Podcast: Loneliness in older adults
Transcript
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Moneeza Walji: Many older adults spend a lot of time alone. Sometimes they can feel so lonely that it begins to affect their well being. But how much of an impact does loneliness have on health? Is it something that doctors need to worry about when assessing a patient? I'm Dr. Moneeza Walji, associate editor for the Canadian Medical Association Journal. Today I'm speaking with two authors of a practice article on loneliness in older adults, published in CMAJ. Dr. Rachel Savage is a postdoctoral fellow at Women's College Research Institute in Toronto. Dr. Nathan Stall is a geriatrician at Sinai Health System and a clinical research fellow at Women's College Research Institute. He is completing a PhD in clinical epidemiology and Healthcare Research at the University of Toronto. In the interest of full disclosure, I just want to mention before we get started with the interview, that Dr. Stall is also an associate editor at CMAJ, but was not involved in the decision making process for this article. I reached them both in Toronto. Welcome. Thank you both for joining me today.
Nathan Stall: Thank you for having us.
Rachel Savage: Hi.
Moneeza Walji: So just to get started, do you mind if each of you tells me a little bit about who you are?
Rachel Savage: Sure. So my name is Dr. Rachel Savage. And as you mentioned, I'm a postdoctoral fellow at Women's College Hospital here in Toronto. I'm a PhD trained epidemiologist and I conduct applied public health research that's focused on improving the health of vulnerable populations like older adults, immigrants and women.
Nathan Stall: And I'm Dr. Nathan Stall. I'm a geriatrician and an internist at Sinai Health System in Toronto. As you also mentioned, I'm a research fellow at Women's College Research Institute. I'm completing a PhD in clinical epidemiology and healthcare research at the Institute of Health Policy Management and evaluation at the University of Toronto.
Moneeza Walji: So what is loneliness? Exactly?
Rachel Savage: I think the important thing to highlight is that loneliness is not a classified disease, but rather it's a feeling and it's often an uncomfortable feeling or a painful one at that. So we feel lonely when there is a gap or a disconnect in the number and quality of social relationships and connections that we have, and what we desire to have or wish to have. In our article, Nathan and I describe that loneliness is perceived social isolation. And I think it's important to highlight that definition as well, because social isolation is often used interchangeably with loneliness, but they're actually conceptually distinct. So social isolation is the objective state of having few social contacts. So having few people around you, I think most of us have felt this distinction between loneliness and social isolation. So an example I like to use is that we can be in a room full of people but still feel lonely or alone. I think for most of us feelings of loneliness are transient, but for others, they can persist for a prolonged amount of time. As clinicians and health researchers were concerned with the latter, because chronic loneliness has been linked to poor health outcomes.
Moneeza Walji: So as you mentioned, it seems like loneliness does have health impacts. So just to get a better understanding of the prevalence, how common is loneliness among older adults.
Rachel Savage: As we highlight in the article, it's very common. Older adults have an especially high prevalence of loneliness compared to other population groups. In the United States 43% of community dwelling older adults report being lonely based on a nationally representative sample. As part of the health and retirement study, estimates here in Canada are slightly lower. Around one in four older women, and one in five older men report feeling lonely, at least some of the time. And that's based on a recent analysis of the Canadian longitudinal study on aging. So I wanted to point out that women consistently self report higher levels of loneliness than men. And this might be for a number of reasons. The first being that women may just be more likely to acknowledge feeling lonely than men. Some other explanations are that women tend to have a longer life expectancy and marry older partners. So that results in a higher proportion of women. Certainly in their older years living alone, women are also more likely to be caregivers and to have lower income. Both of those factors are known to be related to social isolation and to loneliness.
Moneeza Walji: And in your opinion, why is it important for physicians to consider loneliness in a medical context.
Nathan Stall: So I would argue that loneliness has really not been integrated into medical care. And this is despite the fact that we know there's significant adverse impacts of loneliness on quality of life. And epidemiological research shows that there are strong associations with health outcome. So one of the things that we like to highlight is that loneliness actually has a greater impact on health than obesity, physical inactivity, and air pollution. And so as healthcare practitioners see patients, it's important that we assess for loneliness, and we try and target loneliness because these have really profound upstream impacts on health. Loneliness, extends deeply into many aspects of health and wellness. In older adults, the population that we focused on in this article, there's really compelling evidence that it can actually accelerate physiological aging. So it's associated with elevated blood pressure and atherosclerosis. There's an increased risk of coronary heart disease, stroke, and cardiovascular mortality. That's from the cardiovascular side of things. But it's also associated with things that really trouble older adults like functional impairment, depression, and dementia as well. So physicians that are, you know, looking at older adults and healthcare systems that are looking at older adults, if they only really focus on the traditional risk factors, you know, in the setting of cardiovascular health, like hyperlipidemia, and hypertension, there may be missed opportunities to impact factors that may have as great or even greater impact on a patient's health.
