Loneliness in older adults

With the world population rapidly ageing (Reis da Silva, 2023a), it is important to encourage older individuals to age in their own homes. A strong community nursing service can impact all dimensions of an ageing population, such as the physical, psychological, emotional, social and community (Reis da Silva, 2023b). As indicated by the Office for National Statistics (ONS) (2020), the average percentage of the population aged 65 years and over is considerably lower for cities than other types of local authority, making community nursing key to supporting older adults (Reis da Silva, 2023b).

Chronic loneliness is a growing problem faced by the ageing population. Approximately 1.4 million older adults in the UK are lonely, with a further 1.9 million stating they often feel ignored and invisible in their day-to-day life (Age UK, 2018). Adults aged 65 years and over are a population group particularly vulnerable to both loneliness and social isolation. According to the NHS, over one million older adults indicate that they do not speak to a family member, friend or neighbour for over a month (NHS England, 2022).

It has been acknowledged that individuals rarely engage in conversations associated with loneliness. Lack of friendships and social interactions can be viewed as undesirable, creating social stigmas, resulting in individuals not admitting to loneliness. Additionally, the inability to form social relationships can generate negative self-perceptions, including the belief of personal inadequacies or unpleasant characteristics (Rokach, 2013).

Loneliness has significant negative consequences on an individual's health and wellbeing. Holt-Lunstad et al (2010) and Age UK (2015) consider that loneliness is as harmful as smoking 15 cigarettes daily. Research has shown how loneliness increases the r isk of death, heart disease, stroke and many other illnesses (Holt-Lunstad et al, 2015; Valtorta et al, 2016).

Despite research around the topic, there is limited investigation into the experience of loneliness.

According to the King's Fund (Seale, 2016), a collaborative relationship is one in which ‘patient partners’, and health and care providers go beyond the ‘them and us’ relationships, in which power is mostly held by one party, to a more collaborative one where power is shared. The district nurse's responsibilities are outlined in the Queen's Nursing Institute (QNI)/Queen's Nursing Institute Scotland's (QNIS) Voluntary Standards for District Nurse Education and Practise (2015), which highlights the significance of this crucial mode of working:

“The district nurse's role is highly complex and requires skills in negotiating, coaching, teaching and supporting people and their carers, whilst effectively collaborating with other agencies and services involved in enabling people to remain safely in the community.”

Therefore, this emphasises the need to discuss loneliness and the impact it has on older adults, within the context of the district nursing service.

Background

Experiences in loneliness

Research can provide insights into the different ways individuals experience and understand their world, in conjunction to others. Analysing subjective interpretations of a topic enables healthcare professionals to provide appropriate support and care (Parahoo, 2014).

Loneliness

Although they are distinct ideas, loneliness and social isolation are interconnected (Age UK, 2019). A person's perceived quality of connections is linked to the extent of loneliness they experience, which is a subjective sensation related to the discrepancy between their intended and actual levels of social engagement (Age UK, 2019).

The state of one's health and quality of life can be seriously impacted by persistent loneliness (Age UK, 2023). A person's level of social isolation may be measured objectively; it is about the quantity, not the quality, of relationships. Those who experience social isolation can overcome it by interacting with others more frequently (Age UK, 2019).

Loneliness can be defined as a personal and subjective feeling caused by the absence of social interaction and closeness (Rossall et al, 2015). It is recognised as a negative emotion, associated with a gap in the need for social relationships (Age UK, 2017). The charity Mind (2019) elaborates how loneliness is a personal feeling, experienced uniquely by everyone. Loneliness is not the same as being alone; while living alone can increase the risk of loneliness, those who live alone may not necessarily feel lonely (Mind, 2019). It is the circumstances connected to ageing that increases the chance of being lonely, not simply the factor of age. Loneliness is said to occur because of a loss of significant relationships and the lack of opportunity to engage with others (Box 1).

