Social determinants of health (SDOH) encompass the economic, social, and environmental factors of where people live and work (World Health Organization, 2021). As discussed in another article in this issue (see "Addressing Social Determinants of Health: A Care Coordination Approach for Professional Case Managers"), poverty, homelessness, inadequate access to health care, transportation, and nutrition are among the many factors that can undermine the health and wellness of individuals and populations. A deeper understanding of SDOH can also lead to greater awareness of how such "social influences" can affect a much greater segment of the population, particularly as people age.

Social influences have been defined as the communities and social circles in which people live and work-their family members, friends, peers, and even the virtual communities they join through social media. These interactions and connections can impact people's attitudes toward accessing care, as well as how they function and those on whom they rely (Centola, 2013). Here, we take it a step further by looking at how these social influences, including changes in lifestyle, impact people's health, including their ability to care for themselves, and their compliance with a medical regime such as physicians' orders. For example, it has been well documented that the COVID-19 pandemic amplified the dire and often tragic impact of SDOH on the lives of minority and underserved individuals and populations, including greater incidence of infection, contagion, hospitalization, and death (World Health Organization, 2021). When viewed as a social influence, COVID-19 has impacted the broader population as well, regardless of socioeconomic status, due to isolation and loss of social connections during lockdowns and quarantines, exacerbated fears and anxiety, increased incidence of mental health issues such as depression, and an overall state of fatigue and burnout (Centers for Disease Control and Prevention, 2022).

Some social influences arise as a result of aging: for example, loss of mobility (walking or driving) or decrease in cognition. Financial insecurity can increase with age as money set aside for retirement proves insufficient. Inflation has escalated the costs of many household goods and expenses. Many older people, in particular, may be struggling to make ends meet on fixed income and limited savings (Bhattarai, 2022). Elderly individuals who are covered by Medicare have difficulty affording their supplemental coverage, which prevents them from seeking the medical care they need or filling prescriptions. For example, a recent study found that Americans who have low incomes, but do not qualify for government subsidies, often did not fill prescriptions for high-priced medicines; this included 30% of prescriptions for cancer drugs and 50% of prescriptions written for cholesterol and immune disorder medications (Silverman, 2022). A person need not live in poverty to have financial concerns that impact their ability to access care.

With keener awareness of how financial concerns impact clients' health, case managers should be more cognizant of red flags that may signal an underlying problem. For example, individuals may be coming to the emergency department frequently because of complications due to diabetes, high blood pressure, or other health conditions. They may claim to be taking their insulin or other diabetes medications, and yet blood analysis reveals the contrary. Similarly, they may say that they take their blood pressure medication as prescribed; however, they are experiencing extremely high blood pressure. Rather than jump to the conclusion of noncompliance, case managers must take the time to discern what may be going on in their clients' lives. Difficulty affording their medications could result in clients skipping doses or breaking pills in half to make a prescription last longer. A simple question-"tell me what you do from day to day to manage your health conditions"-could reveal more about the challenges the individual faces and how they are coping.

Other social influences on health include death of a spouse or partner and the shrinking of one's social circle due to the death of others. Individuals who are struggling to access care or to care for themselves may be reticent to admit that they have such difficulties in order to preserve their dignity and assert their independence. There can be compounding factors as well, such as lack of education or low literacy skills, which become compounded by a loss of cognition or a change in the person's marital status or personal life. For example, when people say that they cannot see printed material clearly, with excuses such as "I don't have my reading glasses," there may be more to what is being said. The person could be functionally illiterate and may have depended on a spouse or a partner to read for them. But the death of a spouse/partner or divorce could leave the individual without that help. This renders the person unable to read written care instructions postdischarge from the hospital or from a treating physician, or to understand the dosage printed on the medication label. As case managers know, functional illiteracy diminishes health literacy (LeDoux & Mann, 2019).

In addition, people of any age can be affected by addictions. However, with aging, such problems can escalate at a time when people are more vulnerable. It has been well documented for years that addictive disorder among elderly individuals is a public health issue, in part due to the aging of the overall population. As Stewart and Oslin observed, "As the proportion of the elderly population increases, more and more older adults will either develop addictions as a dysfunctional means of coping with the psychosocial consequences of aging or will carry their long-standing addictive behaviors with them into later life. Among the most common of these addictions are smoking, excess consumption of alcohol and gambling" (2001, p.145). A case manager might encounter elderly clients who considered themselves "social drinkers" in their youth. Now, however, they are unaware that their alcohol consumption has increased, which is incompatible with the medications they take. The problem may not come to light until a fall or other accident reveals a previously undetected alcohol problem.

These scenarios are only a few of the multiple examples that professional case managers can encounter in their daily practice. What's needed is greater awareness of how many people are having a harder time managing their health due to SDOH or social influences. With compassion and understanding, case managers can provide the help people need to adjust to changes in their lives and health status.

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