by Tobi A. Abramson, PhD
“Look at all the lonely people… All the lonely people Where do they all come from?” – The Beatles, “Eleanor Rigby” (Yellow Sumbmarine, August 5, 1966)
When Paul McCartney penned “Eleanor Rigby,” he knew a bit about older people, loneliness and social isolation. In a November 1980 interview in the British Sunday paper The Observer, Paul explained:
“When I was a kid I was very lucky to have a real cool dad, a working-class gent, who always encouraged us to give up our seat on the bus for old people. This led me into going round to pensioners’ houses. It sounds a bit goody-goody, so I don’t normally tell too many people. There were a couple of old ladies and I used to go round and say, ‘Do you need any shopping done?’ These lonely old ladies were something I knew about growing up, and that was what ‘Eleanor Rigby’ was about—the fact that she died and nobody really noticed. I knew this went on.”
Sir Paul was right about what was going on back then. Sadly, it is still going on today in significantly greater numbers.
Throughout the industrialized world, chronic loneliness and social isolation have become major public health concerns. Former Surgeon General Vivek Murthy noted the most common pathology he witnessed was not heart disease or diabetes, but rather loneliness (Murthy, 2017). He warned that without a coordinated and earnest plan to address underlying causes, the epidemic of loneliness and social isolation will get worse (ibid). In England, Prime Minister Theresa May recently appointed a Minister for Loneliness in response to a reported 9 million citizens who often or always feel lonely (Yeginsu, 2017). And in Japan, the extreme impact of loneliness and isolation has given rise to the tragic phenomenon known as Kodokushi—people, most often older adults, dying alone and remaining undiscovered for long periods of time (Bremner, 2015).
Feelings of loneliness and social isolation affect people at any age but become particularly more prevalent and serious in later life. Natural events associated with getting older, such as the loss of friends and relatives, hearing loss, and decreased mobility are factors that can contribute to a decline in social interactions. Helping older adults navigate through these difficulties is not easy. However, increased attention is helping to generate innovative community-based solutions, from use of computers and technology to create virtual senior centers to creative engagement programs led by professional teaching artists.
Professionals working with older adults should be aware of these issues, especially for clients aging in place, for several reasons. First, older adults living at home, especially if they are alone, are at a higher risk of social isolation. Second, being socially isolated is associated with higher rates of financial and elder abuse. Third, loneliness exacerbates existing chronic diseases, as well as contributes to declines in mental, physical, and cognitive health functioning. Finally, social isolation and loneliness can often be identified and ameliorated by a concerned professional who can connect older adults to appropriate resources.
Defining Loneliness and Social Isolation
Loneliness and social isolation are in direct contrast to the basic human need for love and belonging. In Maslow’s hierarchy, meeting these needs is essential once a person’s physiological and safety needs have been satisfied. The human need to belong, to connect to others, to give and receive love and affection, and the need for affiliation (being part of a group and the need for intimate relationships and friends), are essential to not only thriving, but to one’s safety and survival.
An evolutionary fitness perspective underscores that humans are a social species and social connections are necessary for survival throughout the life course (Bhatti & ul Haq, 2017; Hawkley & Capitanio, 2015). Belonging and meaningful social connections are chief characteristics found in regions that have the longest-lived individuals in the world (Buettner, 2010). Loneliness and social isolation are, in many ways, a breakdown in our most basic human need for social connection and belonging.
Social isolation and loneliness are terms often used interchangeably as both focus on a lack of social connection, but there are distinct differences. Loneliness is complex. It can be experienced in the company of others where one feels separated and isolated from a special “other” or partner, or one’s peer group, or from society as a whole. Perissinotto, Stijaci Cenzer, & Covinsky (2012) explain loneliness as the “discrepancy between one’s desired relationships and one’s actual relationships” (p. 1079). Thus, loneliness is the subjective feeling or appraisal of being isolated, where one feels that they do not belong, and/or feels a lack of companionship.
Social isolation can occur when there is a lack of contact with other individuals due to situational factors or there are infrequent social interactions. Epidemiologists measure social isolation based on the size or density of one’s social network (i.e., how many friends you have or how often you have contact with family/friends), marital/partner status, and/or living arrangements (Holt-Lunstad, et al., 2017). The size of one’s social network as an indicator of social isolation can be quantified and has been the basis for the general body of research on this topic.
