Journal of Gerontological Nursing

Loneliness in the Elderly

Maura C Ryan, RNC, MSN; Joanne Patterson, RNC, MS

Abstract

Loneliness has become as much a part of Americana as turkey on Thanksgiving - particularly for older Americans.

Abstract

Loneliness has become as much a part of Americana as turkey on Thanksgiving - particularly for older Americans.

Fourth of July fireworks, Thanksgiving turkey, baseball games, hot dogs, and loneliness - all have prevailed in our society long enough to be regarded as "American traditions."1 The notion that loneliness has earned its place among these time-honored American traditions comes as no surprise to poets, philosophers, psychologists, and social scientists, all of whom have long recognized loneliness as a serious social problem.

It is estimated that in any given period, more than a quarter of all American adults feel painfully lonely.2,3 Even when loneliness is not actively experienced, there is reason to believe that it is widely feared. Many Americans have reported that the fear of a lonely old age far outweighs their fear of dying.4 Elderly Americans rank concerns about loneliness secondary only to their fears of crime, poor health, and inadequate income.5

The link between loneliness and old age in the minds of Americans underscores the thinking of those scholars and social scientists who view old age as "fertile ground for loneliness."4 Old age is characterized by multiple losses, many irreplaceable, which frequently occur together or in quick succession. Loneliness is frequently precipitated by loss.6 Mitigating factors such as spouse, close friends, belongings, and employment are often unavailable. In addition, decreases in income and physical functioning, together with the stigma of growing old in a youth-oriented society, all can contribute to feelings of loss, increased isolation, depression, grief, guilt, helplessness, and ultimately, loneliness.7,10

Although there is general agreement that adolescents are by far the loneliest group,11,14 gerontologists contend that the degree of loneliness experienced by the aged is grossly underestimated.4,7,8,11,15 It is generally believed that the scope of loneliness in the elderly has not only received insufficient attention, but its deleterious effects on the physical and mental health of UK elderly, especially those who are isolated, have been underrated.8

The number of elderly in our population continues to grow. Healthcare providers are already encountering increased numbers of the aged in their practice. It is urgent that the phenomenon of loneliness in die elderly be further explored and that existing knowledge about this potentially pervasive and devastating human affliction be shared and commonly understood. The purpose of this article is to examine current thinking related to 1) the definition of loneliness; 2) correlates of loneliness in the elderly; and 3) future research imperatives.

Definition

In contemporary literature, loneliness is commonly defined as "the unpleasant experience that occurs when a person's network of social relationships is deficient either qualitatively or quantitatively."16 In the elderly, who are prone to loss, the concepts of aloneness, solitude, isolation, and grief are often confused with loneliness. In order to gain understanding of the phenomenon of loneliness in the elderly, it is valuable to distinguish between what loneliness is and what loneliness is not.

The concepts of loneliness and aloneness are not necessarily related.17 Whereas loneliness is a negative emotion, being alone is neither necessary or sufficient to evoke feelings of loneliness.18,19 It is possible to be alone without being lonely or to be lonely in a crowd.16,20

Aloneness has an active nature and as such has a potential for constructive healing; loneliness, a passive experience, is ultimately destructive.21 It has been suggested however, that loneliness warrants control but not elimination since it serves as a feedback mechanism critical to survival, especially in the elderly.22

Solitude is a companion of aloneness.20 It is described as the state of being alone or secluded.23 Like aloneness, solitude does not carry the negative connotation of loneliness.

Isolation can be of either a social or emotional nature. It is defined as "knowing relatively few people who are probable sources of rewarding exchanges."24 Isolation does not constitute loneliness, but it does predispose to it.

Grief represents a normal, appropriate response to loss and generally results from a permanent loss such as death. It has been suggested that grief may be a severe state of loneliness since both grief and loneliness result from separation or loss.25

At present, no real theories of loneliness exist. Consequently, loneliness is commonly regarded as "one of the least satisfactorily conceptualized phenomena."26 The lack of a theoretical model to promote understanding and interest in the concept, together with man's inherent fear of loneliness, have been cited as explanations for the slow emergence of loneliness as a focus of study.27,28

Correlates of Loneliness in the Elderly

Much of what is currently known about loneliness in the elderly emanates from six major studies: Sheldon (1948), Townsend (1955), Townsend (1968), Tunstall (1966), Berg, et al (1981), and Kivett (1979). Essentially, these studies have yielded findings which help to predict which elderly are at greatest risk of facing loneliness and ultimately suffering its consequences. Sociological, physiological, and psychological correlates of loneliness in the elderly can be gleaned from this research.

Sociological Correlates - Sheldon 's findings indicated that those experiencing loneliness in a community sample tended to be relatively infirm, widowed or single males, in their 80s, who were living alone. It is interesting to note that all males in the study who reported being very lonely were widowers, while only diree quarters of the very lonely females were widows. This suggests the tendency of older men to rely exclusively on a wife as a confidant while women were able to rely on other women.

