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Loneliness among older people

Loneliness among older people

Questions about the health effects of loneliness have motivated an explosion of new research over the past few years, particularly since social distancing during the COVID-19 pandemic has raised new fears about loneliness levels worldwide.

By Kristen Senz

Loneliness is a distressed feeling arising from the perception that one’s social needs are not being met. For decades, it was considered strictly an emotional and mental health concern, studied mainly by psychologists, philosophers, and poets.

Today, however, health researchers and clinicians across specialties recognize it as a social determinant of health, a factor, like economic stability or access to high-quality education that greatly influences overall health outcomes. In recent years, loneliness has also been described as an epidemic and elevated to a public health crisis, one intensified by social distancing guidelines during the COVID-19 pandemic.

But unlike most other public health crises, loneliness isn’t all bad. About 20% of the population is experiencing a normal, even helpful level of loneliness at any given time, says Liz Necka, a program director in the Division of Behavioral and Social Research at the National Institute on Aging. “That should be expected, because loneliness can be motivating to promote social connection,” Necka says. “The issue is when loneliness becomes chronic.”

Neuroscience and studies of isolated animals suggest that when left untended loneliness triggers an immune response in the body, sparking cycles of inflammation that can lead to a variety of illnesses, ranging from depression and anxiety to high blood pressure, diabetes, stroke, and heart disease. The resultant state of hypervigilance is associated with shifts in personality and decision-making and puts people at higher risk for cognitive impairment and dementia. Oft-cited research places the increased risk of premature death among lonely people at 26%, a rate on par with smoking.

Despite these troubling correlations, however, new evidence suggests that even chronic loneliness might bestow some benefits. Recent neurological research has found that brain regions dealing with reminiscing, imagining, and self-reflection are bulkier and more strongly wired in lonely people.

Loneliness is complicated and hard to measure, and much remains unknown about how and when it predicts poor health or early death. But those and other questions have motivated an explosion of new research over the past few years, particularly since social distancing during the pandemic gave rise to new fears about loneliness levels worldwide.

All the lonely people                                 

Research suggests that 15-30% of the general population is chronically lonely. In the U.S., before the pandemic, about 19% of adults over age 55 were “frequently” lonely, according to data from the Health and Retirement Study (HRS), which is considered the gold standard of representative surveys and is conducted biennially at the University of Michigan.

Contrary to narratives suggesting a growing rate of loneliness among seniors, the prevalence of self-reported “frequent loneliness” among older adults in the U.S. remained relatively flat from 1998 to 2016, according to a recent analysis by James Raymo, a demographer and sociology professor at Princeton University.

“There are little bumps and blips here and there,” says Raymo, who used HRS data and population statistics to identify the effects of loneliness on life expectancy among different population segments, “but it is largely stable over this period, which is a period of time in which attention to and concern about loneliness, and the description of the loneliness epidemic has, from my perspective, grown.”

Polling data suggests that the rate of loneliness among older adults spiked during the pandemic, but younger people seem to have suffered from loneliness at even higher rates as a result of social distancing.

People experience loneliness at all stages of life, but older adults are at a much higher risk of experiencing the related adverse health outcomes, says Necka.

“Older adults have generally been much more resilient than younger adults to social distancing, which I think is somewhat surprising to a lot of people,” she says. Early evidence suggests that, with the reopening of businesses and the easing of social distancing guidelines, loneliness is returning to pre-pandemic levels, Necka adds.

Research hurdles and future directions

Loneliness is complex, nuanced and confusing in that there’s a lack of uniformly accepted terminology surrounding it. For example, social isolation – defined as an objective lack of social contacts – is often conflated with loneliness. But these concepts are distinct; a person can be content without social contact, or lonely despite plentiful social ties, if those connections are not perceived as meaningful.

In addition, while loneliness is linked with increased risk of developing serious health conditions, many of those conditions also increase a person’s risk of experiencing loneliness. This creates a vicious cycle in the lives of patients and a potential endogeneity problem for researchers. (Endogeneity – when a variable not included in a statistical model is related to a variable that is included – can obscure causality in research.)

“I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

Dr. Ashwin Kotwal

Loneliness is also difficult to measure, in part due to problems with pinpointing when loneliness starts and stops and when it persists for too long, as well as the use of various assessments. Further, because it’s unethical to conduct randomized experiments in which people are assigned to be lonely, researchers rely on survey data. But whether those surveys are conducted over the phone or in writing can change the results (research suggests people are more willing to identify as lonely in writing).

