Loneliness: Factors That Clinicians Need to Know

Loneliness is especially common among older adults (OAs) and has gained much attention during the pandemic.¹ Approximately 50% of individuals aged over 60 years are at risk of social isolation and one-third will experience some degree of loneliness later in life.¹ Loneliness has many factors that clinicians should understand to properly treat. It is related to inadequate social interaction, gender, lower socioeconomic status, cognitive decline, and increased mortality risk.¹ It is especially prevalent in nursing home (NH) residents and those diagnosed with cancer and other chronic illnesses, such as heart failure.² 

Furthermore, loneliness is associated with cognitive decline and hopelessness, and has been identified as a risk factor for depression.³ Research has shown that integration of social support can reduce the prevalence of depression. Depressive symptoms are the most common psychological problem in older persons, and those who reside in a NH are 3 to 4 times more likely to suffer psychological problems than those living at home because of the lack of freedom and family support.^2,3 OAs with depression may experience greater loss of functionality. Clinicians who care for OAs need to understand these factors in order to better identify, address, and mitigate loneliness. This article will summarize loneliness, including common theories, age-related concerns, demographics, clinical issues, and potential interventions. 

Though now a well-recognized term, the word “loneliness” was not used regularly in the English language until around 1800.⁴ Prior to that time, the word “loneliness” described the literal physical state of being alone. In the English Dictionary published in 1676, loneliness was defined as “solitude” or “wandering alone.” These definitions did not carry associated negative emotional implications with the meaning. Over time, loneliness has evolved into a term describing a multifaceted emotion. Alberti⁴ describes loneliness as a complex state or “emotion cluster” that includes anger, grief, fear, anxiety, sadness, and shame. McWhirter⁵ defines loneliness as “an enduring condition of emotional distress that arises when a person feels estranged from, misunderstood, or rejected by others, and/or lacks appropriate social partners for desired activities, particularly for activities that provide a sense of social integration and opportunities for emotional intimacy.”⁵

Theories surrounding the causes of loneliness have shifted over time (See Table^6-12). Peplau and Perlman⁶ developed the first core book on loneliness in 1982, summarizing the research and multiple theories of loneliness up to that time. Eight different theoretical approaches emerged.

Perlman and Peplau⁶ summarized loneliness into 3 components. First, it is a result of a deficiency in someone’s social relations. Second, it is subjective: someone who is alone or isolated may not necessarily be lonely, and someone surrounded by others can perceive themselves to be emotionally isolated. Third, it is associated with a negative or distressing sensation.⁶

A person’s cognitive process can have a moderating effect on the experience of loneliness.⁷ Existential loneliness identifies loneliness as part of the human condition.⁸ There is sense of loss that results from an awareness that others do not all experience the world in the same way. Even though individuals have a desire for connectedness, there is a sense of being separated in the universe.⁹

In 1989, the core book by Hojat and Crandall¹³ narrowed the theories into two main ideas. The first was based in the social needs approach and psychodynamic theory. This identifies an affective component, which encompasses the negative emotional experiences of loneliness. The second was based in the cognitive approach, which encompasses the discrepancy between achieved and desired social relationships.^14–16 The cognitive approach is based on the perception and evaluation of social relationships and emphasizes the discrepancy between actual and desired social relationships.^13,17 Narrowing down loneliness as either a cognitive or affective concept has succeeded in getting closer to a unified framework within loneliness research.¹⁵ 

Clearly, cultural and structural shifts in society have historically impacted the understanding and view of loneliness and will continue to do so in the future. Before industrialization in the western world, the traditional roles and way of life focused on community and being bonded to others.¹⁵ Before the twentieth century about 5% of all households (1% of total world population) consisted of just one person. However, over time, individuals less commonly relied on immediate family or community for guidance. Society has become more individualistic, with new forms of social networks and relations rather than close communities/villages. 

