Human beings are essentially social animals, as high-quality social relationships are fundamental to our physical and mental health and well-being at all life stages or ages. Loneliness and social isolation have significant consequences for health, well-being, and longevity. Disruptive life events and life transitions, such as the loss of a spouse or friends, loss of mobility, and retirement, put older individuals at particular risk since they are more likely to be affected by these events. The concepts of loneliness and social isolation are different yet related. Social isolation is the objective state of having a minute or little network of family and friends relations and thus few interactions with other individuals.
On the other hand, loneliness is social pain or painful subjective feeling as a result of the inconsistency between actual and desired social relationships. Lonely individuals are not necessarily socially isolated, and the converse is true. The level at which an individual becomes lonely depends on the culture of the individual and their own expectation of associations. This paper will focus on the scale of loneliness and social isolation, its damage to the health of individuals and their quality of life, and why older people are at risk of social isolation and loneliness. The consequences of isolation and loneliness, what works to address social isolation and loneliness, the role of technology and the health sector in addressing loneliness and social isolation, implementation barriers and key contributors to success will also be discussed.
The Scale of Social Isolation and Loneliness
Hossain et al. (2020) reported a prevalence of loneliness of eighteen percent in India, twenty-five to thirty-two percent in Latin America, and only 3.8% in China. There were also other estimates of loneliness dominance among older individuals, with forty-four percent in India and 29.6% in China (Hossain et al., 2020). However, there is no standard cross-culturally, internationally, widely used valid measure of loneliness and social isolation (Gao et al., 2021). Differences in methods account for a difference in estimates, including the mode of data collection, for instance, self-administered questionnaires or face-to-face, type of measure, and the representatives of the inclusion and sample criteria, for instance, the elderly in ethnic minorities and institutions (Hossain et al., 2020). Compared to the community, the dominance of loneliness is higher in long-term care institutions. This is because the individuals do not interact with other people in long-term care institutions as much as they would have in the community, contributing to the enormous difference.
Before the COVID-19 outbreak, investigators in a 2020 report from the National Health and Aging Trends Study found that twenty-four percent of community-dwelling adults aged 65 years and over were socially isolated in the U.S, and four percent were severely isolated. The AARP Foundation found that thirty-five percent of adults aged forty-five and above reported feeling lonely from their survey in the United States of America (Cotterell et al., 2018). Notably, older adults in the ninth or tenth decades of life go through high rates of severe loneliness and social isolation, even though loneliness appears to be most dominant among American adults below fifty years of age. Because of poorer health, older individuals are more vulnerable to severe health consequences of social isolation and loneliness.
Individuals who are at risk of being socially isolated later in their lives are usually among the oldest unmarried male, having low income and low educational attainment. Social isolation is described as physical isolation, less frequent contact with friends and family, or reduced size and diversity of social network that increase loneliness risks (Chen & Feeley, 2013). Individuals identified as any group in our communities who are likely marginalized are more likely to report that they experience loneliness and social isolation (Prohaska et al., 2020). The consistent finding is that social isolation and loneliness are significant and dominant across every age group due to different measurement methods, even though prevalence varies over different studies partially because of different measurement methods.
Social Isolation and Loneliness Damage Older People’s Health and Quality of Life
There is formidable evidence that loneliness and social isolation increase the chances of mental health deterioration, such as anxiety, depression, suicide, dementia, and cognitive decline, and physical health among older adults, such as stroke and cardiovascular disease (Hakulinen et al., 2018). These two issues, social isolation and loneliness, are also risk factors for abuse and violence against older women and men, which appeared to have increased during the COVID-19 pandemic, at least in the U.S., little focus has been put on the discordance between loneliness and social isolation for instance low loneliness but high social isolation and its influence on health.
Three plausible mechanisms have been proposed currently for the impact of loneliness and social isolation on health. The first is that they result in excess stress reactivity. The physiological systems of isolated and lonely people may absorb more stressors experienced in daily life in the absence of the stress-buffering effect of social support (Fung & Jiang, 2016). Second, they lead to inadequate psychological maintenance and repair processes. For example, loneliness and social isolation may impact the quantity and quality of sleep, which may affect various physical health conditions and poor sleep as a result of increased mortality (Hakulinen et al., 2018). Third, they also result in behavioral risk factors like poor diet, smoking and alcohol consumption, and poor adherence to medical treatments.
Social isolation has been related to a considerably increased risk of premature mortality from every cause. The excess mortality accountable to the risk of social isolation exceeds the influence of physical risk factors such as smoking and obesity (Hakulinen et al., 2018). Complex measures of structural components of social relationships, including network size, marital status, and network participation, have a more substantial effect than unidimensional measures. Respondents with weak social relationships experienced fifty percent greater odds of mortality. Also, low social support leads to increased hospital readmission and mortality rates due to myocardial infractions.
