A Conceptual Framework for Social Determinants of Health and Delirium (SDOH)

Franchesca Arias, PhD
Assistant Professor, Department of Clinical and Health Psychology, University of Florida

By 2050 it is expected that over 22% of the global population will be >60 years old.1 Late adulthood is a unique life stage2 associated with distinct cognitive vulnerabilities and medical needs. Of those ≥ 65 years old in the United States (US), approximately 80% require ongoing care for at least one chronic medical condition3 and account for about 20% of all emergency department visits annually.4 Social determinants of health (SDOH) have been associated with poor outcomes in persons >65 years. Older adults who reside in disadvantaged neighborhoods or experience poverty exhibit worse medical outcomes,5 earlier health-related functional decline,6 premature aging7 relative to their counterparts residing in more affluent areas.

Delirium, a medical condition associated with substantial morbidity and mortality8 and high medical costs,9 is highly prevalent in persons >65 years. It is also a preventable10,11 condition that remains underdiagnosed across all medical settings.12,13 Individual-level factors, such as cognitive impairment, frailty, and pre-existing medical comorbidities, when present prior to an index hospitalization are established risk factors for incident delirium.10,11 Whether social circumstances, demographic characteristics, and lifecourse factors protect against or precipitate delirium in older adults has not been systematically examined.

SDOH are the constellation of economic, psychosocial, and environmental factors present throughout a person’s life that influence health and contribute to health disparities.14 They include socioeconomic status, characteristics of the built environment, and demographic characteristics.15 Given that SDOH factors work in synergy with individual-level characteristics to influence health outcomes, researchers in this area may benefit from utilizing a sound conceptual framework when examining the contributions of SDOH to health.14,15 Given the changing demographic characteristics of the US, and the disproportionate representation of older adults in medical settings, advancing our understanding of the factors that protect or diminish health outcomes in older adults is a public health priority.

Our paper entitled “A Framework of Social Determinants of Health (SDOH) for Delirium Tailored to Older Adults” aimed to provide a rationale for incorporating SDOH factors into delirium research and practice.16 Explicitly, we proposed a SDOH framework for delirium that was tailored to the needs of older adults. Our approach to development of the framework was rigorous and systematic. First, we conducted a thorough literature review and identified over 20 frameworks of SDOH, with 17 being relevant to our work with older adults within clinical settings. Subsequently, we identified key risk factors relevant to delirium in older adults, utilizing three specific SDOH frameworks as well as known risk factors for cognitive decline in older adults17-19.

Finally, we convened a group of experts in neurology, geriatrics, nursing, psychiatry, and psychology to give input on the identified risk factors with the goal of comprehensively capturing the social circumstances, environmental characteristics, and life course factors that may protect against or precipitate delirium in older adults. Our expert panel assisted with grouping the factors into domains, providing suggestions for factors based on their experience working with older adults, and developing/refining the definitions for each of the domains. Ultimately, the authors hope that our framework will stimulate future research seeking to characterize the influence of SDOH on delirium.

In our group, ongoing work in this area has focused on exploring SDOH factors and their association with delirium and delirium-related outcomes,20-23 operationalizing our framework using data from the well-characterized Successful Aging after Elective Surgery (SAGES) cohort, and examining the mechanisms by which SDOH influences delirium in older adults. Elucidating the influence of SDOH on delirium has the potential to affect clinical practice by guiding the development of interventions targeting social factors that directly or indirectly affect health and longevity. SDOH variables may be targets of intervention to support persons at risk of delirium and may assist with promoting independence, reducing medical costs, and improving health-related quality of life in this vulnerable population.


