Social withdrawal

Social withdrawal is a sustained reduction in contact with others and participation in usual activities, beyond the person's baseline. In older adults it is often a sign of an underlying illness, such as depression, dementia, sensory loss or pain, and it carries independent risks of cognitive decline, cardiovascular disease, depression and early death.

Related concepts. Social isolation is an objective lack of contact. Loneliness is the distressing feeling of unmet social need. Withdrawal is the behaviour of pulling back. They overlap but differ, and a person may be isolated without feeling lonely.

Mechanisms. Loss of roles and relationships (bereavement, retirement, driving cessation), reduced mobility, sensory loss, continence concerns, pain and fatigue, cognitive decline with apathy, mood and anxiety disorders, medicines, and poverty or housing factors.

Classification by cause.

• Psychiatric: depression, anxiety, psychosis, grief, substance use.
• Neurological and cognitive: apathy, dementia, Parkinson disease, stroke.
• Sensory and physical: hearing and vision loss, pain, breathlessness, incontinence, fatigue, mobility limitation.
• Medicine related.
• Social and environmental: bereavement, relocation, caregiving, poverty, rural or unsafe surroundings, abuse.

Key distinctions. Gradual withdrawal over years may be a personality trait. Withdrawal over weeks to months in a previously sociable person needs a medical and psychiatric evaluation. Abrupt change in days suggests delirium.

History.

• Onset, tempo, and what changed in the previous 6 to 12 months (bereavement, illness, move, loss of a driving licence, retirement, a carer's death).
• Who the person sees, how often, and what they do with their time.
• Mood, pleasure, sleep, appetite, energy, anxiety, fear of falling or incontinence, suspiciousness, hallucinations, memory change.
• Hearing, vision, mobility, pain, breathlessness and continence.
• Alcohol and substances, medicines, finances, safety at home, and exposure to harm or neglect.
• The person's own account of why they have withdrawn and what they want.

Measures.

• Loneliness: UCLA 3 item scale (6 or more indicates loneliness) or the De Jong Gierveld short scale.
• Social network: Lubben Social Network Scale 6 (under 12 indicates risk of isolation).
• Mood: 15 item Geriatric Depression Scale (over 5 suggests depression) or PHQ-9 (10 or more indicates moderate depression).
• Cognition: Mini-Cog or MoCA (under 26 of 30 suggests impairment). Anxiety: GAD-7 (10 or more).
• Function: Barthel Index or Katz Index.

Examination. Appearance, hygiene, weight, mental state (affect, thought content, psychosis), cognition, hearing (whispered voice test, otoscopy for wax), vision, gait, neurological signs (parkinsonism, focal deficit), cardiovascular and respiratory status, thyroid, skin and signs of injury.

Red flags.

• Suicidal thoughts, plans or recent self harm. Older men living alone carry a high risk.
• Refusal of food or fluids, rapid weight loss, or self neglect.
• Acute change over days with inattention (delirium).
• Psychotic symptoms or command hallucinations.
• Signs of abuse, financial exploitation or neglect.
• New focal neurological signs.

Special groups. Bereavement: grief lasting beyond 6 to 12 months with persistent yearning and functional impairment suggests prolonged grief disorder. Carers of people with dementia are at high risk. Care home residents may be withdrawn because of staffing, noise or a lack of meaningful activity.

Psychiatric.

• Major depression, including late life and psychotic depression.
• Anxiety disorders, social anxiety disorder, agoraphobia.
• Prolonged grief disorder.
• Delusional disorder, schizophrenia with negative symptoms.
• Alcohol use disorder and other substance use.

Neurocognitive.

• Alzheimer disease, frontotemporal dementia (early apathy and loss of empathy), vascular dementia, mild cognitive impairment.
• Hypoactive delirium.
• Parkinson disease, stroke, normal pressure hydrocephalus.

Sensory and physical. Hearing loss, visual impairment, urinary and faecal incontinence, chronic pain, heart failure, chronic obstructive pulmonary disease, anaemia, fatigue syndromes.

Endocrine and metabolic. Hypothyroidism, apathetic hyperthyroidism, adrenal insufficiency, hypercalcaemia, hyponatraemia, B12 deficiency, uraemia.

Medicine related. Benzodiazepines, opioids, antipsychotics, beta blockers, anticholinergics, corticosteroids, antiepileptics.

