Social isolation and loneliness: the new geriatric giants

Scope of the issue.

Estimates from 2017 show that 17% of Canada’s population is aged 65 and older. This population, especially those older than 75 years, is expected to more than double in the next 20 years.¹ Emerging evidence shows that social factors have considerable effects on mortality and many aspects of health in older adults.² Terms such as social isolation, social vulnerability, and loneliness, defined in Box 1,^3,4 are becoming increasingly important topics of discussion. Public health agencies and governments are promoting reducing loneliness and strengthening social networks as important public health goals. In 2013–2014, the National Seniors Council prepared a Health Canada report on the social isolation of seniors.⁵ The UK supports a Minister for Loneliness as well as the Campaign to End Loneliness, a network of organizations working to reduce loneliness in later life through community action, practice, research, and policy.^6,7 The World Health Organization has also created a Global Network for Age-friendly Cities and Communities, a key strategy of which is encouraging social engagement for older adults.⁸

Studies have shown, however, that family physicians have trouble identifying their lonely patients.⁹ A Dutch study found that, while family doctors acknowledged the importance of patients’ feelings of loneliness in their daily practice, they had difficulty responding to these feelings and faced a lack of therapeutic options.¹⁰

The prevalence of social isolation ranges from 6% to 43% in older community-dwelling adults, and 10% to 50% report feeling lonely.^3,5,11

Importance of the problem.

While intrinsic factors such as genetics, medical conditions, and frailty contribute to health, there is growing recognition of the effects of social determinants of health—the conditions in which people are born, live, and age. Loneliness and social isolation were shown in a meta-analysis to be associated with a heightened risk of mortality of 26% and 29%, respectively.¹² This increased mortality risk is in the same category as smoking 15 cigarettes a day and having an alcohol use disorder. In addition, the health risks of loneliness surpassed those associated with obesity.¹² The media has disseminated this finding with the catchy headline “loneliness is the new smoking.” Another recent meta-analysis suggested that the risk of developing dementia for those with high levels of loneliness was 1.58 times greater than for those with a social network.¹³ There is good evidence that individuals who are lonely or socially isolated have an increased risk of physical and mental health problems, as well as increased health services use (Table 1).^{3–5,11–19}

Conversely, increased social engagement has been associated with decreased disability and lower mortality.^19,20 In Holt-Lunstad and colleagues’ meta-analysis, individuals with stronger social relationships had a 50% increased survival likelihood.¹² Social connections have been shown to improve adherence to medical regimens²¹ and to decrease hospitalization time.²

Risk factors.

Many variables have been found to be associated with an increased risk of loneliness, social isolation, and social vulnerability (Table 2).^1,3,4,22

Identifying and reaching patients who are isolated or lonely.

Family physicians and other primary care providers are well placed to identify patients who are isolated or lonely, as these providers might be the only point of social contact for many patients.^7,23–25 In the UK, 3 out of 4 GPs say they see between 1 and 5 people a day who have come in mainly because they are lonely.⁷ It has been suggested that, just as physicians screen for risk factors such as smoking, diet, and exercise, there might be a role for primary care physicians to identify patients who are isolated, lonely, or socially vulnerable and to recommend evidence-based interventions that could strengthen social connections.^25,26

The National Seniors Council report confirmed that a “reactive” approach is currently in place to address the needs of socially isolated individuals, many of whom are not identified or supported until after a crisis.⁵ Validated scales to assess older adults at risk of social isolation and loneliness, who might benefit from intervention, include the Lubben Social Network Scale^27,28 and the Three-item Loneliness Scale (Table 3).²⁹ Single-item screening questions are also available, such as “How often do you feel lonely (hardly ever or never, some of the time, often)?”^11,30 Single-item questions have been less extensively studied but are commonly used in research and might be more practical in clinical practice.^11,30–32

Some communities have used existing data sets pertaining to risk factors for loneliness—for example, mapping geographic areas with more risk factors (to create “a loneliness heat map”) to target services. Other communities have trained “non-traditional referral sources”—individuals with whom older adults might have contact (eg, volunteers, shopkeepers)—an approach called “eyes on the ground.”^7,33,34

Interventions.