Anxiety and Depression
Psychological weakness has been created as a word or term to describe the delicate mental state among many older individuals. Social isolation has significantly impacted individuals with pre-existing mental health conditions such as depression and anxiety. This is mainly heightened when older individuals had a recent bereavement or lived alone. According to Courtin & Knapp (2017), the pandemic-related social isolation caused an increase in loneliness and depression among the elderly, except for those that maintained a connection with their relational networks, who had reported less depression (Courtin & Knapp, 2017). Seventy percent reported low mood at times, and more than half reported loneliness while isolating. This type of isolation has also been related to an increased incidence of completed and attempted suicides, particularly if the individual exhibited dementia or baseline cognitive deficits (Courtin & Knapp, 2017).
An online survey on older individuals quarantined during the COVID-19 pandemic displayed relationships between social isolation and anxiety, stress, posttraumatic stress disorder, and depression. Suicidal attempts, fear, and anxiety among older individuals have increased significantly, especially during the COVID-19 pandemic (Gao et al., 2021). Older individuals may experience fear of death or fear of losing those they love, which can result in serious self-neglect, leading to noncompliance to the recommended precautions standards.
Social isolation can also cause increased cases of neuro-inflammation among the elderly. The majority of designs associated with the neurological effects of social isolation are case series, retrospective analyses, and single-case designs. Several studies have shown the negative impact of isolation on the prefrontal cortex, which controls impulsiveness, decision-making, or executive function (Sharma & Subramanyam, 2020). Loneliness has been correlated with neuro-inflammation and reduced gray matter using neuroimaging in the cerebellum, hippocampus, and amygdala (Sharma & Subramanyam, 2020). Additionally, loneliness has also been associated with a decline in overall volume in the left medial temporal lobe, which has the capacity to severely impact or affect memory.
Loneliness and isolation from support systems may lead to an increase in substance abuse or relapse from individuals recovering from the abuse. According to Shankar et al. (2011), over a third of older individuals with alcohol addiction did not foster alcoholism until later in their lives. The National Institute of Health advocates that the elderly take three drinks or less in a day or seven a week (Shankar et al., 2011). However, one in every ten reports surpasses this amount of alcohol consumption. The lack of face-to-face contact negatively affected individuals who struggle with alcohol addiction.
Isolation also leads to increased use of cannabis and tobacco in some older individuals. For instance, a study found that one percent of older individuals started smoking during the pandemic-related isolation lockdown, yet 7.4% of those who had already smoked before the COVID-19 pandemic had more cigarettes each day (Luhmann & Hawkley, 2016). Two percent of the respondents reported using more cannabis in isolation compared to when they were not socially isolated, and one percent began using it during the social isolation.
Additionally, the pandemic interrupted regular physician visits, leading to drug overuse or abuse among the elderly (Luhmann & Hawkley, 2016; Fakoya et al., 2020). This indicates that social isolation leads to increased drug overuse or substance abuse. Older people whose mental health is impacted by social isolation are at increased risk of relapse, overdose, or abuse since depression is a risk factor for opioid abuse. Depressed older individuals are twice likely to become independent on or abuse opioid therapies.
A majority of older people with an indoors mentality or culture with no exercise are at increased risk of frailty and sarcopenia. Frailty can lead to an increase in hospital admissions from physical deconditioning, fractures, and falls. Also, loneliness and isolation have been related to decreased functional ability and increased fall risk (Hawkley et al., 2019). Loneliness can also cause insomnia or disruption in sleep patterns, leading to decreased physical activity and fatigue. Some older individuals may spend more time in bed when daily activity schedules stop suddenly or isolation from peers happens, which may also disrupt the circadian rhythm of the body. Loneliness and isolation cause a decline in sleep quality, leading to physical inactivity or daytime fatigue. Moreover, loneliness and social isolation have raised the risks of developing stroke and coronary artery disease independent of traditional cardiovascular disease risk factors (Rokach, 2019). Furthermore, patients with cardiac disease experience worse prognoses because of few social relationships. Social isolation is significantly associated with an increase in diastolic and systolic blood pressure.