Social. Elder abuse and neglect, poverty, loss of transport, rural isolation, language or cultural barriers, bereavement, and retirement related loss of role.

Step 1. Establish tempo, exclude delirium and assess suicide risk directly. Asking about suicidal thoughts does not increase risk.

Step 2. Screen for depression, anxiety, cognitive impairment, hearing, vision, mobility, continence and alcohol. Use an audit tool such as AUDIT-C (4 or more in men, 3 or more in women is positive).

Step 3. First line tests: full blood count, urea, creatinine, electrolytes, corrected calcium, glucose and HbA1c, liver tests, TSH, B12, folate, 25 hydroxyvitamin D, CRP. ECG when starting an antidepressant that prolongs QT or when the person has cardiac disease.

Step 4. Targeted tests: audiometry, vision assessment, brain imaging (CT or MRI) when there are focal signs, rapid decline, atypical features or frontotemporal features, and morning cortisol for suspected adrenal insufficiency.

Limitations. Depression screens in dementia are less accurate, so use the Cornell Scale. Loneliness scales do not measure the cause. Investigations are low yield in a patient with an obvious social cause and normal examination, so tailor the panel.

Treat the cause. Correct hearing and vision (wax removal, hearing aids, cataract surgery), treat pain, anaemia, thyroid disease, B12 deficiency and heart failure, treat continence problems, review and reduce sedating drugs, and address alcohol use.

Social interventions.

• Link with community groups, befriending, day centres, intergenerational activity, faith groups and volunteering.
• Exercise groups, walking groups and group learning.
• Transport, home visits, telephone and video contact, and technology training.
• Carer support and respite. Benefit and housing assistance.
• Evidence is strongest for group activities with a purpose and for tackling the cause of isolation, and weaker for simple befriending.

Psychological treatment. Problem solving therapy, cognitive behavioural therapy and behavioural activation for depression and anxiety. Grief focused therapy for prolonged grief.

Depression.

• Sertraline: 25 mg orally once daily in the morning for 1 week, then 50 mg; increase in steps of 25 to 50 mg no more often than weekly to a usual 50 to 100 mg; maximum 200 mg daily; continue 6 to 12 months after remission for a first episode and 2 years or longer for recurrent illness; monitor sodium at 2 and 4 weeks, suicidal thoughts in the first weeks, bleeding with NSAIDs or anticoagulants, falls and serotonin toxicity; halve the dose in hepatic impairment; withdraw over 4 weeks.
• Mirtazapine when insomnia, anorexia and weight loss predominate: 7.5 mg orally at night, increase to 15 mg after 1 to 2 weeks, usual 15 to 45 mg; maximum 45 mg daily; same duration; monitor weight, sedation, sodium, falls, and fever or sore throat (agranulocytosis); use lower doses and slower titration in CrCl under 40 mL/min and in liver impairment.
• Avoid tricyclic antidepressants in older adults because of anticholinergic effects and cardiac toxicity. Avoid benzodiazepines.

Anxiety. Psychological therapy first. Sertraline 25 mg orally once daily for 1 week, then 50 mg, increased in steps of 25 to 50 mg no more often than weekly to a usual 50 to 100 mg (maximum 200 mg daily) where drug treatment is needed, with sodium monitored at 2 and 4 weeks. Avoid regular benzodiazepines.

Safety. If suicidal thoughts are present, do not leave the person alone, remove means, and arrange same day psychiatric assessment. Report suspected abuse through safeguarding procedures.

Monitoring. Review at 2 weeks after starting treatment and every 4 weeks until stable. Repeat GDS, weight, sodium, and social activity at each visit. Reassess at 3 months for response, and refer if there is no improvement after 6 to 8 weeks at an adequate dose.

Referral and escalation. Old age psychiatry for severe or psychotic depression, suicidal thoughts, diagnostic doubt or failed treatment. Memory service for suspected dementia. Audiology, ophthalmology, continence services, social care and voluntary sector services.

Admission criteria. Suicidal intent or plan, self neglect with dehydration or malnutrition, psychotic depression, severe agitation, or delirium needing inpatient care.

Discharge and safety netting. Discharge with a follow up appointment within 1 to 2 weeks, a named contact, a social care plan, and carer information. The person and family are told to seek urgent help for suicidal thoughts, refusal to eat or drink, new confusion, or hallucinations.