« The Dual Agenda: December 4, 2014 Issue

Eldercare Voices

Loneliness and Threats to Health and Well-Being

A perspective from Maureen Mickus, Ph.D.

Consider an emotional state that increases the risk of Alzheimer’s, hypertension and even premature mortality, and yet is rarely assessed by health care providers.  Unlike other mental health concerns, loneliness is generally overlooked despite its serious impact on health and well-being. As social beings, we all have a strong need to connect with others, and negative outcomes result when this need is unmet.

Loneliness can occur at any age and a number of studies suggest that young people may be as lonely as older persons. However, older persons, especially those with disabilities may be at a particularly high risk. Based on the NIH-supported Health and Retirement Study, 19.3 percent of persons over age 65 are lonely, with higher risks for those living alone, widowed, in poor health, and/or of advanced age. In addition to the loss of social relationships and links to declining health, loneliness can also be viewed as a chronic condition representing the continuation of longstanding difficult relationships with family members and limited relationships with friends or neighbors. Even when an elder moves to a congregate setting, such as a retirement home, new friendships can be difficult to establish. A large longitudinal study conducted in the Netherlands indicated that loneliness significantly increased over a seven-year period and was not affected by a move into a residential care setting.

Loneliness is a highly individualized state, defined as one’s perception of deficiency in the desired number or quality of his or her social relationships. Although the term loneliness is often paired with “social isolation,” these represent distinct conditions. Some individuals express loneliness even though they have frequent contact with family and friends. This may result because emotional support from these relationships is in some way inadequate.  Conversely, persons may be relatively isolated with few contacts, but are not lonely. But in many cases, isolation can indeed lead to loneliness.

The risks for both loneliness and social isolation within the US are increasing. Based on the results from a large study on social isolation in the U.S., Americans had, on average, only two close friends as confidants in 2004, down from three close friends in 1985. The percentage of people who noted having no confidant rose from 10 percent to almost 25 percent during this period. An additional 19 percent said they had only a single person (often their spouse), raising the risk of serious loneliness in case the relationship ended. 

Overall, rates of loneliness are likely underestimated, given the associated social stigma of disclosing these feelings, similar to other mental health problems. Lonely individuals may be viewed as deviant or generally undesirable, a stigma which is likely to discourage disclosure to a family member or health care provider for fear of embarrassment. Older adults may be particularly concerned about institutionalization or unnecessarily burdening family members with reports of loneliness.  

Based on the research in this field, loneliness is now recognized as an independent risk factor for a range of health problems, including high blood pressure, sleep dysregulation and even Alzheimer's disease. The perception of social exclusion is significantly associated with elevated triglyceride levels and every unit increase in the level of loneliness increased the odds of being diagnosed with a heart condition three-fold. Interestingly, imaging studies have demonstrated that the aversive feelings that arise from social exclusion or loneliness arise from the same brain region as physical pain. A 2010 meta-analysis indicated that the health risk of unaddressed loneliness confers the same health risk as smoking 15 cigarettes a day. The same study found a 50 percent increased likelihood of survival for those with strong social connections after an average follow-up time of 7½ years.

Loneliness has also been linked to increased frequency of primary care office visits and nursing home admissions, even after controlling for income and physical and mental health.  However, approaches for addressing loneliness can be challenging. Health care providers often feel unprepared to assess and intervene given the psycho-social nature of loneliness and social isolation. Although depression and loneliness may be related, not every individual who is lonely has depressive symptoms. Therefore, pharmaceutical interventions are considered inappropriate to alleviate loneliness. 

The first step might be for providers to include assessments of a person’s social health as a part of routine care. A number of very simple and reliable tools exist, such as the UCLA Loneliness Scale. Many of these assessments are self-reports which can be completed by patients in the waiting room. Providers can also help to build up and encourage the social reserves for the older person to compensate when relationships end. Older people experiencing isolation require practical help and resources, such as transportation or help with shopping.  Finding ways to involve individuals as active members in community events or encouraging older persons to join groups can reap important benefits, especially if these activities enhance self-esteem and personal control. 

Embracing a broader view of health beyond physical symptoms is important. Emotional concerns are often among the most important health issues of the patient. An increasingly mobile society with an overdependence on technology-based relationships is likely to increase the incidence of persons who are lacking in social support in the decades ahead. Identifying and creating innovative approaches for alleviating loneliness and social isolation are warranted.  

Maureen Mickus, Ph.D, is a gerontologist and Associate Professor in the Department of Occupational Therapy at Western Michigan University. Dr. Mickus’ work has centered on aging policy and strategies for maintaining older adults in the community. She has published on a variety of mental health and aging topics, including dementia and depression and serves on multiple boards, including the Michigan Society of Gerontology and Alzheimers Association Great Lakes Chapter. Dr. Mickus is one of two Geriatrics and Gerontology experts partnering with Voices for Better Health advocates in Michigan.

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