Written by Samantha Billings
There is current evidence to suggest that loneliness in older adults can develop into depression, with further complications to health. Loneliness is often experienced by elderly due to isolation from family and loss of social connections (Singh & Misra, 2009). People in this age group are faced with many challenges such as physical, psychological and social role changes, which all have an impact on sense of identity and can affect their ability to live happily (Singh & Misra, 2009). In 1946 The World Health Organisation (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 2016 p.1). Satisfying social relationships is important for maintaining both mental and physical wellbeing, when there’s an impairment to social relationships this can lead to loneliness which can have further negative impacts to health (Mushtaq, Shoib, Shah & Mushtaq, 2014). The first section of this review aims to explore the clinical issue, and a wide variety of literature to support the identified search question. The following sections focus on implications to practice; and recommendations targeted towards health professionals and community action, to address the issue of loneliness in older adults.
Loneliness is an issue in New Zealand as there is an increasing proportion of people in the older age group. The population of individuals aged 65years and over has increased from 11% to 13% over the years 1991-2009, with this steady increase it is expected to reach 21% by 2031(Ministry of Social Development, n.d.). The number of people aged over 65years is estimated to increase from 550,000 in 2009 to one million in 2020, it is predicted that this demographic will eventually outnumber children (Ministry of Social Development, n.d.).
The elderly population is large as a whole, this is due to the continuing advancements in medicine and health care (Singh & Misra, 2009). In the 2001 New Zealand census, the findings demonstrated that 43% of women aged 65 and over lived alone, compared to men, which showed a figure of 20%. The proportion of the elderly living alone has continued to increase since 1960, with fewer older people living with children or relatives (Ministry of Health, 2002). Loneliness is a large contributor to human suffering, and is notably the case in elderly. Loneliness is a subjective feeling of not belonging, isolation and a lack of social companionship (Perissinotto, Cenzer & Covinsky, 2012). Loneliness is not solely reliant on external factors associated with social isolation such as living alone, marital status and number of social outlets and relationships; for example, it is likely for someone to feel alone even while living with a spouse or other individuals and having an active social life (Perissinotto et al., 2012). Loneliness is often referred to as the psychological aspect of social isolation, which reflects the individuals subjective experience (Steptoe, Shankar, Demakakos, & Wardle, 2013).
To determine levels of loneliness most studies use the UCLA (University of California, Los Angeles) loneliness scale, this is a measure of one’s subjective feelings of loneliness. This scale was developed by Russell, Peplau and Ferguson (1978). The scale is a 20 question design, participants rate each question as either O: “I often feel this way”, S: “I sometimes feel this way”, R: “I rarely feel this way and N: “I never feel this way”. Each letter is assigned to a score: O=3, S=2, R=1, N=0. The result of this questionnaire is a continuum of scores ranging from highly socially connected to highly lonely individuals (Russell, Peplau, & Ferguson, 1978).
The experience of loneliness impacts on an individual’s life by affecting them physically, psychologically and socially (Mutafungwa, 2009). Loneliness in older adults has been strongly linked with a significant impact on physical health, in regards to higher blood pressure, effects on the cardiovascular system, poor sleep patterns, immune stress responses and worsening cognition and also has strong correlations to depression (Cornwell & Waite, 2009). These findings are supported in a study conducted in New Zealand based on self-reported loneliness and health in older adults (La Grow, Neville, Alpass & Rodgers, 2012). This study was based on a survey that collected self-reported data from 332 participants about loneliness, mental and physical health, sex, age and marital status. Of this sample 8% stated they were severely lonely, 44% moderately lonely and 48% stated they were not lonely at all. The individuals in the severe and moderately lonely groups had lower scoring in both physical and mental health, whilst the individuals who did not experience feelings of loneliness scored higher in both categories (La Grow et al., 2012). Futhermore, Hawley, Thisted and Cacioppo (2009) outlined in their research that loneliness among older adults is a direct risk factor for decreased physical activity, which can have an impact on other body systems. These studies demonstrate that there is a relationship between loneliness and functional decline.
