Loneliness: Is it a Mental State, Concept, Symptom, Disorder, Condition, or Disease?

Pat Stricker, RN, MEd
Former SVP, Clinical Services
TCS Healthcare Technologies

The Holiday Season, including the celebrations of Christmas, Hanukkah, Kwanzaa, Diwali, Las Posadas, Winter Solstice and the Chinese New Year is a happy, joyous time for most of us, as we look forward to spending time with our extended family and friends. However, for many people who live alone, have few friends, feel lonely or socially isolated, these days are no different than every other day for them. The feelings of loneliness and isolation are even more accentuated at this time of year.  

This made me think about what we really know about loneliness. We know it causes problems for many people, but what has caused the increase in loneliness that is being seen across all age groups? And how many clinicians are aware of the significant health risks associated with loneliness, especially in elderly patients?  Are people aware it is being called the “Silent Killer of the Elderly”?  What is being done to educate people about the risks of loneliness going untreated?  How many people suffer from loneliness in the U.S. and is there a “loneliness epidemic” in the U.S.?  And what should we call it?  Is it a mental state? A concept? A symptom? A disorder? A condition? Or a disease?   

We will review and discuss these things in this month’s article.

Causes of Loneliness
Loneliness is very complex and has many causes. It is dependent on the feelings and perceptions of each individual. There is not a direct cause and effect or statistical significance between living alone and loneliness. Some people may have family and friends nearby and be with others, yet still experience the feeling of loneliness, while others may be alone, yet not feel lonely. 

There are more seniors living alone today, rather than in extended family homes, as was common in earlier years. Years ago people lived in their family homes for decades, stayed in the town in which they were born, and would become deeply rooted in their local communities, allowing them to make meaningful, long-time relationships. Today it is not as common for elderly parents or grandparents to live with their children because more women are working and not home to take care of them. It is also more common today for people to move frequently to other cities for jobs, often leaving behind older family members and friends. This can result in fewer close, meaningful relationships, and the possibility of loneliness.

People are also living longer today and many of them may have outlived their partners, family members and close friends. Since they are living longer, many also have chronic conditions and mobility problems that make it difficult to stay connected with others.

Technology has also had an effect on loneliness. In the past, people spent time talking and being with others. They enjoyed socialization, and it was a big part of their life. Today people rely more on technology, e.g., texting others or sending emails and spend more time on their devices playing games or surfing the internet, even when others are in the same room with them. This results in less meaningful communication with family members and friends.  

Other factors that can lead to loneliness are disabilities and limitations that prevent an individual from maintaining a normal lifestyle and being connected with others. Examples include hearing loss, mobility impairments, transportation issues, speech or language issues, etc.  

Most researchers do not agree there is a “loneliness epidemic” or that today’s older generation is any lonelier than those in previous generations. However, they do agree that the total number of lonely older adults has increased because the overall number of older adults is increasing due to the aging of the baby boomer generation. For example, every day since January 1, 2011, there have been 10,000 baby boomers turning  65 years of age! And that will continue for another 10 years, until 2030. At that time, 18% of the population will be at least 65 years old, compared with only 13% today. That is a dramatic increase.  

Statistics and Studies
The number of baby boomers turning 65 every day is astonishing. That means that over the course of the 19-year time span (from 2011 to 2030), there will be 69,350,000 people moving into the 65+ age group. Just this sudden increase in the number of elderly people means we need to take loneliness seriously.  Since it can lead to significant health issues, depression, substance abuse, and suicide, it is a public health issue that needs to be addressed. It is being studied by state and federal organizations, academic institutions, healthcare organizations and others, and numerous initiatives are being developed to try to manage it. Let’s look at some of the studies and what they have shown.   