The prevalence of loneliness varies among different population segments. Much research has been devoted to understanding which groups are most at risk for experiencing chronic loneliness. People living in poverty and those who suffer from cognitive impairments, mobility issues, and sensory impairments, such as hearing and vision loss, are at the highest risk. A 2020 report by the National Academies of Science, Engineering and Medicine also highlights immigrants and people who identify as LGBTQ+ as being at higher risk.

Medical professionals are increasingly recognizing their role on the front lines of the battle against loneliness. Indeed, for the millions of chronically lonely older adults in the U.S., a quick chat with a doctor is one of very few conversations about their own health and wellbeing.

Dr. Ashwin Kotwal, a researcher and palliative care physician at the University of California in San Francisco, says the pandemic helped to de-stigmatize loneliness, and more clinicians are now asking their patients about their social wellbeing. But systemic change is needed, he says, to accelerate social prescribing (when patients are prescribed social support from community programs) and funding for existing programs.

“We need to start breaking down these boundaries between social needs and medical needs,” says Kotwal. “I really struggle when I see patients who, without even a moment’s hesitation, get approved for a $50,000 Alzheimer’s drug that probably won’t make a difference in their quality of life or wellbeing, but it’s impossible to get funding for some of these social programs that can have a huge impact on their quality of life.”

A broad range of interventions

Because the experience of loneliness varies at the individual level, there is no universally effective intervention.

“You can think of loneliness like setting your thermostat,” explains Necka, of the NIA. “I might prefer my house a little bit warmer; you might prefer your house a little bit colder. What will make us feel socially connected, in terms of the objective interactions we’re having, will differ from person to person.”

Prior to the pandemic, many interventions focused on developing cognitive skills – teaching people how to socialize, an approach based largely on a 2010 meta-analysis of intervention studies. More recently, researchers have seen promising results associated with enrolling lonely people to help others through volunteer programs, Necka says, but these findings have not yet been published. Training social support personnel, such as Meals on Wheels delivery drivers, to practice empathetic listening has also shown promise as a potentially scalable intervention.

The pandemic forced many older people to become comfortable with technologies like videoconferencing to keep in touch with friends and family. This has led to a growing emphasis on digital technology, with many newer intervention studies involving the provision of direct social contact via videoconferencing. Robot companions have also been shown to reduce feelings of loneliness and anxiety.

Both inside and outside of the health care community, there’s a broad recognition of the need for holistic approaches that bring together various disciplines and stakeholders. Experts in a variety of fields, ranging from psychology to public transportation to the arts, have already spent decades studying loneliness and ways to provide relief.

Amy McLennan, a senior fellow in the school of cybernetics at Australian National University, expressed concern in a 2018 letter to the Lancet that health care professionals run the risk of stifling broad-based collaboration by describing loneliness as a health problem to be solved by the medical community. McLennan, who primarily researches obesity, says she’s seen this phenomenon before.

“It’s been really hard to have a conversation around obesity as more than a medical concern because the public imagination of it by now has taken on board this idea of it being a medical thing that needs to be treated by doctors and diagnosed by doctors,” she tells The Journalist’s Resource. “The narratives that we put into the public domain do get picked up by the public, and they’re very hard to unwind later.”

Kotwal, who treats terminally ill patients, sees the pandemic and the growing volume of loneliness-related research as fueling important progress toward an inflection point in health care. Ultimately, he says, without systemic changes that facilitate increased social prescribing and spending on patients’ social wellbeing, the potential for clinicians to help alleviate suffering from chronic loneliness will be severely limited.

“How can we take a little bit of what we’re spending on medical care and redirect it to social care?” asks Kotwal. “I think clinicians have to be advocates for that change. Many of these other disciplines have been trying to do this for a long time, and we are playing catch-up, honestly. We’ve been behind for a long time here. I’m hopeful that the pandemic and some of the growing evidence in this space will push people to start doing this.”

Studies published in recent years have examined the prevalence of loneliness and links between low levels of human contact and poor health outcomes, as well as the efficacy of intervention delivery methods and specific interventions. Below is a curated list of seven peer-reviewed studies on loneliness and social isolation, along with summaries of their most important findings and additional insights from interviews with some of the authors.


Courtesy: Journalists Resource