Social Frailty and Social Isolation in the Context of Dementia: A Simultaneous Concept Analysis. — TEI-tagged view

Ziyue WangpersName, Dympna CaseypersName, Duygu SezginpersName (2025date). “Social Frailty and Social Isolation in the Context of Dementia: A Simultaneous Concept Analysis..” International Journal of Geriatric Psychiatrytitle·j.

Object of study — social frailtyterm·dom and social isolationterm·dom in dementiaterm·key

Research question — how social frailtyterm·dom and social isolationterm·dom are defined in dementiaterm·key, and how the two concepts relate

Contribution — the first account of the distinct and overlapping attributes, antecedents and consequences of social frailtyterm·dom and social isolationterm·dom in dementiaterm·key

Full text — tagged

Social Frailtyterm·dom and Social Isolationterm·dom in the Context of Dementiaterm·key: A Simultaneous Concept Analysisterm·mth.

Abstract Early management of risk factors related to social healthterm·dom such as social frailtyterm·dom and social isolationterm·dom could modify the progression of dementiaterm·key and reduce its impact on people with dementiaterm·key. However, due to overlapping definitions and interchangeable use of measurement tools, the precise distinction between these two concepts is unclear. This simultaneous concept analysisterm·mth aimed to examine the definitions and interrelationships between the concepts of social frailtyterm·dom and social isolationterm·dom within the context of dementiaterm·key.

The simultaneous concept analysisterm·mth method developed by Haase et al. was employed. A literature search was conducted across six databases (Ovid Medline, CINAHL, PsycINFO, Scopus, Embase and Cochrane Library) to retrieve original research, review and theoretical papers, published in English. Data from the literature was synthesised and analysed thematically following Braun and Clarke's six steps.

The attributes of concepts of social frailtyterm·dom and social isolationterm·dom overlap, including being alone and having limited or less social activities, engagements or interactions. The specific attributes of social frailtyterm·dom are financial difficulties and less talk while social isolationterm·dom is distinctly marked by a lack of social networks or social relationships. Socio‐economic welfare is a specific antecedent of social frailtyterm·dom, while decreased access to social resourcesterm·dom and lower social well‐being are distinctive consequences of social isolationterm·dom. Cognitive declineterm·dom and dementiaterm·key are distinctive antecedents of social isolationterm·dom; however, they also exist as shared consequences of both social frailtyterm·dom and social isolationterm·dom.

This simultaneous concept analysisterm·mth clarified the similarities and differences between social frailtyterm·dom and social isolationterm·dom in the context of dementiaterm·key. A clearer understanding of the interrelationships between social frailtyterm·dom and social isolationterm·dom and distinct and overlapping characteristics of them will support strategies to comprehensively address social healthterm·dom issues experienced by people with dementiaterm·key.

Keywords: dementiaterm·key, nursing, simultaneous concept analysisterm·mth, social frailtyterm·dom, social healthterm·dom, social isolationterm·dom Although there are overlaps between the attributes of both concepts, social frailtyterm·dom is a less mature concept in the area of dementiaterm·key than social isolationterm·dom.

Social frailtyterm·dom focuses on the quantity of engaging in social activities or interactions, whereas social isolationterm·dom encompasses a broader range of measurements, focussing on both the quantity and quality of social connectednessterm·dom, not only social interactionsterm·dom. Social frailtyterm·dom might indicate a one‐way reduction of activities such as ‘visiting friends less’ due to the reasons related to people with dementiaterm·key. On the other hand, social isolationterm·dom refers to a reduction or absence of two‐way activities highlighting a broader impact extending beyond socially isolated individuals' actions.

Attributes of social frailtyterm·dom distinctly reflect an absence of social resourcesterm·dom and financial difficultyterm·dom, while decreased access to social resourcesterm·dom and having lower social well‐being are distinctive consequences of social isolationterm·dom. This suggests a relationship between the two concepts. Cognitive declineterm·dom and dementiaterm·key symptoms and diagnosis are antecedents for social isolationterm·dom. On the other hand, cognitive declineterm·dom and increased risk for dementiaterm·key are recognised as consequences of both social frailtyterm·dom and social isolationterm·dom.

This concept analysis provides an improved understanding of the distinctions and overlaps between social frailtyterm·dom and social isolationterm·dom, which can help development of targeted interventions to address specific social needs and improve social healthterm·dom outcomes in dementiaterm·key population.

Introduction The onset age of dementiaterm·key is occurring significantly earlier [ 1 , 2 ], and the prevalence of dementiaterm·key is increasing [ 3 ]. The impact of dementiaterm·key on individuals extends beyond cognitive declineterm·dom, significantly affecting their social healthterm·dom [ 4 ]. The lack of dedicated social healthterm·dom services for people with dementiaterm·key leaves inadequate support for managing the social aspect of their condition, leading to unmet needs related to their social healthterm·dom [ 5 ]. Taking cognisance of the unique social healthterm·dom issues and needs of people with dementiaterm·key could enhance their overall care experiences and health outcomes [ 6 ].