A study conducted by Cigna Health, designed to measure an individual’s subjective feelings of loneliness, was conducted on 20,000 adults 18 years or older. It used the 20-question UCLA Loneliness Scale that identifies people as lonely if they have a score of 43 or higher. The following are the highlights of the report:     

• Nearly half of the respondents reported feeling alone (46%)
• One in four (27%) do not feel there are people who really understand them
• 43% feel their relationships are not meaningful and that they are isolated from others
• 20% feel they do not feel close to people or have people they can talk to (18%)
• Only 27% feel they belong to a group of friends
• Those who live alone are more lonely (avg. loneliness score 46.6) than those who live with others (avg. score 43.5)
• Single parents/guardians who live with children report being more lonely (avg. score 48.2) than those who live alone (avg. score 46.6)
• Surprisingly, adults 18-22 reported being the loneliest generation (score of 48.3) and in worse health than older adults
• Adults 23-37 years of age were close behind with a score of 45.3, followed by those in the 38-51 age group, with a loneliness score of 45.1
• Again surprisingly, adults 72 years or older, reported being the least lonely, with a score of 38.6

The results of the loneliest age groups were definitely surprising. The general thought was that those who were 72 years or older were the loneliest, and this fact was also supported in other studies that were done. Yet this study showed the opposite. The younger age groups reported higher loneliness scores (45.1 to 48.3), while the older age group had a score of 38.6, which did not even meet the lonely threshold score of 43. Only 25% of the older group reported feeling isolated or left out, and 85% reported belonging to a group of friends.   

Another interesting finding was the use of social media and its effect on personal relationships. People tend to believe that the younger generations, who are heavy users of social media, are missing out on more meaningful face-to-face interactions, making them more disconnected and isolated. While the study did show that users of social media had scores indicating loneliness (43.5 and 41.7), it did not show a direct relationship between media use and loneliness. In fact, it showed that in-person interactions with others, physical and mental wellness, and life balance helped alleviate the feelings of loneliness.  

Two other national surveys, the National Social Live, Health and Aging Project and the Health and Retirement Study, compared three groups of over 11,000 Americans born in different periods of the 20th century. The first study included people born between 1920-1947; the second group included the first group plus their spouses or partners; and the third group included those participants and other people born between 1948-1965.  The study looked at the participants’ level of loneliness, overall health, years of education, marital status, and close relationships with family members, family, relatives, and friends. 

The researchers found an increase in loneliness after age 75 associated with living alone or without a spouse/partner, having few close family members and friends, or having poorer health.  This group also had more health issues, loss of mobility, reduced income, and less control and management of life events than younger participants, which made them more vulnerable. Younger participants between the ages of 50 and 74 still had partners, larger networks of friends and more daily social contacts, which resulted in lower loneliness score that had not increased over the past decade. They attributed these factors to this group having better educational opportunities, healthcare, and social relationships than the older generation.        

Another study on social connectedness, based on data from the National Social Life Health and Aging Project, found that 19% of older adults report feeling lonely fairly frequently. Lonely adults usually tend to have lower incomes, are less likely to be married, live alone, report poorer health, have more physical limitations, and fewer friends. They also do not tend to socialize, volunteer, or participate in organized groups on a normal basis.

About 14 million people (28% of older adults) live alone in the U.S. according to a 2017 report profiling older Americans conducted by the Administration for Community Living. The report found that many are not lonely or isolated, while others feel lonely despite being surrounded by family and friends. In addition, it identified that loss of family and friends, lack of income, mobility issues and poor health make older individuals more susceptible to social isolation or loneliness. 

Definitions
Before we go any further, let’s define what we mean by social isolation and loneliness. These terms are often used interchangeably, yet they have significantly different meanings.

Social isolation is described as: an objective physical separation from other people (living alone); complete or near-complete lack of contact between an individual and society; the state of solitude or being apart from all human beings or of being cut off by wish or circumstances from one’s usual associates; imposed isolation from normal social networks caused by loss of mobility or deteriorating health.

Loneliness is described as: a subjective, negative feeling of being alone or separated; usually associated with loss (e.g. loss of a partner, children relocating, retirement, loss of mobility, lack of transportation, etc.); a loss of a sense of connection and community; a self-reported, biased perception or feeling of a situation.  

An article entitled the Quiet Crisis provides a great overview of loneliness and things we should keep in mind. (This article is worth reading).   

