.
      • Azaiza F.
      • Ron P.
      • Shoham M.
      • et al.
      Death and dying anxiety among elderly Arab Muslims in Israel.
      ,
      • Mullins L.C.
      • Lopez M.A.
      Death anxiety among nursing home residents: A comparison of the young-old and the old-old.
      Two cross-sectional studies reported impacts of social support, loneliness, and social engagement in relation to suicidal ideation.
      • Zhang D.
      • Yang Y.
      • Sun Y.
      • et al.
      Characteristics of the Chinese rural elderly living in nursing homes who have suicidal ideation: A multiple regression model.
      ,
      • Zhang D.
      • Yang Y.
      • Wu M.
      • et al.
      The moderating effect of social support on the relationship between physical health and suicidal thoughts among Chinese rural elderly: A nursing home sample.
      Two cross-sectional studies reported that better social connection was associated with less boredom.
      • Ejaz F.K.
      • Schur D.
      • Noelker L.S.
      The effect of activity involvement and social relationships on boredom among nursing home residents.
      ,
      • Slama C.A.
      • Bergman-Evans B.
      A troubling triangle. An exploration of loneliness, helplessness, and boredom of residents of a veterans home.
      Studies also linked social connection to daily crying
      • Palese A.
      • Simeoni A.
      • Zuttion A.R.
      • et al.
      Daily crying prevalence and associated factors in older adult persons living in nursing homes: Findings from a regional study.
      and psychiatric morbidity.
      • Andrew M.K.
      Social capital, health, and care home residence among older adults: A secondary analysis of the Health Survey for England 2000.

      What Interventions/Strategies Support Social Connection for People Living in LTC Homes in the Context of Infectious Disease Outbreaks Like COVID-19?

      After reviewing the studies that met criterion 2 or 3, our team identified 12 interventions and strategies as potentially quick and relatively low-cost to implement and adapt in the current COVID-19 pandemic. There were 23 observational studies and 49 intervention studies that reported social connection outcomes and were relevant to these 12 strategies (see Table 3 and Supplementary Table 2). Among observational studies, the most commonly investigated aspect of social connection was social engagement (n=12; 52%), most often using health administrative data and the RAI index of social engagement. Among intervention studies, the most commonly investigated aspect of social connection was loneliness (n= 18; 37%), most often using the UCLA Loneliness Scale.
      Table 3Summary of Studies Included in Question 2, Total Number of Studies Included and Number of Studies With Statistical Evidence of Positive Impact of Strategy on 1 (or More) Measures of Social Connection, by Study Type (Observational or Intervention)
      Question 2: Interventions or Strategies to Support Social ConnectionTotal (nstudies)Number of Observational Studies ReportingNumber of Intervention Studies Reporting
      ExposureAssociated With Social ConnectionInterventionPositive Impact on Social Connection
      Manage pain138354
      Address vision and hearing loss98811
      Sleep at night, not during the day32111
      Find opportunities for creative expression50055
      Exercise82063
      Maintain religious and cultural practices33200
      Garden, either indoors or outside50053
      Visit with pets14111310
      Use technology to communicate40042
      Laugh together30031
      Reminisce about events, people, and places70076
      Address communication impairments and communicate nonverbally55500
      Some studies included multiple exposures/interventions; total does not reflect number of studies included in review.

      Manage pain

      Eight observational studies tested the association between pain and social relationships or loneliness.
      • Almenkerk S.
      • Depla M.F.I.A.
      • Smalbrugge M.
      • et al.
      Pain among institutionalized stroke patients and its relation to emotional distress and social engagement.
      • Klapwijk M.S.
      • Caljouw M.A.A.
      • Pieper M.J.C.
      • et al.
      Characteristics associated with quality of life in long-term care residents with dementia: A cross-sectional study.
      • Lai C.K.
      • Leung D.D.
      • Kwong E.W.
      • et al.
      Factors associated with the quality of life of nursing home residents in Hong Kong.
      • Lood Q.
      • Björk S.
      • Sköldunger A.
      • et al.
      The relative impact of symptoms, resident characteristics and features of nursing homes on residents’ participation in social occupations: Cross-sectional findings from U-Age Swenis.
      • Tse M.M.
      • Wan V.T.
      • Vong S.K.
      Health-related profile and quality of life among nursing home residents: Does pain matter?.
      • Tse M.
      • Leung R.
      • Ho S.
      Pain and psychological well-being of older persons living in nursing homes: An exploratory study in planning patient-centred intervention.
      • van Kooten J.
      • van der Wouden J.C.
      • Sikkes S.A.M.
      • et al.
      Pain, neuropsychiatric symptoms, and quality of life of nursing home residents with advanced dementia in the Netherlands: A cross-sectional study.
      • Won A.
      • Lapane K.L.
      • Vallow S.
      • et al.
      Long-term effects of analgesics in a population of elderly nursing home residents with persistent nonmalignant pain.
      Two studies found that pain was associated with reduced social relationships scores
      • Lai C.K.
      • Leung D.D.
      • Kwong E.W.
      • et al.
      Factors associated with the quality of life of nursing home residents in Hong Kong.
      and increased loneliness.
      • Tse M.
      • Leung R.
      • Ho S.
      Pain and psychological well-being of older persons living in nursing homes: An exploratory study in planning patient-centred intervention.
      Another study showed that, among residents with persistent pain, analgesic use was associated with improved social engagement.
      • Won A.
      • Lapane K.L.
      • Vallow S.
      • et al.
      Long-term effects of analgesics in a population of elderly nursing home residents with persistent nonmalignant pain.
      Five studies found no association between pain and social connection.
      • Almenkerk S.
      • Depla M.F.I.A.
      • Smalbrugge M.
      • et al.
      Pain among institutionalized stroke patients and its relation to emotional distress and social engagement.
      ,
      • Klapwijk M.S.
      • Caljouw M.A.A.
      • Pieper M.J.C.
      • et al.
      Characteristics associated with quality of life in long-term care residents with dementia: A cross-sectional study.
      ,
      • Lood Q.
      • Björk S.
      • Sköldunger A.
      • et al.
      The relative impact of symptoms, resident characteristics and features of nursing homes on residents’ participation in social occupations: Cross-sectional findings from U-Age Swenis.
      ,
      • Tse M.M.
      • Wan V.T.
      • Vong S.K.
      Health-related profile and quality of life among nursing home residents: Does pain matter?.
      ,
      • van Kooten J.
      • van der Wouden J.C.
      • Sikkes S.A.M.
      • et al.
      Pain, neuropsychiatric symptoms, and quality of life of nursing home residents with advanced dementia in the Netherlands: A cross-sectional study.
      However, 3 of these studies reported that the association between pain and social connection only disappeared after adjusting for other variables,
      • Almenkerk S.
      • Depla M.F.I.A.
      • Smalbrugge M.
      • et al.
      Pain among institutionalized stroke patients and its relation to emotional distress and social engagement.
      ,
      • Klapwijk M.S.
      • Caljouw M.A.A.
      • Pieper M.J.C.
      • et al.
      Characteristics associated with quality of life in long-term care residents with dementia: A cross-sectional study.
      ,
      • Lood Q.
      • Björk S.
      • Sköldunger A.
      • et al.
      The relative impact of symptoms, resident characteristics and features of nursing homes on residents’ participation in social occupations: Cross-sectional findings from U-Age Swenis.
      including in a study that suggested influence of pain on social engagement may depend on the level of cognitive impairment.
      • Almenkerk S.
      • Depla M.F.I.A.
      • Smalbrugge M.
      • et al.
      Pain among institutionalized stroke patients and its relation to emotional distress and social engagement.
      Of the 5 intervention studies addressing pain, 4 showed beneficial impact on social interaction and involvement,
      • Chibnall J.T.
      • Tait R.C.
      • Harman B.
      • et al.
      Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia.
      social relations,
      • Husebo B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      and loneliness
      • Tse M.M.
      • Vong S.K.
      • Ho S.S.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      ,
      • Tse M.M.
      • Ho S.S.
      Pain management for older persons living in nursing homes: A pilot study.
      whereas 1 showed no impact on loneliness.
      • Tse M.M.Y.
      • Yeung S.S.Y.
      • Lee P.H.
      • et al.
      Effects of a peer-led pain management program for nursing home residents with chronic pain: A pilot study.

      Address vision and hearing loss

      Seven observational studies, all using RAI-MDS data, consistently showed an association between visual impairment and lower social engagement.
      • Achterberg W.
      • Pot A.M.
      • Kerkstra A.
      • et al.
      The effect of depression on social engagement in newly admitted Dutch nursing home residents.
      • Bliss D.
      • Harms S.
      • Eberly L.E.
      • et al.
      Social engagement after nursing home admission: Racial and ethnic disparities and risk factors.
      • Branco K.J.
      Religious activities, strength from faith, and social functioning among African American and White nursing home residents.
      • Guthrie D.M.
      • Davidson J.G.
      • Williams N.
      • et al.
      Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: Analysis of interRAI data for home care and long-term care recipients in Ontario.
      • Kang H.
      Correlates of social engagement in nursing home residents with dementia.
      • Li Y.
      • Cai X.
      Racial and ethnic disparities in social engagement among US nursing home residents.
      • Resnick H.E.
      • Fries B.E.
      • Verbrugge L.M.
      Windows to their world: The effect of sensory impairments on social engagement and activity time in nursing home residents.
      For residents with cataracts, cataract surgery was associated with improvements in social interaction.
      • Owsley C.
      • McGwin Jr., G.
      • Scilley K.
      • et al.
      Impact of cataract surgery on health-related quality of life in nursing home residents.
      One randomized controlled trial, assessing the effect of treating uncorrected refractive error (getting glasses), showed improved social interaction.
      • Owsley C.
      • McGwin Jr., G.
      • Scilley K.
      • et al.
      Effect of refractive error correction on health-related quality of life and depression in older nursing home residents.
      Although fewer studies linked hearing impairment to social engagement,
      • Li Y.
      • Cai X.
      Racial and ethnic disparities in social engagement among US nursing home residents.
      ,
      • Resnick H.E.
      • Fries B.E.
      • Verbrugge L.M.
      Windows to their world: The effect of sensory impairments on social engagement and activity time in nursing home residents.
      and some find no association,
      • Achterberg W.
      • Pot A.M.
      • Kerkstra A.
      • et al.
      The effect of depression on social engagement in newly admitted Dutch nursing home residents.
      ,
      • Branco K.J.
      Religious activities, strength from faith, and social functioning among African American and White nursing home residents.
      ,
      • Kang H.
      Correlates of social engagement in nursing home residents with dementia.
      taken in context with the apparent influence of dual sensory loss,
      • Guthrie D.M.
      • Davidson J.G.
      • Williams N.
      • et al.
      Combined impairments in vision, hearing and cognition are associated with greater levels of functional and communication difficulties than cognitive impairment alone: Analysis of interRAI data for home care and long-term care recipients in Ontario.
      hearing loss should also be addressed.

      Sleep at night, not during the day

      One observational study found that sleep disturbances were associated with lower levels of social engagement
      • Garms-Homolovà V.
      • Flick U.
      • Röhnsch G.
      Sleep disorders and activities in long term care facilities—A vicious cycle?.
      whereas another found no association between sleep difficulties and social relationships.
      • Lai C.K.
      • Leung D.D.
      • Kwong E.W.
      • et al.
      Factors associated with the quality of life of nursing home residents in Hong Kong.
      One intervention study tested the impact of a sleep intervention and reported increased participation in social activities.
      • Alessi C.A.
      • Martin J.L.
      • Webber A.P.
      • et al.
      Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents.

      Find opportunities for creative expression

      Five intervention studies tested the impact of creative expression programs, such as art, music, and storytelling, on social connection; 3 reported improvements in social engagement
      • Fritsch T.
      • Jung K.
      • Grant S.
      • et al.
      Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers.
      and social interaction,
      • Weiss W.
      • Schafer D.E.
      • Berghom F.J.
      Art for institutionalized elderly.
      but there were mixed results for social relations and social isolation.
      • Boersma P.
      • van Weert J.C.M.
      • Lissenberg-Witte B.I.
      • et al.
      Testing the implementation of the Veder contact method: A theatre-based communication method in dementia care.
      • Van Dijk A.M.
      • Van Weert J.C.M.
      • Droes R.M.
      Does theatre improve the quality of life of people with dementia?.
      • Roswiyani R.
      • Hiew C.H.
      • Witteman C.L.M.
      • et al.
      Art activities and qigong exercise for the well-being of older adults in nursing homes in Indonesia: A randomized controlled trial.

