Loneliness of Older Adults - #98
Take QuizWhen there is a discrepancy between one’s desired state of social connection and one’s actual relationships, a complex set of feelings termed loneliness occurs.
Loneliness is a subjective, unpleasant state that involves feelings of isolation, disconnectedness, and perceived rejection from peer groups.1 Loneliness is distinct from being socially isolated (see Geriatric Fast Fact #94). It is possible to live alone but not feel lonely and, conversely, one may feel lonely while surrounded by other people.
The COVID-19 pandemic has substantially increased feelings of loneliness for many older adults.2,3 This is significant because chronic loneliness can adversely affect memory, mental and physical health, and longevity.
- Loneliness increases the risk of all-cause mortality by 22-26%, independent of depression.4,5
- Loneliness increases the risk of hypertension, myocardial infarction, stroke, diabetes, high cholesterol, cognitive decline, and systemic inflammation.6,7,8
- Loneliness increases the risk of dementia by 40%, independent of social isolation and genetic risk factors.8
- Loneliness is associated with higher rates of depression, anxiety, and suicide.1
- Loneliness among heart failure patients is associated with a 68% increased risk of hospitalization and 57% increased risk of emergency department visits.1
Older adults are at particular risk of loneliness.1,3 The experience of loneliness is commonly the result of a combination of intrinsic and/or extrinsic factors.9 Risk factors include:
- Age 75 years and older
- Female
- LGBTQ
- Immigrant
- Caregiver
- Limited education
- Low income
- Unemployed, retired, or disabled
- Lives alone or is homebound
- Death of family and friends
- Deteriorating or poor physical or mental health
- Personality traits (e.g., introvert, negative attitude, lack of resilience)
Assessment of a patient’s loneliness in a clinical setting can be done using the 3-item UCLA Loneliness Scale.10 The instrument and instructions regarding cutoff scores can be accessed here:
Adults over the age of 65 years, especially those identified as at risk of loneliness.
Following a positive screen for loneliness, explore why the patient feels lonely. Consider a “social prescription” to local community-based programs for social connection and ongoing support. A meta-analysis of interventions to reduce loneliness suggested the following:
- Enhancing social support
- Increasing opportunities for social interaction
- Improving social skills
- Addressing maladaptive social cognition (e.g., social anxiety, lack of self-esteem)11
- A meta-analysis of studies published between 2000 and 2021, estimates the pooled prevalence of loneliness among older adults aged 65 and older to be 28.6%.12
- More than one-third of adults aged 45 and older feel lonely.1
- Feelings of loneliness are common at the end of life. Nearly 1 in 5 older adults reported frequent loneliness, and over 2 in 3 reported some loneliness during the last four years of life.13
- Define loneliness and how it differs from social isolation.
- Describe the impact of loneliness on patient health.
- Identify risk factors for loneliness in older adults.
- Describe how to assess older patients for loneliness.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
- National Academies of Sciences, Engineering, and Medicine. Social isolation and loneliness in older adults: Opportunities for the health care system. 2020. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663
- Kotwal, A.A., Holt-Lunstad, J., Newmark, R.L., Cenzer, I., Smith, A.K., Covinsky, K.E., Escueta, D.P., Lee, J.M. and Perissinotto, C.M. Social Isolation and Loneliness Among San Francisco Bay Area Older Adults During the COVID-19 Shelter-in-Place Orders. J Am Geriatr Soc. 2021;69: 20-29. https://doi.org/10.1111/jgs.16865
- Malani P, Kullgren J, Solway E, Piette J, Singer D, Kirch M. Loneliness Among Older Adults Before and During the COVID-19 Pandemic. University of Michigan National Poll on Healthy Aging. September 2020. Available at: http://hdl.handle.net/2027.42/162549
- Rico-Uribe, L. A., F. F. Caballero, N. Martin-Maria, M. Cabello, J. L. Ayuso-Mateos, and M. Miret. Association of loneliness with all-cause mortality: A meta-analysis. PLoS ONE. 2018;13(1):e0190033.
- Holt-Lunstad, J., T. B. Smith, M. Baker, T. Harris, and D. Stephenson. Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on Psychological Science. 2015;10(2):227–237.
- Hakulinen C, Pulkki-Råback L, Virtanen M, Jokela M, Kivimäki M, Elovainio M. Social isolation and loneliness as risk factors for myocardial infarction, stroke and mortality: UK Biobank cohort study of 479 054 men and women. Heart. 2018;104(18):1536-1542. doi:10.1136/heartjnl-2017-312663
- Richard A, Rohrmann S, Vandeleur CL, Schmid M, Barth J, Eichholzer M. Loneliness is adversely associated with physical and mental health and lifestyle factors: Results from a Swiss national survey. PLoS ONE. 2017;12(7):e0181442.
- Sutin AR, Stephan Y, Luchetti M, & Terracciano A. Loneliness and risk of dementia. J Gerontol B Psychol Sci Soc Sci. 2020;75(7):1414-1422. doi.org/10.1093/geronb/gby112
- Goodman, A., Adams, A., & Swift H.J. Hidden citizens: How can we identify he most lonely older adults? 2015. The Campaign to End Loneliness: London. Available at: https://www.campaigntoendloneliness.org/wp-content/uploads/CEL-Hidden-People-report-final.pdf
- Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. A short scale for measuring loneliness in large surveys: Results from two population-based studies. Research on Aging. 2004;26(6), 655–672.
- Masi CM, Chen HY, Hawkley LC & Cacioppo JT. A meta-analysis of interventions to reduce loneliness. Personality and Social Psychology Review. 2010;3:219-66.
- Su Y, Rao W, Li M, Caron G, D’Arcy C, Meng X. Prevalence of loneliness and social isolation among older adults during the COVID-19 pandemic: A systematic review and meta-analysis. International Psychogeriatrics. 2022:1-13. doi:10.1017/S1041610222000199
- Kotwal AA, Cenzer IS, Waite LJ, et al. The epidemiology of social isolation and loneliness among older adults during the last years of life. J Am Geriatr Soc. 2021;69(11):3081-3091. doi:10.1111/jgs.17366