Most older people rely on other people for assistance or delivery services to purchase groceries. Donovan & Blazer (2020) highlighted a decrease in nutrition among older adults despite dedicated senior hours in many grocery stores during the COVID-19 pandemic isolation. Also, a majority of the older people experienced food insecurity related to access or supply. Moreover, adults were more susceptible to malnutrition despite having the availability of services and the issues related to supply. This can worsen existing health conditions or cause the start of chronic diseases. During the pandemic-induced isolation, the elderly in residential care settings were isolated during mealtimes, resulting in increased potential for malnutrition, decreased amount of food taken or consumed, and loss of appetite (Donovan & Blazer, 2020). Besides, families who mostly brought food from home were restricted access to the facilities, and dining groups and rooms were closed down, leading to a decline in opportunities in interaction and socialization with others while having meals.
Why Older People are at Risk of Social Isolation and Loneliness
A wide range of system-level, societal, community, relationship, and individual-level factors risk individuals of loneliness and social isolation. Identifying risk factors at these four interacting levels aids in understanding many approaches and interventions that focus on these risk factors to curb social isolation and loneliness (Radvansky et al., 2010). At the individual level, physical factors such as cancer, stroke, or heart disease can raise risks of loneliness and social isolation, even though the association is primarily bi-directional (Radvansky et al., 2010). Mental disorders, such as depression, anxiety, dementia and other reduced physical problems such as reduced hearing capacity and impaired sensory also raise the risks. Additionally, personal traits such as disagreeableness, low conscientiousness levels, and neuroticism or negative effect increase loneliness risks and are partially genetically determined.
Moreover, unfulfilling or challenging relations and a lack of supportive relationships can increase loneliness. Certain life events, such as retirement and bereavement among the elderly, increase the risk of social isolation and loneliness (Gerino et al., 2017). Social groups that include ethnic minorities such as bisexual, gay, lesbian, transgender, and disabled people among older individuals are at a greater risk of social isolation and loneliness. At societal and community levels, limited education, poor housing, inadequate transportation, ageism, remote residence, marginalization, lack of socio-economic resources, and lack of access to digital technology can lead to social isolation and loneliness.
Interventions to Address Social Isolation and Loneliness
Loneliness and social isolation can happen at any age, and strategies and interventions to address them starting earlier may be required. Various sectors must participate for a population-level influence on loneliness and isolation. These levels and sectors include individual and relationship group interventions, community-level strategies, and societal-level strategies. However, older people must be identified and connected to services before being offered help. Hence, the health sector has a vital role in identifying older individuals who are already experiencing loneliness or at risk (Vieira et al., 2016). Connector services have a role in locating older individuals at risk of social isolation and loneliness, understanding the problem, and helping them in getting suitable interventions and services. These connector services include motivational interviews, guided chats, and community services.
Individual and Relationship-Level Interventions
At this level, interventions are based on three key mechanisms, improving and maintaining individual relationships, supporting individuals to create new relationships, and changing the perception of individuals about their relationships. The interventions for loneliness and social isolation that can be considered at this level can be provided in groups, one-to-one, and face-to-face or digital. For instance, mental education, mindfulness, social skills training, and cognitive behavioral therapy support the elderly and also help them understand well. Social activity groups such as befriending services that provide supportive relationships over the phone or in person, mostly by volunteers, can also curb loneliness and social isolation among older individuals.
Additionally, social prescribing, which helps patients get local non-clinical support sources, can be used to tackle the issue at hand (Kharicha et al., 2017). Moreover, psychopharmacology, such as coalitions and campaigns to create awareness for these issues and anti-depressants, can also be utilized. Compared to meeting primarily for social reasons, lonely individuals are most interested in associating with others as they explore activities based on common interests, such as exercise groups. Conversely, interventions that encourage social contact, such as befriending, can be cost-effective.
Digital interventions, such as cheap video communication, computer training programs on areas such as the internet, social networking, artificial intelligence suites, online groups and discussion forums, chatbots, messaging services, and phone debriefing form a significant intervention. However, they are associated with various ethical concerns, such as informed consent and autonomy, potential infringement on privacy, and disparities in access, including for disabled, and elderly individuals (Fakoya et al., 2020). Moreover, the extent to which online relations can enhance face-to-face relations and the possible harmful effects of digital interventions, specifically the risk of increased isolation in older individuals, are poorly understood currently. Therefore, it is important to protect the right to continue being offline and establish alternatives for individuals that are not comfortable connecting digitally.
Various strategies at this level have the ability to assist in reducing social isolation and loneliness among older individuals. Some focus on infrastructure, including transportation, digital inclusion, and the built environment needed to ensure that individuals can form new and sustain their existing relationships and deliver interventions to tackle loneliness and social isolation. Affordable, appropriate, and accessible transportation is essential to ensure that individuals stay connected (Reinhard et al., 2018). For instance, a study in the United Kingdom indicated that free bus travel introduction for individuals who are above sixty years aids in lowering loneliness and depression (Reinhard et al., 2018). The community environment is also significant in preventing or promoting social connection. Public design is also a crucial factor, especially in housing, toilets, lighting, benches, and institutions like libraries and museums (Reinhard et al., 2018). This is because when they are designed with inclusivity, it helps get rid of social isolation and loneliness.