      Exercise

      Two observational studies found the associations between physical activity or participation in physiotherapy and social connection were not statistically significant.
      • Vitorino L.M.
      • Girardi Paskulin L.M.
      • Carneiro Vianna L.A.
      Quality of life among older adults resident in long-stay care facilities.
      ,
      • Wójcik A.
      • Nowak A.
      • Polak M.
      • et al.
      Physiotherapy and quality of life of patients in long-term care.
      Six intervention studies tested the impact of exercise programs. Of the 2 studies that tested the impact of tai chi, one reported improvement in social relationships
      • Hsu C.Y.
      • Moyle W.
      • Cooke M.
      • et al.
      Seated Tai Chi versus usual activities in older people using wheelchairs: A randomized controlled trial.
      and the other found no impact on social support.
      • Lee L.Y.K.
      • Lee D.T.F.
      • Woo J.
      The psychosocial effect of Tai Chi on nursing home residents.
      For other physical activity interventions, one study reported no change in social relations,
      • Castilho-Weinert L.V.
      • Sibele Yoko Mattozo T.
      • Bittencourt Guimãraes A.T.
      • et al.
      Functional performance and quality of life in institutionalized elderly individuals.
      another reported improvements in social participation,
      • Barthalos I.
      • Dorgo S.
      • Kopkane Plachy J.
      • et al.
      Randomized controlled resistance training based physical activity trial for central European nursing home residing older adults.
      and the third, carried out among residents with chronic pain, found decreased loneliness.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • et al.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      Another study that tested the combination of qigong and art suggested that only the art intervention affected social relationships.
      • Roswiyani R.
      • Hiew C.H.
      • Witteman C.L.M.
      • et al.
      Art activities and qigong exercise for the well-being of older adults in nursing homes in Indonesia: A randomized controlled trial.

      Maintain religious and cultural practices

      Three observational studies tested associations between social connection and religious activities, spirituality, and faith. One reported that, for both African American and white nursing home residents, preference for religious activities and drawing strength from faith were associated with higher social engagement.
      • Branco K.J.
      Religious activities, strength from faith, and social functioning among African American and White nursing home residents.
      Another showed that religious coping was positively associated with social support.
      • Koenig H.G.
      • Weiner D.K.
      • Peterson B.L.
      • et al.
      Religious coping in the nursing home: A biopsychosocial model.
      The third study reported that the association between spirituality and social engagement was not statistically significant.
      • Bliss D.
      • Harms S.
      • Eberly L.E.
      • et al.
      Social engagement after nursing home admission: Racial and ethnic disparities and risk factors.

      Garden, either indoors or outside

      Five studies tested the effect of horticulture and indoor gardening programs for LTC residents. Three studies that compared the program to usual care found that the gardening programs were associated with improvements in social relationship and loneliness outcomes.
      • Chu H.Y.
      • Chen M.F.
      • Tsai C.C.
      • et al.
      Efficacy of a horticultural activity program for reducing depression and loneliness in older residents of nursing homes in Taiwan.
      • Tse M.M.
      Therapeutic effects of an indoor gardening programme for older people living in nursing homes.
      • Chen Y.M.
      • Ji J.Y.
      Effects of horticultural therapy on psychosocial health in older nursing home residents: A preliminary study.
      However, the 2 studies that compared the programs with other interventions found no effect.
      • Lai C.K.Y.
      • Kwan R.Y.C.
      • Lo S.K.L.
      • et al.
      Effects of horticulture on frail and prefrail nursing home residents: A randomized controlled trial.
      ,
      • Brown V.M.
      • Allen A.C.
      • Dwozan M.
      • et al.
      Indoor gardening older adults: Effects on socialization, activities of daily living, and loneliness.

      Visit with pets

      Twelve studies assessed the impact of pet interactions and animal-assisted therapy on social connection, and 2 more studied robotic animals. Pet interaction and animal assisted therapy studies showed beneficial impacts on social connection (including reducing loneliness,
      • Calvert M.M.
      Human-pet interaction and loneliness: A test of concepts from Roy's adaptation model.
      • Banks M.R.
      • Banks W.A.
      The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities.
      • Sollami A.
      • Gianferrari E.
      • Alfieri M.
      • et al.
      Pet therapy: An effective strategy to care for the elderly? An experimental study in a nursing home.
      • Vrbanac Z.
      • Zecevic I.
      • Ljubic M.
      • et al.
      Animal assisted therapy and perception of loneliness in geriatric nursing home residents.
      and social interaction)
      • Sollami A.
      • Gianferrari E.
      • Alfieri M.
      • et al.
      Pet therapy: An effective strategy to care for the elderly? An experimental study in a nursing home.
      ,
      • Bernstein P.L.
      • Friedmann E.
      • Malaspina A.
      Animal-assisted therapy enhances resident social interaction and initiation in long-term care facilities.
      • Martindale B.P.
      Effect of animal-assisted therapy on engagement of rural nursing home residents.
      • Richeson N.E.
      Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia.
      • Wesenberg S.
      • Mueller C.
      • Nestmann F.
      • et al.
      Effects of an animal-assisted intervention on social behaviour, emotions, and behavioural and psychological symptoms in nursing home residents with dementia.
      • Winkler A.
      • Fairnie H.
      • Gericevich F.
      • et al.
      The impact of a resident dog on an institution for the elderly: effects on perceptions and social interactions.
      except in 2 studies.
      • Banks M.R.
      • Banks W.A.
      The effects of group and individual animal-assisted therapy on loneliness in residents of long-term care facilities.
      ,
      • Phelps K.A.
      • Miltenberger R.G.
      • Jens T.
      • et al.
      An investigation of the effects of dog visits on depression, mood, and social interaction in elderly individuals living in a nursing home.
      Another study suggested that any visits (ie, with or without pets) increased social interaction.
      • Wallace J.E.
      • Nadermann S.
      Effects of pet visitations on semiambulatory nursing home residents: Problems in assessment.
      Two studies assessing the impact of robotic animals reported beneficial impacts on loneliness
      • Banks M.R.
      • Willoughby L.M.
      • Banks W.A.
      Animal-assisted therapy and loneliness in nursing homes: Use of robotic versus living dogs.
      ,
      • Robinson H.
      • Macdonald B.
      • Kerse N.
      • et al.
      The psychosocial effects of a companion robot: A randomized controlled trial.
      and 1 found that the impact of a robotic dog was similar to that of a live dog.
      • Banks M.R.
      • Willoughby L.M.
      • Banks W.A.
      Animal-assisted therapy and loneliness in nursing homes: Use of robotic versus living dogs.

      Use technology to communicate

      Four studies assessed the impact of communication technology, but 2 were small-scale pilot studies.
      • Neves B.B.
      • Franz R.L.
      • Munteanu C.
      • et al.
      Adoption and feasibility of a communication app to enhance social connectedness amongst frail institutionalized oldest old: An embedded case study.
      ,
      • Siniscarco M.T.
      • Love-Williams C.
      • Burnett-Wolle S.
      Video conferencing: An intervention for emotional loneliness in long-term care.
      The 2 quasi-experimental studies that tested the effect of regular videoconferencing with family members showed beneficial effects for both social support and loneliness.
      • Tsai H.H.
      • Tsai Y.F.
      Changes in depressive symptoms, social support, and loneliness over 1 year after a minimum 3-month videoconference program for older nursing home residents.
      ,
      • Tsai H.H.
      • Tsai Y.F.
      • Wang H.H.
      • et al.
      Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents.

      Laugh together

      Three intervention studies reported the impact of humor therapy; one study of laughter therapy (using laughter and yoga breathing techniques) reported decreased emotional and social loneliness,
      • Kuru Alici N.
      • Zorba Bahceli P.
      • Emiroglu O.N.
      The preliminary effects of laughter therapy on loneliness and death anxiety among older adults living in nursing homes: A nonrandomised pilot study.
      whereas the other 2 interventions were not found to reduce loneliness
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • et al.
      Humor therapy: Relieving chronic pain and enhancing happiness for older adults.
      or social disengagement.
      • Low L.F.
      • Brodaty H.
      • Goodenough B.
      • et al.
      The Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE) study: Cluster randomised trial of humour therapy in nursing homes.

      Reminisce about events, people, and places

      Seven interventions studies tested reminiscence therapy or programs. These studies showed increases in social participation,
      • Siverová J.
      • Bužgová R.
      Influence reminiscence therapy on quality of life patients in the long-term hospital.
      ,
      • Siverova J.
      • Buzgova R.
      The effect of reminiscence therapy on quality of life, attitudes to ageing, and depressive symptoms in institutionalized elderly adults with cognitive impairment: A quasi-experimental study.
      social engagement,
      • Serrani Azcurra D.J.L.
      A reminiscence program intervention to improve the quality of life of long-term care residents with Alzheimer's disease. A randomized controlled trial.
      ,
      • Schafer D.E.
      • Berghorn F.J.
      • Holmes D.S.
      • et al.
      The effects of reminiscing on the perceived control and social relations of institutionalized elderly.
      social interaction,
      • Tabourne C.E.S.
      The effects of a life review program on disorientation, social interaction and self-esteem of nursing home residents.
      social network,
      • Schafer D.E.
      • Berghorn F.J.
      • Holmes D.S.
      • et al.
      The effects of reminiscing on the perceived control and social relations of institutionalized elderly.
      and decreases in loneliness
      • Chiang K.J.
      • Chu H.
      • Chang H.J.
      • et al.
      The effects of reminiscence therapy on psychological well-being, depression, and loneliness among the institutionalized aged.
      but not social relationships
      • Siverová J.
      • Bužgová R.
      Influence reminiscence therapy on quality of life patients in the long-term hospital.
      ,
      • Siverova J.
      • Buzgova R.
      The effect of reminiscence therapy on quality of life, attitudes to ageing, and depressive symptoms in institutionalized elderly adults with cognitive impairment: A quasi-experimental study.
      or social support.
      • Schafer D.E.
      • Berghorn F.J.
      • Holmes D.S.
      • et al.
      The effects of reminiscing on the perceived control and social relations of institutionalized elderly.
      One study found no effect of the intervention on social engagement.
      • Lai C.K.Y.
      • Kayser-Jones J.
      Randomized controlled trial of a specific reminiscence approach to promote the well-being of nursing home residents with dementia.

      Address Communication Impairments and Communicate Nonverbally

      Five observational studies showed that impaired receptive (understanding others) and/or expressive (making oneself understood) communication was associated with reduced social connection. Three studies used RAI-MDS data to examine communication among LTC residents overall
      • Bliss D.
      • Harms S.
      • Eberly L.E.
      • et al.
      Social engagement after nursing home admission: Racial and ethnic disparities and risk factors.
      ,
      • Li Y.
      • Cai X.
      Racial and ethnic disparities in social engagement among US nursing home residents.
      ,
      • Resnick H.E.
      • Fries B.E.
      • Verbrugge L.M.
      Windows to their world: The effect of sensory impairments on social engagement and activity time in nursing home residents.
      whereas 2 studies used assessments of expressive and receptive communication in individuals with dementia.
      • Ballard C.
      • O'Brien J.
      • James I.
      • et al.
      Quality of life for people with dementia living in residential and nursing home care: The impact of performance on activities of daily living, behavioral and psychological symptoms, language skills, and psychotropic drugs.
      ,
      • Potkins D.
      • Myint P.
      • Bannister C.
      • et al.
      Language impairment in dementia: Impact on symptoms and care needs in residential homes.