Huber et al. [ 7 ] proposed a reconfigured definition of health, highlighting the social domain alongside the physical and mental domains. Social healthterm·dom, described as an umbrella concept [ 8 ], includes the capacity to fulfil potential and obligations, the ability to manage life with some degree of independence and participation in social activities [ 7 ]. Social frailtyterm·dom, usually portrayed as someone who lives alone, is unable to provide help to others, goes out less frequently, visits friends infrequently and does not talk to anyone on a daily basis [ 9 ], and social isolationterm·dom serve as markers of social healthterm·dom [ 8 ]. Studies have shown that both social frailtyterm·dom and social isolationterm·dom are linked to cognitive declineterm·dom [ 10 , 11 , 12 ] and the onset of dementiaterm·key [ 13 , 14 , 15 ]. Moreover, social frailtyterm·dom can increase the risk of adverse outcomes for individuals with dementiaterm·key [ 16 , 17 ]. Similarly, social isolationterm·dom is highly associated with the severity of dementiaterm·key [ 18 ] and increases physical and mental health risks for dementiaterm·key [ 13 ]. The literature demonstrates that social frailtyterm·dom and social isolationterm·dom are critical factors that could potentially increase the challenges faced by individuals with dementiaterm·key. It is crucial therefore to investigate the factors contributing to social frailtyterm·dom and social isolationterm·dom to devise preventive measures and interventions for individuals with dementiaterm·key, to enhance their social healthterm·dom.

Notably, the terms social frailtyterm·dom and social isolationterm·dom are sometimes used interchangeably [ 19 , 20 ], which indicates an overlap in their meanings within the dementiaterm·key context [ 21 ]. Social frailtyterm·dom is defined by Bunt et al. [ 22 ] as ‘ a continuum of being at risk of losing or having lost, resources that are important for fulfilling one or more basic social needs during the life span ’. According to Broese [ 23 ], social frailtyterm·dom encompasses insufficient participation or no participation in social networks and the perception of a lack of contacts and support. Conversely, social isolationterm·dom is seen as a lack of social contacts and interactions with family members, friends or the community [ 24 ]. Despite shared elements, there is ambiguity regarding whether social frailtyterm·dom and social isolationterm·dom bear identical meanings, as social isolationterm·dom could be interpreted as a component of social frailtyterm·dom. Therefore a clear understanding of each concept and the exact interrelationship between them is warranted [ 25 , 26 ].

Identification of social frailtyterm·dom and social isolationterm·dom in people with dementiaterm·key and in general population involves the use of measurement tools; however, the items listed in these tools often share overlapping criteria. Bessa et al. [ 27 , 28 ] examined 27 tools that measure social frailtyterm·dom. They reported that most questions to assess social frailtyterm·dom refer to its social domains and include living alone, reduced social networks, lack of social support, lonelinessterm·dom and infrequent social activities [ 27 , 28 ]. However, the item ‘lonelinessterm·dom’ is considered a subjective construct within the definition of social isolationterm·dom [ 29 ]. Another example of this overlap is that several items in the Social Isolationterm·dom Score [ 30 ] used to measure social isolationterm·dom, such as the items ‘living alone’, ‘contacting friends or neighbours’ and ‘talking to friends or neighbours’, share elements with Makizako et al. [ 9 ]'s measurement tool of social frailtyterm·dom. In a study by Díaz Alonso et al. [ 31 ], conducted with a European sample, items reflecting social isolationterm·dom [ 24 ] such as infrequent contact with family, friends and neighbours were used to measure social frailtyterm·dom. In other examples of studies conducted in Asian countries, the Lubben Social Network Scale‐6, which is widely used to assess social isolationterm·dom [ 32 ], was used to measure social frailtyterm·dom [ 19 , 20 ]. These examples demonstrate that the items used in the respective tools to measure social frailtyterm·dom and social isolationterm·dom overlap and are used interchangeably. There is a need thus to examine each concept carefully and identify the similarities, differences and interrelationships between them. This will contribute to differentiating the meaning of these concepts as well as clarifying their respective measurement tools. The overlap in current measurement tools for social frailtyterm·dom and social isolationterm·dom is noted, but in the context of dementiaterm·key, there is no evidence of how these concepts are understood or what precise interrelationship exists.

Simultaneous concept analysisterm·mth is a strategy used to explore two or more concepts to achieve a greater comprehension of each concept and their interrelationship [ 33 ]. Through a detailed analysis of the antecedents, attributes, and consequences of social frailtyterm·dom and social isolationterm·dom, a better understanding of their definitions can be ensured. Having a clear understanding of these two concepts will help researchers and clinicians identify the socially frail and socially isolated individuals with dementiaterm·key, to address their specific needs. Furthermore, this level of understanding will enhance the design of interventions and care practices, leading to improved healthcare outcomes and quality of life for both socially frail and socially isolated people with dementiaterm·key.

Methods Aim This simultaneous concept analysisterm·mth aimed to examine the concepts of social frailtyterm·dom and social isolationterm·dom within the context of dementiaterm·key. This analysis identified distinguishing, overlapping and similar attributes, antecedents and consequences for each concept and explored their interrelationships simultaneously.