• Loneliness isn’t just an emotional state or state of mind. It’s a health condition that has the ability to impact the heart, brain and mortality, so it should be treated like a disease.
• Humans are social creatures. That doesn’t mean they just like being social. It means they need socialization to survive.
• Social isolation takes a toll on us emotionally, psychologically and physically.
• If loneliness persists for longer than 2 weeks, it is linked to heart disease, high blood pressure, depression, stroke and Alzheimers’, due to increased inflammation.
• Social relationships should be taken seriously, just like anything else that affects our health.
• Loneliness does not mean just being alone or lonely. It really depends on how an individual feels about relationships. The more satisfied they are with them, the less lonely they are.
• Vulnerability peaks in the 50s as things start to change: parents die, couples divorce, children move away, people lose or change jobs, health starts to decline and mortality starts to become a reality.  This leads to dissatisfaction and can progress to loneliness.
• Wealth, education, a close community, a healthy marriage and a successful career can help protect against loneliness.
• Loneliness is easier to prevent than treat.  

Individuals who are genetically prone to loneliness can feel lonely even when surrounded by people or involved in a rich social life, while those not genetically prone may still feel lonely based on situations in their life. 

So, as you can see, loneliness isn't the same thing as being alone. Loneliness is a subjective, negative feeling or perception of being alone, while social isolation is an objective physical separation from others. Isolation is usually a more serious issue mentally and emotionally, since individuals are physically separated from others and there are fewer personal interactions, which is not healthy. This condition is also harder to treat than loneliness, especially if an individual is not totally committed to trying to re-socialize.   

One thing to keep in mind – we all need peace, quiet, and solitude at times, and that is not isolation or loneliness. However, being alone needs to be a choice in order to be healthy.

NOTE: for the remainder of this article I will use the term loneliness instead of using “loneliness and social isolation,” since most of the studies were conducted looking at loneliness. It is assumed that social isolation would also have the same results.  

Social Determinants of Health
Improving health and achieving health equity requires broad approaches that include the health system as the key driver of health and health outcomes. In addition, other social, economic, and environmental factors that affect health are also included. Examples of these factors include: socioeconomic status, education, neighborhood and physical environment, employment, social support networks and access to health care. These social determinants of health (SDOH) define conditions in which we are born, grow, live, work and age. They were identified in a 2008 report by the World Health Organization, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health and included as one of the four overarching healthcare goals for the decade in the Healthy People 2020 report — to “create social and physical environments that promote good health for all.” These five SDOH provide everyone with an opportunity to make choices that can lead to good health.

Healthy People 2020's five key areas of social determinants of health include the following: Neighborhood and Built Environment, Health and Health Care, Social and Community Context, Education, and Economic Stability.

As you have probably noticed, loneliness and social isolation are not listed as specific social determinants of health, but they are included under the Social and Community Context determinant. Food Insecurity has also been identified as a determinant that is a major concern and falls under the Economic Stability determinant. The Kaiser Family Foundation (KFF) adds Food as a sixth SDOH and has added Health Outcomes. 

A major focus has been placed on developing healthcare initiatives to better address each of these social determinants of health. Some examples include: policies and practices to promote health and health equity; state and federal Medicaid and Medicare initiatives; payment reform; and activities by managed care plans and providers to identify and address social needs. Other programs and initiatives are being developed by state and federal agencies, academic institutions, healthcare organizations and other private companies and organizations. 

Health Risks
Loneliness is a common source of distress, suffering, and impaired quality of life for adults older than 60. Numerous studies have identified the adverse outcomes and physical risks associated with loneliness and have identified it as a predictor of poor health and functional decline and death.

The most amazing studies to me are those that show the increase in mortality risks due to loneliness:

• One study found that the health risks are comparable to the dangers of smoking and obesity, increasing mortality risk by up to 30%.
• Other research shows that loneliness has the same impact on mortality as smoking 15 cigarettes per day!
• Lonely people are 50% more likely to die prematurely than those with healthy social relationships.
• Loneliness may lead to an early death.
• Another study found that living alone was a predictor of cardiac events in men and all-cause mortality in both men and women. It showed that participants also reported significantly poorer mental and physical health and quality of life, as well as symptoms of anxiety and depression.

In a 2010 AARP Research survey of adults age 45 and older, 35% of the respondents were identified as lonely, based on the UCLA Loneliness Survey. Loneliness was self-reported in 55% of those who said they had poor health and the number of diagnosed medical conditions confirmed this finding. Drug use was also positively associated with loneliness in this group. As a comparison, only 25% of those who reported their health as excellent self-reported as lonely. 