      Discussion

      Our systematic search of published research on social connection in LTC residents identified 133 studies. We found 61 studies that assessed the association between social connection and mental health outcomes; overall, these studies suggest social connection is possibly associated with better mental health in LTC residents. We used 72 observational and intervention studies, combined with stakeholder experience and advice, to highlight 12 strategies that might be used and adapted by LTC residents, families, and staff to help build and maintain social connection in LTC residents.
      Among the studies linking social connection to mental health outcomes, many had methodological limitations. In particular, some studies did not incorporate strategies to account for confounding and most were cross-sectional, making it impossible to establish temporal order. For example, with respect to the latter, studies included here considered social connection as a predictor of depression whereas others identified in our search considered it an outcome
      • Chang H.T.
      • Liu L.F.
      • Chen C.K.
      • et al.
      Correlates of institutionalized senior veterans' quality of life in Taiwan.
      • Carreiro-Martins P.
      • Gomes-Belo J.
      • Papoila A.L.
      • et al.
      Chronic respiratory diseases and quality of life in elderly nursing home residents.
      • Drageset J.
      • Espehaug B.
      • Kirkevold M.
      The impact of depression and sense of coherence on emotional and social loneliness among nursing home residents without cognitive impairment—a questionnaire survey.
      • Honda Y.
      • Meguro K.
      • Meguro M.
      • et al.
      Social withdrawal of persons with vascular dementia associated with disturbance of basic daily activities, apathy, and impaired social judgment.
      • Petrovsky D.V.
      • Sefcik J.S.
      • Hanlon A.L.
      • et al.
      Social engagement, cognition, depression, and comorbidity in nursing home residents with sensory impairment.
      • Prieto-Flores M.E.
      • Forjaz M.J.
      • Fernandez-Mayoralas G.
      • et al.
      Factors associated with loneliness of noninstitutionalized and institutionalized older adults.
      —in reality, bidirectional relationships are likely.
      • Santini Z.I.
      • Jose P.E.
      • York Cornwell E.
      • et al.
      Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis.
      Further, studies that described and compared populations within LTC were infrequent; few studies reported stratified results (eg, by race or ethnicity,
      • Branco K.J.
      Religious activities, strength from faith, and social functioning among African American and White nursing home residents.
      ,
      • Li Y.
      • Cai X.
      Racial and ethnic disparities in social engagement among US nursing home residents.
      age,
      • Mullins L.C.
      • Lopez M.A.
      Death anxiety among nursing home residents: A comparison of the young-old and the old-old.
      sex,
      • Foebel A.
      • Ballokova A.
      • Wellens N.I.
      • et al.
      A retrospective, longitudinal study of factors associated with new antipsychotic medication use among recently admitted long-term care residents.
      or level of cognitive impairment)
      • Fessman N.
      • Lester D.
      Loneliness and depression among elderly nursing home patients.
      ,
      • Choi H.
      • Jung Y.I.
      • Kim H.
      Factors related to aggressive behaviors among older adults in nursing homes of Korea: A cross-sectional survey study.
      ,
      • Freeman S.
      • Spirgiene L.
      • Martin-Khan M.
      • et al.
      Relationship between restraint use, engagement in social activity, and decline in cognitive status among residents newly admitted to long-term care facilities.
      or restricted to certain populations (eg, new residents).
      • Keister K.J.
      Predictors of self-assessed health, anxiety, and depressive symptoms in nursing home residents at week 1 postrelocation.
      ,
      • Saleh N.
      • Penning M.
      • Cloutier D.
      • et al.
      Social engagement and antipsychotic use in addressing the behavioral and psychological symptoms of dementia in long-term care facilities.
      Research assessing differences by resident-level demographic and clinical factors and other characteristics (eg, distinguishing new and established residents) would inform the development of interventions, as would incorporating measures of home-level characteristics.
      We identified 12 strategies that may help build and maintain social connection in LTC residents during COVID-19. Our review builds on previous reviews of interventions to address social connection among LTC residents
      • Mikkelsen A.S.B.
      • Petersen S.
      • Dragsted A.C.
      • et al.
      Social interventions targeting social relations among older people at nursing homes: A qualitative synthesized systematic review.
      • Quan N.G.
      • Lohman M.C.
      • Resciniti N.V.
      • et al.
      A systematic review of interventions for loneliness among older adults living in long-term care facilities.
      • Brimelow R.E.
      • Wollin J.A.
      Loneliness in old age: Interventions to curb loneliness in long-term care facilities.
      by also considering observational research and contextualizing findings through consultation with organizations representing LTC residents, families, and staff. However, similar to those reviews, we found limited research evidence and that most intervention studies were not randomized and often excluded residents with cognitive impairment. We also found no studies conducted in the context of infectious disease outbreaks. Although our stakeholders provided insights into the applicability of these strategies during COVID-19, given the frequency of disease outbreaks in LTC homes, more research is needed to address the specific challenges such scenarios present to LTC.
      We also note 2 important caveats to the strategies we identified. First, some represent fundamental aspects of resident care whereas others will not be relevant to every LTC resident or home. In particular, pain is reported as a measure of nursing home quality,
      • Jones R.N.
      • Hirdes J.P.
      • Poss J.W.
      • et al.
      Adjustment of nursing home quality indicators.
      and the importance of addressing sleep,
      • Ye L.
      • Richards K.C.
      Sleep and long-term care.
      hearing,
      • Meyer C.
      • Hickson L.
      Nursing management of hearing impairment in nursing facility residents.
      and vision
      • Campos J.L.
      • Höbler F.
      • Bitton E.
      • et al.
      Screening for vision impairments in individuals with dementia living in long-term care: A scoping review.
      have previously been highlighted for this population. For other strategies, each resident's needs, values, family situation and circumstances will be distinct just as every LTC home context will present unique challenges and opportunities for implementation; for example, some strategies rely partly or entirely on technology, which presents its own challenges to residents, families, and homes.
      • Chu C.H.
      • Donato-Woodger S.
      • Dainton C.J.
      Competing crises: COVID-19 countermeasures and social isolation among older adults in long term care.
      Second, enacted in the catastrophically common scenario of infection control measures that exclude families and isolate residents from others in the home, all strategies rely on a healthy, sustained LTC workforce. Without these vital interactions with families and other residents, problems of deteriorating mental health among residents are compounded by already-strained LTC staff who are now further challenged to provide care, including social connection, to residents. LTC homes worldwide must be supported to address problems of chronic understaffing
      • McGilton K.S.
      • Escrig-Pinol A.
      • Gordon A.
      • et al.
      Uncovering the devaluation of nursing home staff during COVID-19: Are we fuelling the next health care crisis?.
      and a workforce crisis in LTC.
      • Estabrooks C.A.
      • Straus S.
      • Flood C.M.
      • et al.
      Restoring trust: COVID-19 and the future of long-term care. Royal Society of Canada.
      Our scoping review used a comprehensive search strategy to identify published literature that quantified aspects of social connection in LTC residents. Still, we acknowledge certain limitations. First, we did not review intervention studies using social connection as a means of addressing some other outcome (eg, responsive behaviors).
      • Cohen-Mansfield J.
      • Werner P.
      Management of verbally disruptive behaviors in nursing home residents.
      • Cohen-Mansfield J.
      • Marx M.S.
      • Thein K.
      • et al.
      The impact of stimuli on affect in persons with dementia.
      • Cohen-Mansfield J.
      • Marx M.S.
      • Dakheel-Ali M.
      • et al.
      The use and utility of specific nonpharmacological interventions for behavioral symptoms in dementia: An exploratory study.
      • Rajkumar A.P.
      • Ballard C.
      • Fossey J.
      • et al.
      Apathy and its response to antipsychotic review and nonpharmacological interventions in people with dementia living in nursing homes: WHELD, a factorial cluster randomized controlled trial.
      Although we had intended to include such studies,
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      in practice, categorizing interventions as targeting social connection was difficult to operationalize. We acknowledge that characterizing these studies would have been useful to delineate the associations between social connection and mental health. Second, we did not describe associations among the different social connection variables, that is, how concepts such as social networks, social support, social engagement, loneliness, and social capital relate to one another. Studies that clarify the conceptual underpinnings and relationships among these factors
      • Leedahl S.N.
      • Sellon A.
      • Chapin R.K.
      Assessment of multiple constructs of social integration for older adults living in nursing homes.
      ,
      • Leedahl S.N.
      • Chapin R.K.
      • Little T.D.
      Multilevel examination of facility characteristics, social integration, and health for older adults living in nursing homes.
      and the mechanisms by which interventions/strategies might impact social connection
      • O’Rourke H.M.
      • Collins L.
      • Sidani S.
      Interventions to address social connectedness and loneliness for older adults: A scoping review.
      will advance knowledge in this area. Third, our definition of social connection excluded outcomes such as eye contact, facial expressions, and body language and this may have disproportionately excluded studies of persons with advanced dementia. New measures of social connection, developed specifically for persons with dementia (and at different dementia severities),
      • Budgett J.
      • Brown A.
      • Daley S.
      • et al.
      The Social Functioning in Dementia scale (SF-DEM): Exploratory factor analysis and psychometric properties in mild, moderate, and severe dementia.
      ,
      • Sommerlad A.
      • Singleton D.
      • Jones R.
      • et al.
      Development of an instrument to assess social functioning in dementia: The Social Functioning in Dementia scale (SF-DEM).
      will be helpful for future research in this area. Finally, we initiated this scoping review, prior to the COVID-19 pandemic,
      • Bethell J.
      • Babineau J.
      • Iaboni A.
      • et al.
      Social integration and loneliness among long term care residents: Protocol for a scoping review.
      to describe the literature but not to make recommendations for practice.
      • Lockwood C.
      • dos Santos K.B.
      • Pap R.
      Practical guidance for knowledge synthesis: Scoping review methods.
      As such, we did not include an assessment of the quality of the studies included in our review,
      • Arksey H.
      • O'Malley L.
      Scoping studies: Towards a methodological framework.
      • Levac D.
      • Colquhoun H.
      • O'Brien K.K.
      Scoping studies: Advancing the methodology.
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • et al.
      PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. The PRISMA-ScR Statement.
      and this may limit interpretation for policy and practice.

      Conclusions and Implications

      Our study underscores the importance of social connection for the mental health of residents of LTC homes and identifies strategies that may help build and maintain social connection in this population during COVID-19. Although these findings rely on incomplete evidence, this apparent limitation does not diminish the imperative to address social connection within LTC homes—both during COVID-19 and beyond. Still, further research is needed to explore the role of social connection over time and for different populations within LTC homes as well as in the context of infectious disease outbreaks.

      Acknowledgments

      Our thanks to Ellen Snowball, Kaitlyn Lem, Omar Farhat, Jenny Jing, Souraiya Kassam, and David Jagroop for their assistance selecting the studies and charting the data. Ellen Snowball also created the infographic art summarizing results available at http://www.encoarteam.com/index.html.

      Supplementary Data

      Supplementary Table 1Summary of Studies Used to Address Question 1, Presented According to Mental Health Outcome
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignSocial ExposureMental Health OutcomeStudy Finding
      Depression (n=35 studies)
       Ahmed, 2014
      Study reports more than 1 mental health outcome.
      EgyptGeriatric home residents (N=240)Exclusion: cognitive impairment (MMSE score < 25)Cross-sectionalLoneliness, using a 3-item loneliness scaleDepression, using the shorter version of the Geriatric Depression Scale (GDS-15)Loneliness often (OR 5.02, 95% CI 1.96-12.90; P = .001) or sometimes (OR 3.79, 95% CI 1.35-10.66; P = .011) associated with depression
       Chau, 2019AustraliaLong-term care residents (N=81)Exclusion: moderate to severe cognitive impairment (MMSE score < 18)CohortSocial support, using the Multidimensional Scale of Perceived Social Support (MSPSS)Depression, using Geriatric Depression Scale short form (GDS-15)Worse perceived social support was associated with increased depression over time (P < .001)
       Cheng, 2010Hong KongNursing home residents (N=71)Exclusion: moderate to severe cognitive impairment (MMSE score < 18)Cross-sectionalSocial network, using the network mapping procedure

      Social support (received and provided)

      Social engagement (visits), using contact frequency
      Depression, using the Geriatric Depression Scale (GDS)Number of contacts with and social support from staff and fellow residents and support provided to all network members were all inversely associated with depression (P < .05)
       deGuzman, 2015The PhilippinesNursing home residents (N=151)None specifiedCross-sectionalSocial support, using the Social Support Scale and support from family and health care providers or from other personnelDepression, using the Geriatric Depression Scale (GDS)Social support, from either family or staff, was not associated with depression
       Drageset, 2013
      Study reports more than 1 mental health outcome.
      NorwayNursing home residents (N=227)Inclusion: “cognitively intact” [0.5 or less on the Clinical Dementia Rating Scale (CDR)]Cross-sectionalSocial support, using the revised Social Provision Scale (SPS): attachment, social integration, opportunity of nurturance, and reassurance of worthDepression, using the Hospital Anxiety and Depression Scale (HADS)Social support subdimensions of social integration (OR 0.96, 95% CI 0.93-0.99; P = .02) and reassurance of worth (OR 0.95, 95% CI 0.91-0.99; P = .006) were associated with less depression
       Farber, 1991United StatesNursing home residents (N=70)Exclusion: moderate-to-severe dementiaCross-sectionalSocial support, using the Quality of Relationship Scale

      Social engagement (visits and phone calls), using family-reported information on frequency of visits and phone calls
      Depression, using Center for Epidemiological Studies–Depression (CES-D) scaleQuality of relationships (P = .001) but not frequency of interaction (P = .23) were inversely associated with depression
       Fessman, 2000United StatesNursing facility residents (N=170)Inclusion: sufficient cognitive abilityCross-sectionalSocial network, using assessment of close friends

      Social engagement (visits), using who, and how often, outsiders visited them (number of visitors/month)

      Loneliness, using the UCLA Loneliness Scale
      Depression, using the Zung depression scaleThe number of visits per month from friends and relatives was unrelated to depression; however, the number of close friends was inversely associated with depression (P < .01).