Study Design This study employed simultaneous concept analysisterm·mth (SCA) using a framework developed by Haase et al. [ 33 , 34 ], based on Rodgers’ evolutionary concept analysis methodology [ 35 ]. This simultaneous concept analysisterm·mth was registered on the Open Science Framework [ 36 ]. The analysis involved nine steps [ 33 ], which are described in detail below: Step 1‐Development of the Consensus Group The consensus group comprised three researchers (Z.W., D.C., D.S.), whose research focuses on dementiaterm·key and social frailtyterm·dom. The core consensus group (Z.W., D.S.) met biweekly to discuss the concept analysis process including the development of the SCA strategy, refined definitions of each concept, identification of the specific elements of each concept, and their sequence of occurrence and clarification of interrelationships. The full consensus group met every 6 weeks to review the process over 7 months.

Step 2‐Selection of Concepts to be Analysed With the aim of this simultaneous concept analysisterm·mth, two concepts, named social frailtyterm·dom and social isolationterm·dom, were selected following comprehensive discussions between three researchers (Z.W., D.C., D.S.). The analyses were conducted for each concept simultaneously in the context of dementiaterm·key.

Step 3‐Refinement of the Concept Clarification Approach A scoping review of the literature was performed. Specific elements of this approach are described below: Data Source The literature searches were performed on six databases: Ovid Medline, CINAHL, PsycINFO, Scopus, Embase and Cochrane Library.

Literature Search The literature search followed the guidelines for scoping review [ 37 ]. A pilot search on PubMed was conducted to identify all terms related to the two concepts of social frailtyterm·dom and social isolationterm·dom as well as dementiaterm·key. The MeSH terms ‘Social Isolationterm·dom’, ‘Dementiaterm·key’ and ‘Alzheimer Disease’ were identified. However, there were no relevant MeSH terms for ‘social frailtyterm·dom’. The final literature search strategy was refined with the assistance of a librarian. The final search was conducted in December 2023. All searches were limited to English, without a time limit. Detailed search strategies for all databases and preliminary search results are presented in Supporting Information S1 : Appendix 1.

Eligibility Criteria According to the PRISMA‐ScR [ 37 ] guidelines, the publications were screened using the following inclusion criteria (1) provide conceptual or operational definitions or descriptions of social frailtyterm·dom, or social isolationterm·dom, (2) address the topic within the context of dementiaterm·key, (3) reporting from the perspectives such as various contexts including different care settings (e.g., community, residential care or acute care), diverse populations, and professional background of authors, (4) published in peer‐reviewed journals following any study design including review articles, editorials, and commentaries and (5) published in English. Following a semantic approach, publications were included if they defined the terms social frailtyterm·dom or social isolationterm·dom. Publications excluded were those that (1) include social frailtyterm·dom or social isolationterm·dom but did not provide a definition or description, (2) were not in the context of dementiaterm·key, (3) were not published in peer‐reviewed journals, (4) were only conference paper, (5) were not available in English, (6) focussed on social frailtyterm·dom or social isolationterm·dom only in caregivers of people with dementiaterm·key considering that this is not the scope of this SCA, (7) were protocol registrations on an online platform or (8) were not available in full‐text.

Literature Selection The search results were imported to Endnote, and afterwards to Rayyan for de‐duplication and systematic screening. A random selection of publications (10% of the search results) was piloted by three researchers for the screening of titles and abstracts (Z.W., D.S., H.Z.). The conflicts between the researchers were resolved by discussions and consensus. This ensured the clarification and refinement of the inclusion and exclusion criteria. After that, two researchers (Z.W. and H.Z.) completed the title and abstract screening for the remaining publications. For the full text screening, a random selection of 10% of the publications were screened by two researchers (Z.W., D.S.), and the remaining publications were screened by one researcher (Z.W.). In case of unclarity regarding inclusion of a full text publication, discussions were held between two researchers (Z.W., D.S.) and decisions were made by consensus.

Data Extraction Data extraction was carried out following the data extraction form developed by Z.W. and D.S., including (1) title, the year of publication, author (s)’ names and their disciplines; (2) design of the publication; (3) aims of the publication; (4) population/participant characteristics, setting, assessment tools (if any); (5) conceptual definitions, operational definitions and narrative descriptions by people with dementiaterm·key as reported; (6) factors identified as antecedents of the concepts; (7) identified consequences of the concepts; (8) concepts identified by authors as relevant to the concepts of interest; (9) ‘alternative terms’ used by authors to refer to the concepts; (10)any examples (such as cases) of social frailtyterm·dom or social isolationterm·dom provided by authors; (11) information reported as the primary or secondary source; (12) other notes. Data was extracted from the included publications by Z.W. and the data was reviewed by DS for accuracy.

