Loneliness among older people: A research roundup

By Kristen Senz

July 7, 2022

loneliness
Social distancing has raised new fears about loneliness levels worldwide. (De Visu/Adobe)

Loneliness is a distressing 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 recognise 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 US’s 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 US, 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 US 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 an 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 US, 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 destigmatize 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 image 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.

Research Roundup

Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review

Julianne Holt-Lunstad, Timothy Smith; et al. Perspectives in Psychological Science, March 2015

One of the most-cited studies on loneliness and social isolation, this paper concludes that a lack of human connection is as detrimental to health as other established risk factors, like smoking and obesity. The researchers examined 70 studies conducted between 1980 and 2014, for a total sample size of more than 3.4 million adults with an average age of 66, in an effort to determine the extent to which social isolation, loneliness, and living alone influenced the likelihood of death among the sample population.

They concluded that the increased likelihood of death was 26% for reported loneliness, 29% for social isolation, and 32% for living alone. The differences in these effect sizes was not statistically significant, explains Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University, and most of the studies included in the analysis did not look at more than one condition to determine overlap (i.e. whether someone who lived alone was also lonely). All of the studies did, however, control for initial health status, as a way to rule out reverse causality. The results suggest that social isolation and living alone are as much a predictor of early death as loneliness, but the reasons why are presumed to be different.

“If you’re having a heart attack, and there’s no one in your home to call [000] — that’s going to have a significant effect on whether you survive that heart attack or not,” Holt-Lunstad tells The Journalist’s Resource.

While age and prior health status were significant in determining effect size, the results were consistent across genders and world regions, according to the study. Social isolation was more predictive of death in people younger than age 65, the researchers found.

A Meta-Analysis of Interventions to Reduce Loneliness

Christopher Masi; et al. Personality and Social Psychology Review, August 2010

In this meta-analysis, the researchers examined 50 randomised group comparison studies on the efficacy of various loneliness interventions, concluding that the most effective among them addressed issues with social cognition, or how people process and apply information about other people.

A lonely person, in other words, might interpret social interactions as more negative than they are and use these negative interpretations to confirm thoughts about their own lack of social abilities or worthiness, thus perpetuating loneliness. The researchers theorize that this pattern stems from the state of hypervigilance associated with persistent loneliness, which can impair executive function and decision-making.

This led to a series of intervention strategies addressing “maladaptive social cognition,” though many proved ineffective after further study.

The Epidemiology of Social Isolation and Loneliness Among Older Adults During the Last Years of Life

Ashwin Kotwal; et al. Journal of the American Geriatrics Society, August 2021

In this study, the researchers looked to understand the rates and risk factors of social isolation and loneliness among people who were within four years of death. By modelling data from the Health and Retirement Study combined with other data sources, the researchers found that about 19% of people in the study sample experienced social isolation, 18% experienced loneliness, and 5% experienced both.

Risk factors for both isolation and loneliness included having an individual net worth of less than $6,000, hearing impairment and difficulty preparing meals. Factors associated with loneliness, but not social isolation, included being female, having pain, incontinence, and cognitive impairment.

“We really are now thinking about addressing these social needs as an important opportunity to improve people’s quality of life when people are seriously ill or even finding ways to integrate them into their medical goals,” says Kotwal.

Accompanying the research paper, in the same issue of the journal, is an editorial, written by two physicians at Icahn School of Medicine at Mount Sinai in New York. Drs. Diane Meier and Sean Morrison advocate for increasing government support for addressing the social determinants of health, which play a considerable role in the health experiences of older adults in America.

“Despite recognition of the foundational role of social factors in achieving health, we continue to put nearly all of our taxpayer-funded healthcare dollars into direct medical services (more than 95% of healthcare dollars at a cost of >$10,000 per person per year),” they write. “This mismatch between spending and need results in our healthcare quality being ranked 37th among that of 100 developed nations, behind Costa Rica, and just ahead of Cuba and Slovenia.”

Loneliness at Older Ages in the United States: Lonely Life Expectancy and the Role of Loneliness in Health Disparities

James Raymo and Jia Wang,. Demography, June 2022

Using data from the University of Michigan’s Health and Retirement Study, the researchers applied the statistical tools of demography to calculate a measure they call “lonely life expectancy” to understand the impact of loneliness on average life expectancy for various population segments. For example, men 55 years and older, on average, spend about 3.4 years lonely, which equates to roughly 14% of their total average life expectancy. This study also found that rates of loneliness among older adults remained relatively steady from 1998 to 2006.

One of the surprising findings from the research was that disparities in rates of loneliness along racial lines depended on how loneliness was defined, says lead study author James Raymo, a demographer and sociology professor at Princeton University. Using scales that measure respondents’ “sense of belonging” and “feeling left out” resulted in higher discrepancies in rates of loneliness among racial and ethnic minorities compared with whites.

The study also showed that higher rates of loneliness among disadvantaged groups do not directly correlate to higher rates of mortality or disease, Raymo says.

