4.08 Loneliness

November 22, 2017

Presented by:

Dr Iain Wilkinson (Consultant Geriatrician East Surrey Hospital)

Dr Jo Preston  (Consultant Geriatrician St George’s Hospital)

 

Sip of MDTea

PDF here

 

Broadcast date: 21st November 2017

Sip of MDTea (pdf here)

 

 

 

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Episode 4.08 Show Notes (pdf here)

Loneliness

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Presented by: Dr Jo Preston & Dr Iain Wilkinson

Faculty: Wendy Grosvenor, Pam Trangmar, Gabor Szekely

Broadcast Date: 21st November 2018

 

Sip of MDTea points:

  1. Over 1 million older people say they are always or often feel lonely  
  2. Loneliness can be as harmful for our health as smoking 15 cigarettes a day
  3. People with a high degree of loneliness are twice as likely to develop Alzheimer’s as people with a low degree of loneliness
  4. 9% of older people feel trapped in their own home
  5. Nearly half (49%) of all people aged 75 and over live alone

 

Learning Outcomes

Knowledge:

  • To understand what loneliness is and how to identify

Skills:

  • To identify if a person is lonely
  • To help staff prepare and engage in constructive dialogue with older people experiencing loneliness in ways that can bring about positive change

Attitudes:

  • To understand that ageing may impact on loneliness
  • To understand how older people may view loneliness and the impact on their wellbeing

 

Definitions:

  1. Age UK:

 

  • “a subjective of lacking desired affection, closeness and social interaction with others.”

 

  • It is one of the major factors older people worry about.

 

2) Our Hidden Citizens (2015)  report describes loneliness as:

 

“a negative experience that involves painful feelings of not belonging and disconnectedness from others. It occurs when there is a discrepancy between the quantity and quality of social relationships that we want, and those that we have. Thus, loneliness is a subjective psychological perception.”

Goodman, A., Adams, A., and Swift, H.J. (2015) Hidden citizens: How can we identify the most lonely older adults? London: The Campaign to End Loneliness

 

Practical definition

“the unpleasant experience that occurs when a person’s network of social relationships is deficient in some important way, either quantitatively or qualitatively”

 

There are two components of loneliness can be distinguished:

  • emotional loneliness, stemming from the absence of an intimate relationship or a close emotional attachment (e.g., a partner or a best friend),
  • social loneliness, stemming from the absence of a broader group of contacts or an engaging social network (e.g., friends, colleagues, and people in the neighborhood).

Perlman, Daniel and L. Anne Peplau. 1981. “Toward a Social Psychology of Loneliness.” Pp. 31-43 in Personal Relationships 3: Personal Relationships in Disorder, edited by R. Gilmour and S. Duck. London: Academic Press

As such, loneliness can be felt even when surrounded by others.

  • Nearly half (49%) of all people aged 75 and over live alone
  • 9% of older people feel trapped in their own home  
  • 6% of older people (nearly 600,000) leave their house once a week or less
  • Over 1 million older people say they are always or often feel lonely  
  • Nearly half of older people (49% of 65+ UK) say that television or pets are their main form of company
  • Loneliness can be as harmful for our health as smoking 15 cigarettes a day
  • People with a high degree of loneliness are twice as likely to develop Alzheimer’s as people with a low degree of loneliness
  • People who took part in more health-maintaining and independence-maintaining behaviours were less likely to feel isolated and more likely to feel that their community was a good one to grow old in.
  • Nearly 200,000 older people in the UK do not receive the help they need to get out of their house or flat – 30% would like to leave more.

 

AGE UK Document on loneliness

 

The English Longitudinal Study of Ageing (2013) splits the concept of loneliness into 4 key elements:

  • Feeling lack of companionship
  • Feeling left out
  • Feeling isolated from others
  • Feeling in tune with other people

AGE UK Evidence review

English Longitudinal Study of Ageing

Loneliness has an impact on wellbeing and a range of personal circumstances such as poor health, living alone and lack of support network are contributing factors to loneliness. (Office for National Statistics (ONS) 2015, Age UK 2015).

 

Insights into loneliness, Older People and Well-being, 2015.  J. Thomas Measuring National Well-being (office for National Statistics)

As such in many ways “loneliness may be regarded as a “geriatric giant”…

Quick review here of the geriatric giants: Incontinence, Immobility, Instability, Impairment of intellect.  

Most of the GG’s are associated with loneliness

Lonely people use sedatives, sleeping pills and alcohol more than others. Furthermore, loneliness is associated with poor sight,hearing impairment, and sleeping problems, as well as with dietary inadequacies.

 

Loneliness among older people (2003) P Rputasalo, KH Pitkala

The Missing Million:

https://www.campaigntoendloneliness.org/the-missing-million/

 

How to Engage people in the assessment of loneliness?