Step 4‐Clarification of Individual Concepts According to Haase et al. [ 33 ], the purpose of data analysis is not to develop a new, complete or finished definition of concepts, but rather to provide clarification of each concept. A thematic analysis was performed as suggested by Haase et al. [ 33 ] to examine the concepts of social frailtyterm·dom and social isolationterm·dom to strengthen the characterisation and clarification of each concept. Braun and Clarke's six steps [ 38 , 39 ] were followed for the thematic analysis. The extracted data was categorised into the groups of conceptual definitions, operational definitions and narrative descriptions. The data was first read and coded by Z.W. [ 33 , 40 ]. As part of this process, separate coding manuals were developed for attributes, antecedents and consequences. Another researcher (D.S.) then reviewed this coding and consensus was reached on the coding. The codes were collated and categorised into draft constructs for each concept by Z.W. and D.S. The constructs, which represent themes in the thematic analysis process, were then compared with each other to identify the common factors and distinctive attributes, antecedents, and consequences of both concepts. The term ‘distinctive’ was used to describe an attribute, antecedent or consequence that is present in only one of the two concepts but not both, and therefore played a crucial role in differentiating one concept from another.

Step 5‐Development of Validity Matricesterm·mth Validity matricesterm·mth were constructed for attributes, antecedents and consequences (Z.W.) through the identification of common factors and an examination of the connections between concepts to attain theoretical coherence. During this iterative process, Z.W. and D.S. interrogated each element, identified inconsistencies and gaps and made revisions as needed until all the elements were identified within the context of dementiaterm·key.

Steps 6 and 7‐Revision of Individual Concept Clarification and Re‐Examination of Validity Matricesterm·mth The consensus group convened to review the previous classifications of concepts and make any required revisions. Additionally, the group engaged in discussions, examinations and re‐evaluations of the concept analyses and validity matricesterm·mth. Taking into account each element, considering others through constant comparisons to clarify the interrelationships and differences between the two concepts.

Step 8‐Development of a Process Modelterm·mth After a consensus on attributes, antecedents and consequences were more clearly delineated a process modelterm·mth was developed [ 33 ]. The model examined the similarities and differences across concepts, and the interrelationships across both concepts and processes throughout the model.

Step 9‐Submission of the SCA Results to Peers for Critique After exploring the concepts of social frailtyterm·dom and social isolationterm·dom, the simultaneous concept analysisterm·mth results were shared with peers, such as dementiaterm·key researchers ( n = 14), clinical practitioners in dementiaterm·key care ( n = 14) for example, staff at memory clinics and memory assessment support services and a Patient and Public Involvement (PPI) contributor (a family caregiver of a person with dementiaterm·key), by presenting the protocol and the preliminary results in meetings, seminars, and conferences to obtain their input, feedback and an objective evaluation of the findings. They were contacted via the TeamUp for Dementiaterm·key Research (TUDR) of the Alzheimer Society of Ireland (TUDR is a service where people living with dementiaterm·key and their families can register their interest in involving in dementiaterm·key research). The researchers working in dementiaterm·key and clinical practitioners were identified from a local hospital and community care services in Ireland, Psychosocial Dementiaterm·key Research Group within the authors' affiliated university, INTERDEM Academy [ 41 ] and peers and attendees of conferences related to dementiaterm·key. The preliminary and final results were also disseminated to people with dementiaterm·key during these conferences and their feedback was incorporated into the final report of this SCA.

Results Overview of the Results Selection of Sources of Evidence A total of 5445 publications were identified for title and abstract screening. The full texts of 217 publications were examined, from which 67 publications were selected for data. The process is detailed in a flow diagram (Figure 1 ) [ 42 ].

The Reporting Items for Simultaneous Concept Analysisterm·mth flow diagram includes searches of databases and other sources. Source: M. J. Page, J. E. McKenzie, P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D. Mulrow, et al. “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” BMJ 372 (2021): n71, 10.1136/bmj.n71. For more information, visit: http://www.prisma‐statement.org/ .

Characteristics of the Included Publications Type of Evidence and Setting The majority of studies were cross‐sectional ( n = 17) [ 12 , 20 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ], secondary analyses of datasets ( n = 14) [ 13 , 17 , 26 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ], semi‐structured and structured interviews ( n = 6) [ 69 , 70 , 71 , 72 , 73 , 74 ] or longitudinal studies ( n = 5) [ 75 , 76 , 77 , 78 , 79 ]. The remaining studies included various other types of research studies and reviews, such as quasi‐experimental studies or systematic reviews ( n = 25) [ 16 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 ].

Most studies were conducted in community settings ( n = 32), followed by nursing homes or residential settings ( n = 14), and hospital or clinic settings ( n = 5). A few studies reported multiple settings ( n = 2), and the remaining did not report specific settings ( n = 14).

Characteristics of the Population of Participants Many publications involved people diagnosed with dementiaterm·key ( n = 18), people living with or without dementiaterm·key combined ( n = 6) and people at risk for dementiaterm·key ( n = 3). Other specific groups included those with early‐stage dementiaterm·key ( n = 1), mild or mild to moderate stage dementiaterm·key ( n = 3), mildly severe to very severe dementiaterm·key ( n = 3) and LGBT (lesbian, gay, bisexual and transgender) people with dementiaterm·key ( n = 1). The remaining 32 papers had people without dementiaterm·key at the baseline of a longitudinal study ( n = 17), with some not reporting population characteristics ( n = 15).

Reporting Disciplines of Authors Publications were often from multidisciplinary teams ( n = 20), with authors from the background of nursing science ( n = 10), health science or public health ( n = 4), social science ( n = 4), psychiatry ( n = 7), psychology ( n = 2) and neurology ( n = 4) and the information systems ( n = 1).

