Loneliness is lethal

I have witnessed first-hand the distressing effects that loneliness can have on a person. Having worked as a care assistant with older adults, predominantly with dementia, I have seen those who were no longer able to live with their loved ones, those who had lost their significant others and were unable to manage living alone, and those whose family had stopped visiting for a number of reasons. It was a place where a visit from family could have the biggest impact and the smallest act of kindness could make a person's day. It made me realise how lucky I am to have family so closely around me.

The Covid-19 outbreak and resulting lockdown has been difficult for everyone. Fortunately, with technology most of us have been able to keep connected and still communicate with the people we love. However, I think about the many older adults who come from a generation where such technology was non-existent, and so have less access and understanding of it, meaning they are even more isolated than the rest of us. These are also the individuals that are often already more disconnected than the wider population and are more likely to be more reliant on society's help; they may depend on the one visitor or activity they have each week. How has lockdown affected those who are living alone?

The dangers of loneliness

As human beings, we are designed for social contact; it's been the key to our success as a species. Now, we are living through a time where being connected can be lethal; but so can loneliness. Isolation from society is so disturbing and cruel to humans that it has been used as a form of punishment and even torture throughout history.

More recent literature has shown that social isolation or living alone can increase mortality risk as much as smoking 15 cigarettes a day or having an alcohol related disorder (Holt-Lunstad et al., 2015). Loneliness has been associated with an increase in both risk of coronary heart disease and in risk of stroke (Valtorta et al., 2016), as well as increasing the risk of high systolic blood pressure (Hawkley et al., 2010). 

Research has also shown that loneliness is correlated with an increased risk of dementia and mild cognitive impairment (Lara et al., 2019). Just today, a systematic review and meta-analysis published in Ageing Research Reviews has suggested that social isolation could be a greater risk factor for dementia than previously believed.People over 55 who live alone are 30 per cent more likely to develop dementia than those who live with others, according to the study led by Dr Roopal Desai (UCL Psychology & Language Sciences), who notes: 'More and more people are living alone, particularly older people, and some studies have also suggested that increasing numbers of people are experiencing loneliness in countries such as the UK. Our findings suggest that low social contact could have serious implications for dementia rates, especially as dementia rates are already rising due to ageing populations.'

In terms of pandemic living, a recent review of the psychological impact of quarantine (Brooks et al., 2020) identified a number of adverse psychological consequences including depression, stress, poor concentration, confusion, anger, difficulty sleeping, low mood, irritability, anger and emotional disturbance. These can all have a major impact on an individual's wellbeing, in terms of both their mental and physical health.

The implications

So loneliness is a major risk factor for serious health problems. Research suggests it is also an independent risk factor in care home admissions in England (Hanratty et al., 2018). Will we therefore see an increase in older adults being admitted into care, as a result of the global pandemic? As a section of healthcare which is already under pressure, how will a possible increase in admissions affect the quality of care that this population receives? We can also question what the effect will be on those older adults who continue to live at home alone. 

Of those who are already in care homes, we may see deterioration in those who have not been able to have visits from their relatives. The presence of family members is incredibly important to the wellbeing of dementia patients, to provide the familiarity and sense of belonging that they need. When working with these patients myself, I saw how differently they would respond to a family member, even in more advanced stages of their illness. Furthermore, UK charities have recently highlighted concern over 'deterioration' in residents' mental and physical health, particularly for those living with dementia, who make up more than 70 per cent of the population of care homes (Alzheimer's Society, 2020). They argued that family carers are essential for these individuals, not only for attachment and practical reasons, but also as they can act as an advocate for them; acting as their voice, memory and identity.

What can we do?

The recent Brooks et al review identified different stressors which may contribute to the negative psychological effects of quarantine. This included quarantine duration, fears of infection, frustration and boredom, inadequate supplies and insufficient information. Taking action as a society to minimise these stressors as much as possible may help to reduce the negative psychological effects.

One way of reducing stressors would be to offer as much accurate and helpful information as possible, ensuring it is accessible and easy to understand. Older adults are a population who are at greater risk of being hard of hearing, have poorer eyesight and more likely to have cognitive decline. Clinical staff should ensure that information is provided in a format that is accessible, to minimise the negative effects that this stressor can cause. It will also make them feel more connected to the greater cause and bigger picture, and having a better understanding of the situation will ensure they stay motivated. We should also ensure that this population is provided with adequate supplies, such as food and medicines, to reduce anxieties over where they will next be coming from. 