Moneeza Walji: So you mentioned some of the health impacts. I'm always interested to know if there's any mortality effects for you. Have you found in your research that it is a risk factor for mortality?
Rachel Savage: Yes, it is. So loneliness has long been recognized to affect quality of life and the mental health of individuals. But only recently do we have robust evidence that loneliness is an important predictor of longevity. So in 1988, House and colleagues published a seminal review in the Journal of Science that reviewed five prospective studies that demonstrated a link between social relationships or lack of social relationships, and an increased risk in mortality. This review has since been updated in published reports, in 2015, by Dr. Julianne Holt-Lunstad from Brigham Young University, and her and her colleagues conducted a meta analysis of 70 prospective studies involving more than 3 million individuals. And they found similarly that loneliness increased the likelihood of death by 26%. And I think to put this in context, and as Nathan had alluded to benchmarked against other risk factors, this magnitude of effect is equivalent to smoking 15 cigarettes a day, or being obese. So in short, loneliness is one of the most important modifiable risk factors for premature mortality. Some of the mechanisms that have been proposed for how loneliness might exert effects on our mortality are firstly, that being lonely increases our blood pressure, which can then lead to premature cardiovascular disease. Another hypothesis, and research supports this is that lonely people tend to have higher levels of cortisol circulating, so that stress response can lead to a cascade of events that then put the individual at higher risk for mortality. There's also another hypothesis that lonely individuals develop maladaptive health behaviors. And so that means maybe if you're feeling lonely, you might start to care less about other aspects in your life. For example, having a good diet, which is usually promoted by eating with others, for example. You may care less about being physically active, and things like that. And then the last mechanism is around sleep quality. So there have been a number of studies that have shown that individuals who are lonely actually experienced poorer sleep. And of course that's an important risk factor for mortality as well.
Nathan Stall: Just to echo what Rachel said. So that sort of distress that one experiences when they're lonely, that distress that stems from the feeling of not having as many social contacts as desired. It's been likened to sort of trigger the biological changes associated with the evolutionary fight or flight responses. And those are the four ways that Rachel highlighted in terms of health behaviors, cardiovascular activations, cortisol levels, and sleep, all disturbed by that fight or flight response that one may have.
Moneeza Walji: Wow. So the impact of loneliness is much more profound than I anticipated in older adults. Is it possible that because of this lack of contact, and this feeling of isolation, that some older adults may be going to their health care provider under a certain pretext, but really, they're just lonely and looking for some form of contact, even if it's just from their doctor?
Nathan Stall: Absolutely. So the United Kingdom has really been leading a lot of the way in terms of loneliness research, and they surveyed their general practitioners, and this is something we highlight in the article. And so more than 75% of the general practitioner surveyed in the United Kingdom reported seeing between one to five patients a day who visited primarily for loneliness. So it's important to recognize that patients may actually seek social contact through their health care visits. As someone who practices clinical medicine, this is something I see everyday and I think would resonate with a lot of the readers of the article and those who may be listening to the podcast. Patients often come in with nonspecific medical diagnoses. We ascribe them inappropriate diagnoses, like failure to cope or social visits. And it's really, it's likely that loneliness is one of the many contributors to these presentations that we often don't recognize, and we don't assess in great detail.
Moneeza Walji: So then when seeing older patients in the hospital or in the outpatient setting, is there a better way then to assess loneliness in these patients?
Nathan Stall: Yeah, absolutely. So the first thing is, we shouldn't assume we know who is or who is not lonely. As Rachel mentioned, you can have a wealth of social contacts, but still feel lonely. So the 2012 study that looked at loneliness and the health impacts of loneliness and older adults. They actually found that those who reported feeling lonely, most of the participants were living with others and more than 60%, who are lonely, were married. So don't make assumptions about who you think, is lonely and not lonely. The other thing is that there are several validated instruments available to clinicians and healthcare practitioners that will allow them to screen for loneliness in the clinical setting. The one we've highlighted is the three item loneliness scale. And this is three simple questions that you can ask your patients and the sum score can give you an indication of whether or not the patient is likely to be lonely or not.