Additional data revealed that of those who were restricted in mobility, the bedfast were least lonely; they usually had a care giver in attendance. Sheldon also found that those who were restricted to their homes were the loneliest. He theorized that this group represented those who were well enough to be left alone but not well enough to leave home. However, Sheldon concluded that "loneliness is not the simple direct result of social circumstances but rather an individual response to an external situation to which other old people may react quite differently."29

The 1955 Townsend findings resembled those of Sheldon. He concluded that the "underlying reason for loneliness in old age was desolation rather than isolation."30 Townsend defined desolation as "being recently deprived of the companionship of someone who is loved either through death or separation;" he perceived isolation as the circumstance in which a person has few contacts with family and community.30 Perhaps Townsend's most important finding was that lifelong isolates were usually not lonely and that loneliness was not necessarily a reaction to extreme isolation.

In probably the most extensive and most often quoted study of loneliness in the elderly, Townsend31 found that although relatively few elderly reported frequent loneliness, occasional loneliness was quite common. Loneliness was found to be much more related to loss than to enduring isolation. The loneliest by far were the widowed, especially the recently widowed. Loneliness was more intense if the widowed were childless or if contact with offspring was infrequent.

Tunstall32 found slightly higher percentages of elderly who reported loneliness than Townsend. In addition, he found a strong correlation between isolation and self-reported loneliness. Females reported more loneliness than men. Elderly who had infrequent contact with their children were more lonely than married persons without children.

Berg, Mellstrom, Persson, et al found that 12% of the males and 25% of the females in their homogeneous sample of more than 1000 community-based Swedish elderly experienced loneliness "sometimes" or "often." Feelings of loneliness were linked to living alone, lack of personal contact with others, and widowhood. Loneliness was found to be prevalent among widows (43%) and widowers (44%). Six percent of married males and 15% of married females reported being lonely, with the higher figure among females possibly related to the greater number of wives caring for older, ill, or disabled spouses.

Their findings also revealed that too little subjective contact with friends and children resulted in loneliness and that no relationship existed between loneliness and educational level or previous outside employment. In addition, lonely females more often than males reported discontent with living conditions and less availability of an automobile. It was concluded by the researchers that the most important factors associated with feelings of loneliness in the elderly were widowhood, lack of contact with children and old friends, and above all, the loss of a spouse.

The findings of Berg, et al are not markedly different from those of the other researchers relative to either the extent of loneliness in the elderly or indicators of those who are at risk . This is relevant since the social system is supportive in Sweden and the group was homogeneous. Economics, education, and availability of a car were additional variables measured. The former two variables were not found to be associated with loneliness. This may be related to the social assistance available to the elderly and the higher educational level in Sweden. Lack of a car contributes to isolation which could lead to loneliness.

In his study of 418 rural American elderly, Kivett34 found that 15.5% reported frequent loneliness and 41.8% reported occasional loneliness. The most important factors related to loneliness were adequacy of transportation, widowhood, availability of organized social activity, and frequency of phone calls.

The higher incidence of loneliness reported by the elderly in Ki veil 's síudy probably reflects the rural sample. This is supported by the emergence of adequacy of transportation as the most significant correlate of loneliness. The availability of an automobile was also a correlate of loneliness in the findings of Berg, et al. Kivett 's findings also concur with the former findings relative to widowhood and loneliness in old age. However, those findings do not discriminate between recent and longstanding widowhood.

A sociological profile of the lonely elderly person who resides in the community emerges from these studies. In general, this person has recently lost his or her spouse, is childless or has infrequent contact with children, and does not have easy access to transportation.

Five of the six studies found that females tended to be lonelier than males, although widowers were found by Sheldon to be the loneliest group of all.

Physical Correlates - Townsend's31 findings demonstrate a significant relationship between physical incapacity and loneliness in the elderly. This relationship existed regardless of living arrangements (ie, living alone or with others). Townsend's findings also indicate a strong link between self-evaluation of poor health and loneliness. More older people who rated their health as poor or fair reported that they were lonely irrespective of living arrangements.

Tunstall's32 findings are congruent with Townsend's. In his study, selfreported loneliness rose in direct proportion to physical incapacity for both males and females. Loneliness was reported by 13% of the males with no physical incapacity but by 43% of those males affected. Similarly, loneliness was reported by 25% of the females with no physical incapacity but by 52% of those females affected.

The findings of Berg, et al33 yield more specific information relative to the physical correlates of loneliness in the elderly. Impaired hearing and vision were not found to be related to loneliness, however few visually or hearingimpaired subjects were included in the sample.

Both lonely males and females complained of multiple psychosomatic illnesses, probably indicative of anxiety. Negative self-assessments of health, fatigue, physician visits, and medication consumption were also more prevalent among lonely rather than nonlonely subjects.

Kivett's34 findings also support the relationship between poor health status and loneliness in the elderly. The primary distinction between the never lonely and the often lonely was found to be physical or social loss, specifically either loss of health or loss of spouse. In addition, his findings indicate that the older adult's perception of health status has more relative importance to feelings of loneliness than actual physical limitations. From this Kivett concluded that "perceived poor health predisposes older adults to loneliness through social and emotional isolation."34

Finally, in contrast to Berg, et al, Kivett noted a significant relationship between adequacy of vision and loneliness in his sample of rural elderly. Several explanations for this finding are plausible, including the obvious one that he may have surveyed a larger number of visually impaired subjects. Also, reading and television viewing are popular activities among rural populations and both require good eyesight.

