The National Palliative Care Research Center

Curing suffering through palliative care research.


Ashwin Kotwal MD, MS

Assistant Professor

University of California, San Francisco

Grant Year
Grant Term
2 years
Grant Type
Kornfeld Scholars Program

Project Description
Social Health among Older Adults in the Last Years of Life

Loneliness and social isolation are related, but distinct, social risk factors critical to the health of older adults in their last years of life. Loneliness is a subjective feeling of being alone and occurs in nearly 20 million adults over 60 years old, whereas social isolation is an objective loss in the number of relationships with family, friends, or the community, and occurs in nearly 9 million adults over 60 years old. Both social risk factors are independently associated with poor health outcomes relevant to late life such as depression, functional impairment, and mortality. However, loneliness and social isolation have been largely unexplored in palliative care literature. Our objective is therefore to establish the epidemiology of loneliness and social isolation in the last years of life among older adults and determine their association with intensive health care use at the end of life. Using a U.S. nationally-representative cohort of 2,282 older adults who died within two years of responding to questions about loneliness and social isolation we investigate two specific aims: 1) to determine the prevalence and predictors of loneliness and social isolation during the last two years of life, and 2) to determine the relationship between loneliness and social isolation with health service use, including hospice use, ICU use, and ED visits, at the end of life using Medicare claims data. This proposal will provide valuable real-world clinical data on the prevalence of two frequently unrecognized social risk factors and whether they are associated with barriers to high quality of end-of-life care. Future directions of this work include developing and piloting interventions to prevent loneliness and social isolation, recognize and treat them when detrimental to quality of life, and address barriers to high quality end-of-life care in the socially vulnerable. 

Ashwin Kotwal, MD, MS is an Assistant Professor of Medicine in the Division of Geriatrics at the University of California, San Francisco (UCSF) School of Medicine. He received his B.A. in Anthropology at Northwestern University, and his M.S. in Biostatistics and M.D. at the University of Chicago. He went on to complete his Internal Medicine residency at Harvard University’s Brigham and Women’s Hospital. He then became the first to complete UCSF’s two-year integrated clinical fellowship in Geriatrics and Palliative Care. In addition, he is currently a research scholar in the UCSF Claude D. Pepper Older Americans Independence Center. Dr. Kotwal’s research focuses on the intersection of geriatrics and palliative care and efforts to understand and improve social connections of older adults at the end of life through clinical practice, health systems, and policy.