Box 1.Statistics on loneliness

• Individuals aged 50 years or older, are more likely to experience loneliness if they don't have someone with whom to confide, are widowed, have bad health, can't accomplish their goals, feel as though they don't belong in their community, or live alone (Age UK, 2018)
• According to Age UK (2015), 17% of older adults say they communicate with friends, family, and neighbours less frequently than once a week, and 11% say they do so less frequently than once a month
• According to Age UK (2018), 24% of adults in England who are 50 years of age or older report feeling lonely occasionally, and 7%, or almost 1.4 million people, report feeling lonely frequently
• AgeUK (2018; 2019) projects that 2 million adults in England who are 50 years of age or older may experience loneliness within the next ten years if steps are not taken to address the issue
• Living alone, being lonely, and being socially isolated have all been linked to a higher risk of dying young (Holt-Lunstad et al, 2010; American Psychologyical Association, 2017)
• A 40% higher risk of dementia is linked to loneliness (Sutin et al, 2018)
• A higher chance of getting cardiovascular disease (CVD) is linked to deficiencies in social relationships (Xia and Li, 2018)
• According to Age UK (2015), almost 5 million people, or 49% of the elderly population, believe that their primary sources of companionship are television or pets
• According to The Campaign to End Loneliness (2015), 9% of seniors say they feel isolated from society
• The Campaign to End Loneliness (2015) reports that three out of every four general practitioners (GPs) in the UK see one to five patients a day who have come in primarily because they are lonely
• Spending £1 on addressing loneliness can result in a £3 reduction in medical expenses (Mcdaid et al, 2017).

Older adults

Sabharwal et al (2015) investigated the criteria for being considered an ‘older adult’ and discovered that there is a great deal of variation in the age criteria, ranging from 50–80 years. These discrepancies were not specific to the orthopaedic subspecialty, or the country/region where the research was being developed. To help with maintaining consistency, in this article, an older adult is classified as 65 years old or over (Sabharwal et al, 2015). While there has been deliberation associated with classifying this age as younger, because of different considerations of when ageing starts, when ageing starts, this review will reference older adults as 65 years and over. The 2021 census results show the population of England and Wales has continued to age since 2011 (ONS, 2023). The number of people aged 65 years and over increased from 9.2 million in 2011 to over 11 million in 2021, and the proportion of people aged 65 years and over rose from 16.4% to 18.6% (ONS, 2023). The UK ageing population accounts for more than 12 million people aged 65 years and over. Of this, 5.4 million are 75 years and over, 1.6 million are 85 years and over and over 500 000 are 90 years and over (ONS, 2018a). It is estimated that roughly 1.4 million older adults have chronic loneliness within the UK (Age UK, 2018) – a figure predicted to increase to 2 million within the next 5 years, reflecting the continuous and prevalent problem of loneliness.

Impact of loneliness

Physical impacts

Loneliness can have significant impacts on physical and psychological health. Upon reviewing literature, there was notable research regarding the association between loneliness and nutrition. A study used random sampling to explore the association between nutrition and loneliness in 1200 adults aged over 65 years. (Boulos et al, 2016). They identified both loneliness and social isolation as independently related to an increased risk of malnutrition. The odds increased by 1.6 for social isolation and a 1.2-fold increase was noted for loneliness (Boulos et al, 2016). Another study highlighted that loneliness can cause mood decline, leading to reduced appetite and nutrition intake and subsequent malnutrition (Eskelinen et al, 2016).

Moreover, a meta-analysis study investigated the association between loneliness and social isolation as risk factors for stroke and coronary heart disease (Valtorta et al, 2016). Exploring 23 longitudinal observational studies, the authors discovered poor social relationships were connected to a higher risk of both coronary heart disease by 29% and stroke by 32% (Valtorta et al, 2016). Furthermore, another meta-analytic review explored the association between loneliness, social isolation and mortality (Holt-Lunstad et al, 2015). This prospective study analysed 70 research studies, totalling 3 407 134 participations, over an average of 7 years. The results identified that loneliness, social isolation and living alone significantly increased mortality rate. After the consideration of participants' covariates, the increased probability of death was reported as 26% for loneliness. The figures of both studies portray the consequential negative impact loneliness can have on health.