By 1950, the number of single-person households increased to 9%. The number rose even more steeply in the 1960s as divorce rates increased, birth rates fell, and lifespans increased. Now it is estimated that 1 of 7 adults live alone.¹⁸ In industrialized countries, loneliness is thought to affect one-third of the population.¹⁹ Loneliness does not seem to be affected by income, education, sex, or ethnicity. It does, however, seem to have a relation to age.¹⁹ It decreases between the ages of 50 and 74 but increases again after age 75.¹¹ In society today, loneliness is thought to cause negative impacts to an individual’s health, productivity, happiness, and wellbeing. And as the population is aging, loneliness is becoming a public health issue.¹⁹

This is of increasing importance in this new age of pandemics and social isolation, whether self-motivated or government/health agency imposed. Loneliness is now becoming an epidemic of its own. More than ever, people are deprived of companionship of others, touch and human connection, and human intimacy. This is especially true for our older population in nursing facilities, most of which are still restricting visitors in this time of COVID-19. It is also affecting the older population who are self-isolating in their homes. Many concerns are being raised about the mental and physical health implications of this isolation. COVID-19 has exacerbated a loneliness problem that already existed, just as it highlights the socioeconomic divide. And with or without a pandemic, there is no one-size-fits-all solution.²⁰ 

Aging is more than a passing of time or gaining of experience. Aging represents a physiological change, a breaking down, of the human body over time. It represents a fulminant alteration in the physical state of being that is often irreversible. These changes will occur at different rates with different individuals and are often impacted by other physical, emotional, and social conditions, as well as genetics. It is impossible to completely generalize aging, which emphasizes the importance of individualization of a person’s condition and care. However, these changes, which are highly variable in rate and onset, are major contributors to an individual’s ability to engage in and with their environment. The degree of impact of aging on a person’s physical condition makes that individual increasingly vulnerable to environmental stressors and will often result in varying degrees of social isolation and loneliness, with loss of purpose often accompanying loss of function. Examples of how physiological changes impact function and isolation are discussed below.

Frailty is defined as the state when physiological reserves are reduced to the point at which susceptibility to disease is increased.²¹ Frailty is not a disability in and of itself: it is the clinical manifestation of the later stages of homeostenosis (the impaired ability to compensate for physiological changes),²² leading to intolerance of changes in condition. It is an independent risk factor for mortality and morbidity (complications resulting from illness or injury). Ten percent of community-dwelling persons aged ≥65 years have a diagnosis of frailty, and 45% of those ≥85 years old meet criteria.²³ Frailty puts people at increased risk of dependency and is a major contributor to social isolation.

Changes in gait, with loss of balance and falls, often leads to decline in physical function, with likely increased social isolation and decreased participation in events and activities. There is a decline in vibratory sensation and proprioception, as well as vestibular changes, as one ages. Add to this the sarcopenia (muscle loss) and subsequent weakness that is part of the aging process, and the result is falls.²² These falls often lead to fear of future falling and mistrust of unfamiliar environments, which will often result in people staying in their homes, being unwilling to travel, and isolation. These changes also increase dependency on external supports, such as walkers, for mobility. This leads to increase in effort with attempts to leave the home, as these devices cannot be left behind when a person leaves the house. Also, many physical spaces are not fully equipped for persons who rely on devices for their mobility, which can increase embarrassment and inconvenience. It often becomes easier to stay inside, with increased isolation as the result. 

Weight loss is also a major contributor to frailty and functional loss. Constipation, due to decreased colon contractions and decreased thirst drive, dysphagia, decreased saliva production, and poor dentition that often accompanies aging are all major contributors as well. Infiltration of fat into muscle fibers (an aspect of sarcopenia) leads to weakness and increased fatigue. Oral intake is often dependent on community for food access, meal preparation, and consumption. Shopping can take a lot of physical and cognitive effort. People eat more in groups, and social isolation is an independent risk factor for poor oral intake and weight loss, which can exacerbate frailty and decline in a vicious cycle. 

There are a variety of other physiological changes related to aging that lead to decline in physical function. Myocardial perfusion declines with age, and an increase in systolic blood pressure due to loss of vascular elasticity can lead to impairment of brain perfusion autoregulation and subsequent dizziness. In the pulmonary system, an increase in residual volume, a decrease in vital capacity, and an increase in tendency to hypoxemia due to loss of elasticity of lung parenchyma can result in increased shortness of breath and decreased activity tolerance. These changes lead to fatigue and decreased exercise tolerance and eventually, decreased activity and function in general.²²