Depression is a common condition amongst older adults with a significant impact on wellbeing and quality of life. Depressive symptoms not only significantly affect psychological wellbeing but are significant predictors of physical well-being and mortality (Singh & Misra, 2009). A study in the United Kingdom explored how 110 older adults viewed depression and its causes (Lawrence et al., 2005). In this study, Lawrence et al., (2005) states that depression was often described as an inevitable consequence of loneliness. More than half of the participants emphasized how a lack of support, isolation and feelings of loneliness were direct causes or factors for depression (Lawrence et al., 2005). This is supported by information gathered from a survey that analysed the relationships between depressive symptoms, sense of coherence and emotional/social loneliness, conducted by Drageset, Esphaug and Kirkevold (2012). Findings from this survey showed that a higher level of depressive symptoms were associated with a high level of emotional loneliness. The evidence gathered from these studies support the idea that there is a relationship between feelings of loneliness and depression.
Research suggests that loneliness might be an independent risk factor for depression. O’Luanaigh and Lawlor (2008) state that although loneliness and depression are distinct entities, there is evidence to show a strong association between the two. Research indicates that older adults who are lonely will often have depressive symptoms and develop a diagnosis of depression, however depressed individuals do not always report feelings of loneliness (O’Luanaigh et al., 2008). Cacioppo (2006) describes loneliness and depressive symptoms as separate constructs, however when both factors are present they can work interdependently in diminishing health in older adults (Cacioppo, Hughes, Waite, Hawkley, & Thisted, 2006). This idea is further demonstrated in a study by Stek et al. (2005), which explores whether depression in older adults was fatal only when participants also experienced feelings of loneliness. The results showed that when depression and perceived loneliness were assessed in follow up appointments, neither had an impact on mortality on their own, however those who suffered from both had a higher mortality risk of 2:1 (Stek et al., 2005).
Over a 12-month period, the prevalence of depressive disorders has been estimated to be 2% for men and 5% for woman over 65, living in the community in New Zealand (Best Practice Advocacy Centre New Zealand, 2011). Older adults living with depression are likely to show changes in cognitive functioning and somatic changes, e.g. disturbances in sleep, agitation and general loss of interest (Best Practice Advocacy Centre New Zealand, 2011). Depression is not part of the normal ageing process (Fiske, Wetherell & Gatz, 2010). It is often difficult to diagnose depression in older adults as disturbances in sleep, fatigue and low energy levels (associated with medical conditions) can often mimic depressive symptoms (Cacioppo et al., 2006).
Lenze et al. (2005) examined the relationship between persistently high depressive symptoms and changes in functional ability over a 4-year period in older adults. From a sample of 5,888 subjects, three characteristics were identified in the sample population: persistently depressed individuals who experienced symptoms over 4 years, temporarily depressed individuals whose symptoms resolved over time and non-depressed individuals with persistently low depressive symptoms (Lenze et al., 2005). Depressive symptoms, functional ability (in activities of daily living), cognitive function (mental state assessment) and medical morbidity (cardiovascular/ cerebrovascular conditions) were all factors measured over the course of the study (Lenze et al., 2005). This study showed that older adults who presented with persistent depressive symptoms had a higher incidence of functional decline in all categories (Lenze et al., 2005). This shows that there is a significant relationship between depression and poor health outcomes.
Auckland University conducted an assessment of services promoting independence & recovery in elders (ASPIRE trial). The ASPIRE trial showed that loneliness almost doubled the likelihood that an older adult would enter residential care (Parsons et al., 2006). The ASPIRE trial also showed the increased likelihood of hospital admissions (Parsons et al., 2006). Loneliness poses implications to health care as with increased hospital admissions there is an increased cost to the health system. Loneliness can lead to poor health outcomes and can manifest into chronic illnesses such as cardiovascular disease, inflammatory diseases and mental health conditions (Cornwell & Waite, 2009). Chronic conditions require management within the hospital setting. Addressing the issue of loneliness in older adults within the community can prevent further complications arising.