Mental health impacts

A descriptive study of 913 older adult participants explored the association between depression and loneliness (Aylaz et al, 2012). These two factors were closely associated, with those experiencing loneliness reporting a 37% increased risk of depression. Additionally, a study investigating cognitive function and loneliness involving 8382 participants aged 65 years and over, demonstrated how loneliness, independent of other factors, predicts an accelerated rate of cognitive decline (Donovan et al, 2017). Over 12 years, cognitive decline is estimated to be 20% faster in those who are lonely, showing a significant psychological impact (Donovan et al, 2017).

Loneliness has detrimental consequences to one's life. A literature review of 52 papers from various countries explored primary factors relating to suicide in the older adults (Minayo and Cavalcante, 2010). Loneliness and social isolation were identified as significant triggers of suicide.

Current guidelines

Currently, there are limited guidelines and policies relating to loneliness. However, in 2018 the government set a strategy for managing loneliness, now identified as an important step in providing long-lasting action to tackle loneliness (UK Government, 2018). The strategy is based on building more connections in society with increased support in multiple areas. This encompasses education, accessing information, encouraging good practice, enabling relationships and consistently measuring loneliness and effective interventions. In doing so, there is hope that change and appropriate management strategies will be adopted to reduce loneliness.

Loneliness and healthcare

Another aspect to consider is how loneliness impacts healthcare utilisation. A longitudinal study of 3130 participants explored the association among older adults and unplanned hospitalisation. Reduced social interaction was significantly related to an increased risk of admissions and unplanned hospitalisation (Pimouguet et al, 2017). Additionally, hospital discharges are also affected; a study of 278 participants with hip fractures discovered those who were isolated or at high risk of isolation were linked to delayed discharges. It was found that 62 individuals had delayed discharges, resulting in a loss of 419 bed days, with the total length of stay increasing by 11.5%. Consequently, a delay in discharge resulted in costs increasing between 11.2–30.7% (Landeiro et al, 2016). As the study was conducted in Portugal with a different healthcare system, the transferability of these results to the UK healthcare system may be limited; however, this still emphasises the impact loneliness has on healthcare services. Furthermore, loneliness has been directly linked to an increased risk of care home admission even after considering confounding variables of age, illness and disability (Hanratty et al, 2018). Additional research discovered loneliness increases rehospitalisation, length of stay, physician visits and adverse discharge outcomes (Newall et al, 2015; Hawker and Romero-Ortuno, 2016; Pimouguet et al, 2017).

A study by Zhao et al (2018) was the first to use a moderated mediation model to examine the association between depression symptoms and loneliness among senior citizens residing in assisted living facilities. In the survey, 26.6% of senior residents in nursing homes reported having symptoms of depression. A mediating factor in the relationship between depression symptoms and loneliness was resilience. Additionally, social support affected the degree of mediation, with higher social support probably reducing the indirect effect more. Zhao et al (2018) also discussed that it might be crucial to create interventions that combine elements of boosting social support and resilience in order to lessen depressive symptoms in older adults who are lonely, particularly those who have low levels of both.

Dahlberg and McKee (2014) have offered insightful information about social, psychological and health variables linked to emotional and social isolation. These authors agreed that before developing successful intervention policies and tactics, it is crucial to distinguish between the social and emotional elements of loneliness. This study's models of social and emotional loneliness shows divergence in these areas (Dahlberg and McKee, 2014). Another study (Singh et al, 2016) showed that patients in solitary rooms had higher levels of loneliness as compared to those admitted in multi-bed wards. After being admitted to a solitary room, loneliness climbed dramatically in comparison to the pre-admission level. The authors recommended the proportion of solitary rooms in the new hospital design be determined by taking into account the negative effects of isolation on the elderly (Singh et al, 2016).

Measuring loneliness

To measure loneliness, the University of California Los Angeles (UCLA) loneliness scale is used (Russell, 1996). This 20-item scale measures loneliness and social isolation by incorporating a four-point rating scale, ranging from ‘never’ to ‘always’ when answering questions. The scale is reliable and valid, but criticised for its length and complexity; therefore, a three-item UCLA loneliness scale was developed (Hughes et al, 2004). There is no standard score that considers an individual as lonely; instead, it is advised scores are based individually and whether it changes over time (ONS, 2018b). The scale is appropriate for those aged 16 years and above, being government-recommended as it is quick, easy and already used worldwide (Campaign to End Loneliness, 2015; ONS, 2018b). The three-item scale is advantageous as it is versatile; for example, it can be self-completed, or by someone asking the questions or over the telephone (Hughes et al, 2004; Campaign to End Loneliness, 2015). However, this scale uses only negative wording, unlike the 20-item scale which includes positive questioning. Negative wording can cause respondent bias and healthcare professionals can experience difficulties approaching sensitive topics when it solely involves negatively worded questions, creating a limitation (Campaign to End Loneliness, 2015).