Many organisations (such as U3A) that offer individual's opportunities to learn, develop their interests and socialise, were some people's life line prior to the Covid-19 pandemic. These have now begun to develop ways of carrying out these groups differently or virtually. Although it's excellent that organisations such as this are offering groups virtually, it may mean that many people no longer have access to them. Some people may need support to use the technology which allows them to access these virtual groups. Other people, however, may not have the technology or may not be able to afford the technology to access them. As practitioners, it's important for us to have knowledge of these organisations and groups, so that we are able to offer support and education to enable users to access them, as well as create awareness of them. Some people may not have needed these groups prior to Covid-19, but may now benefit from knowing about these groups and being able to access them if they wish, as they now may be less connected than before.

Maunder et al. (2003) discussed the use of informal networks of telephone contacts, which has been used in previous outbreaks to support medical staff. A telephone support line, staffed by psychiatric nurses, was also an effective strategy, ensuring people have a professional to talk to. A similar system could be particularly useful for older adults, who may have little access to mainstream social networks, and would provide them with an alternative social community and a means of staying connected. As a profession, Psychologists have the skills to have a valuable role in this and could offer clinical support to vulnerable individuals both formally and informally over the telephone.

To allow care home residents to be more connected to their families, charities such as Dementia UK and Alzheimer's Society have recently suggested that relatives of dementia patients should be treated the same as key workers, thus meaning that they would be regularly tested for Coronavirus so that they are able to visit family members, reducing the negative effects of social isolation. However, this raises some logistical problems, in order to ensure that care home residents are protected from further coronavirus outbreaks. Further research looking into this, considering factors such as the need for physical as well as visual contact, the effect of the use of screens and maintaining a social distance, may help to guide practitioners in the best way to facilitate this. 

Although this pandemic has been challenging, as clinicians it has given us an opportunity to reflect on the importance of staying connected and the negative consequences of social isolation. Collectively we must think creatively to identify ways we can prevent loneliness in older adults (which can lead to physical and mental health decline) whilst also ensuring they are kept safe from the virus itself; preparing us for a similar situation that may arise again in the future. 

- Kate Rushby-Jones (Assistant Psychologist)

See also our May 2018 collection on 'the social cure'

References

Alzheimer's Society (2020, July 9). An open letter to the Government- allow family carers key worker status. Retrieved from https://www.alzheimers.org.uk/news/2020-07-09/open-letter-secretary-state

Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L., Wessely, S., Greenberg, N., Rubin, G.J. (2020) The psychological impact of quarantine and how to reduce it: rapid review of evidence. The Lancet, 395,912-920.

Hanratty, B., Stow, D., Moore, D.C., Valtorta, N.K., Matthews, F. (2018) Loneliness as a Risk Factor for Care Home Admission in the English Longitudinal Study of Ageing. Age and Ageing, 47(6), 896-900.

Hawkley, L.C., Thisted, R.A., Masi, C.M., Cacioppo, J.T. (2010) Loneliness Predicts Increased Blood Pressure: 5-year Cross-Lagged Analyses in Middle-Aged and Older Adults. Psychology and Aging, 25 (1), 132-41.

Holt-Lunstad, J., Smith, T.B., Baker, M., Harris, T.  Stephenson, D. (2015). Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Perspectives on Psychological Science: A journal of the Association for Psychological Science, 10 (2), 227-37.

Lara, E., Martĺn-Marĺa, N., De la Torre-Luque, A., Koyanago, A., Vancampfort, D., Izquierdo, A., Miret, M. (2019) Does Loneliness Contribute to Mild Cogntive Impairment and Dementia? A Systematic Review and Meta-Analysis of Longitudinal Studies. Ageing Research Reviews, 52, 7-16.

Maunder, R., Hunter, J., Vincent, L., Bennett, J., Peladeau, N., Leszcz, M., Sadavoy, J., Verhaeghe, L.M., Steinberg, R., Mazzulli, T (2003). The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ, 168(10), 1245-51.

Valtorta, N.K., Kanaan, M., Gilbody, S., Ronzi, S., Hanratty, B. (2016) Loneliness and Social Isolation as Risk Factors for Coronary Heart Disease and Stroke: Systematic Review and Meta-Analysis of Longitudinal Observational Studies. Heart, 102 (13), 1009-16.