Loneliness: An essential aspect of the wellbeing of older people

Abstract: The overall aim of this thesis was to explore loneliness by identifying associated factors and predictors for loneliness among older people. This research was also undertaken to examine the association between loneliness and healthcare consumption. In addition, the reserach explored the experience of loneliness and
evaluated the effects on loneliness, symptoms of depression and life satisfaction of a case management intervention for frail older people.
Study I was a quantitative study with a longitudinal design involving persons 78 years or older and drawn from the Swedish National Study on Aging and Care. The sample comprised of 828 people at baseline (2001) who were followed-up after three years (n=511, 2004) and six years (n=317, 2007). The sample was divided into two groups, based on if the persons felt lonely or not. Factors such as personality traits, health complaints, self-reported health status and life satisfaction were included for identifying associated factors and predictors for loneliness. Studies II-IV were based on a main study with an experimental design, comprising 153 persons, 65+ years, living at home, with dependency in ADL and repeated contact with the healthcare services. Study II had a cross-sectional design drawn from the baseline assessment
(n=153) of the main study. Self-reported data and register data was used to investigate the association between use of healthcare and loneliness, health status and health complaints. Study III had a qualitative design and explored the experience of loneliness by performing interviews with 12 persons (10 women), recruited from the main experimental study. The interviews were analysed by using qualitative content
analysis. Study IV was a randomised controlled trial, including 153 persons randomised to an intervention (n=80) or control group (n=73) and evaluated the effect of a case management intervention after six and 12 months.Three outcomes were evaluated in regards to effectiveness; loneliness, symptoms of depression and life satisfaction.
The results in Study I showed that 52 per cent of the sample at baseline felt lonely sometimes or often (mean age 84 years). The strongest associated factor for loneliness was living alone (OR=6.1, 95%, CI=3.8-9.9) and the strongest predictors for loneliness at both follow-ups, at three and six years, was feeling lonely at baseline (OR=7.2, CI=3.9-13.4 and OR=5.4, CI=2.8-10.5). Those associated factors and predictors that were identified were mainly related to psychosocial outcomes. Study II showed that 60 per cent of the frail older participants (mean age 82 years) had experienced loneliness occasionally or more often during the previous year. Those who felt lonely used significantly more outpatient services, including visits at the emergency department, compared to their peers who did not feel lonely (p=0.026). Only depressed mood was found to be independently associated with total use of
outpatient services (B=7.4, p<0.001). In Study III, the experience of loneliness among frail older people was interpreted in the overall theme “Being in a Bubble” illustrating as being in an ongoing world but excluded because of the participants’ social surroundings and the impossibility to regain losses. The theme “Barriers” illustrated how participants had to face barriers, physical, psychological and social barriers for
overcoming loneliness. The theme “Hopelessness” revealed the experience when not succeeding in overcoming the barriers and was characterised by loss of spirit and seeing loneliness as an unchangeable state. The last theme “Freedom” illustrated a positive co-existing dimension of loneliness which offered independence and time for reflection and recharging. Study IV evaluated the effect of a case management
intervention for frail older people living at home in regards to loneliness, symptoms of depression and life satisfaction. At baseline, there were no significant differences between the intervention and control groups in regards to the main outcomes or sociodemographic factors. According to intention-to-treat no significant differences were found for any of the outcomes, at any time point between the two groups.
When accounting for complete cases, significant differences in favour of the intervention were found at six months for loneliness (RR=0.5, p=0.028) and life satisfaction (ES=0.4, p=0.028), as well as for depressive symptoms after 12 months (ES=0.5, p=0.035).
Loneliness is fairly common among older people and once the feeling is established, it is likely to stay. Factors related to psychological wellbeing appeared as the major reasons for loneliness. Frail older people tend not to differ in regards to prevalence, compared to older people in general. Frail older people who felt lonely used more outpatient services, including visits to the emergency department compared to their
not lonely peers. However, it was not loneliness per se that was found to be associated with use of healthcare but rather depressed mood. The experience of loneliness among frail older people showed that it was a prevalent issue, regardless of intensity and was associated with physical and social losses. Case management for frail older people was not effective in regards to loneliness, symptoms of depression and life satisfaction. Nevertheless, there were indications that case management could be beneficial in terms of these outcomes.
Loneliness is an important factor that could be associated with lower wellbeing and needs to be actively targeted. Because of the complexity, where single causes are difficult to isolate a comprehensive and individualised approach is recommended. Loneliness can be problematic regardless of intensity and is likely to be unresolved, if left unattended. This implies that appropriate assessments of
loneliness and other aspects of psychological wellbeing should be undertaken.