      Loneliness was positively associated with depression, but statistically significant only for those with Alzheimer's disease.
       Gan, 2015ChinaNursing home residents (N=71)None specifiedCohortLoneliness, using the UCLA Loneliness ScaleDepression, using the Center for Epidemiologic Studies Depression (CES-D) scaleLoneliness was associated with depression (P < .05); mediation analysis indicated that rumination did not mediate the relationship between loneliness and depression
       Hjaltadóttir, 2012
      Study reports more than 1 mental health outcome.
      IcelandNursing home residents (N=3694)None specifiedNot statedSocial engagement, using the RAI Index of Social Engagement (ISE)Depression, using RAI Depression Rating Scale (DRS)Compared to residents with higher social engagement, moderate (OR 5.14, 95% CI 4.26-6.19; P < .001) and low (OR 2.19, 95% CI 1.80-2.67; P < .001) social engagement associated with depression symptoms
       Hollinger-Smith, 2000United StatesNursing home residents (N=130)None specifiedCohortSocial support, using the Older Americans Resources and Services (OARS) social resources indicators

      Social support (affective), using the Perception of Touch Scale
      Depression, using the Geriatric Depression Scale (GDS)

      Diagnosed depression, using clinical diagnosis on record
      Using GDS, social resources and affective social support were inversely associated with depression (P < .001)

      Using diagnosed depression, only affective social support was associated with depression (P < .001)
       Hsu, 2014TaiwanLong-term care (intermediate care facility and nursing home) residents (N=174)Inclusion: cognitively intact as assessed by the Short Portable Mental Status.

      Exclusion: diagnosis of dementia
      Cross-sectionalSocial engagement, using the Socially Supportive Activity Inventory (SSAI) evaluating 9 different types of social activities and frequency, meaningfulness, and enjoymentDepression, using the Chinese Geriatric Depression Scale (GDS-15)In 8 of 9 social activities, the more meaningful and enjoyable the resident rated the activity, the more significant the correlation for fewer depressive symptoms (P < .05); of all the activities, only the “pleasure trips” showed no association with depressive symptoms
       Jongenelis, 2004The NetherlandsNursing home residents (N=350)Exclusion: moderate to severe cognitive impairment (MMSE score < 15)Cross-sectionalLoneliness, using the de Jong Loneliness Scale

      Social support, using the shortened version of the Social Support List–Interaction (SSL12-I) scale
      Depression, using the Geriatric Depression Scale (GDS) and the Schedule of Clinical Assessment in Neuropsychiatry (SCAN)Loneliness was found to be associated with subclinical (OR 3.38, 95% CI: 1.72-6.63), minor depression (OR 4.52, 95% CI 2.06-9.90), and major depression (OR 22.32, 95% CI 2.55-195.66); lack of social support (OR 3.32, 95% CI 1.01-10.94) was associated with major depression
       Keister, 2006
      Study reports more than 1 mental health outcome.
      United StatesNew nursing home residents (N=114)None specifiedCross-sectionalSocial support, using the Modified Inventory of Socially Supportive Behaviors assessing 4 dimensions of social support (informational, tangible, emotional, and integration support)Depression, using the Geriatric Depression Scale (GDS)One dimension of social support was positively associated with depressive symptoms; as tangible support increased, depressive symptoms increased (P < .05)
       Kim, 2009Korea and JapanNursing home residents (N=184)None specifiedCross-sectionalLoneliness, using the Revised UCLA Loneliness ScaleDepression, using the shorter version of the Geriatric Depression Scale (GDS-15)Loneliness was a significant predictor of depression for the Korean (P < .01) and Japanese residents (P < .01)
       Kroemeke, 2016
      Study reports more than 1 mental health outcome.
      PolandNursing home residents (N=180)Exclusion: diagnosis of dementia or mild cognitive impairmentsCross-sectional (at baseline) and longitudinal (after 1 mo)Social support (received and provided), using the Berlin Social Support Scales (BSSS)Depression, using Center for Epidemiological Studies–Depression (CES-D) scaleIn cross-sectional analysis, there was an inverse relationship between receiving support and depression; in longitudinal analysis, neither received support nor given support were associated with depressive symptoms
       Krohn, 2000United StatesNursing home residents (N=29)Inclusion: “cognitively intact"Cross-sectionalLoneliness, using the UCLA Loneliness ScaleDepression, using the Geriatric Depression Scale (GDS)There was a positive association between loneliness and depression (P = .020).
       Kwok, 2011ChinaNursing home residents (N=187)Exclusion: moderate to severe cognitive impairment (MMSE score < 18)Cross-sectionalSocial support (perceived institutional peer support and perceived family support), using modified version of the Lubben Social Network ScaleDepression, using the Geriatric Depression Scale (GDS)No association between perceived family support and depressive symptoms; higher level of perceived institutional peer support was significantly correlated with a lower level of depressive symptoms (P < .001)
       Leedahl, 2015United StatesNursing home residents (N=140)Exclusion: moderate to severe cognitive impairment (MDS 3.0 Brief Interview for Mental Status < 13 or MDS 2.0 Cognitive Scale score > 2)Cross-sectionalSocial network, using the concentric circle (ie, egocentric network) approach

      Social capital, using the indicators norms of reciprocity and trust

      Social support, using a modified version of the Inventory of Socially Supportive Behaviors

      Social engagement, using Likert scale questions about participation in various social activities within and outside the nursing home and a question about group/organization participation
      Depression, using the Geriatric Depression Scale (GDS)Social networks had a positive indirect relationship with mental health, primarily via social engagement; social capital had a positive direct relationship on mental health
       Lin, 2007TaiwanNursing home residents (N=138)Inclusion: “cognitively intact"

      Exclusion: score of 4 or less on the Short Portable Mental Status Questionnaire (SMPSQ)
      Cross-sectionalSocial support, using the Social Support Scale to measure perceived social support from nurses, nurse aides, family, and roommatesDepression, using Center for Epidemiological Studies–Depression (CES-D) scaleLack of social support from nurses

      (P = .034), family (P < .001), and roommates (P = .012) were correlated with depressive symptoms; in adjusted analysis, social support from family was inversely associated with depression (P < .001)
       Lou, 2013Hong KongLong-term care residents (N=1184)None specifiedCohortSocial engagement, using the RAI Index of Social Engagement (ISE)Depression, using the RAI Depression Rating Scale (DRS)At baseline, social engagement was inversely associated with depressive symptoms; increases in social engagement had a significant inverse association with changes in depressive symptom scores over time
       McCurren, 1999United StatesNursing home residents (N=85)Exclusion: diagnosis and symptom progression consistent with advanced irreversible dementiaCross-sectionalSocial network, using the Salamon-Conte Life Satisfaction in the Elderly Scale (LSES) social contacts subscaleDepression, using the Geriatric Depression Scale (GDS)Social contact was inversely correlated with depression (P = .001)
       Nikmat, 2015MalaysiaNursing home residents (N=149)Inclusion: cognitive impairment (Short Mini Mental State Examination (SMMSE) < 11)Cross-sectionalLoneliness/social isolation, using the Friendship Scale (FS)Depression, using the Geriatric Depression Scale (GDS)Loneliness/social isolation was associated with depression (P < .001)
       Patra, 2017GreeceNursing home residents (N=170)None specifiedCross-sectionalSocial support, using the Multidimensional Scale of Perceived Social Support (MSPSS)

      Social engagement (visits), using frequency of visits by relatives
      Depression, using the shorter version of the Geriatric Depression Scale (GDS-15)Social support was inversely associated with depression (P < .001); fewer visits from relatives was associated with depression (P < .001)
       Potter, 2018United KingdomCare home residents (N=510)None specifiedCohortSocial engagement, using the RAI Index of Social EngagementDepression, using the shorter version of the Geriatric Depression Scale (GDS-15)Controlling for home-level covariates, social engagement was not associated with depression
       Pramesona, 2018IndonesiaNursing home residents (N=181)Exclusion: diagnosed with severe cognitive impairment or

      dementia
      Cross-sectionalSocial support, using a classification: from spouse, family, staff or others or no one; and type of support, using a classification: psychological or financial or no supportDepression, using the Geriatric Depression Scale (GDS)In univariate analysis, lack of social support was associated with depression (OR 2.11, 95% CI 1.15-3.87; P = .15) but not in adjusted analysis (OR 2.11, 95% CI 0.48-9.32; P = .33); type of support was not associated with depression
       Segal, 2005United StatesNursing home residents (N=50)Exclusion: cognitive impairmentCross-sectionalSocial support, using Social Support List of Interactions (SSL12-I)Depression, using the Geriatric Depression Scale (GDS)Correlation between social support and depression was not statistically significant
       Somporn, 2012ThailandNursing home residents (N=237)None specifiedCross-sectionalLoneliness, using the UCLA Loneliness Scale

      Social engagement, using scheduled social activities
      Depression, using the Thai Geriatric Depression Scale (TGDS-30)Loneliness (P < .001), and lack of social activity (P < .001) were associated with depressive symptoms
       Tank Buschmann, 1994United StatesNursing home residents (N=50)None specifiedCross-sectionalSocial support (affective), using the Perception of Touch ScaleDepression, using the Geriatric Depression Scale (GDS)Affective social support was associated with reduced depression (P < .001)
       Tiong, 2013SingaporeNursing home residents (N=375)Exclusion: uncommunicative or unable to respond meaningfully (eg, dementia)Cross-sectionalSocial engagement (visits), using questions about frequency of visitorsDepression, using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteriaLack of social contact was associated with depression (OR 2.33, 95% CI 1.25-4.33)
       Tosangwarn, 2018ThailandCare home residents (N=128)Exclusion: severe cognitive impairmentCross-sectionalSocial support, using the Thai Version of Multidimensional Scale of the Perceived Social Support (MSPSS)Depression, using the Thai Geriatric Depression Scale (TGDS-30)Perceived social support was inversely associated with depression (OR 0.969, 95% CI 0.939-0.999; P = .044).
       Tsai, 2005Taiwan and Hong KongNursing home residents (N=364)Exclusion: moderate to severe cognitive impairment (MMSE score < 16 for participants with no formal education; MMSE score < 20 for primary school graduates or higher)Cross-sectionalSocial support, using the Social Support Scale (including social support network, quantities of social support, and satisfaction with social support subscales)Depression, using the Chinese Geriatric Depression Scale–Short FormSatisfaction with social support and social support network were significantly and negatively related to depressive symptoms (P < .01)
       Tu, 2012TaiwanLong-term care residents (N=307)None specifiedCross-sectionalSocial support, using the Social Support Scale (assessing social companionship, emotional support, instrumental support, and informational support)Depression, using Center for Epidemiological Studies–Depression (CES-D) scaleAmong social support subscales, only social companionship was inversely associated with depression in adjusted analysis (P < .05); all were associated with depression in unadjusted analysis
       Vanbeek, 2011The NetherlandsLong-term care dementia unit (nursing and residential home) residents (N=502)None specifiedCross-sectionalSocial engagement, using the Index of Social Engagement (ISE)Depression, using the MDS Depression Rating Scale (DRS)Association between social engagement and depression was not statistically significant
       Yeung, 2011Hong KongNursing home residents (N=187)None specifiedCross-sectionalSocial support, using a questionnaire about family support; residential social support; and residential social participationDepression, using the Geriatric Depression Scale (GDS)Only residential social support was associated with depression (OR 0.36, 95% CI 0.24-0.53)
       Zhao, 2018ChinaNursing home residents (N=323)Exclusion: severe cognitive impairment (MMSE score < 10)Cross-sectionalLoneliness, using a Chinese version of the UCLA Loneliness Scale

