In this podcast, Editor in Chief, Helen Saul explores research from the NIHR into loneliness among older adults. She is joined by Andrew Steptoe, Professor of Psychology at UCL who carried out some of the studies. Kalpa Karicha, from the Campaign to End Loneliness, discussed the implications for many of us right now: improving the quality of our relationships when we’re in middle-age could make a difference. And Occupational therapist Sarah Page advised on measures that could help. “If you’re going to have a care plan that says ‘medication four times/day’, why can’t it also say ‘activities four times/day?’. You can also read a transcript here.
The COVID-19 pandemic threw a spotlight on loneliness. Social distancing separated people from their family and friends and caused heartache. It had the potential to create loneliness on a major scale.
Anyone can become lonely, but the changes that come with age put older people at particular risk. They may live alone, for example, or be unable to continue with activities they previously enjoyed. The health and wellbeing of this vulnerable group has been a national Government priority since 2018.
The NIHR funds and delivers world-leading health and care research. NIHR Evidence highlights important pieces of NIHR-funded research, summarised in plain language as NIHR Alerts. This Collection brings together key findings on loneliness in older adults, to build a picture of what is known, and what is needed, to address the problem.
What is loneliness?
There is overlap between loneliness and social isolation and one can lead to the other. But they are not the same. Social isolation is a measure of the number of contacts people have; loneliness relates to the quality of their relationships. People may happily choose to have only a few contacts, but they would not choose to feel lonely.
Older people may become lonely after the loss of a spouse. Other common triggers include retiring from work, having reduced mobility, or being unable to take part in activities they enjoy. Sometimes there is no obvious reason for the feeling.
A recent NIHR-supported review highlighted how widespread the problem is. It included 39 studies from 29 countries and found that, on average, one in four adults over 60 reports feeling lonely. For those aged more than 75, the figure is almost one in three (31%).
Some groups have a dramatically increased risk of loneliness. Another NIHR project, Improving the Experience of Dementia and Enhancing Active Life (IDEAL), looked at carers of people with dementia. It found that almost two in three (62%) felt lonely. Most (81%) were partners or spouses of the person with dementia; others were family members, friends or neighbours. Given that around 700,000 people in the UK provide informal, unpaid care for someone with dementia, these figures represent widespread distress and a serious public health issue.
“I was active and happy in my late 70s, running around after my children and grandchildren. Then I had a hip operation that went wrong, and I became someone who couldn’t move and couldn’t do my own shopping. And then my daughter died suddenly from cancer. It was as if the bottom had dropped out of my world. I went into myself and thought there was not a lot of point in carrying on. It went on for a long, long time. I cut everyone off and isolated myself."
Gwen Frith, Public Contributor, St Helen’s, Lancashire
"In lockdown, the general population experienced what older people put up with normally. There was no difference for many of them during the pandemic because they are already isolated and lonely. They were living the COVID-19 life before the pandemic came along. That’s so sad."
Sarah Page, Occupational Therapist and Senior Lecturer, University of Bedfordshire
Loneliness takes a heavy toll on health
Loneliness is more than a negative feeling. It takes a heavy toll on health and well-being. New NIHR research included more than 4,000 adults from the long-running English Longitudinal Study of Ageing (ELSA). This group of over-50s answered questions every two years for 12 years. Researchers found that loneliness was linked to nearly one in five (18%) cases of depression one year later. The effect of loneliness decreased with time but was still associated with one in ten (11%) cases of depression after 12 years. The researchers conclude that up to one in five cases of depression in older adults could be prevented by reducing loneliness.
Another research paper from ELSA looked at a group of 6,600 people with a mean age of 66. During the follow up (six years on average), 220 of the group developed dementia. The researchers found that being lonely increased the risk of dementia by one-third. By contrast, having two or three close relationships decreased the risk of dementia by three-fifths.
Both of these ELSA studies underlined the distinction between social isolation and loneliness mentioned earlier. The first found a link between loneliness and depression, even in people who were not socially isolated. The second found that being isolated, with few or infrequent social contacts, did not predict dementia. It seems that the quality of someone’s relationships is more important than how often they meet up in person.