Various interventions aimed at reducing loneliness and social isolation have been studied (Table 4).^14,35–46 Multiple systematic reviews evaluating these interventions have come to different and often contradictory conclusions.^14,35–46 For example, several systematic reviews have found improved outcomes with group interventions that are educational or social, or which combine exercise with a leisure or psychosocial intervention.^35–38 Other reviews, however, demonstrate greater evidence for one-on-one interventions (such as videoconferencing, Internet use, and animal therapy).^39–42,46 The systematic reviews comment on the poor methodologic quality of the primary studies, including small sample sizes, follow-up not being long enough to see health benefits, lack of measurement of health care use, and lack of consistency on whether and how social isolation or loneliness are measured.^14,35–46 The review done by the Agency for Healthcare Research and Quality rated fewer than half of the included studies as fair or good quality.³⁸

Given the poor quality of the studies, it is difficult to draw conclusions about which factors contribute to successful interventions. It has been suggested that the mechanism by which technology might address social isolation is through enhancing connections to family and friends, gaining social support, engaging in areas of interest, and boosting self-confidence.⁴¹ Gardiner et al suggest in their integrative review that the most successful interventions share the following features: adaptability to a local context and local control of the design, a community development approach (where interventions are designed and implemented by service users), and productive engagement activities (either individually or as a group) rather than passive activities.⁴³

“Social prescribing” is a new model addressing social isolation and loneliness that is being widely adopted and promoted in the UK and that is being studied in communities in Ontario.^7,47 This is a broad approach to the delivery of interventions that focuses not on what is delivered but on how services are delivered to a local community. In this model, a patient is identified within primary care and referred to a navigator who assesses their needs and connects them to appropriate services (eg, caregiver respite, sensory services, recreation, transportation, food, or income supports). Individual studies of this model show improvements in self-reported health measures and reductions in health service usage. However, a recent systematic review of social prescribing found that the current evidence fails to provide sufficient detail to judge either success or value for money, as most of the studies are small and of poor quality.⁴⁵

Practical approach to loneliness and social isolation.

Given the lack of clear guidelines as to which interventions are effective for which individuals and the diverse needs and preferences of older adults, we suggest clinicians use an individualized, patient-centred approach in addressing social isolation and loneliness (Box 2).^7,14,38,48

Social services involvement is essential in selecting the interventions most appropriate to the context of a particular patient. Many cities have central websites and telephone lines (eg, Canada 211) with searchable databases of services. In our own and others’ experiences, creating a directory of local assets can be a valuable reference tool in the electronic medical record, available in hard copy in the office or distributed on home visits. Community centres and public libraries also often offer exercise programs, social programs, and computer training for older adults (Table 5).

Addressing barriers to implementing interventions

Transportation needs: Connecting older adults to reliable and affordable transportation is often a prerequisite to their remaining engaged in the community and in supporting relationships.^3,7

Sensory loss and mobility restrictions: A 2008 review of social isolation in community-dwelling seniors found that rehabilitation for mild or moderate hearing loss was effective in improving communication disabilities and reducing loneliness.¹⁴ No studies were found that evaluated the effects of interventions for other age-related functional disabilities such as vision loss or mobility restrictions. However, the authors of the review point out that research is not necessarily needed to confirm that correcting mobility restrictions or vision loss could improve quality of life and social engagement.¹⁴

Participating in many interventions is only possible after optimizing mobility, vision, and hearing.

Income: Cost can be a barrier to participating in social programs. Older adults should be encouraged to submit their tax forms, as government benefits exist for low-income seniors.⁴⁹ Programs might waive fees or use a sliding scale for low-income older adults.

Gaps in understanding and research: underserved populations.

First-generation immigrants struggle to access mainstream interventions for loneliness owing to lack of familiarity with resources as well as language and cultural barriers. In the National Seniors Council report, this population identified challenges in finding care facilities and social programming in their language of choice.⁵ The literature does not describe how seniors of different ethnicities experience loneliness and isolation. The level of social isolation experienced by older Indigenous people is not known. However, cultural and structural factors, coupled with high rates of traumatic events over the person’s life, might increase the risk of loneliness and social isolation.⁵⁰ The Agency for Healthcare Research and Quality review notes that only 1 of the 8 good-quality studies reported on the ethnicity of participants.³⁸

Older adults who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and related communities) are at a high risk of loneliness and social isolation.^50–52 A survey by the American Association of Retired Persons found that most older adults identifying as LGBTQ+ are concerned about having enough support from family and friends as they age.⁵¹ Many LGBTQ+ older adults express a desire for LGBTQ+ specific services and housing.^50,51

Despite being in the company of others, older adults living in residential or long-term care still experience high levels of loneliness and isolation. As many as 44% of seniors living in long-term care in Canada have been diagnosed with depression or have symptoms of depression, and these residents are more likely to be socially isolated.⁵³ Most of the research on institutionalized older adults has involved persons who were cognitively intact, and there were no systematic reviews specific to long-term care. Feelings of loneliness and isolation are common in dementia, and these patients might find it more difficult to cope with the feelings associated with these problems.⁴⁰ In addition, senior caregivers are often a socially isolated, hidden population, and further research is needed to identify which interventions are effective in this group.¹⁴

Although the association between poverty and social isolation is well described, there is very little literature on the effects of poverty on the experience of loneliness and social isolation.