In summary, existing research suggests that physical variables have considerable influence on self-reported loneliness in the elderly. However, selfevaluation of poor health is a stronger correlate of loneliness in the elderly than actual physical disability.

Psychological Correlates - It is generally acknowledged that loneliness is a psychological phenomenon having powerful implications for mental health and illness.27,35,36 Yet, the relationship between loneliness and psychological distress in the elderly has received little attention.

Since the findings from studies of loneliness in the elderly yield little information relative to specific psychological correlates, findings from studies of other populations are also presented with the understanding that they require verification in the elderly.

An incidental discovery made by Townsend31 in his study of loneliness in the elderly was that in the countries from which his sample was drawn, suicide rates rose with increasing age. The highest suicide rate occurred among men in late life. Townsend suggested that loss of spouse, retirement, loss of physical and mental agility, isolation, desolation, and loneliness were all implicated.

Berg, et al33 found that one of the most important factors associated with loneliness in the elderly was depression. In addition, lonely widows were significantly more likely to have a prior history of "mental troubles." Lonely respondents of both sexes demonstrated greater neurotic ism than their nonlonely counterparts.

In younger populations, signs and symptoms of loneliness have been found to masquerade as alcoholism,8,37,38 over-eating,27,39 drug dependency and depression,10,40,41 or all of the above.6,42,43 A strong correlation between loneliness and anxiety also has been reported,6,27,44,45 as well as a correlation between loneliness, hostility, and submissiveness in college students.46

It is generally agreed that widowhood is a major cause of loneliness in adulthood, regardless of age.17,31-33,47,48 Childless widows suffer lower overall well-being and more loneliness than widows with children.48,49 These findings are consistent with those of Townsend and Tunstall in their studies of loneliness in the elderly.

Among those over 60, forced separation has been identified as a major reason for loneliness.14 When the separation is imposed by social or geographical conditions, intense feelings of loneliness result.50 Desperation, depression, boredom, and self-pity are most frequently associated with loneliness in this situation.14

Widowhood, depression, and forced separation have particular relevance as psychological correlates of loneliness in elderly populations. Evidence also implicates multiple psychosomatic complaints, anxiety, alcoholism, overeating, and drug dependency as correlates of loneliness in younger populations. Further investigation of all of these variables as they relate to the elderly is clearly indicated.

Summary

To date, most research relative to loneliness in the elderly has been conducted in the community and indicates that females complain of loneliness more frequently than men. The loneliest group of all appears to be those who have lost their spouse within the previous five years, suggesting that loneliness is much more related to loss than to isolation. Childless widows and those who have infrequent contact with their children are the loneliest among the widowed. Lack of transportation has been found to contribute to loneliness in rural populations.

A consistently strong relationship among physical incapacity, self-evaluation of poor health , and loneliness in the elderly has been reported. Since incapacity leads to decreased social contact, these findings are understandable. A correlation between sensory deficits and loneliness also has been established.

Loneliness has been linked to an observed pattern of increased suicide rates among the aged. Depression also has been implicated as a precipitant of loneliness, but the relationship remains unclear. Existing knowledge about loneliness in the elderly represents only a beginning. Further research related to this topic is vital.

Future Research Imperatives

Upon review of the research to date on loneliness in the elderly, three important foci for future investigations emerge: 1) loneliness among the institutionalized and acutely ill aged; 2) caregiving practices which either precipitate or mitigate loneliness in the elderly; and 3) instrumentation.

Since most of the research on loneliness in the elderly thus far has involved community-based samples, an obvious gap exists in knowledge about loneliness among the aged who are hospitalized, institutionalized, critically ill, or dying. These circumstances result in separation, loss, and stress, all suspected correlates of loneliness. Currently, 40% of the 1.3 million hospital beds in America are occupied by elderly. There are 23,000 nursing homes in this country and one out of five people over the age of 65 will experience nursing home placement prior to death.51 It is crucial that the loneliness phenomenon be explored among such a large and possibly vulnerable population.

Existing loneliness research focuses on the aged themselves. Since large numbers of the elderly are subject to frequent contact with healthcare providers, it is also of value to examine care-giving practices which may precipitate or mitigate the loneliness experience in this age group.

Historically, instrumentation has been a problem in loneliness research. Only survey-type studies have been conducted to examine loneliness in the elderly. The development of the Revised UCLA Loneliness Scale44 may herald a new approach to the study and measurement of loneliness in all age groups. This tool has already been deemed a valid indicator of loneliness among college students.12,42 Establishing its validity and reliability as an indicator of loneliness among the elderly would be a worthwhile undertaking.

It is imperative that future research, relative to loneliness in the elderly, ultimately provide information needed for early detection and interventions aimed at reducing the duration and intensity of the loneliness experience. If healthcare providers want to work effectively with the aged, the loneliness phenomenon must be better understood and addressed.

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10.3928/0098-9134-19870501-04

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