Prevalence of Loneliness and Social Isolation
In the U.S. and around the globe, people of all ages, but particularly older adults, are increasingly experiencing loneliness and isolation on a regular basis (HoltLundstad, 2018). Determining the extent of these conditions is difficult, however, because the measures vary and are not regularly collected. The many factors that go into data collection and other variables are beyond the scope of this article, but it is noteworthy that demographics such as single, married or living alone “… are relatively crude indicators of social disconnection (e.g., someone who is single or lives alone may still have a wide social network). They are, nonetheless, robust predictors of health outcomes and thus should still be taken seriously” (Holt-Lundstad, 2018). Combined with other data sources such as participation in civic engagement and volunteer activities, these indicators reveal that the prevalence rates are likely much higher than reported for loneliness and social isolation, particularly among older adults (ibid).
According to a recent AARP report, social isolation and loneliness present growing public health threats, with a conservative estimate of more than 8 million Americans ages 50 and older affected by isolation. Of the respondents, 35% reported feeling lonely and 45% of respondents reported feeling lonely for 6 or more years (AARP, 2017). If living alone is a reliable crude indicator for experiencing social isolation and loneliness, then the number of older adults who fall into this category is likely higher. Almost 30% of those 65 or older live alone. For women in this age group, 36% live alone, increasing to 45% for women 75 years and older (ACL, 2016).
Health and Well-Being
As noted, loneliness and social isolation have received increasing attention from the media, lay public, and from researchers who are studying the distress and health implications arising from these circumstances. Regardless of the definition, these experiences can contribute to the deterioration of the physical and mental health of an older person, overall poorer general health (Luo & Waite, 2014), poorer health outcomes, and decreased longevity.
Those 60 and older who identify themselves as being lonely were 59% more likely to experience a decline in their ability to perform basic activities of daily living, i.e., grooming, toileting, dressing, etc., and had more problems with mobility (Perissinotto et al., 2012). Moreover, loneliness and social isolation were found to be risk factors for coronary heart disease and stroke (Holt-Lunstad & Smith, 2016). Loneliness, specifically, has been linked to high or elevated blood pressure (Hawkley & Capitanio, 2015; Perisonotto et al., 2012) and increased cortisol inflammatory responses to stress (Hackett, Hamer, Endrighi, Brydon, & Steptoe, 2012). An inverse relationship appears to be correlated between social support and morbidity and mortality (Holt-Lunstad, Smith, & Layton, 2010). In other words, lonely older adults with less social support and social connectedness are more likely to die earlier. Those 60 years of age and older who reported feeling lonely had a 45% increased risk of death (Perissinotto et al., 2012). Some of the most staggering data indicates that loneliness was as robust a predictor of early death as alcoholism, smoking 15 cigarettes a day, and a stronger predictor than obesity or a sedentary lifestyle (AARP, 2017).
Loneliness in older adults has been linked to cognitive deficits, cognitive decline, and dementia in several studies. It is both a predictor and marker of pathological changes in the brain as well (Bhatti & ul Haq, 2017). Holt-Lunstad et al. (2017) reported that older adults who described themselves as being lonely, regardless of whom they lived with, were twice as likely to develop dementia over a three-year period. Predictably, feeling lonely is correlated to decreased quality of life (Shankar, Hamer, McMunn, & Steptoe, 2013). Social isolation is likewise found to have similar negative influences on health (Luo & Waite, 2014; Choi et al., 2015; Jaremka et al., 2014). It is increasingly evident that social relationships and connectedness to others influences health outcomes and warrants being taken as seriously as other risk factors.
Risk for Older Adults vs. Other Age Groups
Perceptions of loneliness may depend on one’s stage in life. The objective indicators of social isolation that underlie loneliness may vary dramatically among the young and the old. For example, an adolescent may feel lonely if they have only two good friends, but an 85-year-old may feel socially connected still having two good friends (Luhmann & Hawkley, 2016). Research reveals higher reports of loneliness in those in early and late adulthood, with middle-aged adults reporting lower levels of loneliness than these other two age groups (Luhmann & Hawkley, 2016). It is unclear if these findings will shift as boomers enter their retirement years; loneliness may become a serious health issue for this age group as well. This in part may arise due to the increasing, dominant use of technology as a means of communicating and interacting with others. Technology and technological advances may prove to be a mixed bag, as technology has the contradictory potential to both combat and exacerbate the risk and experience of loneliness and isolation. Future research will need to explore the impact that this shift will have on aging boomers’ experiences and whether (and how) technology utilization will impact the size of one’s social networks, social connectedness, the feeling of social isolation, and loneliness.