Numerous other studies have shown that loneliness can lead to the following health related issues:

• Increased cortisol stress levels that can impair cognitive performance and increase the risk of vascular problems and heart disease
• Alteration of cells in the immune system that promote inflammation, which is necessary to heal from injuries, but it can increase the risk of chronic disease, if the inflammation lasts too long
• Build-up of plaque in the arteries
• Growth and spread of cancer cells
• Inflammation in the brain cells leading to Alzheimer’s disease
• Weakened immune cells that fight viruses, making them more vulnerable to infectious diseases
• Significant increase in the risk of cardiovascular, psychiatric and metabolic traits
• Sicker patients with poor healthcare due to lack of follow-up, poor nutrition or lack of medication compliance
• Diabetes, depression, dementia, and substance abuse
• Increased stress due to finances, health problems, and everyday issues will be a higher risk because of lack of social and emotional support

Clearly, these studies proved that loneliness is a big problem that can lead to a variety of physical health issues, psychological problems and societal issues. Due to the numerous links between loneliness and health status, healthcare providers need to be on the lookout for loneliness and aware that it is a condition that can afflict almost anyone. Loneliness might be one of the most important social determinants of health for older people.

Prevention
Having shown the importance of identifying loneliness, the next step is to take the information obtained in the studies and determine what type of interventions can be implemented to prevent and treat these conditions.

Prevention strives to promote independence, prevent or delay the deterioration of aging, illness or disability and delay the need for more costly and intensive services. Prevention provides three levels of support to help patients maintain independence and good health and promote well-being. The intervention levels represent a continuum of support:

• Primary: the 1st level is designed to promote well-being for individuals with few care needs or symptoms
• Secondary: the 2nd level focuses on early intervention
• Tertiary or intensive intervention: the 3rd, most intensive level, focuses on intermediate care

The range of interventions includes activities to reduce loneliness help with practical everyday tasks, and provide health advice and general suggestions to encourage social activities. The key to developing interventions is to focus on identifying the most efficient and cost-effective services aimed at preventing loneliness. 

The Cigna Study findings reinforced the need and importance of belonging to a community and the universal need for regular, meaningful, in-person interactions, which leads to lower loneliness scores and better health outcomes. Getting the right balance of sleep, work, socialization, family and “me” time was found to be essential in lowering loneliness scores. When this was accomplished, the participants had a better sense of community and connectedness. Overall, getting the right balance in these areas made them feel like they:      

• Wanted/needed companionship
• Have someone they can turn to
• Were part of a group of friends
• Could find companionship when they need it
• Had things in common with others

Other research showed that focus should be placed on these key items when developing loneliness interventions:

• Quality of life and well-being
• Specific social interventions, such as:
  -Befriending and using community navigators: Resulted in less loneliness
  Befriending was found to reduce depression and was cost effective, while community navigator interventions were effective in identifying socially isolated individuals.
  -Mentoring: The use of mentors was less clear; one study showed positive outcomes while another found no difference
  -Social groups: Older participants in these groups had a greater survival rate than those who did not belong to a social group
• Encouraging the use of services: Those who used the services increased their social interactions and community involvement
• Add flexibility and adapt the services: Tailor them to an individual’s preferences
• Key things to be sure to do
  -Make an effort to maintain close, meaningful friendships
  -Exercise routinely and get enough sleep: Both regulate mood and overall health
  -Practice gratitude: Focus on things that provide the a feeling of being fortunate
  -Take a class: Attend a new class you’ve never tried before; meet new friends in the class
  -Volunteer: Help others and feel good about that; gives a sense of purpose; raises self-esteem; reduces the feeling of loneliness
  -Talk to others: 30 seconds of friendly conversation has a positive impact on mood
• Exercise the brain with active learning
• Identify a mission and purpose in life: Leads to healthier immune cells and healthier outcomes
• Encourage working toward a social cause with others who share the same values: Helps to develop a greater sense of community.
• Work to improve social connections: Remember that social media is not a cure for loneliness. It is the quality of connections that is important – not the quantity of connections. Face-to-face interactions and meaningful connections are the type of activities that are important. Encourage the following:
  -Schedule more coffee dates or face-to-face meetings with friends
  -Encourage continued contact with a network of friends
  -Maintain daily social contacts
  -Become a caregiver: Provides a sense of accomplishment and well being
• Stress the fact that they should fight the tendency to withdraw when feeling isolated
  -Encourage to stay active and engaged even if they don’t feel like it
• Encourage them to seek professional help, when depression, anxiety, or other mental health issues cause them to feel disconnected: Need to break the self-perpetuating cycle
• Be sure to include loneliness assessments in the patient’s general risk assessment