Moneeza Walji: Do you mind just outlining those three questions?
Nathan Stall: Sure. So the first question is, how often do you feel that you lack companionship? All questions are scored on a scale of one to three where one is hardly ever two is some of the time and three is often. The second question is how often do you feel left out? And the third question is how often do you feel isolated from others? So respondents who score six to nine are considered lonely based on the three item loneliness scale.
Rachel Savage: We've decided to highlight this scale, there are, of course, other ones available. But there is some research from the UK Office of National Statistics that shows that asking the questions this way in this order, actually elicit a higher proportion of individuals that report being lonely than if you just outright directly ask patients how often they feel lonely. So I think in a clinical setting, some of these questions can be very sensitive. And I think asking them in this order in this way, it sort of eases into the conversation around loneliness and opens up the dialogue a little bit better than just outright asking a patient if they feel lonely.
Moneeza Walji: And just out of curiosity, are these scales validated in just the older population? Or is it the general population as well?
Rachel Savage: They've been validated in both and in a range of settings. So face to face, but also by telephone.
Moneeza Walji: That's an amazing tool to have as a clinician I think. Do we have any research or any data about loneliness in different cultures? Does loneliness manifest differently in different cultural or ethnic groups?
Nathan Stall: That's an interesting question. And I don't think we have great data on this. But we know that social structure plays a huge part in how people's social connectedness. So people from different cultures and different religions tend to particularly as people approach the end of their life have different living relationships in different ways that they connect to family. So there's the concept of filial piety, which is well sort of published in the literature about how some cultures more than others, take it upon themselves to live with their parents to have multi generational households. And I'm not sure that there's good data that that's necessarily protective. Because as we talked about, you know, it's not just the people you have around you, it's also that you have to be satisfied that the social connections you have around you are fulfilling your social needs and requirements. But I think it's an interesting question. A thought provoking question for research, particularly in Canada, when, as you point out, we do have such a multicultural society.
Rachel Savage: But there are certainly different groups of older adults that are at higher risk of being lonely or socially isolated. And that also includes newcomers to Canada, and immigrants as well. So people that can experience stigma and who, you know, are separated from their family, and may face discrimination. So that's an important consideration. And certainly there needs to be more research in these specific populations to understand the causes and what we can do to prevent and mitigate this from happening.
Moneeza Walji: So we've determined that loneliness based on your research is very common, and it's directly linked to declines in health and even mortality. What can doctors do for patients who they've identified are suffering from loneliness?
Nathan Stall: Yeah, so I think the first thing as you mentioned, the question is that it's important to look for, and it's important to recognize loneliness, I think this is the critical first step in this process. The second thing to recognize here is that loneliness is complex. So what causes loneliness for one patient may be completely different for another patient. And because of that, the interventions are going to be completely different for different sets of patients. So it's unlikely to be a one size fits all solution here. And the final thing to point out is that there really is a need for robust research on interventions focused on social risk factors to improve health outcomes. So we know from these epidemiological studies, that there are significant associations between health and loneliness. We need to know whether the interventions targeted at loneliness have the same impact on improving health outcomes. That being said, there are things that a clinician could focus on the individual level. And then I think there are sort of larger societal and public health interventions that need to occur to tackle loneliness. So on the individual level, when you're seeing a patient in the clinic, it's to understand what are the factors that are contributing to a person feeling lonely, and then to try and make a recommendation for interventions based upon this. So for one individual, it may be that they actually don't have the opportunity for social contact. That may be because there's a barrier for that social contact, and there's a need to get them transportation to get to places where they can have social contact. For other individuals that might be different. It might be that they have poor social skills, or they have maladaptive sort of social skills, and it might be engaging them in psychotherapy, or CBT to help modify that. One of the emerging tools, which has received a lot of attention that we've highlighted in our article is social prescribing. So social prescribing is an intention and structured way of connecting people with local non clinical services and supports in the community. So this has made news recently, not just here in Canada, but worldwide. So one of the examples that was actually featured in the CMAJ News in the past several months, was a program with the Montreal Museum of Fine Arts. So they're using social prescriptions where doctors provide a prescription to go to the Museum of Fine Arts, and they're using this as a way to help alleviate symptoms of anxiety. This model has been replicated also in Toronto as well with the galleries and museums here as well. So one of the thought leaders of this in the United Kingdom likened it to you know, just as a doctor's prescription can only really improve health if the patient has access to a well stocked pharmacy. Social prescribing can only really work if you have a well stocked community. So a lot of the time, the answer is for things to tackle loneliness lie in the community. So that being said, I think part of the issue, or part of the sort of larger issue here when we talk about tackling loneliness is what can we do at a population level? How do we organize society? How do we organize community so that we have a greater sense of social connection and a greater sense of being together to foster healthy relationships and to foster social connections? And I think that we really need to prioritize loneliness and social connectivity has critical social determinants of health.
