“Human beings are social by nature, and high-quality social relationships are vital for health and well-being.”

–  Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System by the National Academies of Sciences, Engineering, and Medicine

Introduction

‘Healthy Aging’ has become a focus and key buzz term in many health agendas. The expression is often coupled with images of smiling, ultra-fit silver-haired seniors undertaking highly physical challenges or exploring exotic places. While people are certainly living longer and should be supported to continue to engage fully with society, this ideal of hyper active older adults does not consider the diversity of the aging experience. Those who go through physical deterioration, mental decline, frailty, and other impacts of aging are also entitled to a high quality of life, but often find themselves isolated.

Staying connected through the golden years is now considered one of the predictors for health and longevity. Susan Pinker, developmental psychologist and writer, has said, “Social isolation is the public health risk of our time. The secret to living longer may be your social life.”  While social isolation and loneliness can strike at any time during a person’s lifespan, older adults are particularly vulnerable. The negative physical and mental health effects associated with social isolation and loneliness are comparable to those caused by smoking, obesity, and inadequate physical inactivity. As populations across the world are trending towards an increase in older adults, addressing social isolation and loneliness in the elderly is an emerging critical public health issue (National Academies of Science Engineering and Medicine, 2020).

In episode 77 of the Public Health Insight podcast, the team together with Ann McLeod and Justine Levesque from Age-friendly Peterborough discuss the health implications of social isolation and loneliness in older adults and their caregivers and how the COVID-19 crisis impacted the situation. 

In this blog post, we’ll be exploring the following questions:

• What is meant by social isolation and loneliness and why are older adults at risk?
• What are the health implications of social isolation and loneliness?
• How did the COVID-19 crisis impact the situation?
• What are some solutions to address social isolation and loneliness in older adults?

What is meant by social isolation and loneliness and why are older adults at risk?

Social isolation and loneliness are intertwined concepts but with slightly different definitions.

Social isolation is a lack of quality contact with others. This is an objective measure, with the number of contacts a person has being quantifiable. Loneliness, by contrast, is a subjective concept where a person feels isolated. A person may have many contacts but feel lonely or few contacts and be content with no feelings of loneliness (Government of Canada, 2022).

Social isolation and loneliness are widespread amongst the older adult populations. In Canada, between 19 and 24% of older adults report feeling isolated or lonely (Government of Canada, 2022), a trend similar to the United States, the United Kingdom, and across Europe (National Academies of Science Engineering and Medicine, 2020; NHS, 2021; World Health Organization, 2021).

Anyone regardless of age can feel socially isolated or lonely, and age alone does not increase the risk of experiencing these feelings. However, older adults are more likely to experience the risk factors associated with social isolation and loneliness due to the physical changes that accompany aging, loss of close family and friends, and retirement from the workforce. These factors  can shrink social circles and reduce the number of quality contacts a person has (Government of Canada, 2022; National Academies of Science Engineering and Medicine, 2020).

Key risk factors for social isolation and loneliness include but are not limited to:

Living alone

Many older adults, particularly in Western cultures, value living independently and do not live with children or other family members. Adults are more likely to experience the loss of a partner as they age, increasing their chances of living alone.

Chronic illness/poor health

Eighty percent of adults over 65 in the United States report at least one chronic condition, which often result in physical limitations that make it difficult for people to leave their homes. Further, many people with complex medical needs report that frequent trips to their health centres and need for intervention consumes all of their available time, leaving little opportunity to maintain relationships (Government of Canada, 2022; National Academies of Science Engineering and Medicine, 2020).

Sensory impairment such as loss of hearing or vision

Impaired vision and hearing can make it difficult to interact with others. Sensory loss can result in the suspension of driving privileges and make public transportation difficult to navigate, reducing mobility (National Academies of Science Engineering and Medicine, 2020).

Anxiety or depression

Social isolation and loneliness are more common in adults with anxiety or depression. Older adults with anxiety disorders are more likely to experience loneliness, even when their social networks include a high number of quality contacts (National Academies of Science Engineering and Medicine, 2020).

Dementia

Becoming socially withdrawn is a potential sign of dementia and cognitive impairment. People tend to disengage as their memory, language skills, and reasoning begin to fade (National Academies of Science Engineering and Medicine, 2020).

Being a caregiver

Family caregivers are at risk for social isolation and loneliness, particularly when caring for a person with demanding mobility needs or cognitive impairment. Caregivers often give up other societal contacts such as work or hobby groups to meet the demands of their caregiving role. Caregivers are also at a further risk for social isolation and loneliness if the loved one for whom they are caring dies, particularly if their existing social network has disintegrated during their caregiving years (National Academies of Science Engineering and Medicine, 2020).

 What are the health implications of social isolation and loneliness?

Many of the risk factors for loneliness and social isolation discussed above are considered bidirectional, with the loneliness and isolation exacerbating the conditions that further isolate the individual (Government of Canada, 2022; National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021).

Research clearly shows that older adults who experience social isolation and/or loneliness are at an increased risk of premature death (Government of Canada, 2022; National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021). 

Social isolation and loneliness are further linked to:

Increased risk of cardiovascular disease and stroke

Perhaps one of the most concerning findings of research into social isolation and loneliness is the connection to cardiovascular disease (CVD) and stroke independent of other risk factors. Weak social connections have been shown to increase the risk of CVD and stroke by 29% and 32% respectively, making social isolation and loneliness as hazardous as well-established risk factors such as obesity, lack of physical activity, smoking, and substance abuse (National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021). Social isolation and loneliness are also linked to risk factors for CVD and stroke such as type 2 diabetes and high cholesterol (National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021).