"People who are lonely lose their appetite. You can see their apathy and lack of motivation. They say there’s no point in getting dressed or having breakfast. They might have a fridge full of food from family carers but they don’t feel like eating. It has a knock-on effect on their health and increases their risk of falling."
Sarah Page, Occupational Therapist
How to address loneliness in the community
Social prescribing addresses people’s non-medical needs – such as loneliness – by linking them to sources of support in the local community. Social prescribers, or link workers, are often based at GP surgeries. Individual GPs have employed link workers since the 1990s, but the idea was given impetus in the NHS long-term plan (2019). Social prescribing is now incorporated into NHS England’s comprehensive model of personalised care.
A review of 118 documents on social prescribing found that link workers can help people develop a sense of belonging and confidence. They need to have extensive, up-to-date knowledge of local services and organisations that people can access. NHS England has produced guidelines for implementing social prescribing in primary care. This research found that more consideration is needed of the time it takes for a link worker to build a relationship with a patient. Social prescribing is relatively new and schemes need the full support of commissioners, GPs and other primary care staff, if the full benefit is to be realised.
"I finally realised that by doing things for other people I could help myself. I started going along to set the table for the Age UK luncheon club. I helped at the Christmas Fair and sold raffle tickets at the beer festival. At first, I found the contact with people hard work. I’d come home thinking I’m not going to do that again. But I realised I was better off trying."
Gwen Frith, Public Contributor
"Although engaging in community groups is important to some, many do not want to socialise in that way because they feel safer and more confident in their own homes. But they do need to feel they are not completely alone. Sometimes they miss having someone to sit with them, not necessarily to talk or to do anything with, but just to have the company."
Sarah Mendonca, Specialist Occupational Therapist, Falls Prevention Service, Sutton
"If you’re going to have a care plan that says ‘medication four times/day’ why on earth can’t it also say ‘intervention activities four times/day’? Why is that so far removed from reality? Short interactions and some quality conversation would make such a difference to people. It could keep them in their own homes for longer and reduce the cost of care homes.’"
Sarah Page, Occupational Therapist
How professionals can help people in the community
Recommendations from Sarah Mendonca, Occupational Therapist:
- "Social prescribing via the GP, befriending services or a regular telephone call from a volunteer. Organisations that link people to sources of support in the community can reduce social isolation.
- Transport links. Older people may no longer drive, and lack the confidence to use public transport. They are more likely to attend schemes or groups if transport is provided.
- Two minutes more with visiting health professionals such as district nurses or occupational therapists. People enjoy small interactions, having someone make them a cup of tea, or put their lunch out.
- A direct question and answer. Asking directly ‘Do you feel lonely or isolated?’ may encourage people to respond more than a general enquiry (‘How are you feeling?’). Engage with the person’s answers and try to help them do things they enjoy.
- Goal-setting. A mental health goal could be to contact a group or organisation within the next 4 weeks. Having achieved that, a service user might be motivated to achieve the next goal – to go to the group.
- Encourage older people to keep a diary. Reflecting on the past week is particularly important for those with cognitive impairment who might forget that they saw a neighbour, or went out one afternoon.
- Aids and adaptations. Simple equipment can keep people independent, and engaged in meaningful activities, for longer.
- Encourage volunteering. Helping someone else, by going to sit with them, or to take them shopping, is a short one on one interaction that can make both feel better."
The importance of social interactions in reducing the risk of loneliness – and potentially of other diseases – is becoming established. One example is the APPLE-Tree programme (Active prevention in people at risk of dementia: lifestyle, behaviour change and technology to reduce cognitive and functional decline), in people with memory problems who are at risk of developing dementia. The programme encourages older people with memory problems to adopt lifestyle changes including becoming more socially and mentally engaged. APPLE-Tree is being tested in a randomised trial to see whether it could lower the risk of dementia.
More work is needed among different communities in the UK. Participants in the IDEAL and ELSA studies are mostly White British. Less is known about other groups, and it is likely that different ethnic communities have different cultural understanding of isolation and loneliness. It is also known that some may face particular problems in accessing care for mental health issues.