Period and Number of the Included Publications The publications span the years 1990–2024. Publications reporting on social frailtyterm·dom were from 2017 to 2023 ( n = 10), while those reporting on social isolationterm·dom were from 1990 to 2024 ( n = 57). In the recent five years, there were five publications on the concept of social frailtyterm·dom, while 25 on social isolationterm·dom. The significant difference in the number of publications suggests that, compared to social isolationterm·dom, social frailtyterm·dom is a relatively new concept and not widely explored in dementiaterm·key care and research. A table summarising the characteristics of the included 67 publications is provided in Supporting Information S2 : Appendix 2.

Clarification of Individual Concepts and Validity Matricesterm·mth of Social Frailtyterm·dom and Social Isolationterm·dom Overview of Conceptual Definitions, Operational Definitions and Narrative Descriptions Ten publications were analysed for definitions and descriptions of social frailtyterm·dom, and 57 publications on social isolationterm·dom. Overall, four publications discussed both social frailtyterm·dom and social isolationterm·dom.

Both concepts of social frailtyterm·dom and social isolationterm·dom shared a common theme of reduced social interactionsterm·dom or engagement. Based on the conceptual definitions, social frailtyterm·dom can broadly include the elements of resource insufficiency and unfulfillment of social needs, and operational indicators of social frailtyterm·dom include financial difficultyterm·dom. By contrast, social isolationterm·dom is primarily described as reduced social networks, with operational measures that focus on the quality and quantity of social contact. From the narrative descriptions of people with dementiaterm·key, social frailtyterm·dom is often expressed through lonelinessterm·dom and poor social contact. Similarly, social isolationterm·dom meant having fewer friends, lacking closing relationships, being socially disconnected, living alone and being ignored (Table 1 ).

Definitions and descriptions of social frailtyterm·dom and social isolationterm·dom.

Clarification for Attributes of Social Frailtyterm·dom and Social Isolationterm·dom Sixteen attributes were identified for social frailtyterm·dom from 61 constructs across eight publications, and 17 for social isolationterm·dom from 183 constructs across 42 publications (Table 2 ).

Validity matricesterm·mth for attributes, antecedents and consequences of social frailtyterm·dom and social isolationterm·dom.

Both concepts of social frailtyterm·dom and social isolationterm·dom share common factors such as living alone and experiencing lonelinessterm·dom. Significant overlaps of attributes between social frailtyterm·dom and social isolationterm·dom exist in limited or less social activities, engagement or interactions, less social support from friends or relatives, infrequent social contact and visits and limited self‐management abilities or competence.

Attributes specific to social frailtyterm·dom include financial difficultyterm·dom and less talk, which serve as operational definitions of the concept. Less frequently going out, a lack of social resourcesterm·dom and failure to fulfil basic needs, are also distinctive attributes of social frailtyterm·dom.

Distinctive attributes of social isolationterm·dom include a lack of social networks or social relationships. The attributes categorised under ‘being alone’ include not being married or having a partner, objective physical separation from others, feeling apart from others and being ignored by others. When compared with social frailtyterm·dom, the attributes of social isolationterm·dom provide more details about the nature of social isolationterm·dom rather than some indicators such as being alone or lack of social activities.

Clarification for Antecedents of Social Frailtyterm·dom and Social Isolationterm·dom Five antecedents were identified from six constructs across one publication for the concept of social frailtyterm·dom, and 12 antecedents were identified across 31 publications for social isolationterm·dom (Table 2 ).

The concept of social frailtyterm·dom and social isolationterm·dom shared several antecedents including age‐related factors, being alone, and lack of social activities. Ageing was an antecedent for social frailtyterm·dom, while the publications on social isolationterm·dom specifically reported age‐related hearing loss as an antecedent. Being alone was a shared construct for both social frailtyterm·dom and social isolationterm·dom. Contributing constructs for this were living alone, not being married or having a partner for social frailtyterm·dom, and exclusion from others for social isolationterm·dom. Lack of social activities was described as an antecedent of both social frailtyterm·dom and social isolationterm·dom, while social isolationterm·dom also highlighted meaningful activities besides the quantity of social activities.

Impact of socio‐economic welfare was the only reported construct as an antecedent of the onset of social frailtyterm·dom. Dementiaterm·key diagnosis and symptoms, less contact and lack of communication, no inclusive residential care services, and cognitive declineterm·dom, followed by negative public attitudes, smaller social networks and decreased social interactionsterm·dom were distinct antecedents of social isolationterm·dom.

Clarification of Consequences of Social Frailtyterm·dom and Social Isolationterm·dom Eight consequences were identified for social frailtyterm·dom from 31 constructs across eight publications and 11 for social isolationterm·dom from 56 constructs across 19 publications (Table 2 ).

Consequences such as cognitive declineterm·dom, increased risk for dementiaterm·key, physical and functional effects and negative health‐related outcomes overlapped in both social frailtyterm·dom and social isolationterm·dom. Additionally, depressive symptoms were reported as consequences of both concepts, while literature on social isolationterm·dom also reported adverse mental health and increased stress and anxiety highlighting its negative psychological effects. Negative effects on quality of life were also identified as consequences of both concepts in terms of (with links to) harmful effects on quality of life or decreased satisfaction with quality of life.