***Nerd Alert***

There are a number of scales that can be used to assess loneliness all are quite quick:

  • The Campaign to End Loneliness Measurement Tool – 3 item
  • The De Jong Gierveld Loneliness Scale – 6 item scale (see below)  mix of emotional and soical aspects
  • The UCLA Loneliness Scale – 3 items again
  • Single-item ‘scale’.

There are pros and cons to these – nicely reviewed in a document by the campaign to end loneliness (link in show notes)

 

Summary of these scales can be found here::

https://www.campaigntoendloneliness.org/wp-content/uploads/Loneliness-Measurement-Guidance1.pdf

 

However some argue that there is little difference between subjective measure results and those obtained by asking the question ‘do you feel lonely?’

We think the key thing is to be inquisitive and ask the question…but who to ask? When?

What are the factors associated with loneliness?

The Hidden Citizens research identified a number of pathways into loneliness, which separate into internal and external factors:

Internal factors reflect the importance of understanding the person:

  • Their socio-economic characteristics
  • Values
  • Beliefs
  • Personality
  • Resilience
  • Self-esteem and confidence (or lack thereof)
  • The way they understand and relate to themselves and others

 

External factors reflect the importance of understanding the person in context:

  • What does their social world look like to them, and how is it experienced?
  • Does the person have supportive relationships with family and friends?
  • Are there local formal or informal social groups to which the person belongs or could belong?
  • Are there factors that prevent social connection, such as a lack of transport?
  • Has the person experienced a recent significant change in their life (this might include bereavement, moving house, retiring, physical ill health, stopping driving)?

 

When to think about loneliness?

Estimates of prevalence of loneliness tend to concentrate on the older population and they vary widely, with reputable research coming up with figures varying between 6 and 13% (up to 8.5 million people (given UK population of 65.5million) of the UK population being described as often or always lonely.

There may be other important factors at play,, but there is evidence, particularly from ELSA, that being alone (especially without a partner or spouse) is the major determinant of loneliness in the majority of older people in England.

 

  1. So older people…(from the GO project)
    • 7 per cent of older people were often lonely and 31 per cent sometimes lonely
    • 11–17 per cent were socially isolated in 2001 – these rates had remained relatively stable in the previous 50 years.

The Growing Older (GO) project had isolation and loneliness as one of its 25 themes.

GO programme website (Sheffield University/ ESRC):

www.growingolder.group.shef.ac.uk

GO programme, Findings 17 (available at:

www.growingolder.group.shef.ac.uk/ChristinaVic_F17.pdf

  1. Not just older people: loneliness is a dynamic concept and varies across the lifecourse
  2. Loss of friends
    1. having friends is a more important factor in warding off loneliness than frequent contact with these friends
  3. Poor health
  4. Reduced family contact
    1. contact with children is an especially effective antidote to loneliness. This appears to apply to cross-generational contacts in general, i.e. contact with children and young people as well as contact with one’s own (grown-up) offspring
    2. having children but not feeling close to any of them is associated with higher rates of loneliness than being childless
  5. Wealth
    1. there is a clear and significant correlation between low socio-economic status and loneliness
    2. although wealth is an important determinant of people’s life satisfaction its effects decline over 75

 

Analysis from the August 2011 ONS Opinions Survey, Well-Being Module

 

What do do about it? – Health promotion Interventions

Loneliness has complex causes – schemes designed to address it need to take other circumstances into account.

Targeting those – lower socio-economic groups, widowed, physically isolated, people who have given up driving, those with sensory impairment and the very old has proven most effective.

A systematic review of health promotion interventions shared several characteristics:

  • they were group interventions with a focused educational input,
  • or they provided targeted support activities;
  • they targeted specific groups;
  • they enabled some level of participant and/or facilitator control or consulted with the intended target group before the intervention;
  • they evaluated an existing service or activity or were developed and conducted within an existing service;
  • Physical activity interventions were also effective.

Ineffective interventions shared one characteristic, they were one-to-one activities conducted in people’s own homes.

Preventing social isolation and loneliness among older people : a systematic review of health promotion interventions. (2005) M. Cattan, M. White, J. Bond, A. Learmouth

A more recent review found similar things but was able to pull out key elements of potentially successful interventions.

  • Common characteristics of effective interventions were:
    • Developed with a theoretical basis
    • Offering social activity and/or support within a group format.
    • Interventions in which older people are active participants also appeared more likely to be effective.

Interventions targeting social isolation in older people: a systematic review. Dickens et al. BMC Public Health 2011, 11:647

 

For instance, one ESRC research study highlighted the crucial role of community centres for minority ethnic older women in ‘offering a meeting point for sharing identity, language, culture and experiences.’