      Social support, using the Multidimensional Scale of Perceived Social Support (MSPSS)
      Depression, using the Hospital Depression Scale (HDS)The association between loneliness and depressive symptoms was partially mediated by resilience; the indirect effect of the mediation model was moderated by social support
      Responsive behaviors (n=9 studies)
       Chen, 2000United StatesNursing home residents (N=129)Exclusion: no cognitive impairment (MMSE score > 24)Cross-sectionalSocial interaction, using the Social Interaction Scale (SIS) subscales: Institutional Interaction and Family/Community InteractionAggressive behavior, using the Ryden aggression scale 2 (RAS2) with 3 subscales: physically aggressive behavior); verbally aggressive behavior; sexually aggressive behaviorSocial interaction was inversely associated with physical aggression (P < .05) but not verbal or sexual aggression
       Choi, 2018KoreaNursing home residents (N=1447)None specified (but results stratified by dementia)Cross-sectionalSocial engagement, using the RAI Index of Social Engagement (ISE)Aggressive behaviors, using RAI data on physical abuse, verbal abuse, socially inappropriate or destructive behaviors and/or resistance to care in the last 3 dSocial engagement was associated with less aggressive behavior among those without dementia (OR 0.31, 95% CI 0.15-0.62; P < .001) but not among those with dementia (OR 0.74, 95% CI 0.51-1.08)
       Cohen-Mansfield, 1990United StatesNursing home residents (N=408)None specifiedCross-sectionalSocial network (quality and size/density), using the Hebrew Home Social Network Rating Scale (HHSNRS)Screaming, using the Cohen-Mansfield Agitation Inventory (CMAI)Poor quality of the social network was associated with screaming (P < .01)
       Cohen-Mansfield, 1992United StatesNursing home residents (N=408)None specifiedCross-sectionalSocial network, using a questionnaire developed by research team—frequency of contact with staff, visitors, and others; intimacy with staff and visitors; frequency of visitorsAgitation, using the Cohen-Mansfield Agitation Inventory (CMAI): aggressive behavior, physically nonaggressive behavior and verbally agitated behaviorIntimacy of social network inversely associated with total number of agitated behaviors (P < .01), aggressive behavior (P < .01), and verbally agitated behavior (P < .01); the size and density of the social network did not differentiate agitated individuals from other residents
       Draper, 2000AustraliaNursing home residents (n=25 cases and n=25 controls)None specifiedCase-controlSocial engagement, using the Social Activity Inventory (SAI) items on group activities, hobbies, independent ADL, physical activities, culture-specific programs, visitors, and the involvement of family and friends in the nursing homeVocally disruptive behaviorParticipation in group activities (P = .005), hobbies (P = .004), and culture-specific programs (P = .005) less common among cases
       Hjaltadóttir, 2012
      Study reports more than 1 mental health outcome.
      IcelandNursing home residents (N=3694)None specifiedNot statedSocial engagement, using the RAI Index of Social Engagement (ISE)Behavioral symptoms, using RAICompared to residents with higher social engagement, moderate social engagement was associated with behavioral symptoms (OR 1.38, 95% CI 1.15-1.66; P < .001) but not those with lowest social engagement (OR 0.89, 95% CI 0.73-1.09)
       Kolanowski, 2006United StatesNursing home residents (N=30)Inclusion: dementia diagnosis that met DSM-IV criteria, and MMSE score <24Cross-sectionalSocial interaction, using the Passivity in Dementia Scale (PDS)

      Social withdrawal, using the withdrawal subscale of the Multidimensional Observation Scale for Elderly Subjects (MOSES)
      Agitation, using the Cohen-Mansfield Agitation Inventory (CMAI)Agitation was significantly greater under high social interaction as compared with low social interaction (P < .001) regardless of the extraversion score
       Livingston, 2017EnglandCare home residents (N=1489)Inclusion: diagnosis of dementia or screened positive for dementiaCross-sectionalSocial engagement (visits), using the number of family visitsAgitation, using the Cohen-Mansfield Agitation Inventory (CMAI)

      Neuropsychiatric symptoms (agitation), using the Neuropsychiatric Inventory (NPI)
      Number of family visits was not associated with CMAI agitation caseness (OR 0.984, 95% CI 0.914-1.059) or NPI agitation caseness (OR 0.990, 95% CI 0.976-1.005)
       Marx, 1990United StatesNursing home residents (N=408)None specifiedCross-sectionalSocial network (quality and size/density), using the Hebrew Home Social Network rating Scale (HHSNRS)Aggression (physical, verbal, sexual, and self-abuse), using the Cohen-Mansfield Agitation Inventory (CMAI)Poor quality of social network associated with aggression, including physical, verbal, and self-abuse (P < .05)
      Mood, affect, and emotion (n=8 studies)
       Beerens, 2018The NetherlandsLong-term care residents with dementia (N=115)Inclusion: a formal diagnosis of dementiaCross-sectionalSocial interaction, using the Maastricht Electronic Daily Life Observation-tool (MEDLO-tool)Mood, using the Maastricht Electronic Daily Life Observation-tool (MEDLO-tool)Social interaction was associated with higher (positive) mood (P < .001)
       Cheng, 2010
      Study reports more than 1 mental health outcome.
      Hong KongNursing home residents (N=71)Exclusion: moderate to severe cognitive impairment (MMSE score < 18)Cross-sectionalSocial network, using the network mapping procedure

      Social support (received and provided)

      Social engagement (visits), using contact frequency
      Positive affect, using the Chinese Affect ScaleNetwork size, contact with family, support from family, support from staff and fellow residents, and support provided to all network members were all associated with positive affect (P < .05)
       Cohen-Mansfield, 1993United StatesNursing home residents (N=408)None specifiedCross-sectionalSocial network, using the Hebrew Home Social Network Rating ScaleDepressed affect, using the Depression Rating Scale.Poor quality of social networks associated with depressed affect
       Gilbart, 2000CanadaContinuing care and long-term care residents (N=385)None specifiedNot statedSocial support, using questions about type and level of support provided by a number of possible significant others

      Social engagement, using the RAI Index of Social Engagement (ISE)
      Affect, using the Short Happiness and Affect Research Protocol (SHARP)

      Positive and negative affectivity, using the Measure of the Intensity and Duration of Affective States (MIDAS)

      Mood state, using RAI Mood State Resident Assessment Protocols
      Social engagement was positively associated with SHARP (P = .0001) and MIDAS scores (P = .0001) but inversely associated with mood state problems (P = .0002)
       Jao, 2018United StatesNursing home residents (N=126)Inclusion: diagnosis of dementia following Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) and MMSE scores between 7 and 24CohortSocial interaction, using the Passivity in Dementia Scale (PDS)Affect, using the Philadelphia Geriatric Center Apparent Affect Rating Scale; 2 positive affect states (interest and pleasure) and 3 negative affect states (anxiety, anger, and sadness) were includedSocial interaction was associated with higher interest and pleasure at within- and between-person levels (P < .001); increased social interaction significantly predicted higher sadness (P = .01) and anxiety (P < .001) at the within-person level; social interaction was not associated with anger
       Kroemeke, 2016
      Study reports more than 1 mental health outcome.
      PolandNursing home residents (N=180)Inclusion: no cognitive disorder (no diagnosis of dementia or mild cognitive impairments)Cross-sectional (at baseline) and longitudinal (after 1 mo)Social support (received and provided), using the Berlin Social Support Scales (BSSS)Positive affect, using 3 items (joy, satisfaction, and optimism) from the Positive and Negative Affect Schedule (PANAS)In cross-sectional analysis, there was a significant positive relationship between providing and receiving support and positive affect; in longitudinal analysis, neither received support nor given support were associated with positive affect
       Lee, 2017United StatesNursing home and assisted living residents (N=110)Inclusion: diagnosis of dementia following Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) and MMSE score < 24Cross-sectionalSocial interaction, using observations of interaction between nursing staff and nursing home residents (verbal or nonverbal; positive, negative, or neutral)Positive and negative emotional expressions, using observationsVerbal (P < .01) and verbal + nonverbal (P < .01) interactions were associated with positive emotional expressions; verbal + nonverbal (P = .01) interactions were associated with negative emotional expressions.

      Positive (P < .01) and neutral interactions (P < .01) were associated with positive emotional expression; neutral (P = .00) and negative interactions (P = .02) were associated with negative emotional expression
       Sherer, 2001IsraelNursing home residents (N=43)Exclusion: Alzheimer's diseaseCross-sectionalSocial network, using 25 open-ended questions about number of friends, whether they visit them, when, frequency of visits, duration, content of visits, what was good or bad about them, satisfaction from visits, and frequency of other communicationsMorale, using the Philadelphia Geriatric Center Morale Sub-Scales for agitation (anxiety and dysphoric mood), attitudes toward own aging, and lonely dissatisfactionNumber of friends had a positive association with attitudes toward aging (P < .05); meeting friends had a positive association with the 3 morale variables (P < .05); duration of visits was not related to morale levels
      Anxiety (n=3 studies)
       Ahmed, 2014
      Study reports more than 1 mental health outcome.
      EgyptGeriatric home residents (N=240)Exclusion: cognitive impairment (MMSE score < 25)Cross-sectionalLoneliness, using a 3-item loneliness scaleAnxiety, using the Arabic version of the Hamilton Anxiety ScaleLoneliness often (OR 4.46, 95% CI 1.36-14.68; P = .014) was associated with anxiety but not loneliness sometimes OR 2.47, 95% CI 0.64-9.54; P = .19)
       Drageset, 2013
      Study reports more than 1 mental health outcome.
      NorwayNursing home residents (N=227)Inclusion: “cognitively intact” [0.5 or less on the Clinical Dementia Rating Scale (CDR)]Cross-sectionalSocial support, using the revised Social Provision Scale (SPS): attachment, social integration, opportunity of nurturance and reassurance of worthAnxiety, using the Hospital Anxiety and Depression Scale (HADS)The social support subdimension of attachment was associated with less anxiety (OR 0.97, 95% CI 0.94, 0.99; P = .019)
       Keister, 2006
      Study reports more than 1 mental health outcome.
      United StatesNew nursing home residents (N=114)None specifiedCross-sectionalSocial support, using the Modified Inventory of Socially Supportive Behaviors assessing 4 dimensions of social support (informational, tangible, emotional, and integration support)Anxiety, using the State-Trait Anxiety InventoryOne aspect of social support was positively associated with anxiety; as informational support increased, anxiety increased (P < .05)
      Medication use (n=3 studies)
       Foebel, 2015CanadaLong-term care residents (N=47,768)None specifiedCohortSocial engagement, using RAINew antipsychotic medication use, using RAI measure of drugs in the 7 d prior to assessmentReduced social engagement associated with lower risk of new antipsychotic use (OR 0.78, 95% CI 0.71-0.87; P < .001)
       Hjaltadóttir, 2012
      Study reports more than 1 mental health outcome.
      IcelandNursing home residents (N=3694)None specifiedNot statedSocial engagement, using the RAI Index of Social Engagement (ISE)Hypnotic drug use, using RAI data on drug use for more than 2 d in past weekCompared to residents with higher social engagement, moderate (OR 1.06, 95% CI 0.93-1.22) and low (OR 0.92, 95% CI 0.80-1.06) social engagement not associated with hypnotic drug use
       Saleh, 2017CanadaNewly admitted residents (N = 2639)Inclusion: diagnosis of Alzheimer's disease or other dementiasCross-sectionalSocial engagement, using the RAI Index of Social Engagement (ISE)Antipsychotic medication use, using RAI measure of drugs in the 7 d prior to assessmentSocial engagement was associated with antipsychotic use when controlling for sociodemographic variables (OR 0.86, 95% CI 0.82-0.90; P <.001) but association disappeared when controlling for health variables (OR 0.97, 95% CI 0.97-1.00; P = .21)
      Cognitive decline (n=2 studies)
       Freeman, 2017CanadaNursing home residents (N=111,052)Included, results stratified by diagnosis of dementiaCohortSocial engagement, using the RAI Index of Social Engagement (ISE)Cognitive performance, using the RAI Cognitive Performance Scale (CPS)Social engagement was protective against cognitive decline (P < .001), and more pronounced for residents without a diagnosis of dementia
       Yukari, 2016Czech Republic, England, Finland, France, Germany, Israel, Italy, and the NetherlandsNursing home residents (N=1989)None specifiedCohortSocial engagement, using 7 items, similar to the RAI Index of Social Engagement (ISE)Cognitive performance, using the RAI-MDS Cognitive Performance Scale (CPS)Lower social engagement associated with a greater cognitive decline; the greatest cognitive decline observed among socially disengaged residents with dual sensory impairment (1.87; 1.24:2.51).
      Death anxiety (n=2 studies)
       Azaiza, 2010IsraelNursing home residents (N=65)None specifiedCross-sectionalSocial support, using the Social Support ScaleDeath and dying anxiety, using 2 scales based on Carmel and Mutran (1997)Higher social support was associated with lower death anxiety (P < .05)
       Mullins, 1982United StatesNursing home residents (N=228)None specifiedCross-sectionalSocial support, using subjective assessment of the extent of the social support the resident received from othersDeath anxiety, using the Death Anxiety ScaleAmong younger residents (age < 75 y), lack of social support associated with higher death anxiety
      Boredom (n=2 studies)
       Ejaz, 1997United StatesNursing home residents (N=175)Inclusion: cognitively alertCross-sectionalSocial engagement (inside the nursing home), using RAI-MDS variable for group activities that involve social interaction and time spent alone

      Social network (inside the nursing home), using the total number of people (residents and staff) to whom the resident felt close and friendship with other residents

      Social interaction (inside the nursing home), using positive interactions and negative interactions