Rachel Savage: And just to add, I think there are particular life events and transitions that occur within the lifespan of older adults in particular, that sort of place them at higher risk or make them more prone to loneliness. And as physicians, it's probably important to be attuned to those events occurring and to pay special attention to their patients at those transition points. So for older adults, in particular, a lot of causes for loneliness are related to losing a spouse or a close family member. Also declining health, which can impede mobility. And as Nathan had talked about, the ability to be connected and mobile within the community, and other transitions like retirement. So those may be sort of key times to interact with patients in particular, and to ask them questions about how they're feeling related to these transitions.
Moneeza Walji: I think that's a very good point as a health care provider to remain attuned to not only the health of the patient, but the entire milieu that they're living in is extremely important. I imagine there might be some stigma associated with loneliness as well. Why did you feel it was important to write this article for CMAJ and get the message out there about loneliness in older adults?
Rachel Savage: Yeah, I think as loneliness receives more attention in the broader media, it's becoming more normalized and socially acceptable and hopefully attitudes towards it are changing. I think for both Nathan and myself are interest in loneliness has really stemmed from speaking with older adults themselves. So Nathan in his capacity as a geriatrician and me through actual interviews with older adults. So last spring, we conducted a series of focus groups with members of the retired teachers of Ontario. And we have a long standing research relationship with the retired teachers of Ontario, through the Endowed Chair of geriatric medicine that they've awarded to Dr. Paula Rochon, who is our VP of research here at Women's College Hospital and a co author of this paper. And when we spoke with these retired educators, we learned that a key priority for them as they age is to stay socially connected, but we learned some of the struggles that they face in doing so. And that it can be really difficult when you face health challenges, when you lose a partner, or if you live in a remote region that doesn't have good accessibility to the services and connections that you wish you had. And I think when you hear some of the heartbreaking stories of, you know, older adults who feel alone, and maybe that their lives have lost some of their magic, once they lose a partner, it becomes really hard to ignore loneliness. And so certainly we wanted to profile the issue and bring greater awareness to it. And I think another reason we were interested in writing this is that there are many studies on the risks of loneliness and a range of health outcomes, but comparatively few that describe practically what can be done to help these individuals. So we wanted to provide clinicians, those who see lonely patients every day with this information so that they can begin to have an open dialogue with their patients and work towards addressing some of these issues.
Nathan Stall: Yeah, just to echo what Rachel said, you know, we're reading a lot about this, which is great. The former Surgeon General Vivek Murthy, under Barack Obama in the United States. He actually took this on as one of his key issues in his tenure as Surgeon General. I think this is all great. But sometimes, when there's sort of a groundswell of attention to an issue like this, and particularly when media and other sources are ascribing words like epidemic of loneliness. The sort of catastrophize-ation of language language can garner initial support and initial attention to the issue, but actually can cause sort of long term inaction in terms of targeting the underlying issue because it can just seem so overwhelming to people. So it's important to come back to the fact that loneliness is a key social determinant of health. We focus on older adults, but across the age span, in fact, and that it's a real target for sort of upstream health individuals as practitioners and it should be recognized as such and it should be acted upon as such.
Moneeza Walji: Thanks for both taking the time to talk to me today about this important topic.
Nathan Stall: Thanks for having us. We really appreciate it.
Rachel Savage: It was a pleasure.
Nathan Stall: I've been speaking with Dr. Nathan Stall, geriatrician at Sinai health system and a research fellow at Women's College Research Institute. And Dr. Rachel Savage. I'm a postdoctoral fellow at Women's College Research Institute in Toronto. To read the practice article they co-authored visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Moneeza Walji associate editor for CMAJ. Thank you for listening.