Urinary incontinence can also be a contributor to isolation. Fear of odor or embarrassment of “accidents” often leads people to not wanting to leave their house or even have visitors. Reduced tissue integrity in women, or increased prostate size in men, often leads to incomplete bladder emptying and increased post-void residuals. Not only is this a socially impactful condition because of perceived embarrassment, but there is also increased risk for infections and mortality.²²

Sensory changes that occur with age increase the risk of social isolation with decreased ability to participate in social interactions. Vision changes that occur with age include impaired dark adaptation with decreased ability to see at night or in places that are not well lit. Decreased contrast sensitivity makes it difficult to detect changes in flooring, steps, or curbs outside, which increases risk of trips and falls. Hearing loss is also prevalent with age, specifically regarding a loss of high frequency tones. There is a slowing of central processing of sound and increased difficulty discriminating and targeting source of sound, leading to increased effort in processing conversation and general environmental cues that make total and fulfilling engagement more challenging.²²

Cognition also declines with age. Over time, there is a loss of neurons and synapses within the brain, with decline in central processing of information. There are increased tangles and plaques with dramatic increase in the development of Alzheimer dementia, the sixth leading cause of death in the United States.^24,25 Data shows 33% of Americans will die with some component of Alzheimer dementia, with more than 50% of people aged ≥85 years having Alzheimer dementia.^24,25 

Other central neurological changes also occur with aging. There is a decline in neurotransmitter function with increased risk of depression, microvascular white matter changes with increased cerebrovascular disease, stroke, TIAs, and slowed central processing and reaction times, which can impair the ability to drive. A thinner blood-brain barrier leads to increased susceptibility to toxins, such as alcohol and medications that can impact cognition. Cognitive changes are a critical contributor in self-neglect and social isolation, whether due to apathy and depression as a primary symptom of cognitive impairment, embarrassment, increased sleep patterns with this condition, safety, or the significant effort it takes to process the external environment.²²

The process of aging comes with a dramatic change in a person’s baseline physical condition, independent of disease state. However, disease and injury will produce stress, which results in greater impact to the individual. This is not because of differences in the disease, but because of differences in substrate. How this impacts one’s ability to participate in their social environment can be as variable as the individual themselves but will almost certainly lead to increased risk and impact of social isolation over time.²²

With an aging population in the United States and around the world, it is more common for people to develop chronic and debilitating conditions that may render them dependent on others for one or more activities of daily living. As dependence on others grows, it often becomes difficult to stay in their homes, often due to their escalating care needs and lack of in-home nursing support. As these care needs increase, individuals may enter long term care communities to obtain more care that would not be available to them as readily at home.

According to the National Center for Health Statistics,²⁶ LTC services include a broad range of supportive services that help meet the needs of frail, OAs who may have lost the capacity for selfcare or whose selfcare is limited because of chronic illness, injury, or physical or cognitive impairment. 

LTC communities include a broad spectrum of living arrangements, from independent living to long-term NH care. The proportion of OAs residing in NHs or institutional residences has declined in the past 20 years; however, there has been a rise in the proportion of OAs living in assisted living facilities.²⁷ Independent living communities encompass a wide range of housing arrangements that can include individual apartment style communities and housing co-ops. Residents traditionally live independently but have common areas available to them to gather with other members of the community. Residents typically do not require help with activities of daily living and may wish to be part of larger community.  

According to the National Center for Assisted Living,²⁸ there are approximately 28,000 assisted living communities in the United States and more than 8,000,000 residents. About 71% of residents are female, and most residents are over the age of 75 years, with 30% of residents between the ages of 75- and 84-years-old and 52% aged 85 years or more.²⁸ Residents of assisted living communities often need help with only a few activities of daily living and do not require 24-hour skilled nursing care. The most common activity of daily living that residents of assisted living require help with is bathing, followed by walking. Four of ten residents are living with some form of dementia, and over 50% have underlying hypertension.²⁸ The average length of stay in assisted living is about 22 months, and roughly 60% of residents will transition to skilled nursing centers.²⁸ 