      Social engagement (outside the nursing home), using variables for each of the number of visits from family and friends in past month
      Boredom, using interview item that asked subjects to rate how often they were bored in the nursing homeNegative social relationships associated with boredom (P < .01)
       Slama, 2000United StatesVeterans Home residents (N=35)Inclusion: cognitively intact per Section B (Cognitive Patterns) of the Minimum Data Set (MDS)Cross-sectionalLoneliness, using the UCLA Loneliness ScaleBoredom, using question from Geriatric Depression Scale (GDS)Loneliness was correlated with boredom (P = .009)
      Suicidal thoughts (n=2 studies)
       Zhang, 2018ChinaNursing home residents (N=205)Exclusion: a diagnosis of “dementia” or moderate to severe cognitive deficit (MMSE score < 16 for participants with no formal education and a MMSE score <20 for primary school graduates or above)Cross-sectionalSocial support, using the Multidimensional Scale of Perceived Social Support (MSPSS)Suicidal thoughts, using item 9 of the Beck Depression Inventory (BDI)In univariate analysis, those with suicide thoughts reported lower social support from family (P < .001), friends (P < .001), and significant others (P < .001); perceived social support from family, friends, and significant others moderated the relationship between physical health and suicidal thoughts
       Zhang, 2017ChinaNursing home residents (N=205)Exclusion: a diagnosis of “dementia” or moderate to severe cognitive impairment (MMSE score < 16 for participants with no formal education and an MMSE score <20 for primary school graduates or above)Cross-sectionalLoneliness, using the UCLA Loneliness Scale

      Social engagement, using the frequency of visits with their children, and the numbers of different types of social activities in which they engaged
      Suicidal ideation, using item 9 of the Beck Depression Inventory (BDI)In univariate analysis, those who had higher loneliness, fewer visits from their children, and participated in fewer social activities all had higher suicidal ideation scores (P < .05); in path analysis, results suggest loneliness can impact suicidal ideation, mediated by depression and hopelessness; frequency of visits and engagement in social activities can also affect suicidal ideation (mediated by loneliness or self-esteem, respectively)
      Psychiatric morbidity (n=1 study)
       Andrew, 2005EnglandCare home residents (N = 2493)None specified (but use of proxy respondents based on the results of a cognitive function screen)Cross-sectionalSocial engagement, using group participation

      Social support, using the Social Support Index (SSI)
      Psychiatric morbidity, using the General Health Questionnaire (GHQ), where scores ≥4 were taken to define a “case” of psychiatric morbidity, and scores <4 a “non-case”Severe lack of social support associated with increased odds of psychiatric morbidity (OR 1.62, 95% CI 1.05-2.52) but not moderate lack of social support (OR 0.87, 95% CI 0.53-1.41); no association between group participation and psychiatric morbidity (OR 0.95, 95% 0.88-1.03)
      Daily crying (n=1 study)
       Palese, 2018ItalyNursing home residents (N=8875)None specifiedCross-sectionalSocial engagement, using involvement in socially based activitiesDaily crying, defined as the occurrence of at least 1 episode of crying daily over the last monthResidents involved in socially based activities were less likely to cry on a daily basis (OR 0.882, 95% CI 0.811-0.960)
      Study reports more than 1 mental health outcome.
      Supplementary Table 2Summary of Studies Used to Address Question 2, Presented According to Strategy and Study Type (Observational or Intervention)
      1. Manage Pain
      Observational studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Almenkerk, 2015The NetherlandsNursing home residents with chronic stroke (N=274)None specifiedCross-sectionalPain, using Resident Assessment Instrument- Minimum Data (RAI-MDS)Social engagement, using RAI-MDS Revised Index for Social Engagement (RISE)Substantial pain was associated with low social engagement (OR 4.25, 95% CI 1.72-10.53; P < .05), but only in residents with no/mild or severe cognitive impairment; this relation disappeared adjusted for Neuropsychiatric Inventory Questionnaire score (OR 1.95, 95% CI 0.71-5.39)
      Klapwijk, 2016The NetherlandsNursing home residents with dementia (N=288)Inclusion: moderate to very severe dementia, using the Reisberg Global Deterioration Scale (Reisberg GDS) 5-7Cross-sectionalPain, using the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-D)Social relations, using the QUALIDEM

      Social isolation, using the QUALIDEM
      In unadjusted analysis, pain was associated with social relations (OR 0.88, 95% CI 0.83-0.94; P < .01) and social isolation (OR 0.88, 95% CI 0.82-0.94; P < .01). Associations were no longer statistically significant in multivariable analysis.
      Lai, 2015
      Study listed under more then one strategy.
      Hong KongNursing home residents (N=125)None specifiedCross-sectionalPainSocial relationships, using the WHOQOL-BREFPain associated with lower social relationships score (P < .001)
      Lood, 2017SwedenNursing home residents (N=4451)None specifiedCross-sectionalPain, using the Pain Assessment in Advanced Dementia ScaleSocial engagement, using a list of study-specific items on participation (eg, going on an outing/excursion, having everyday conversations with staff not related to care)Pain was correlated with less participation in social occupations (P < .01); however, it was no longer statistically significant in the adjusted model
      Tse, 2013Hong KongNursing home residents (N=535)Exclusion: mental disorder or cognitive impairmentCross-sectionalPain, using an 11-point numeric rating scale (NRS)Loneliness, using the UCLA Loneliness ScaleIn unadjusted analysis, pain was not associated with loneliness (P = .557).
      Tse, 2012Hong KongNursing home residents (N=302)None specifiedCross-sectionalPain, using the Geriatric Pain AssessmentLoneliness, using the UCLA Loneliness ScaleIn unadjusted analysis, pain associated with higher loneliness (P = .05).
      Van Kooten, 2017The NetherlandsNursing home residents (N=199)Inclusion: diagnosis of dementia

      Exclusion: Parkinson disease dementia, alcohol-related dementia, cognitive deficits due to psychiatric disorders
      Cross-sectionalPain, using the Mobilization Observation

      Behavior Intensity Dementia (MOBID-2) Pain Scale
      Social relations, using the QUALIDEMThe association between pain and social relations was not statistically significant for mild (P = .25) or moderate-severe pain (P = .25)
      Won, 2006United StatesNursing home residents with persistent pain (N=10,372)Exclusion: moderate to severe cognitive impairment based on a Cognitive Performance Scale (CPS) score of >2 (equivalent of <19 in MMSE)CohortAnalgesic use, standing long-acting opioids (vs standing-acting opioids; standing nonopioids; and no analgesics)Social engagement, using RAI-MDS Index of Social EngagementStanding long-acting opioids (vs standing nonopioids) were associated with improvements in social engagement (propensity adjusted rate ratio 1.60; 95% CI, 1.02-2.48)
      Intervention studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Chibnall, 2005United StatesNursing home residents with moderate-to-severe dementia (N=25)Inclusion: moderate-to-severe dementia indicated by a stage 5 or 6 on the Functional Assessment Staging (FAST)YesRandomized controlled trial, crossoverAnalgesic medication, 4 weeks of acetaminophen (3000 mg/d) (vs placebo)Social interaction (direct and passive social involvement), using Dementia Care Mapping (DCM)

      Social withdrawal, using DCM
      Acetaminophen intervention group exhibited significant increases in direct social interaction (P = .05) and passive social involvement (P = .006)
      Husebo, 2019NorwayNursing home residents (N=723)NoneNursing homes randomizedCluster-randomized controlled trialStaff education and training on communication, systematic pain management, medication review, and activities (vs usual care)Social relations, using the QUALIDEM

      Social isolation, using the QUALIDEM
      During the follow-up (month 4-9), there was an intervention effect for social relations (P < .05)
      Tse, 2012ChinaNursing home staff (N=147) and residents (N=535)Exclusion: cognitive impairment and history of mental disordersNursing homes randomizedCluster-randomized controlled trialIntegrated pain management program including a physical exercise program and multisensory stimulation art and craft therapy, 1 h/wk for 8 wk (vs usual care)Loneliness, using the Chinese version of Revised UCLA Loneliness ScaleIntervention group showed significantly lower loneliness after the program (P < .001). There was no change in the control group.
      Tse, 2013ChinaNursing home staff (n=60) and residents (n=90)Inclusion: oriented to time and placeNursing homes randomizedPretest-posttest (2 groups)Integrated pain management program that included garden therapy and physiotherapy exercise for the residents, 1 h/wk for 8 wk (vs usual care)Loneliness, using the Chinese version of Revised UCLA Loneliness ScaleIntervention group showed significant improvement in loneliness after the program (P < .05) but not in the control group
      Tse, 2016ChinaNursing home residents (N=50)Inclusion: score ≥6 in the Abbreviated Mental Test. Exclusion: cognitive impairment or mental disordersNursing homes randomizedPretest-posttest (2 groups)Group-based pain management program that included physical exercise, interactive teaching and sharing of pain management education, 1 h twice per wk for 8 wk (vs usual care)Loneliness, using the Chinese version of Loneliness ScaleLoneliness decreased in both intervention and control groups; no significant difference in loneliness between the 2 groups at baseline or week 12
      2. Address Vision and Hearing Impairments
      Observational studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Achterberg, 2003The NetherlandsNewly admitted nursing home residents (N=562)None specifiedCross-sectionalVision impairment, using the Resident Assessment Instrument–Minimum Data Set 2.0 (RAl-MDS)

      Hearing impairment, using RAI-MDS
      Social engagement, using RAI-MDS Index of Social EngagementVision impairment associated with low social engagement (OR 1.7, 95% CI 1.1-2.5; P = .011) but not hearing impairment (OR 1.0, 95% CI 0.7-1.6; P = .85)
      Bliss, 2017
      Study listed under more then one strategy.
      United StatesNew nursing home residents followed to 1 y (N=15,927)None specifiedCohortVision impairment, using RAI-MDSSocial engagement, using RAI-MDS Index of Social Engagement 1 y after admissionVision impairment associated with lower social engagement at 1-y follow-up (P < .001)
      Branco, 2007
      Study listed under more then one strategy.
      United StatesAfrican American and white nursing home residents (N = 1667)None specifiedCross-sectionalVision impairment, using RAI-MDS

      Hearing impairment, using RAI-MDS
      Social engagement, using RAI-MDS Index of Social EngagementStratified by racial/ethnic group: impaired vision was associated with lower social engagement among whites (P < .001) but not African Americans; the associations with hearing impairment were not statistically significant
      Guthrie, 2018CanadaLong-term care (LTC) residents (N= 110,578)None specifiedCross-sectionalVision impairment, using RAI-MDS

      Hearing impairment, using RAI-MDS

      Dual sensory impairment, using RAI-MDS

      Deafblind Severity Index (DbSI)
      Social engagement, using RAI-MDS Index of Social EngagementResidents with cognitive impairment and dual sensory impairment (DSI) experienced the lowest rates, based on the raw proportions, on 5 of 6 Index of Social Engagement items
      Kang, 2012United StatesNursing home residents with dementia (N=153)Inclusion: diagnosis of Alzheimer's disease or other dementia, as recorded in their medical chartsCross-sectionalVision impairment, using RAI-MDS

      Hearing impairment, using RAI-MDS
      Social engagement, using the MDS-NH section F1e Sense of Involvement/InitiativeVision impairment inversely associated with social engagement (P = .039); the association with hearing impairment was not statistically significant.
      Li, 2014
      Study listed under more then one strategy.
      United StatesNursing home residents (N = 868,011)None specifiedCross-sectionalVision impairment, using RAI-MDS

      Hearing impairment, using RAI-MDS
      Social engagement, using RAI-MDS Index of Social EngagementResults suggest, when stratified by racial/ethnic group, highly or severely impaired vision and more than minimal difficulty hearing had lower social engagement for all groups
      Owsley, 2007United StatesNursing home residents with cataracts (N=45)Exclusion: moderate or severe cognitive impairment (MMSE score < 14)CohortCataract surgerySocial interaction, using the Nursing Home Vision-Targeted Health-Related Quality of Life Questionnaire (NHVQoL)Cataract surgery group exhibited significant score improvements in social interaction (P = .033)
      Resnick, 1997
      Study listed under more then one strategy.
      United StatesNursing home residents (N=18,873)None specifiedCross-sectionalVision impairment, using RAI-MDS

      Hearing impairment, using RAI-MDS
      Social engagement, using RAI-MDS Index of Social EngagementVision: minimal (OR 1.19, 95% CI 1.10-1.29), moderate (OR 1.40, 95% CI 1.19-1.63), and severe vision impairment (OR 1.51, 95% CI 1.23-1.86) were all associated with low social engagement.