Other aspects of frailty, such as physical frailty and psychological frailty, were reported as distinct constructs regarding consequences of social frailtyterm·dom. Feeling lonely and having reduced social resourcesterm·dom and well‐being were distinct to the concept of social isolationterm·dom as the consequences of it.

Antecedents, attributes, and consequences of each concept of social frailtyterm·dom and social isolationterm·dom in relation to one another are provided in the process modelterm·mth (Figure 2 ).

Process modelterm·mth of social frailtyterm·dom and social isolationterm·dom. *: A process modelterm·mth serves as a tool for analysis and a predecessor to theories, not to be a theoretical or causal model.

Discussion This simultaneous concept analysisterm·mth (SCA) examined conceptual definitions, operational definitions and narrative descriptions of concepts of social frailtyterm·dom and social isolationterm·dom. It also explored similarities and differences between antecedents, attributes and consequences of two concepts, and analysed their relationship in the context of dementiaterm·key. The detailed exploration of social frailtyterm·dom and social isolationterm·dom enhanced the understanding of the conceptual framework for social healthterm·dom of people with dementiaterm·key [ 8 ], where social healthterm·dom is both an outcome and vital part of managing dementiaterm·key, emphasising the need for addressing the social healthterm·dom risks of people with dementiaterm·key.

Although the number of publications on the two concepts of social frailtyterm·dom and social isolationterm·dom included in this SCA is quite varied, similarities and differences exist in the definitions, descriptions, attributes, antecedents and consequences of each concept. In this SCA, only 10 publications were included for the analysis of social frailtyterm·dom while 57 publications were included for analysing the concept of social isolationterm·dom. Social frailtyterm·dom, which is suggested as a relatively recent concept within dementiaterm·key research, has drawn little academic interest and has only started to appear in the literature since 2017 [ 12 ]. In contrast, social isolationterm·dom has been extensively explored and well‐studied both for definitions [ 24 ] and measurement tools [ 43 , 87 ]. Other studies on social isolationterm·dom such as influencing factors [ 84 ], associations with dementiaterm·key incidence [ 63 ] and intervention programmes and their impact on individuals living with dementiaterm·key [ 72 ] also support the extensive body of research on this concept. This disparity indicates that social frailtyterm·dom is a less mature concept than social isolationterm·dom, which requires further investigation in the context of dementiaterm·key specifically regarding its application and social healthterm·dom outcomes in dementiaterm·key populations.

The publications included in this SCA highlighted the interlinked nature of the two concepts of social frailtyterm·dom and social isolationterm·dom, demonstrating different facets of each concept. Both concepts overlap in several aspects of their attributes, primarily in ‘limited or less social activities, engagement or interactions’ both on the conceptual and operational definitions of the two concepts [ 16 , 17 , 54 , 76 ]. Social frailtyterm·dom uniquely includes operationalised items such as ‘less frequently going out’ [ 54 ], while ‘engagement in social activities’ is a definition and measurement item of social isolationterm·dom [ 86 ]. Furthermore, social isolationterm·dom has also been referred as a degree of social disconnection [ 84 ] and inadequate quality and quantity of social connectednessterm·dom [ 57 ]. Social interactionsterm·dom refer to the direct acts of communication or engagement with others [ 104 ], while social connectednessterm·dom is a broader term that includes living arrangementsterm·dom, size of social networks, and engagement in social activities [ 105 ]. This suggested the concept of social frailtyterm·dom focuses only on the quantity of engaging in social activities or interactions, whereas social isolationterm·dom encompasses a broader range of measurements, focussing on both the quantity and quality of social connectednessterm·dom not only interactions.

Publications included in this SCA suggest that social frailtyterm·dom involves a one‐way reduction or absence in the attribute ‘visiting friends less’ [ 95 ] indicating that the number of visits to friends is reduced due to the reasons related to the person with dementiaterm·key. Studies suggested that such people with social frailtyterm·dom have more impaired ability in terms of verbal fluency [ 106 ] and have issues with hearing impairment [ 107 ], which might affect their desire, interest, or capacity to visit friends. This reflects another unique attribute ‘less talk’ [ 54 ], which was also an item in most measurement tools for social frailtyterm·dom. In contrast, social isolationterm·dom is suggested to refer to more of a reduction or absence in two‐way activities, for example, both visiting friends and being visited by friends [ 63 ]. This highlights a much broader impact extending beyond the socially isolated individuals' actions. It might also reflect the distinctive attribute ‘lack of social networks and social relationships’ [ 15 ]. Individuals experiencing social isolationterm·dom reported that being ignored by others contribute to reduced interactions with their social networks, leading to fewer visits by others [ 73 ]. Additionally, having ‘smaller social networks’ [ 69 ] is identified as a distinctive antecedent of social isolationterm·dom, suggesting that attributes and antecedents may overlap within the concept of social isolationterm·dom.