 Women, Ethnicity and Empowerment in Later Life, Haleh Afshar, Myfanwy Franks and Mary Maynard, ESRC, 2002

Befriending services:

Jury is still out we feel but the services are low level and felt to be effective. One study of a national project found:

“The most important finding was that the service helped older people to gain confidence, re-engage with the community and become socially active again”

 

Cattan, Kime, Bagnall (2011) The use of telephone befriending in low level support for socially isolated older people – an evaluation Health Soc Care Community. 2011 Mar;19(2):198-206

 

A further review of 5 different services looked at what within the services was effective (what’s the recipe if you like).

  • Findings suggest that befriending offers some compensation for loss of elective relationships from older adults’ social networks, providing opportunities for emotional support and reciprocal social exchange through development of safe, confiding relationships.
  • Good conversational skills and empathy were the foundation of successful relationships within which commonalities were then sought.
  • Befrienders broadened befriendees’ perspectives on life (particularly among older adults in residential care).
  • Social engagement was a powerful mechanism of action, particularly in terms of connecting people back into the community, reinforcing meaningful social roles and connecting to a past life that had often been significantly disrupted by loss.

Lester et al. (2012) An exploration of the value and mechanisms of befriending for older adults in England Ageing & Society (32). 307-328

One such programme is the ‘Call in Time’ programme run by Age UK. It’s easy for people to sign up (or you to sign people up) and all the information is on the Age UK website.

‘Call in Time’ Age UK’

Men

Loneliness is reported by around 5-7 per cent of older men. Research has shown that social isolation, loneliness, and stressful social ties are common in men and associated with poor physical and mental health, higher risk of disability, poor recovery from illness and early death.

But finding social activities that are acceptable by older men is a challenge. Older men are less likely to join groups than older women (and that is where much of the intervention evidence is as we have seen)..

Participation in work-like activities may give men a sense of achievement and belonging. Studies demonstrate that successful interventions for which facilitate learning new skills, using/improving acquired skills, sharing knowledge with peers, promote a sense of accomplishment, and provide opportunities social engagement in a fun and engaging manner.

  • One example is a programme called ‘Men in Sheds’, which began in Australia and now has groups in the US, Canada, Ireland, and the UK:
    • The core elements of Men’s Sheds are that they are voluntary and social organisations providing hands-on activities for men aged 50 years of age and older who are co-participants in a defined space.
    • Sheds provide a space for older men to meet, socialise, learn new skills and take part in activities with other men.
    • Most Sheds are equipped with a range of workshop tools. Shed programmes aim to improve men’s physical, emotional, social and spiritual health and well-being.
    • The role of a Shed in encouraging and engaging men in informal adult learning activity is thought to be particularly important.
    • Some Sheds also provide health related information and ‘signpost’ men to relevant services. In almost all cases, they are tailored to their local context, rather than being standardised.

An evaluation of the UK pilots found:

  • Two broad categories of Shed experience emerged throughout the findings. Firstly, for some, Sheds present a pleasant and desirable hobby or activity; secondly, for others, particularly older men at risk of social isolation or emotional breakdown, they offer a vital support mechanism.
  • The overall Shed project appears to achieve its aims of reducing isolation and contributing to the mental well-being of older men through social contact and meaningful activity.  
  • Where target populations have been reached, there is evidence to suggest that Sheds provide important access to social support for those experiencing loneliness and isolation or depression following challenging life events.
  • The coordinator was identified as a vital factor in the success of all three Sheds but with differing levels of input. The coordinator role is thus integral to any consideration of the future management and sustainability of Shed projects.

Milligan, C. et al (2012) Evaluation of the Men in Sheds Pilot Programme Final Report, Faculty of Health and Medicine, commissioned by Age UK  

New technologies

A review of 17 studies in 2004 showed that: Further research into interventions using new technologies to reduce loneliness in older people is recommended.

Reducing loneliness amongst older people: a systematic search and narrative review Aging & Mental Health Vol. 18 , Iss. 6,2014

 

A survey of 222 ppl >55yrs showed:  that greater use of the Internet as a communication tool was associated with a lower level of social loneliness. But…a greater use of the Internet to find new people was associated with a higher level of emotional loneliness

Sum S et al (2008) Internet use and loneliness in older adults.Cyberpsychol Behav.11(2):208-11.

 

Locally age UK may well have access to the available resources or talk to your local social services who are likely to have a handle on what’s out there.

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

Curriculum Area
NHS Knowledge Skills Framework Suitable to support staff at the following levels:

  • Personal and People Development: Levels 1-3
  • Service Improvement: Level 1 – 2
Foundation curriculum Section

3 – 11

Title

Discharge planning

Core Medical Training Management of long term conditions and promoting self-care
GPVTS program Section 3.07 – Men’s Health – Depression

Section 3.10 – Care of people with mental health problems

ANP (Draws from KSF) 9 KSF Core2 Level 4

10 KSF HWB7 Level 4…they are an integral part of the CGA process

20 KSF HWB5 Level 4 – Demonstrates that they have a supportive role in helping patients to manage and live with illness.

 

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