Skilled nursing centers or long-term NHs are institutions for people who need skilled nursing care or around-the-clock care and help with more activities of daily living. The 2004 National Nursing Home Survey found²⁹ 1.5 million OAs aged 65 years and older have spent time in a NH, and 51% of NH residents require assistance with all activities of daily living. The most common chronic conditions of NH residents include cognitive and mental disorders and disease of the circulatory system.²⁹ According to the National Center for Health Statistics, there were approximately 1.3 million people living in NHs, and the majority of LTC service users were 65 years and older in 2015.²⁶ In 2014, the Centers for Medicare and Medicaid Services (CMS) reported that 7.8% of NH residents were 95 years of age or older, 33.8% were between 85-94 years old, 26.5% were 75-84 years old, and 16.5% were 65-74 years old.²⁶ CMS reported that over 65% of the NH population is female, and 76.1% of residents are non-Hispanic Caucasian.²⁶ 

The care that residents of NHs receive is traditionally focused on medical needs and activities of daily living. However, it is important to consider that overall wellbeing at any stage in life is more than just basic personal care or nursing care. Psychosocial needs of individuals are strongly correlated to mental health and overall wellbeing. Residents in care facilities are often in a new environment, away from those who are familiar, and they can experience loss of relationships, identity, and personal control. People enter the different forms of NHs at a time in life when they are less independent. There is an element of isolation for most residents as they become more dependent on others for their care needs. Additionally, as they are away from their home, they may not see those they were previously close to as often, increasing the loneliness they experience. The adjustments required to transition to nursing facilities can be difficult on residents, and without an emphasis on addressing their psychosocial needs, most will have difficulty thriving in their new environment.

The Centers for Medicare and Medicaid Services’ Nursing Home Quality Initiative created quality reports that include addressing the psychosocial wellbeing of residents in NHs as an important metric.³⁰ Addressing the psychosocial needs of residents in NHs requires facilities to take steps to mitigate the social isolation many residents experience, as well as promote an environment of consistency, collaboration, and incorporation of care beyond just the physical needs of the residents. 

It is crucial to be aware of interventions that can mitigate loneliness. An important individual trait to foster is resilience. Resilience is a protective mechanism that can lessen negative emotions and help maintain improved wellbeing among older individuals. Social support can foster one’s resilience while reducing depression.^3,31 Social support provides emotional comfort and involves being caring and promoting empathy, love, and trust. Effective interventions have been those that offer social activity and/or support within a group format. Interventions where older people have been active participants are more likely to be effective.³¹

Clinically, it is challenging to know the association between interventions such as contact with friends and families, social support, and loneliness among NH residents and other OAs. Some studies appear to support the importance of visitation by significant others and loved ones in reducing loneliness. Unfortunately, one-third of NH residents were found to seldom have visitors, which is a challenge for clinicians attempting to tackle loneliness.^1,3 Of course, these studies were prior to the pandemic, so additional research is needed to comprehensively understand the entire impact of ceasing visitation upon OAs living in these facilities. Group reminiscence therapy can be an effective approach to lowering loneliness, anxiety, and depression among OAs.¹

One creative approach may be videoconferencing. Videoconferencing is recognized as a feasible way to promote social interaction and reduce depressive symptoms.³¹ With technological advancements in mobile phones and tablets that are more elder-friendly, it is feasible to have these devices readily accessible at facilities and in the community for OAs. 

Another promising strategy to promote social support is animal-assisted therapy.³² Once a week animal-assisted therapy has been shown to reduce loneliness in NH residents. It is the interaction between the cat or dog (whether living or robotic), not the increased socialization among the other residents, that accounts for lessening loneliness. Thus, one-on-one visits are more effective than group visits. Some studies have shown that there is no difference in reducing loneliness between the use of a living dog vs a robotic dog.³² Robotic cats and dogs should be considered when the needs of living animals cannot be met.

Interventions to reduce loneliness and/or social isolation are complex, as they have several interacting components (eg, goals, personnel, activities, resources, and delivery mode). There is no one-size-fits-all approach, and it is recommended that the assessment of individual needs be conducted to determine if group, individual, or a combination of activities should be undertaken.³¹

Clinicians need to be aware of these findings and work towards fostering more social interactions in their daily practice. Developing interactive programs between OAs and their loved ones can promote social interaction while minimizing loneliness. Clinicians should strive to be open to interventions like robotic animal-assisted therapy and encourage residents to participate in these interventions. More attention should be paid to OAs diagnosed with cancer and other chronic illnesses to implement loneliness screening plans. Physical environment should be evaluated to promote social interaction among residents in facilities. Home health agencies and services should integrate loneliness screening into their routine assessments when caring for OAs who live alone. The first step in mitigating loneliness is recognition of the problem and a willingness to discuss strategies with staff, colleagues, and older patients and their loved ones. 