District nurses can use the three-item UCLA loneliness scale for a quick and effective assessment of loneliness.

Current interventions

An integrative review investigated 39 studies regarding interventions that reduce loneliness (Gardiner et al, 2018). This encompassed social facilitation, psychological therapies, animal-assisted therapy, social and leisure activities. Social facilitation was the most prominent category mentioned but, was concluded to only have some success in reducing loneliness or social isolation. Similarly, most categories reported some success, but the extent of this was unknown. Psychological therapies incorporating mindfulness, stress reduction and reminiscence group therapy was the only category to significantly reduce loneliness and have positive impacts on other aspects of life such as satisfaction. However, it is unclear as to what the individual factors contributing to the intervention's success are, whether it is associated with the therapeutic approach, the group interaction, or both. Furthermore, a systematic review on e-interventions in reducing loneliness concluded there was insufficient quality of evidence to show that internet-based interventions reduced loneliness (Chipps et al, 2017). Both reviews confirmed the lack of quality research within this topic area, highlighting the need for appropriate interventions to manage loneliness.

District nurses may be the first or only people in contact with older adults living in the community by themselves; therefore, they may be aware of signs of loneliness, such as changes in activity or mood, loss of sight or hearing, absence of visitors, or changes in hygiene (Day et al, 2020). Nurses are able to assist patients in accessing appropriate interventions or services if they have a better understanding of the patients' preferences. This is because, as Skingley (2013) points out, ‘interventions will only be effective if they appeal to the participants involved.’

The potential role of health visitors

In order to address psychological health as well as clinical needs, coordination of this multiagency activity is necessary. For this strategy to be effective, it is necessary to place a strong emphasis on health promotion and illness prevention (Day et al, 2020). Health visitors are in a good position to assist with this care. Health visitors have long been regarded as having the ability to satisfy the needs of older members of the community, even though they have traditionally served mothers and young children rather than older adults (Brocklehurst, 1982; Day et al, 2020). Health visitors have historically been essential in helping people of all ages, offering a more comprehensive ‘family-centered approach’, and supporting older citizens in their homes with major public health needs such as bereavement, loneliness, isolation, caring duties, and heart and stroke rehabilitation (Day et al, 2020).

For more than 20 years, the health visiting programme for older adults has helped individuals who have little support from friends and family, by undertaking comprehensive assessments, and organising programmes and services to lessen hospital admissions, social isolation and loneliness (Spanswick, 2016; Day et al, 2020). Health visitors have expertise in therapeutic communication techniques and interventions, including cognitive behaviour therapy and motivational interviewing. These approaches have the potential to significantly improve outcomes for older adults, who are becoming increasingly vulnerable and isolated (Day et al, 2018; Day et al, 2020).

Other possible courses of action

Other possible courses of action are one-to-one, group or community based interventions (Skingley, 2013). Befriending, mentorship, house visits, phone assistance, gatekeeping (like care navigators), and community linkers such as wardens are a few examples of individual interventions (Day et al, 2020). Friendship fosters independence, resilience and emotional wellbeing (Mulvihill, 2011; Day et al, 2020). Phone befriending services, and ‘call in time programme,’ a nationwide pilot programme was evaluated. It comprised eight telephone assistance programmes, each with its own operational structure, overseen by nonprofit or voluntary organisations in various places around England and Scotland. This methodology can assist senior citizens in regaining their self-esteem, reintegrating them into society, and encouraging them to take up social activities (Cattan et al, 2010; Day et al, 2020).