On the contrary, digital inclusion strategies are hard to implement since they raise the issue of various digital divides, such as between older people and younger people, between those who cannot use or afford digital technology and those who can, between lower and higher-income countries, and between older individuals those 60 years and above and those 80 years and over. Therefore, it is necessary for all the stakeholders, government institutions, and policymakers to ensure connection among the elderly people by making information technology accessible for them and creating a follow-up program for those who prefer to prevent them from exclusion. (Fakoya et al., 2020). Additionally, they should include accessibility requirements necessary to digital information, products, and services to reduce loneliness and social isolation among elderly individuals in their programs, strategies, and policies associated with information and communication technologies.
Moreover, it should provide relevant digital training and knowledge to enable older individuals to embrace new technologies. Other community strategies, such as volunteering, increase social connections and the well-being of individuals who volunteer and provide personnel for interventions to curb social isolation and loneliness (Fakoya et al., 2020). Additionally, promoting age-friendly communities designed to promote active, healthy aging in line with the WHO framework aid in reducing loneliness among older individuals (Kharicha et al., 2017). They can help promote collaboration and raise awareness across different stakeholders within a local area to tackle loneliness and social isolation.
Societal Level Strategies
Strategies employed at this level to reduce loneliness and isolation include regulations that prevent discrimination and marginalization, social and economic equality, social cohesion, digital divides, and solidarity in all generations. They may try to change social norms that hinder social association, such as focusing on the accumulation of financial instead of social capital. Similar to WHO’s health policies, social policies can help tackle loneliness and social isolation. Social in all policies would include loneliness and social isolation in all appropriate policies and sectors such as labor and pensions, housing, employment, education, transportation, and the environment (Holt-Lunstad, 2020). For instance, policies could be implemented to include flexibility in the labor market, allowing older individuals more options in when and how they retire. This could assist in the transition to retirement from working life and foster intergenerational support where retired workers act as mentors to younger workers.
However, social isolation and loneliness among older people neglected social determinants of health until recently. Currently, they are considered as quality public health issues in various nations and public policies. (Victor et al., 2018). For example, the United Kingdom Government appointed a loneliness minister in 2018 and introduced a connected society approach to curbing loneliness. Japan embraced the same idea in 2021, partially in response to the COVID-19 pandemic, where the Prime Minister created an inter-ministerial task force to tackle the issue and added a loneliness minister to his cabinet. The National Academies of Sciences, Engineering, and Medicine in the U.S published a consensus report in 2020 entitled social isolation and loneliness in older adults: opportunities for the health care system.
United Nations Decade of Healthy Ageing 2021–2030, which includes four interconnected action or focus areas, is one of the most prominent international, national and regional policies employed in dealing with loneliness and social isolation. They include ensuring long-term access for the elderly, delivering primary health and integrated care services adapted to older individuals. Also, changing how we act, feel, and think towards aging and age, and making sure that communities participate in fostering the abilities of older individuals.
The Role of Technology in Addressing Loneliness and Social Isolation among Older Individuals
Technological applications appropriate for loneliness and social isolation among the elderly vary from established tools like video conferencing and social media groups to enhanced virtual reality and artificial language functions. These tools are significant in enhancing virtual connection among communities and societies as they have a great connection. On the other hand, artificial intelligence applications are designed to offer support or companionship functions through virtual reality systems, conversational agents, or social robots, which enable recollection with engagement with new simulations or familiar experiences. Questions of cost, feasibility, acceptability, and accessibility have to be addressed in evaluating technological interventions for loneliness and social isolation (Holt-Lunstad, 2020). As much as new technologies can positively impact the health of the elderly, it is also necessary to consider potential harms, mostly in privacy, autonomy, and informed consent areas.
The Role of the Healthcare Sector
The healthcare sector can work with five broad goals in addressing loneliness and social isolation in older individuals. Translating current research into healthcare practices is the first goal. The second one is developing more robust evidence on efficient assessment, intervention, and prevention approaches or strategies. The third goal is strengthening ties between community-based networks and resources and the healthcare system. Strengthening ongoing training and education is the fourth goal. Lastly, the fifth goal that the healthcare system can utilize is improving awareness (Donovan & Blazer, 2020). General health physicians have exceptional opportunities or chances to reduce loneliness and suffering among the elderly. This is because lonely older individuals often tend to consult their physicians or doctors due to their high degree of physical disability. As a result, general physicians are the most professional group to likely meet with lonely individuals.