Increased risk of cognitive decline

Poor social connection is linked to dementia and cognitive impairment in older adults, with the risk of dementia increasing by as much as 50% in older adults experiencing high levels of loneliness (National Academies of Science Engineering and Medicine, 2020).

 Increased risk to mental health

Older adults experiencing social isolation and loneliness are at an increased risk of depression, anxiety, and suicidal ideation. This risk remains elevated irrespective of age, sex, social economic status, or relationship status (National Academies of Science Engineering and Medicine, 2020).  

Increased risk of violence and abuse

Socially isolated older adults are at an increased risk of experiencing and being the perpetrator of elder violence and abuse. Elder abuse is linked to psychological distress, displacement, and at its extreme, threats to physical safety and death. The COVID-19 crisis has increased the risk of elder abuse in the context of social isolation and loneliness (World Health Organization, 2021).

 How did the COVID-19 crisis impact the situation?

The unprecedented COVID-19 crisis put a sudden stop to most face-to-face social activities. Depending on where a person lived, recommendations quickly evolved from advising people to avoid excessive contact where possible to enforcing strict home quarantines punishable by hefty fines. In some cases, people have been advised to isolate away from members of their own household. Those aged 65+ were particularly encouraged to comply with COVID-19 precautions as they are at a higher risk of severe disease (Seifert & Hassler, 2020).  

Reducing close contact with others and the cancellation/postponement of social activities was shown to increase loneliness in older adults with a larger impact seen during the first wave of the disease. Potential factors that may have contributed to the increased loneliness include the limited opportunity for social engagement and the labelling of older adults as ‘at risk’ causing some friends to avoid interactions (Choi, Farina, Wu, & Ailshire, 2021; Seifert & Hassler, 2020).

The long-term implications of COVID measures on social isolation and loneliness remain to be seen. Future research can elucidate what factors contributed to social isolation and loneliness, their short- and long-term health impacts, and protective mechanisms that can be put in place.

 What are some solutions to address social isolation and loneliness in older adults?

The causes of social isolation and loneliness are complex and ‘older adults’ is hardly a homogenous group. Interventions to target social isolation and loneliness in older adults, therefore, require a collaborative approach at multiple levels (Government of Canada, 2022).

Individual and peer level interventions

At an individual level, determining which older adults are at risk for social isolation and loneliness then connecting these individuals to services can help strengthen their social connections and prevent negative health impacts. For example, peer support groups for people with similar interests can help connect older adults and encourage relationship maintenance (National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021).

Addressing the risk factors can also help protect against social isolation and loneliness. For example, screening for and ensuring older adults with hearing loss have access to appropriate aids will help mitigate the impact of hearing loss on social relationships (National Academies of Science Engineering and Medicine, 2020).

Digital interventions, such as training older adults to use digital solutions to reach out to others, is of particular interest in the wake of the COVID-19 pandemic. The act of attending training in this area is also an opportunity to meet social contacts (World Health Organization, 2021).

As people become socially isolated, many start to view social contact as scary and dangerous. This further discourages them from leaving their comfort zone and making new connections, exacerbating the problem. In these cases, cognitive behavioural therapy, mindfulness training, or medication may be helpful (National Academies of Science Engineering and Medicine, 2020; World Health Organization, 2021).

Community based interventions

Planning communities around the needs of older adults can help ensure they stay included in society. The built environment plays a large role in social inclusion. Designing public spaces with adequate lighting, plentiful benches, and clean, accessible toilets can help improve social connections. Addressing transport needs allows older people to maintain freedom and independence, reducing loneliness. In the United Kingdom, free bus access for over 60s was shown to reduce loneliness and depression (World Health Organization, 2021).

Age-friendly communities, or communities that encourage healthy aging, support older adults in the community to maintain connected, active lives. These initiatives collaborate across multiple sectors and stakeholders to address social inclusion, ideally with older adults at the helm and highly involved with project design and evaluation (Government of Canada, 2022). Check out Claire Borgaonkar’s article on Age-friendly Peterborogh’s ‘Social Inclusion and Social Connection’ project using participatory action research to inform on models that promote social inclusion in older adults.

Societal interventions

As many populations are aging, addressing social inclusiveness at a societal level is becoming critical to ensuring older adults stay connected. This includes enacting laws and policies that address discrimination, agism, and social economic inequities in the elderly (World Health Organization, 2021).

Conclusion/Key Takeaways

• The term ‘healthy aging’ elicits images of elderly athletes leading thrilling and active lives. In reality, everyone experiences aging differently, but all should have the opportunity to experience the highest attainable quality of life.
• The natural process of aging can leave older people at a higher risk of feeling lonely or becoming socially isolated, which has been shown to negatively impact health and lead to premature mortality.
• The COVID-19 crisis interrupted many activities that can help seniors stay connected.  Older adults were exceptionally impacted by COVID-19 control strategies and encouraged to isolate, exacerbating loneliness and social isolation.
• Interventions at multiple levels are needed to tackle the causes of loneliness and social isolation. One intervention gaining momentum is investing in ‘age-friendly communities’ which work across multiple sectors to ensure older adults can fully engage with society.

Written: Malissa Underwood, BSN, MPH