      Hearing: Only severe hearing impairment (OR 1.42, 95% CI 1.10-1.83) was associated with low social engagement.
      Intervention studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Owsley, 2007United StatesNursing home residents (>55 y old) with uncorrected refractive error (N=142)Exclusion: moderate or severe cognitive impairment (MMSE score < 14)YesRandomized controlled trialImmediate refractive error correction (vs delayed correction)Social interaction, using the Nursing Home Vision-Targeted Health-Related Quality of Life Questionnaire (NHVQoL)At follow-up, refractive error group exhibited higher social interaction (P = .03)
      3. Sleep at Night, Not During the Day
      Observational studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Garms-Homolovà, 2010GermanyNursing home residents (N=2577)None specifiedCross-sectionalSleep disturbances, “sleepless, has difficulty falling asleep or staying asleep” (insomnia) and “non-restful sleep/tired in the morning” (NRS), using RAI-MDSSocial engagement, using RAI-MDS Index of Social Engagement (ISE)Compared to those with no sleep disturbances, those with pronounced sleep disturbances had lower social engagement (P < .01)
      Lai, 2015
      Study listed under more then one strategy.
      Hong KongNursing home residents (N=125)None specifiedCross-sectionalSleep difficultySocial relationships, using the WHOQOL-BREFSleep difficulty was not associated with social relationships score
      Intervention Studies
      First Author, yearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Alessi, 2005United StatesNursing home residents with daytime sleepiness and nighttime sleep disruptions (N=118)None specifiedYesRandomized controlled trialMultiple nonpharmacologic efforts to improve sleep, ie, decreased daytime in-bed time, 30 min of outdoor sunlight exposure, increased physical activity, and structured bedtime routine (vs usual care)Social engagement, using observations of participation in social activities and calculated as percentage of observations per dayIntervention group exhibited significant increases in social engagement (P < .001)
      4. Find Opportunities for Creative Expression, Like Art, Music, and Storytelling
      Intervention Studies
      First Author, yearCountryPopulation (N=)Inclusion/Exclusion Related To CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Boersma, 2018NetherlandsResidents with dementia (n=141) and their professional caregivers (n=136)Inclusion: cognitive problems due to dementiaNoPretest-posttest (2 groups)Veder contact method, a person-centered method using theatrical, poetic, and musical communication for application in 24-h care that encourages social interaction (vs usual care)Social relations, using the QUALIDEM

      Social isolation, using the QUALIDEM
      Implementation of VCM led to significant positive improvements in the residents' social relations (P = .002).

      The association with social isolation was not statistically significant
      Fritsch, 2009United StatesNursing home residents with dementia and staff (2088 ten-minute observation periods that were conducted in 20 nursing homes)Inclusion: dementiaNursing homes randomizedPost only (2 groups)TimeSlips program, a group storytelling program that encourages creative expression among persons with dementia, 1 h/wk for 10 wk (vs usual care)Social engagement, using 10-min, coded observationsThere were higher levels of social engagement among residents in TimeSlips homes (P = .003)
      Roswiyani, 2019∗IndonesiaOlder adult nursing home residents (N=267)Exclusion: moderate or severe cognitive impairment (MMSE score < 18)YesRandomized controlled trial (4 groups)Art activities + qigong exercise (intervention integration); art activities only; qigong only, 90 min twice per week for 8 wk (vs control)Social relationships, using the WHOQOL-BREFThere was an increase in social relationships in the intervention integration and art groups (but the increase was larger in the art group); the comparison of the art group to the control group was statistically significant (P = .019)
      Van Dijk, 2012NetherlandsNursing home residents (N=169)Inclusion: diagnosed dementiaNoPretest-posttest (3 groups)Veder Method for group theater living-room activities with trained professional caregivers (group 1) or professional actors (group 2) [vs regular reminiscence group activity (group 3)]Social relations, using the QUALIDEM

      Social isolation, using the QUALIDEM
      At post-test, group 2 showed less socially isolated behavior (P = .04); no difference was observed in social relations
      Weiss, 1989United StatesNursing home residents (N=49)None specifiedNoPretest-posttest (2 groups)Textile art classes, 1 h 3 times per week for 8 wk (vs control)Social network, using number of other residents in the nursing home a subject reported knowing by name

      Social interaction
      Quality of social interaction was significantly higher in posttest (P = .01)

      No difference was observed in social network (P = .14)
      5. Exercise
      Observational Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Vitorino, 2012BrazilLong-stay care facility residents (N=77)None specifiedCross-sectionalPhysical activity, yes or noSocial relationships, using the WHOQOL-BREF

      Social participation, using the WHOQOL-OLD
      Physical activity was not associated with social relationships (P = .561)
      Wójcik, 2017PolandNursing home residents (N=58)None specifiedCross-sectionalParticipation in rehabilitation and satisfaction with its progress, via questionnaireSocial relationships, using the WHOQOL-BREFThe association between participation in rehabilitation and quality of life was not statistically significant
      Intervention Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Barthalos, 2016HungaryNursing home residents (N=45)Exclusion: moderate or severe cognitive impairment (MMSE score < 15)NoPretest-posttest (3 groups)Physical activity, resistance training 45 min twice per week vs physical + mental activity (weekly lectures and discussions on aging and quality of life) vs control (no physical or mental training)Social participation, using the WHOQOL-OLDBoth physical activity (P = .004) and physical + mental activity (P = .004) groups improved in social participation
      Castilho-Weinert, 2014BrazilNursing home residents (N=43)None specifiedNoPretest, postest (1 group)Physical therapy program, recreational dynamic activities and psychomotor circuits, 30 min/wk for 16 wkSocial relationships, using the WHOQOL-BREFThere was no change in social relations (P = .384)
      Hsu, 2016TaiwanLong-term care residents (N=60)Exclusion: cognitive impairment (MMSE score < 25)YesRandomized controlled trialSeated tai chi exercise, 40 min 3 times per week for 26 wk (vs usual activity control group)Social relationships, using the WHOQOL-BREFSeated tai chi intervention improved social relations (P < .005)
      Lee, 2010ChinaNursing home residents (N=139)Inclusion: intact cognitive function (abbreviated mental test score >6)NoPretest-posttest (2 groups)Tai chi exercise, 1 h 3 times per week for 26 wk (vs control group)Social support (network and satisfaction), using the Chinese version of the Social Support Questionnaire–Short Form (SSQ6)No significant changes were detected regarding the effect of the tai chi program on social support
      Roswiyani, 2019∗IndonesiaNursing home residents (N=267)Exclusion: moderate or severe cognitive impairment (MMSE score < 18)YesRandomized controlled trial (4 groups)Art activities + qigong exercise (intervention integration); art activities only; qigong only, 90 min twice per week for 8 wk (vs control)Social relationships, using the WHOQOL-BREFThere was an increase in social relationships in the intervention integration and art groups (but the increase was larger in the art group); the comparison of the art group to the control group was statistically significant (P = .019)
      Tse, 2014ChinaNursing home residents with chronic pain (N=396)Exclusion: cognitive impairmentNursing homes randomizedPretest-posttest (2 groups)Physical exercise program, consisting of muscle strengthening, stretching, and massages, 1-h/wk for 8 wk (vs no treatment control)Loneliness, using the Chinese version of UCLA Loneliness ScaleThe intervention group showed significant decrease in loneliness (P < .05) and the control group did not show any significant improvement
      6. Maintain Religious Observations
      Observational Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Bliss, 2017
      Study listed under more then one strategy.
      United StatesNew nursing home residents followed to 1 y (N=15,927)None specifiedCohortSpirituality, using RAI-MDSSocial engagement, using RAI-MDS Index of Social Engagement 1 y after admissionSpirituality not associated with social engagement at 1-y follow-up (P = .06)
      Branco, 2007
      Study listed under more then one strategy.
      United StatesAfrican American (n = 172) and white (n = 1595) nursing home residentsNone specifiedCross-sectionalReligious activities, using RAI-MDS

      Strength from faith, using RAI-MDS
      Social engagement, using RAI-MDS Index of Social Engagement (ISE)Among both African American and white residents, strength from faith (P < .01) and religious activity preference (P < .001) were positively associated with social engagement
      Koenig, 1997United StatesNursing home residents (N=115)None specifiedCross-sectionalReligious coping, using the Religious Coping Index (RCI)Social support, using frequency of visitors, frequency of other contacts, intimacy with staff, and intimacy with visitorsReligious coping was positively associated with social support (P = .01)
      7. Garden, Either Indoors or Outside
      Intervention studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Brown, 2004United StatesNursing home residents (N=66)Inclusion: could cognitively comprehend

      and answer questions
      NoPretest-posttest (2 groups)Indoor gardening program once per week for 5 weeks (vs twice a week for 2 wk)Loneliness, using the UCLA Loneliness Scale

      Social support, using the revised Social Provisions Scale
      There were no significant differences in social support or loneliness between participant groups
      Chen, 2015TaiwanNursing home residents (N=10)Exclusion: diagnosed cognitive impairmentNoPretest-posttest (1 group)Indoor horticultural program once per week for 10 wkLoneliness, using the UCLA Loneliness Scale, Version 3Loneliness decreased from baseline to follow-up at weeks 5 and 10 (P < .001)
      Chu, 2019TaiwanNursing home residents (N=150)Exclusion: cognitive impairment (MMSE score < 25)YesRandomized controlled trialHorticultural program for 8 wk (vs usual care)Loneliness, using the 20-item UCLA Loneliness Scale, Version 3Loneliness decreased over time in the experimental group (P < .001), but increased in the control group (P < .001)
      Lai, 2018Hong KongFrail and prefrail nursing home residents (N=111)Inclusion: normal cognition (Chinese Abbreviated Mental Test score >5) or mild cognitive impairment

      (questionable or mild dementia according to the Clinical Dementia Rating scale)
      YesRandomized controlled trialHorticulture program for 1 h/wk for 8 wk (vs social activities)Social engagement, using the Index of Social Engagement

      Social network, using the Lubben Social Network Scale
      There was no statistically significant difference over time, in social outcomes, between the groups
      Tse, 2010Hong KongNursing home residents (N=53)Inclusion: cognitively intactNursing homes randomizedPretest-posttest (2 groups)Indoor gardening program for 8 wk (vs usual care)Loneliness, using the Revised UCLA Loneliness Scale

      Social network, using the Lubben Social Network Scale
      There were significant increases in social networks (P < .01) and reductions in loneliness (P < .01) for the experimental groups but not the control groups (P > .05)
      8. Visit With Pets
      Observational Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Calvert, 1989United StatesNursing home residents (N=65)Inclusion: pass mental screening (correctly answering 3 items from the Pfieffer's Short Portable Mental Status Questionnaire)Cross-sectionalPet interaction (in pet programs), categorized into high vs low pet interaction groupsLoneliness, using the UCLA Loneliness ScaleThose in the high pet interaction group were statistically and significantly less lonely than those in the low pet interaction group (P = .03)
      Intervention Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Banks, 2002United StatesLong-term care residents (N=45)Exclusion: cognitive impairment, diagnosed or MMSE score < 24YesRandomized controlled trialAnimal assisted (AAT) once per week vs AAT 3 times per week vs no AATLoneliness, using the UCLA Loneliness ScaleBoth AAT intervention groups showed lower loneliness than control group (P < .05) both the 2 AAT groups did not differ from each other
      Banks, 2005United StatesLong-term care residents (N=37)Exclusion: cognitive impairment (MMSE score < 24)YesRandomized controlled trialAnimal-assisted therapy (AAT) group vs AAT individual, all 30-min sessions once per weekLoneliness, using the UCLA Loneliness ScaleLoneliness decreased for AAT individual (P < .05) but the difference was not statistically significant for AAT group. Posttest scores did not differ between groups
      Bernstein, 2000United StatesLong-term care residents (N=33)None specifiedNoAnimal-assisted therapy (AAT) vs arts and crafts and AAT vs snack bingoSocial interaction, using observation (brief conversation, long conversation, touch)Cognitively alert patients in AAT groups showed more brief conversation (P < .01) and long conversation (P < .01) but less touch. They also initiated brief conversation more frequently (P = .009)