The doctor or practitioner can refer lonely individuals to appropriate bodies, including voluntary organizations, local churches, social services, and neighborhood schemes, through gaining their confidence and listening to lonely individuals or patients. The healthcare sector can also do a regular assessment with validating tools to determine older individuals experiencing loneliness or social isolation. Moreover, the healthcare sector can address the underlying causes, including mobility limitations or hearing loss. They can also make necessary social care connections and document social isolation and loneliness in the electronic health record (Holt-Lunstad, 2020). For example, one of the main initiatives of The John A. Hartford Foundation is the Age-Friendly Healthcare Systems which is one of the ways in which healthcare systems can implement the NASEM (National Academies of Sciences, Engineering, and Medicine) report on isolation. In association with the Institute for Healthcare Improvement, Catholic Health Association and the American Hospital Association developed an evidence-based 4Ms framework for age-friendly care. That is what matters to the person: medication, mobility, and motivation. These 4Ms serve as interactive guideposts or responsibilities set for health systems to make sure they meet the unique needs of the elderly.
Inter-professional care teams can address and assess loneliness, isolation, and their related risk factors by determining what matters to the patient or individual and making that vital to the documented care plan. Healthcare systems can also determine difficulties contributing to isolation through assessing mobility, medications, and mentation, such as depression and dementia at every visit. Through payment models, policies, and practices that encourage tackling the 4Ms and the social health determinants, accountable care organizations and health plans can strengthen this type of care (National Academies of Sciences, Engineering, and Medicine). The 4Ms framework for elderly care is mainly employed with other interventions, including community para-medicine, telehealth, and virtual networks that healthcare systems can utilize to deal with loneliness and social isolation (Kharicha et al., 2017). In addition, educational curricula among healthcare or medicine schools should include content associated with loneliness and social isolation and information on clinical intervention and assessment strategies.
Development, implementation, and selection of potential interventions for loneliness and social isolation have several barriers, including participant recruitment. It is challenging to know which individuals are experiencing loneliness unless there is awareness of the issue. Another barrier associated with the implementation of the interventions is participant engagement. Barriers that enhance loneliness and social isolation often create participation barriers even if one is interested in participating (Victor et al., 2018). For instance, inaccessible meeting places to individuals with limited mobility or disabilities, lack of access to transportation, and living in an isolated area. Also, funding can qualify as a barrier to implementing interventions for tackling loneliness and social isolation among individuals.
Key Contributors to Success
One of the most common ingredients for successful intervention implementation is an early partnership with other community groups and organizations. Health systems and other partnering organizations have a crucial role in publicizing interventions and client referrals. Government partnerships can also aid in the facilitation of program scaling. Building routine check-ins with these organizations and other external stakeholders to address the challenges expected or program engagement, program progress, and stories of impact or success about the program is another factor of success (Victor et al., 2018). Another key ingredient for success is publicly normalizing social isolation and loneliness and encouraging the reduction of associated stigma associated with social isolation and loneliness. For example, talking about loneliness on the radio or in newspapers.
Gaining community trust also qualifies to be considered a barrier. This is because people going through loneliness or social isolation may not always be comfortable joining related interventions due to relocation. Another barrier is clarifying the intervention target population because there are participants who have different experiences and conditions, which may impact the intervention or group where common experiences are an essential therapeutic program component (Victor et al., 2018). As a result, selecting program participants in relation to their common experiences is vital to the success of a program.
Social isolation and loneliness are significant factors among older adults. It is an issue that requires maximum attention because of its negative outcome. Numerous studies support the impact of loneliness and isolation. Statistics have also shown that approximately 7.7 million people were isolated in the US before the pandemic, and forty-five percent of the population are older people. Other research has shown increased loneliness among older individuals in China and India. The poor and the LGBTQ are the most affected groups among older people. Older people are at risk of isolation and loneliness because of physical factors such as heart disease and other physical problems. The consequences of this isolation are mortality, anxiety and depression, substance abuse, physical effects, nutritional deficits, and neurological effects.
There are various interventions that help curb the issue at different levels. The first level is individual and relationship intervention, which comprises social skills behavioral therapy. At the second level, or community level, the programs include transportation, accessibility to digital information, products and service, and a built-in environment. The third level is the societal level, including social-economic inequality, digital divides, and social cohesion. Technology and health sectors have also played a critical role in addressing loneliness and isolation in the elderly. However, implementation barriers such as participant recruitment and participant engagement hinder intervention implementation. Consequently, some factors may aid in the success of the programs, including partnerships with other community groups and organizations.
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