“We show that Blacks are lonelier than whites,” Raymo tells The Journalist’s Resource. “We show that less educated people are lonelier than higher educated people. But [further] analysis shows that, despite the fact that we know loneliness to be related to health outcomes and mortality, the concentration of higher levels of loneliness among more disadvantaged people does not account for their higher levels of mortality or higher probability of onset of disability and things like that. So that was a little bit surprising – how little salience loneliness had in accounting for, at least in a statistical sense, the differences in these various health outcomes across the racial, ethnic, and educational groups.”

Friends from the Future: A Scoping Review of Research into Robots and Computer Agents to Combat Loneliness in Older People

Norina Gasteiger, Kate Loveys, Mikaela Law, and Elizabeth Broadbent. Clinical Interventions in Aging, May 2021

Based on a review of 29 studies, this paper concludes that current research points to “social robots” as an effective way to reduce loneliness in older adults, “using features that encourage direct companionship and facilitate social interactions.” Because the majority of the studies reviewed (24) dealt with robots — like Paro, a robotic baby seal used to comfort nursing home residents — the research was inconclusive on the efficacy of “computer agents,” like chatbots.

Elizabeth Broadbent, a professor in the Department of Psychological Medicine at the University of Auckland in New Zealand, was an author of this paper, as well as past research on Paro, which was developed in Japan.

“It makes these little seal noises, like helpless animal noises,” she says. “And that makes you want to pick it up and comfort it and cuddle it and pat it and talk to it as well.”

The majority of studies showed that robots or computer agents positively impacted at least one loneliness outcome measure. Some unintended negative consequences on social outcomes were reported, such as sadness when a robot was taken away from a study participant.

Overall, the robots helped combat loneliness by acting as a direct companion (69%), a catalyst for social interaction (41%), facilitating remote communication with others (10%) and reminding users of upcoming social engagements (3%).

Evaluation of the Effectiveness of Digital Technology Interventions to Reduce Loneliness in Older Adults: Systematic Review and Meta-analysis

Syed Ghulam Sarwar Shah; et al. Journal of Medical Internet Research, June 2021

This paper outlines results from an evaluation of six studies of loneliness interventions designed to facilitate increased social connections using digital technologies, including five clinical trials. A total of 646 people (66% of them women) with an average age of 73-78 participated in the six studies, each lasting three months or more, examining interventions involving live videoconferencing, as well as Alexa-like audio and televised video support.

The overall effect estimates showed no statistically significant difference in the effectiveness of digital technology interventions compared with that of usual care or other interventions. However, the researchers note that the quality of evidence was very low to moderate in the trials.

Lead researcher Syed Ghulam Sarwar Shah, a physician and senior research fellow at Oxford University, says he believes the results demonstrate that digital technology interventions are no substitute for human interaction in the real world. As a result, he is working on developing an app called Evzein, which seeks to leverage local restaurants and pubs as places where lonely people can meet and connect.

Shah says additional research is needed to determine whether digital technology interventions are effective in reducing loneliness among young people and other specialized groups that were disproportionately affected by loneliness during the pandemic.

Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits

Namkee G. Choi, Renee Pepin, C. Nathan Marti, Courtney J. Stevens, and Martha L. Bruce. American Journal of Geriatric Psychology, July 2020

These researchers modified a short-term intervention known as “behavioural activation” that is usually used to address mild depressive symptoms in older adults, with the goal of reducing loneliness. A randomized controlled trial showed promising results for the intervention, both initially and during a follow-up study conducted a year later.

Behavioural activation involves educating recipients about the condition it is looking to address, in this case, loneliness, in an effort to normalise it. An interventionist trained in BA assists people in identifying activities that hold particular value for them and finding new ways to engage in them, despite the functional or health limitations they might be experiencing. If church is really important to someone, for example, but they no longer attend because they don’t have a driver’s license, behavioural activation focuses on helping them find another way to get there, explains Renee Pepin, an assistant professor of community and family medicine at Dartmouth College’s Geisel School of Medicine.

In the study, Meals on Wheels recipients in New Hampshire and Texas were split into two groups. One group received regular behavioural activation sessions via teleconference; the other group received friendly chats via teleconference, without the specialized intervention. Compared to the group that received friendly visits, the behavioural activation group experienced a 10% greater increase in social interaction, 20% greater decrease in loneliness, 39% greater decrease in depressive symptoms, and 21% greater decrease in disability.

“The intervention holds promise for scalability in programs that already serve homebound older adults,” the researchers write.

Pepin says participants hired to deliver the intervention in the study were not Meals on Wheels drivers. “We tried to select people with similar characteristics as people who work for home-delivered meals,” she said. “A next step for this line of research is absolutely to see, does it work the same way or similarly if we actually do employ people who work within these agencies to deliver this intervention?”

This article first appeared on The Journalist’s Resource and is republished here under a Creative Commons license.


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