Although both concepts involve less or an absence of social support from friends, families or relatives, the attributes of social frailtyterm·dom distinctly reflect an absence of broader social resourcesterm·dom and financial difficultyterm·dom [ 16 , 17 , 95 ]. Social resourcesterm·dom refer to resources or services that individuals with dementiaterm·key and their family caregivers can apply for, such as day care, home help services, responsive care and home care, which can provide additional support to them [ 108 , 109 ]. Socially frail people with dementiaterm·key might retire early from their employment due to dementiaterm·key symptoms [ 110 ], which could to economic challenges and lack of access to healthcare or other essential services they need. The lack of social resourcesterm·dom might often intersect with economic challenges, highlighting how financial difficultyterm·dom directly affects an individual's ability to engage with and access required social resourcesterm·dom. Limitations with the welfare system might also lead socially frail individuals to financial difficulties [ 111 ]. This reflects the distinctive antecedent ‘impact of socio‐economic welfare’ of social frailtyterm·dom [ 95 ]. Financial difficultyterm·dom as one of the distinctive attributes of social frailtyterm·dom can be an important consideration under the socio‐economic factors [ 95 ] when developing or adapting measurement tools for social frailtyterm·dom and informing the development of prevention programmes for social frailtyterm·dom in the dementiaterm·key population.

‘Decreased access to social resourcesterm·dom’ [ 84 ] and having ‘lower social well‐being’ [ 90 ] are identified as distinctive consequences of social isolationterm·dom. People with dementiaterm·key who are experiencing social isolationterm·dom are more likely to experience poorer health outcomes than those who are not [ 112 ], possibly due to increasingly lacking access to essential social resourcesterm·dom and having reduced social well‐being. As social isolationterm·dom advances, the reduced access to social resourcesterm·dom and lower social well‐being potentially contribute to social frailtyterm·dom. This indicates that attributes of social frailtyterm·dom and consequences of social isolationterm·dom overlap, showing while both concepts are related, each has its distinct pathways and impacts. The relationship between this attribute of social frailtyterm·dom and consequence of social isolationterm·dom might suggest that social frailtyterm·dom and social isolationterm·dom are interrelated and mutually influence each other. Figure 2 displays distinct and overlapping antecedents, attributes, and consequences of both concepts. Figure 3 presents a selection of examples to illustrate how these antecedents, attributes, and consequences link and differentiate the concepts of social frailtyterm·dom and social isolationterm·dom. We emphasise that the connections we show between the two concepts and their antecedents, attributes, and consequences should not necessarily be interpreted as causal pathways. Our results highlight the importance of early management of dementiaterm·key and social frailtyterm·dom by enhancing social resourcesterm·dom and decreasing the risks and effects of social isolationterm·dom. By addressing such issues, interventions can be more effectively designed to target social healthterm·dom outcomes for people with dementiaterm·key.

Examples of antecedents, attributes, and consequences that link and differentiate the concepts of social frailtyterm·dom and social isolationterm·dom. *The figure represents the interrelated and mutual influences between both concepts together with their consequences and antecedents.

Based on the available literature, ‘cognitive declineterm·dom’ and ‘dementiaterm·key symptoms and diagnosis’ act as antecedents only for the concept of social isolationterm·dom. This suggests that the onset of cognitive declineterm·dom and dementiaterm·key might lead to individuals' social isolationterm·dom. Cognitive declineterm·dom may reduce an individual's ability to engage in social interactionsterm·dom due to memory loss [ 67 ], and lead to challenges in communication [ 68 , 74 ]. Similarly, the diagnosis of dementiaterm·key might contribute to social isolationterm·dom due to changes to social networks [ 72 ], potentially linking with stigma or discrimination from public [ 69 , 73 ]. On the other hand, ‘cognitive declineterm·dom’ and ‘increased risk for dementiaterm·key’ are recognised as consequences of both social frailtyterm·dom and social isolationterm·dom [ 54 , 61 , 65 , 99 ]. This indicates a relationship between both concepts, due to overlapping antecedents and consequences related to dementiaterm·key risk, symptoms and diagnosis (Figure 3 ). The concepts of social frailtyterm·dom and social isolationterm·dom have been used interchangeably in previous research [ 9 , 19 , 20 , 27 , 28 , 29 , 30 , 31 , 32 ], and this SCA identified some overlaps between these concepts; however, although they are interrelated, they are not identical. This suggests that managing social frailtyterm·dom might prevent individuals' cognitive declineterm·dom and reduce the risk of dementiaterm·key. It could also be possible to both prevent social isolationterm·dom by managing cognitive declineterm·dom and to prevent further progression of cognitive declineterm·dom and decrease the risk for dementiaterm·key by managing social isolationterm·dom. This can be addressed by development of prevention and management programmes targeting both social frailtyterm·dom and social isolationterm·dom in the dementiaterm·key population and those at risk. Additionally, it may help the recognition of the unique challenges faced by those with early onset dementiaterm·key, who may experience social frailtyterm·dom or social isolationterm·dom at a younger, potentially more active stage in their lives. Managing social frailtyterm·dom and social isolationterm·dom in early‐onset dementiaterm·key might also potentially slow the progression of their disease. Understanding the unique challenges experienced by this population can aid in developing more targeted care strategies and services for people with dementiaterm·key. This approach could help maintain the quality of life and improve health outcomes of people with dementiaterm·key, potentially reducing inequalities in dementiaterm·key population.