“We need to do more work in prevention and preparation for older age and frailty. A lot of people who have never exercised are very surprised when they get older and their mobility is poor. Educating people to change their habits when they are young would make such a difference. For most of our service users, it is the loss of function and mobility that leads to loneliness and isolation.”
Sarah Mendonca, Occupational Therapist
"When the pandemic started, I volunteered to speak to four people every day. They were lonely and isolated, it really was sad. They didn’t have relatives and their carers just came and left. I still ring a couple of them, but less often now. Ringing them helped me too. I have come out of my loneliness. But I still have to shake myself sometimes, tell myself off, and keep going out.”
Gwen Frith, Public Contributor
How families and friends can help
Recommendations from Sarah Page, Occupational Therapist:
- "Avoid undermining the person’s skills. Allow older people to do their own washing and shopping for as long as possible. If a family carer takes on this care, the opportunity may be lost for conversation to ease loneliness.
- Better awareness of dementia. Someone with dementia may be quiet in company because they are struggling to find words, not because they don’t want visitors. Family and friends need to know more about dementia to be reassured that they are welcome."
Addressing loneliness in care homes
Care home residents are not alone in the same way as older people in the community, but many are lonely. Research has found that residents may have as little as two minutes of social interaction a day.
The Wellbeing and Health for People Living with Dementia (WHELD) programme demonstrated the value of social interaction and personalised pleasant activities for people in care homes. Simple measures improved residents’ quality of life. They not only showed less agitation or depression but had fewer GP visits and emergency hospital admissions. Providing more social interaction ultimately saved money.
In one initiative, a virtual quiz connected several care homes online by Skype. Residents enjoyed getting to know others in the same care home and chatting to those in other homes. Staff were enthusiastic, and the quizzes were feasible and low-cost. In ongoing work, the research team intends to monitor changes in loneliness, isolation and wellbeing before and after virtual activities.
Improving care in residential homes is a challenge. In the more complex WHELD programme, it took up to nine months for staff training to become embedded in practice. The Skype quizzes were more successful the second time they were tried.
Care home staff may need ongoing support for complex interventions to be successfully introduced. In Dementia Care Mapping (DCM), nominated staff put themselves in the place of residents. They carefully observe residents’ experiences and assess their responses. The staff team then work together to develop action plans to improve care.
DCM is a carefully thought out intervention, but research found that it had mixed results in different care homes. A key finding was that managers need to be actively engaged from the outset, so that staff receive the support they need for such complex interventions to be introduced more widely.
"It can be a different type of loneliness in care homes. Some people don’t get visitors and care staff are really busy. But their time, energy and interest, when they see people as individuals, can all make such a difference. If someone is not talking and not interacting, that doesn’t mean they don’t want to."
Sarah Page, Occupational Therapist
How care staff can help
Recommendations from Sarah Page, Occupational Therapist:
- "Activities. Meaningful activities such as singing, gardening or crafts are not expensive.
- Placement schemes. Occupational therapy or physiotherapy students could have placements in care homes which would benefit both.
- Life stories. Making a memory box or book with an older person can bring happy moments to life for an older person and remind them that they still have a fulfilled life."
Research suggests that almost one in three people over 75 – and almost two in three carers of people with dementia - are lonely. These figures are disturbing in themselves but they also represent a huge future burden of ill health. Studies have shown a strong link between loneliness now, and both depression and dementia in years to come.
A concerted effort to reduce loneliness in older adults should therefore bring long-term benefits to the physical health of the population. It would also make a difference immediately to those people and their carers.
At the heart of all of the interventions suggested in this Collection is the need to see older people as individuals. Health and care staff are under unprecedented pressure after more than a year of dealing with the pandemic. But just two minutes extra with each older patient could make interactions more meaningful.
New interventions need to be evidence-based. Research has pointed to difficulties in introducing change. It suggests that care home staff need ongoing support to bring in new programmes to engage elderly residents. Future research will also be needed to explore loneliness among diverse groups in the population.
Research to date suggests that short interactions could make a world of difference to some of the most vulnerable in society. There is an urgent need to make these interactions happen, and to reduce the toll of loneliness among older people.