Research has demonstrated that intergenerational programmes are advantageous for senior citizens in terms of a variety of health outcomes (Teater, 2016; Day et al, 2020). When age groups are mixed, senior citizens might feel supported and connected to the community. Both mental and physical health benefit from this. Children and senior citizens in the neighbourhood participated in artistic activities as part of the ‘Time after Time’ project (Teater, 2016; Day et al, 2020). The older participants' emotional wellbeing improved as a result of their heightened sense of value and importance. Long-term treatments that have been assessed, including combining nursing homes and preschools, have improved quality of life indicators like mood, self-esteem and activity levels (Doll and Bolender, 2010).

Group interventions can focus on particular needs (such as diabetes, chronic wounds or psychotherapy), and can have an educational component or be activity-based social groups (like day centres, community cafés, or lunch clubs) (Skingley, 2013; Day et al, 2020). As chronic wound care needs are more common in the older population, ‘leg clubs’ are also effective means by which district nurses treat the elderly.

Discussion

The Nursing and Midwifery Council (2022) states that district nurses are highly skilled in starting and leading practise developments and collaborating with individuals, formal and informal carers, and other services to promote the idea of patient-led care and self-care, when feasible (QNI/QNIS, 2015; Ryder, 2016). Additionally, in investigating and putting into practise the concepts of successful cooperation in a multi-agency, multi-professional setting that facilitates the integration of social and health services, person-centered care is anticipated and planned for throughout the entirety of the individual's journey (QNI/QNIS, 2015; Ryder, 2016).

This article aimed to provide an overview on loneliness in older people and examine and analyse existing research, with a focused emphasis on how insights from this body of literature can significantly contribute to the enhancement of care provided by community nurses.

The impact of loneliness on older adults in the context of district nursing is a significant concern, affecting both their physical and mental wellbeing. It may contribute to conditions such as cardiovascular issues, weakened immune function, and overall decreased resilience to illnesses. Lack of social interaction can lead to sedentary lifestyles, poor nutrition and neglect of self-care, exacerbating existing health conditions. It can also contribute to the development or worsening of depression and anxiety. The absence of social connections and meaningful relationships can lead to feelings of isolation, hopelessness and a decline in cognitive function, and can impact quality of life (Aylaz et al, 2012; Holt-Lunstad et al, 2015; Eskelinen et al, 2016; Valtorta et al, 2016; Donovan et al, 2017).

Loneliness increases use of healthcare services in older adults. Those experiencing loneliness may be more likely to seek medical attention, leading to increased demands on district nursing services (Landeiro et al, 2016; Pimouguet et al, 2017). The emotional toll of loneliness may also complicate the management of chronic conditions, requiring additional support from district nursing professionals and social support.

Furthermore, district nursing plays a crucial role in addressing loneliness by providing not only medical care but also emotional and social support. Building strong nurse-patient relationships can act as a buffer against loneliness, fostering a sense of connection and trust (Newall et al, 2015; Hawker and Romero-Ortuno, 2016; Pimouguet et al, 2017; Hanratty et al, 2018).

Conclusion

Effective district nursing interventions should be built that go beyond traditional healthcare services. This could include strategies for preventing and mitigating loneliness, such as community-based programmes, support groups and initiatives that promote social engagement.

A holistic approach to care that considers both the physical and emotional well-being of older adults is crucial for tackling the complex issue of loneliness.

In summary, the impact of loneliness on older adults in the context of district nursing is multifaceted, affecting both physical and mental health. District nursing professionals play a vital role in recognising, addressing and preventing loneliness to enhance the overall well-being of older individuals under their care.

Key points

• Loneliness affect older adults in several dimensions
• District nurses are able to assess loneliness in older adults with 3-item UCLA loneliness scale
• Several interventions could be implemented to prevent loneliness. Namely, revisit the role of the health visitor, and interventions as one-to-one, group, or community.

CPD reflective questions

• Define loneliness in the context of older adults, incorporating perspectives from various disciplines such as psychology, sociology, and gerontology
• Discuss the multifaceted nature of loneliness, considering both subjective and objective aspects
• Investigate the specific challenges district nurses may encounter when caring for older adults experiencing loneliness
• Explore strategies for district nurses to identify and address loneliness in their patients, considering both preventive measures and intervention strategies.