Examples of other concept analyses of social frailtyterm·dom [ 113 ] and social isolationterm·dom [ 114 ] in older adults have been noted. A recent concept analysis of social frailtyterm·dom in the context of older adults [ 113 ] reported that low cognitive function, including dementiaterm·key, is one of the psychological consequences of social frailtyterm·dom in older adults. This aligns with our analysis of ‘cognitive declineterm·dom’ as a consequence of social frailtyterm·dom in the context of dementiaterm·key. It suggests that social frailtyterm·dom should be managed in older adults to delay cognitive declineterm·dom in order to prevent dementiaterm·key onset. Another concept analysis, which was about social isolationterm·dom in older adults [ 114 ] also described dementiaterm·key and decline in cognition as possible causes of social isolationterm·dom in the older population, which also supports our results identifying ‘cognitive declineterm·dom’ and ‘increased dementiaterm·key risk’ as consequences of social isolationterm·dom in the context of dementiaterm·key. Our SCA further added to the existing knowledge by simultaneously analysing both concepts of social frailtyterm·dom and social isolationterm·dom and specifically exploring these concepts in the context of dementiaterm·key.

Potential limitations to this SCA include interpretive bias during the categorisation of conceptual and operational attributes of each concept, however, this simultaneous concept analysisterm·mth process followed guidelines outlined by Méndez‐Sánchez [ 115 ] and was reviewed and discussed by the consensus group members through regular meetings. The common factors and distinctive attributes, antecedents, or consequences of both concepts in this SCA are also limited by the quantity of publications, particularly concerning social frailtyterm·dom. It is important to note that the disparate number of publications on social frailtyterm·dom and social isolationterm·dom could have influenced the identification of distinctive attributes, antecedents or consequences. It is also recognised as a limitation that non‐English publications were excluded, thereby potentially omitting some relevant evidence. Another limitation is that people with dementiaterm·key and clinical practitioners were not directly involved in the development of this SCA. However, they were part of the process by providing feedback on the preliminary and final results.

Despite the limitations listed above, this SCA has several strengths. Following a comprehensive review and synthesis of the literature, this SCA is the first to identify the distinct and overlapping attributes, antecedents, and consequences of both social frailtyterm·dom and social isolationterm·dom in the context of dementiaterm·key, thereby enhancing the clarity of definitions and elucidating their interrelationships. Additionally, this SCA is the first to explore both the differences and similarities between these two important concepts. This SCA also included publications that were longitudinal studies including baseline populations without dementiaterm·key and their results contributed to the development of antecedents, attributes, and consequences of both concepts. We focussed on both of these population groups to identify the interrelationships in the literature and present the broader picture of social frailtyterm·dom and social isolationterm·dom in populations at pre and post diagnosis stages of dementiaterm·key. The results of this SCA will inform the development of more targeted and effective strategies to address social frailtyterm·dom and social isolationterm·dom in people with dementiaterm·key, contributing significantly to both academic and practical advancement in the field of dementiaterm·key care. Future studies should evaluate the results of this simultaneous concept analysisterm·mth using relevant primary data collection methods [ 33 ]. This SCA also highlighted the need for more publications particularly concerning social frailtyterm·dom in dementiaterm·key.

Conclusion This publication supports the use of SCA and the development of more comprehensive social frailtyterm·dom and social isolationterm·dom measurement tools for use with people with dementiaterm·key. Furthermore, the findings from this study can be used to better identify people with dementiaterm·key at risk of social frailtyterm·dom or social isolationterm·dom as well as guide future researchers and policymakers to develop social frailtyterm·dom or social isolationterm·dom prevention and management programmes, thereby improving the social healthterm·dom of people with dementiaterm·key.

Author Contributions Ziyue WangpersName: conceptualization (lead), funding acquisition (lead), methodology (lead), project administration (lead), writing – original draft preparation (lead), writing – review and editing (equal). Dympna CaseypersName: conceptualization (equal), methodology (supporting), supervision (supporting), writing – review and editing (supporting). Duygu SezginpersName: conceptualization (equal), funding acquisition (supporting), methodology (supporting), supervision (lead), writing – original draft preparation (supporting), writing – review and editing (equal).

Ethics Statement This study represents secondary research and did not require ethical approval.

Conflicts of Interest The authors declare no conflicts of interests.

Supporting information Supporting Information S1 Supporting Information S2 Acknowledgements The authors acknowledge the assistance of Rosie Dunne, research support librarian at the University of Galway, for her guidance and feedback on the literature search strategy. The authors also acknowledge the assistance of Hongyu Zhang, for her contribution to title and abstract screening.

Data Availability Statement The data that support the findings of this study are openly available in Open Science Framework at https://osf.io/n586a , reference number https://doi.org/10.17605/OSF.IO/N586A .

References Associated Data Supplementary Materials Supporting Information S1 Supporting Information S2 Data Availability Statement The data that support the findings of this study are openly available in Open Science Framework at https://osf.io/n586a , reference number https://doi.org/10.17605/OSF.IO/N586A .