A 92-year-old White, widowed woman, Mrs A, was seen by a geriatric psychiatrist to rule out a depressive disorder after she was admitted to a local LTC facility because of failure to thrive. Nursing was concerned that she was oftentimes teary and staying withdrawn while she was polite and cooperative with her activity of daily living care. The geriatric psychiatrist’s report stated that she had been born, raised, and lived in Texas until her husband died of old age 4 years prior. Subsequently, she moved to live with her daughter. Unfortunately, her medical condition became worse, and she voluntarily decided to move to a facility to alleviate her daughter’s burden. Mrs A reported her husband was “a good provider and loving person” and “I had a good marriage.” She was a homemaker and raised 1 son and 2 daughters. Unfortunately, her son was killed in an automobile collision in his late 20s. Her younger daughter, a traveling nurse, lives in Texas. Mrs A enjoyed being a choir member in her church and had a dog and a cat when she lived in Texas. Her medical history reveals that she suffers from end-stage renal disease, hypertension, type 2 diabetes mellitus, neuropathy, transient ischemic accident, osteoarthritis, and generalized weakness. She sleeps 6 to 7 hours at night and maintains a fair appetite. She has kept her body weight about the same since she moved into the facility. She is wheelchair bound and requires renal dialysis 3 times a week. Mrs A has no prior history of psychiatric conditions. She reports that she was not feeling depressed but was not feeling happy either. She has no death wish or suicidal ideation. She denied any psychotic symptoms. Mrs A scored 21/30 in Montreal Cognitive Assessment and 6/15 in Geriatric Depression Scale. She was given a diagnosis of adjustment disorder, not otherwise specified, and referred to a recreational therapist and a counselor. Both therapists identified loneliness as contributing to her overall wellbeing. Mrs A began attending a singing group at the facility, and her counselor provided a short-term therapy based on acceptance and commitment method. Also, her recreational therapist recommended a trial of a robotic cat and a robotic dog. On a follow-up visit with the geriatric psychiatrist after 3 months, Mrs A was found to be far less withdrawn with no recent crying spells. She also attended Sunday morning services on a regular basis. The geriatric psychiatrist determined that she was psychiatrically stable and was not in need of a pharmacotherapeutic intervention.

Future research should explore relationships between videoconferencing and characteristics of NH resident’s family members, factors influencing its use, effects of it on the health of the residents and families, and the cost effectiveness, as well as differences between community-dwelling OAs and facility-based. Additionally, future studies should include the impact of serious illness diagnoses and loneliness. Scant research has been dedicated to studying loneliness in NH residents to explore if loneliness in NHs is different. Little is known about the prognostic significance of loneliness in NHs or how to tailor interventions to better care for this diverse population. Furthermore, research is needed to focus on the impact of the pandemic upon OAs who are at higher risk for contracting these viruses and having more serious complications.

Loneliness is a common condition among the older population and may contribute to poorer physical and mental health. It is often overlooked by physicians and other health care professionals who are focused on more serious diagnoses. To better care for our older adult patients, it is critical to identify loneliness, understand its impact upon OAs, and implement strategies to mitigate it. 

Authors: Phyllis Whitehead, PhD, APRN/CNS, ACHPN, RN-BC, FNAP¹ • Shereen Gamuladdin, MD² • Carolyn White, FNP/GNP, ACHPN² • Christi Stewart, MD¹ • Sarah Dewitt, MD¹ • Kye Kim, MD³

Affiliations:
¹Carilion Roanoke Memorial Hospital Palliative Care Service
²Centra Health Palliative Care Service
³Carilion Clinic Center for Healthy Aging

Disclosures:
The authors report no relevant financial relationships.

Address correspondence to:
Kye Kim, MD
Carilion Clinic Center for Healthy Aging
2001 Crystal Spring Avenue, #302
Roanoke, VA 24014 
kykim@carilionclinic.org

Citation: Ann Longterm Care. Published online: January 9, 2023. doi:10.25270/altc.2023.01.001.