Identifying and Addressing Risk Factors for Social Isolation
There is no silver bullet, no direct and easy solution for addressing social isolation and loneliness among older adults. Those who work with older adults can intervene on numerous levels, but first it is important to understand the various factors older adults face that put them at risk for social isolation and loneliness. Risk factors linked to social isolation can be grouped into these categories: events (loss of spouse/partner or close friends, becoming a caregiver, undergoing major life transitions, living alone); physical (both sensory or mobility losses, chronic illness); psychological (mental health problems, i.e., depression, dementia, life transitions); or socio-economic (low income, limited financial resources, being a caregiver, living in rural or unsafe communities, poor social support networks, cultural barriers, non-English speaking) (AARP, 2012).
At the broadest level, it is essential to identify individuals who may be experiencing any of the above risk factors and help them find ways to preserve and bolster their existing social networks. Perissinotto et al. (2012) refers to this as a primary prevention approach and Nobel (2017) similarly refers to this in his pyramid of vulnerability model.
Professionals working with older adults need to become better at detecting individuals who identify as lonely and are beginning to disconnect but who are still healthy. Including screening questions or loneliness questionnaires, such as the UCLA Loneliness Scale or the adapted 3-item scale (Penninx et al., 1998) as a regular part of medical and psychosocial evaluations, or as part of the initial client intake process, is critical to identify those at this level of risk, before the impact of loneliness takes a toll on the older person’s physical and mental health. For older adults identified as lonely and socially isolated, it is important to reduce the progression that the negative effects of loneliness might be having on their health (tertiary prevention; Perissinotto et al., 2012). While a number of strategies such as virtual senior centers, community gardens, and intergenerational day care programs are being employed to bolster social connection, creative engagement has been shown to be an especially useful intervention.
Creative and Artful Engagement: A Strategy for Reducing Loneliness and Social Isolation
Often lonely individuals are less likely to be active in programs that can help them to build social networks (AARP, 2017). The task is to connect people to community arts programs and resources, ideally before they become at risk. Participating in creative and artful activities that focus on intergenerational activities, lifelong learning, civic engagement, and health and wellness can offer opportunities for older adults to become more involved with others within their communities and thereby help to decrease loneliness, social isolation, and improve physical and mental health. Creativity for older adults allows individuals to create meaning, finish unfinished business, and make a lasting statement (Cohen, 2000). Creativity also allows for engagement in purposeful activities that foster a sense of competence, purpose, growth, and improve self-esteem and coping skills.
Collaboration engages the mind, body, and soul, provides opportunities for regeneration and healing, and can be a powerful tool in keeping older adults from experiencing social isolation and loneliness. Many creative engagement activities (i.e., dancing, chorale groups, theater, etc.) foster membership and a sense of belonging by their collaborative, participatory nature.
There are also physiological benefits to engaging in creative activities that can possibly offset the health consequences associated with loneliness and social isolation. Engaging in creative activities has been shown to stabilize heart rate, regulate hormone levels, and increase hormones associated with feeling good. In addition, decreases in pain level, improved mood, improved physical functioning, and positive neurological changes have been found when older adults participate in various art forms. Cohen’s (2000) research on participation in chorale groups found that participants had fewer doctor visits, fewer falls, lower medication use, and lower levels of depression.
The issue of social isolation and loneliness is multifaceted and will require a multidisciplinary approach to come up with innovative solutions at the individual, community, and societal levels. Creative engagement may offer one pathway for some older adults who are experiencing the negative effects of social isolation and loneliness. Being creatively and artistically engaged allows for involvement in meaningful activities, provides practical ways to reduce loneliness by reconnecting to others and to one’s community, increasing the size of one’s social network, improving the quality of social supports, and increasing the frequency with which one has contact with others. Engaging individuals in the arts throughout the life course may serve as a primary prevention tool in combatting and preventing social isolation and loneliness before negative health effects can take hold. •CSA