Treatment Interventions
A longitudinal study in Amsterdam of 4,880 older adults born between 1908 and 1957 showed that most loneliness interventions are not very effective because people do not tend to change their personal situation. Those born later in the 20th century were less lonely because they felt more in control and were better able to manage their lives. Because they were younger, most still had partners, a more diverse network of friends and more daily social contact. The study identified the need for interventions that can help patients become self-efficient and gain the necessary skills to counteract loneliness.  

We need to be able to research and create meaningful interventions for both loneliness and social isolation. Examples include:

• Develop specific interventions for both loneliness and social isolation
• Determine the most effective approaches to mitigate the risk factors
• Identify the effectiveness of interventions to assure it will make meaningful changes in health outcomes
• Identify people prone to these issues and determine who would benefit most from the interventions
• Advocate for and support further research for these issues based on aging processes and the social determinants of health
• Find ways to engage older adults in technology that excites them so it can lessen their loneliness and enrich their lives. Technology can be difficult for older adults, but if it is introduced slowly and with programs that they enjoy, it can help to improve health outcomes. Studies have shown that 9 out of 10 older individuals liked technology, felt it saved them time, and gave them flexibility in communication once they actually started using it.   

Studies have shown that health outcomes in older adults can be improved by promoting social engagement and helping seniors maintain interpersonal relationships. There is a support group that has provided a list of “10 Things To Do If You’re Feeling Lonely” to help lonely or isolated people become more connected to those around them. I’d suggest reading this and using it in interactions with patients.

An article in Case Management Advisor, For Older Patients, Loneliness Might Be Biggest Social Determinant of Health, offers detailed, sound suggestions for Case Managers to help patients overcome loneliness and achieve connections. They focus on five specific areas:

1.       Assessing patients for social isolation and loneliness 

2.       Identifying barriers to social connections, including behavioral and physical health issues 

3.       Finding community resources

4.       Reaching out to families/neighbors, when appropriate

5.       Using technology as a way to connect

For example, they indicate that over 50% of healthcare organizations have contracts with Uber Health or Lyft to transport patients to activities and appointments. Payers are even paying for this, as it may eliminate a costly admission. I highly recommend reading this article for more detailed information on specific ideas. 

Conclusion
While loneliness has always seemed like a simple social issue, I think most people would be surprised to see the level of impact it has on our health status. Looking at the long list of health risks it poses and its linkages with other serious conditions and diseases, it is easy to see how important it is. It is obvious that loneliness has a very close mind-body connection and we must find better ways to improve good physical and mental health.  

Just as we pay attention to obesity, smoking and lack of exercise as risk factors, we need to pay more attention to loneliness as a key factor in our life expectancy. We need to routinely assess our patients for loneliness, especially those that are most vulnerable. We also need to make sure we have a care plan developed for dealing with this condition – one that carries over into all the potential diseases and conditions it has linkages with.   

This condition is getting more attention than it had in the past, but we need to make sure we include it in all our clinical programs. We also need to provide loneliness education to our clinical staff, so they are aware of the importance of identifying patients and know how to help them manage this condition. Physicians need to be included in training as well, since they need to be part of the discussion when discussing patient lifestyle factors.     

As you can see, loneliness is more than just a mental state, or concept, or symptom, or disorder, or condition. As described in the Indian Journal of Psychiatry, loneliness has been described as: a “treatable, rather than irreversible condition” and as an “appropriate condition for therapeutic intervention,” and as a “disease for the elderly (aged 60 years and above)”. However, today it is still officially designated as a “symptom of a mental health problems,” but “based on its epidemiology, phenomenology, etiology, diagnostic criteria, adverse effects, and management it should be considered a disease,” with a classification of a psychiatric disorders. Whatever it is called, it is a formidable challenge that we have to work to control.