      Semialert/nonalert patients in AAT showed less brief conversation, but more long conversation
      Martindale, 2008United StatesNursing home residents (N=20)Included.NoPretest-posttest (2 groups)Animal-assisted therapy, five 1-h sessions over 6 wk (vs traditional recreation therapy activities)Social interaction, using observation of interacting with people and the Passivity in Dementia ScaleInteracting with people was significantly greater for the AAT group (P = .032)
      Phelps, 2008United StatesNursing home resident (N=5)Exclusion: diagnosed dementia; cognitive impairment (MMSE score < 24)NoMultiple baseline designDog visits, 5-10 min once per week for 6 wkSocial interaction, using observational frequency of verbal and nonverbal interaction with other residents and with the dogDog visits had no significant effect on social interaction
      Richeson, 2003United StatesNursing home residents with dementia (N=15)Inclusion: diagnosed dementia; moderate or severe cognitive impairment (MMSE score < 16)NoPretest-posttest (1 group)Animal-assisted therapy, 1 h 5 d per week for 3 wkSocial interaction, using a data collection tool to determine if social interactions increase after interactions with therapy dogs and their handlersSocial interaction increased pretest to posttest (P < .05)
      Sollami, 2017ItalyNursing home residents (N=28)Inclusion: mild or absent cognitive impairment (as assessed by MMSE)YesPretest-posttest (2 groups)Animal-assisted intervention, 1 h 2 times per week for 16 sessions (vs control, usual care)Loneliness, using the UCLA Loneliness Scale

      Social interaction, using the Quality of Life Scale in Late-Stage Dementia (QUALID)
      Intervention group showed significantly decreased loneliness (P = .001) and improved positive social interactions (P = .001)
      Vrbanac, 2013CroatiaNursing home residents (N=21)None specifiedNoPretest-posttest (1 group)Animal-assisted therapy, 90 min 3 times per week for 6 moLoneliness, using the UCLA Loneliness ScaleLoneliness decreased after animal-assisted therapy (P = .003)
      Wallace, 1987United StatesNursing home residents (N=8)None specifiedNoPet visitation program, 15 min, 3 times per week for 8 wk (vs visits without dogs)Social interaction, using a behavioral activity questionnaireOnly a significant effect of visitations (P < .01), indicating that visits, either with or without pets, increased social interaction
      Wesenberg, 2019GermanyNursing home residents with mild to moderate dementia (N=19)Inclusion: diagnosed Alzheimer's disease or vascular dementiaNoPretest-posttest (2 groups)Animal-assisted intervention with a dog, once per week for 6 mo (vs control intervention without dogs)Social interaction, using observational frequency; divided into verbal interaction, touch, nonverbal interaction and body postureDuring the animal-assisted intervention, significantly longer and more frequent periods of social interaction were observed than during the control intervention
      Winkler, 1989AustraliaNursing home residents (N=21)None specifiedNoPretest-posttest (1 group)Resident dogSocial interaction, using observation Sanson-Fisher behavioral observation instrument, including group behaviorsSix weeks after the dog's arrival, a significant increase in frequency of interactive behaviors was seen; by 22 wk, behaviors had reverted to baseline levels
      Robotic Animals
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Banks, 2008United StatesNursing home residents (N=38)Exclusion: cognitive impairment (MMSE score < 24) or Alzheimer's diseaseYesRandomized controlled trial (3 groups)Weekly animal-assisted therapy (AAT) with a living dog or AAT with a robotic dog, 30 min/wk for 8 wk (vs control)Loneliness, using the UCLA Loneliness ScaleAAT with either AIBO or a living dog resulted in similar improvements in loneliness when compared with control group (P < .05)
      Robinson, 2013New ZealandRetirement home, hospital and rest home residents (N=40)None specifiedYesRandomized controlled trial (2 groups)Activity sessions with robotic seal (PAIRO), 1 h, twice per week for 12 wk (vs control)Loneliness, using the UCLA Loneliness ScaleThose in the intervention group decreased in loneliness over time, whereas those in the control group increased in loneliness; there was a significant difference between groups in loneliness change over time (P = .033)
      9. Use Technology to Communicate
      Intervention Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Neves, 2018CanadaLong-term care home residents (N=5)Exclusion: dementiaNoPretest-posttest (1 group), feasibility studyAccessible communication appSocial support, using the Abbreviated Duke Social Support Index

      Social interaction, using the Abbreviated Duke Social Support Index

      Loneliness, using the short revised UCLA Loneliness Scale
      Increases in social support (P = .105) and social interaction (P = .097) were not statistically significant

      The association with loneliness was not statistically significant.
      Siniscarco, 2017United StatesLong-term care facility residents (N=8)Exclusion: cognitive impairment (MMSE score < 24)NoPretest-posttest (1 group)Videoconferencing (1 or more times per week for 2 mo)Loneliness (emotional), using DeJong Gierveld Loneliness Scale

      Social isolation, using PROMIS instruments

      Social support (emotional and informational), using PROMIS instruments
      Emotional loneliness and social isolation decreased slightly, but not significantly

      Emotional support and informational support increased slightly, but not significantly.
      Tsai, 2010TaiwanNursing home residents (N=57)Exclusion: moderate or severe cognitive impairment (MMSE score < 16 for those with no formal education or MMSE score < 20 for those with at least a primary school education)Nursing homes randomizedPretest-posttest (2 groups)Videoconferencing (at least 5 min/wk for 3 mo) vs regular care onlySocial support, using the Social Supportive Behavior Scale

      Loneliness, using the UCLA Loneliness Scale
      Subjects in the experimental group had significantly higher mean emotional and appraisal social support scores at 1 wk and 3 mo after baseline (compared to control group).

      Subjects in the experimental group also had lower mean loneliness scores at 1 wk and 3 mo after baseline.
      Tsai, 2011TaiwanNursing home residents (N=90)Exclusion: moderate or severe cognitive impairment (MMSE score < 16 for those with no formal education or MMSE score < 20 for those with at least a primary school education)Nursing homes randomizedPretest-posttest (2 groups)Videoconferencing (at least 5 min/wk for 3 mo) vs regular care onlySocial support, using the Social Supportive Behavior Scale and including emotional, informational, instrumental, and appraisal support

      Loneliness, using the UCLA Loneliness Scale
      Videoconference program had a long-term effect in alleviating loneliness and improved long-term emotional social support and short-term appraisal support, but decreased residents' instrumental social support.

      There was no effect on informational social support.
      10. Laugh Together
      Intervention Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Kuru-Alici, 2018TurkeyNursing home residents (N=50)Exclusion: Alzheimer's disease or other dementiaNoPretest-posttest (2 group)Laughter therapy, 35-40 min twice per week for 5 wk (vs control, no intervention)Loneliness (emotional and social), using the De Jong Gierveld Loneliness ScaleIntervention associated with decreased emotional and social loneliness with statistically significant difference from control group (P < .001)
      Low, 2013AustraliaNursing home residents (N=398)None specifiedYesCluster randomized controlled trialHumor therapy from professional performers (ElderClowns + Laughterbosses), for 2 h once per week for 9-12 wk (vs usual care)Social disengagement, using the Multidimensional Observation Scale for Elderly Subjects (MOSES)Groups did not differ significantly over time on social disengagement (P > .05)
      Tse, 2010ChinaNursing home residents with chronic pain (N=70)Inclusion: cognitively intact (indicated by a score ≤8 on the abbreviated mental test)NoPretest-posttest (2 group)Humor therapy program, 1 h/wk for 8 wk (vs control)Loneliness, using the revised UCLA Loneliness ScaleIntervention group showed significant decreases in loneliness (P < .001) but not for the control group; however, difference between groups was not statistically significant
      11. Reminisce About Events, People, and Places
      Intervention Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionRandomized (Yes/No)Study DesignInterventionSocial OutcomeStudy Finding
      Chiang, 2010TaiwanInstitutionalized residents (N=92)Exclusion: moderate or severe cognitive impairment (MMSE score < 19)YesRandomized controlled trialReminiscence therapy 90 min/wk for 8 wk (vs wait list control)Loneliness, using the Revised UCLA Loneliness ScaleIntervention group showed a decrease in loneliness, with significant difference between groups (P < .001)
      Lai, 2004ChinaNursing home residents with dementia (N=101)Inclusion: dementia diagnosisYesRandomized controlled trialIndividual life story book to encourage reminiscence once per week for 6 wk vs comparison (social contacts) vs control (no program)Social engagement, using the Social Engagement ScaleThere were no statistically significant differences in social engagement between the groups
      Schafer, 1985United StatesNursing home residents (N=185)None specifiedNoPretest-posttest (4 groups)Three intervention groups (1 h/wk for 12 wk): (1) audio tapes + structured group intervention; (2) structured group intervention, and (3) audio tapes + individual activity vs control (no treatment)Social network, using the ratio of the number of other participants a subject knew divided by the total number of people

      Social engagement, using the spontaneous initiation of activities with other residents

      Social support, using whether resident reports there was someone in whom they could confide
      There were statistically significant differences between the groups for social network (P = .02) and social engagement (P = .02)

      Group 2 associated with increased social network and the highest social engagement.

      The association with social support was not statistically significant.
      Serrani-Azcurra, 2012ArgentinaNursing home residents with dementia (N=135)Inclusion: diagnosed with Alzheimer's disease and Folstein Mini Mental Exam Score above 10YesRandomized controlled trialLife-approach reminiscence therapy, 1 h biweekly for 12 wk vs active control (counseling and informal social contacts) vs passive controlSocial engagement, using the Social Engagement ScaleSocial engagement increased in the intervention group, with significant difference between groups (P < .01)
      Siverova, 2014Czech RepublicHospitalized long-term care elderly patients (N=41)Inclusion: mild or moderate cognitive impairment (9 < MMSE score < 24)NoPretest-posttest (1 group)Narrative group reminiscence therapy, 40-60 min once per week for 6-8 wkSocial relationships, using the WHOQOL-BREF

      Social participation, using the WHOQOL-OLD
      Intervention was not associated with change in social relationships (P = .63) but there was an increase in social participation (P = .002)
      Siverova, 2018Czech RepublicOlder adults in institutional care (N=116)Inclusion: mild or moderate cognitive impairment (10 < MMSE score < 24)NoPretest-posttest (2 groups)Group narrative reminiscence therapy, 40-60 min/wk for 8 wk (vs standard care)Social relationships, using the WHOQOL-BREF

      Social participation, using the WHOQOL-OLD
      There were no statistically significant differences in social relationships.

      The intervention group showed an increase in social participation, with a significant difference with control group (P = .041).
      Tabourne, 1995United StatesNursing home residents (N=40)Inclusion: diagnosis of Alzheimer's disease or other cognitive disorderNoPretest-posttest (2 groups)Life review program, 2 sessions per week for 12 wk (vs control)Social interaction, using observer ratingsThere was a significant increase in social interaction for the experimental group (P < .001) but not for the control group; the pre-posttest differences between groups was statistically significant (P < .001)
      12. Address Communication Impairments and Communicate Nonverbally
      Observational Studies
      First Author, YearCountryPopulation (N=)Inclusion/Exclusion Related to CognitionStudy DesignExposureSocial OutcomeStudy Finding
      Ballard, 2001EnglandCare facility (residential and nursing homes) residents (N=112)Inclusion: dementia, using AGECAT (“organic disorder”) and the Clinical Dementia Rating Scale (CDR) category of 0.5 or greaterCross-sectionalLanguage function, using Sheffield Screening Test for Acquired Language DisordersSocial withdrawal, using Dementia Care Mapping (DCM)Greater impairment of receptive language was associated with increased social withdrawal (P = .03).
      Bliss, 2017
      Study listed under more then one strategy.
      United StatesNew nursing home residents followed to 1 y (N=15,927)None specifiedCohortCommunication difficulty, using RAI-MDSSocial engagement, using RAI-MDS Index of Social Engagement 1 year after admissionCommunication difficulty associated with low social engagement at 1-y follow-up (P < .001)
      Li, 2014
      Study listed under more then one strategy.
      United StatesNursing home residents (N= 868,011)None specifiedCross-sectionalCommunication difficulty, using RAI-MDS (assessing whether primary mode of expression was speech and the resident was able to make themselves understood by others)Social engagement, using individual items from RAI-MDS Index of Social Engagement (ISE)Communication difficulty associated with lower social engagement
      Potkins, 2003EnglandNursing home and social care facility residents (N=315)Inclusion: dementia, using AGECAT (“organic disorder”) and the Clinical Dementia Rating Scale (CDR) category of 0.5 or greaterCross-sectionalExpressive and receptive language function, using the Sheffield Screening Test for Acquired Language DisordersSocial withdrawal, using Dementia Care Mapping (DCM)

      Social engagement, using participation in social activities and Dementia Care Mapping (DCM)
      Both expressive (P = .04) and receptive aspects of language (P < .01) were correlated with decreased participation in social activities.

      Social withdrawal was only correlated with receptive language difficulties (P = .01).
      Resnick, 1997
      Study listed under more then one strategy.
      United StatesNursing home residents (N=18,873)None specifiedCross-sectionalCommunication difficulty, using RAI-MDS (assessing whether resident's primary mode of communication is defined and resident is able to be understood by others)Social engagement, using individual items from RAI-MDS Index of Social Engagement (ISE)Communication difficulty associated with low social engagement (OR 1.72, 95% CI 1.51-1.95)
      Study listed under more then one strategy.

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