  1. Kanasi, E., Ayilavarapu, S., & Jones, J. (2016). The aging population: demographics and the biology of aging. Periodontology 2000, 72(1), 13-18.
  2. Widick, C., Parker, C. A., & Knefelkamp, L. (1978). Erik Erikson and psychosocial development. New directions for student services, 1978(4), 1-17.
  3. Thorpe, J. M., Thorpe, C. T., Kennelty, K. A., & Pandhi, N. (2011). Patterns of perceived barriers to medical care in older adults: a latent class analysis. BMC health services research, 11(1), 181.
  4. Ashman, J.J., Schappert, S.M. & Santo, L. (2020). Emergency Department visits among adults aged 60 and over: United States, 2014-2017. NCHS Data Brief, no 367. Hyattsville, MD: National Center for Health Statistics Data Brief.
  5. Kind, A. J. H., Jencks, S., Brock, J., Yu, M. G., Bartels, C., Ehlenbach, W., . . . Smith, M. (2014). Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization. Annals of Internal Medicine, 161(11), 765-U736. doi:10.7326/M13-2946
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  7. Crimmins, E. M., Kim, J. K., & Seeman, T. E. (2009). Poverty and biological risk: the earlier “aging” of the poor. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 64(2), 286-292.
  8. American Psychiatric Association [APA] (2013). Diagnostic and statistical manual of mental disorders, 5th Edition. American Psychiatric Publishing.
  9. Gou, R. Y., Hshieh, T. T., Marcantonio, E. R., Cooper, Z., Jones, R. N., Travison, T. G., … & SAGES Study Group. (2021). One-year Medicare costs associated with delirium in older patients undergoing major elective surgery. JAMA surgery, 156(5), 430-442.
  10. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), 911-922. doi:10.1016/S0140-6736(13)60688-1
  11. Maclullich, A. M., Anand, A., Davis, D. H., Jackson, T., Barugh, A. J., Hall, R. J., … & Cunningham, C. (2013). New horizons in the pathogenesis, assessment, and management of delirium. Age and ageing, 42(6), 667-674.
  12. Hamrick, I., & Meyer, F. (2013). Perioperative management of delirium and dementia in the geriatric surgical patient. Langenbeck’s archives of surgery, 398(7), 947-955.
  13. De la Cruz, M., Fan, J., Yennu, S., Tanco, K., Shin, S., Wu, J., … & Bruera, E. (2015). The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center. Supportive Care in Cancer, 23(8), 2427-2433.
  14. Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The lancet, 372(9650), 1661-1669.
  15. Shokouh, S. M. H., Mohammad, A. R. A. B., Emamgholipour, S., Rashidian, A., Montazeri, A., & Zaboli, R. (2017). Conceptual models of social determinants of health: A narrative review. Iranian journal of public health, 46(4), 435.
  16. Arias, F., Alegria, M., Kind, A. J., Jones, R. N., Travison, T. G., Marcantonio, E. R., … & Inouye, S. K. (2022). A framework of social determinants of health for delirium tailored to older adults. Journal of the American Geriatrics Society, 70(1), 235-242.
  17. Alegria, M., Pescosolido, B. A., Williams, S., & Canino, G. (2011). Culture, race/ethnicity and disparities: Fleshing out the socio-cultural framework for health services disparities. In Handbook of the sociology of health, illness, and healing (pp. 363-382). Springer, New York, NY.
  18. Hill, C. V., Pérez-Stable, E. J., Anderson, N. A., & Bernard, M. A. (2015). The National Institute on Aging health disparities research framework. Ethnicity & disease, 25(3), 245.
  19. Solar O, I. A. (2010). A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Geneva; WHO Document Production Services.
  20. Jones, R. N., Rudolph, J. L., Inouye, S. K., Yang, F. M., Fong, T. G., Milberg, W. P., … & Marcantonio, E. R. (2010). Development of a unidimensional composite measure of neuropsychological functioning in older cardiac surgery patients with good measurement precision. Journal of clinical and experimental neuropsychology, 32(10), 1041-1049.
  21. Arias, F., Chen, F., Fong, T. G., Shiff, H., Alegria, M., Marcantonio, E. R., … & Inouye, S. K. (2020). Neighborhood‐Level Social Disadvantage and Risk of Delirium Following Major Surgery. Journal of the American Geriatrics Society, 68(12), 2863-2871.
  22. Arias, F., Chen, F., Shiff, H., Marcantonio, E. R., Jones, R. N., Schmitt, E. M., … & Inouye, S. K. (2022). Parental Education and Delirium Risk after Surgery in Older Adults. Clinical Gerontologist, 1-14.
  23. Shiff, H. M., Arias, F., Dufour, A. B., Carr, D., Chen, F., Gou, Y., … & Inouye, S. K. (2022). Paternal Occupation and Delirium Risk in Older Adults: A Potential Marker of Early-Life Exposures. Innovation in aging, 6(5), igac050.
Posted in Delirium Research, NIDUS Blog.

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