Loneliness is an important public health issue. The current literature supports the need for appropriate intervention strategies that specifically target loneliness in the elderly (O’Luanaigh et al., 2008). Successful management of loneliness and depression is dependent on health professionals enabling the client to be active in their management plans, a partnership between health professionals and consumers is a predictor of successful outcomes (Best Practice Advocacy Centre New Zealand, 2011). This is supported by the principles of The Treaty of Waitangi which are partnership, participation and protection (Nursing Council of New Zealand, 2011). The nurse demonstrates partnership by working with the individual, whanau or community to achieve a mutual goal of improving health outcomes. Participation involves including the consumer in all areas of their treatment plan, including decision making and planning. Protection is working to ensure that health consumers receive healthcare that protects their privacy, values and culture (Nursing Council of New Zealand, 2011).
Nicholson (2012) provides evidence to suggest that public health professionals are not assessing loneliness in older adults, despite their access to very vulnerable homebound older adults. Because loneliness is not routinely assessed, it can often go undetected. Providing holistic care to this vulnerable demographic requires primary health nurses to assess social well-being when they carry out assessments with the client (Nicholson, 2012). Education plays a critical role in assisting nurses and health care professionals in noticing the signs and symptoms of loneliness in older adults. The issues that surround loneliness should be discussed within nursing programmes and workshops to help raise awareness (Murphy, 2006). While working with older adults experiencing feelings of loneliness, it is important for nurses to be genuine in their interactions and act compassionately and be empathetic during conversations (Mutafungwa, 2009).
Ebersole (2002) outlines that nurses working with older adults often see them at their most vulnerable. Often nurses and carers in the community are seen as a main source of social support, however due to work conditions they often do not have the time to talk with their clients (McCann, Ryan, Mckenna, 2005). Age Concern New Zealand are currently targeting this issue with their Accredited Visiting Service (AVS). AVS is a befriending service that matches volunteers up with older adults in the community. This service provides regular visits to older adults who would like more company. Clients of this service state that they feel less lonely and the service makes a positive difference on their lives (Age Concern New Zealand, n.d.). The Ministry of Health supported that this approach is effective, through a review of befriending services in New Zealand. This review concluded that befriending services provide invaluable means of support and social connectedness to older adults experiencing feelings of loneliness (Ministry of Health, 2004).
Interventions such as day centre services and social groups aim to assist older adults in widening their social circles, these services have shown to alleviate feelings of loneliness and help assist older adults in having more fulfilled lives (Windle, Francis, & Coomber, 2011). Cohen-Mansfield and Perarch (2014) evaluated 34 interventions and found that educational programmes were successful in alleviating loneliness in both one-on-one and groups formats. Shared activities such as gardening, physical activities and art were particularly effective in getting older adults involved and reducing loneliness (Cohen-Mansfield et al., 2014). It is part of the nurse’s role to advocate for their patient’s where the requirements go above the nurse’s scope of practice; referrals to resources within the community help maintain dimensions of the holistic framework (St John & Keleher, 2007). There is a wide range of pharmacological treatments available to help alleviate symptoms of depression (Best Practice Advocacy Centre New Zealand, 2008). The use of psychological therapy and pharmacological therapy together is effective in the treatment of depression, psychological treatments include: cognitive therapy, supportive psychotherapy and interpersonal therapy (Best Practice Advocacy Centre New Zealand, 2011).
This literature review has critically discussed and evaluated the research question “Are older adults who experience feelings of loneliness predisposed to depression and poorer health outcomes?” There is strong evidence to suggest that loneliness can manifest into depression with further complications to health. Like many other developed countries, New Zealand has an ageing population. Loneliness is common in older adults and will continue to become a larger issue as this demographic grows. Loneliness is an important health focus for nurses and health professionals, it poses a risk of increased admissions into rest home and hospital facilities. Research has shown that addressing older adults’ mental health needs in a mutual partnership helps improve health outcomes while working towards a common goal. Nurses need to be educated on this issue in the vulnerable older adult population. It is essential that nurses carry out thorough health assessments that include assessing the individuals’ social well-being. Community involvement is an effective intervention in reducing loneliness and preventing further health decline, this has been shown through Age Concern’s AVS program.
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