March/April 2018

Clinical News: Elders' Loneliness Constitutes a Health Problem
By Laurie A. Theeke, PhD, FNP-BC, GCNS-BC
Today's Geriatric Medicine
Vol. 11 No. 2 P. 27

Loneliness is a prevalent problem for older adults, with loneliness being reported by as many as 31% of older adults globally and 17% of American midlife and older adults.1,2 Loneliness is linked to psychological and physiological health problems for older adults. It has been reported as a major predictor of depressive symptoms,3-5 functional decline,6,7 and mortality in adults.8,9 Loneliness exerts this power because as a biopsychosocial stressor it elicits a neuroendocrine stress response, which impacts the human ability to maintain homeostasis, thereby contributing to adaptations that negatively impact health.10-12

Chronically lonely individuals have been reported to have increases in proinflammatory cytokines,11 C-reactive protein,13,14 and fibrinogen,3,12,14 all of which contribute to cardiovascular disease. Loneliness has therefore been linked to high blood pressure, coronary heart disease, stroke, cognitive decline, depressive symptoms, symptoms of anxiety, and metabolic syndrome in midlife and older adults.14-23 Finally, loneliness should become a health priority because it is a known contributor to poor sleep habits, which influence human physiological restorative capacity and immune status.24-27

Lonely older adults have reported experiencing social stigma with loneliness and report negative emotional responses to loneliness such as worry, anger, fear, and sadness and social responses such as self-isolation and diminished community involvement.28,29 The experience of loneliness and these responses to it can prompt a downward spiral in health and functional ability, leading to mortality.9

Foundational Studies of Elders' Loneliness
Our research team has completed multiple studies of loneliness. Initially we studied data from the Health and Retirement Study, which highlighted the prevalence of loneliness (19.3%) and identified predictors and health outcomes associated with loneliness for older adults living in the United States.30 We determined predictors of loneliness to be marital status, poor self-report of health, total number of chronic illnesses, functional impairment (gross and fine motor impairment), and living alone.31 We then analyzed data for 13,812 (5,349 male) US adults aged 50 and older for prevalence (17%), predictors, and health outcomes associated with loneliness. In this group, low educational level and low income were also predictive of loneliness, and negative health outcomes associated with loneliness included less physical activity, more tobacco use, a greater number of chronic illnesses, higher depression scores, and greater than average number of nursing home stays.2 This work was foundational and provided evidence about the significance of loneliness as a health problem requiring intervention.

LISTEN for Older Adults' Loneliness
As a result of this work, we developed Loneliness Intervention Using Story Theory to Enhance Nursing-Sensitive Outcomes (LISTEN), a novel intervention for loneliness, and completed the first randomized trial, which included measures of feasibility, acceptability, and effectiveness of LISTEN on loneliness, physiological stress response, psychosocial functioning, and chronic illness measures.6,32,33 The five core topics of LISTEN include the following: belonging over the life course; past and current relationships; place in community; meaning of loneliness; and coping with loneliness. Thinking about and discussing these core topics helps lonely people identify what matters most in their personal experience of loneliness, derive a personal meaning of loneliness and belonging, sort out positive and negative personal relationships, brainstorm ways of participating in communities, come to terms with the personal challenges of loneliness, and identify potential new ways of coping with loneliness.

Results from the preliminary trial of LISTEN indicate a continued decline in mean loneliness scores (as measured by the UCLA Loneliness Scale) for lonely participants of LISTEN groups (p=0.029) while those in attention control education group sessions experienced a rise in loneliness scores beginning six weeks after the final session. The intervention received overwhelmingly positive evaluations from participants for acceptability, and there was no attrition in the intervention group.33 Participants in the LISTEN groups also reported fewer depressive symptoms, measured significant decline in systolic blood pressure, and reported enhanced overall social support 12 weeks after the last LISTEN session, potentially indicating that participating in LISTEN resulted in thinking changes or action for social support.

What Providers Should Know About Loneliness and LISTEN
Health care providers should recognize that loneliness is prevalent and that it can be amenable to intervention. Making loneliness a health priority would include a recommendation for screening for loneliness as part of excellence in primary and geriatric care. This would be an appropriate first step for a national health initiative on loneliness. Once the problem is recognized, the stigma related to loneliness will be reduced, and providers can have open conversations with patients about loneliness and its impact on health. Though larger trials are needed, LISTEN has the potential to be delivered via technology, rendered by trained laypersons in the community, implemented in long term care settings, and delivered to individuals. The ultimate goal is for LISTEN to be considered as a reimbursable therapy to treat loneliness in older adults.

— Laurie A. Theeke, PhD, FNP-BC, GCNS-BC, is an associate professor at the West Virginia University Schools of Nursing and Medicine. An alumna of the Robert Wood Johnson Nurse Faculty Scholars Program, which funded the initial development and pilot testing of LISTEN, she has developed a focused program of research on the problem of loneliness. As a clinical specialist in gerontological nursing, her clinical experience includes more than 15 years of practice solely in geriatrics.

References
1. Steed L, Boldy D, Grenade L, Iredell H. The demographics of loneliness among older people in Perth, Western Australia. Australas J Ageing. 2007;26(2):81-86.

2. Theeke LA. Sociodemographic and health-related risks for loneliness and outcome differences by loneliness status in a sample of U.S. older adults. Res Gerontol Nurs. 2010;3(2):113-125.

3. Mezuk B, Choi M, DeSantis AS, Rapp SR, Diez Roux AV, Seeman T. Loneliness, depression, and inflammation: evidence from the Multi-Ethnic Study of Atherosclerosis. PLoS One. 2016;11(7):e0158056.

4. Holwerda TJ, van Tilburg TG, Deeg DJ, et al. Impact of loneliness and depression on mortality: results from the Longitudinal Ageing Study Amsterdam. Br J Psychiatry. 2016;209(2):127-134.

5. Cacioppo JT, Hughes ME, Waite LJ, Hawkley LC, Thisted RA. Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychol Aging. 2006;21(1):140-151.

6. Theeke LA, Mallow JA, Moore J, McBurney A, Rellick S, VanGilder R. Effectiveness of LISTEN on loneliness, neuroimmunological stress response, psychosocial functioning, quality of life, and physical health measures of chronic illness. Int J Nurs Sci. 2016;3(3):242-251.

7. Shankar A, McMunn A, Demakakos P, Hamer M, Steptoe A. Social isolation and loneliness: prospective associations with functional status in older adults. Health Psychol. 2017;36(2):179-187.

8. Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med. 2012:172(14):1078-1083.

9. Luo Y, Hawkley LC, Waite LJ, Cacioppo JT. Loneliness, health, and mortality in old age: a national longitudinal study. Soc Sci Med. 2012;74(6):907-914.

10. Cacioppo JT, Cacioppo S, Capitanio JP, Cole SW. The neuroendocrinology of social isolation. Annu Rev Psychol. 2015;66:733-767.

11. Hackett RA, Hamer M, Endrighi R, Brydon L, Steptoe A. Loneliness and stress-related inflammatory and neuroendocrine responses in older men and women. Psychoneuroendocrinology. 2012;37(11):1801-1809.

12. Steptoe A, Owen N, Kunz-Ebrecht SR, Brydon L. Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology. 2004;29(5):593-611.

13. McDade TW, Hawkley LC, Cacioppo JT. Psychosocial and behavioral predictors of inflammation in middle-aged and older adults: the Chicago Health, Aging, and Social Relations Study. Psychosom Med. 2006;68(3):376-381.

14. Shankar A, McMunn A, Banks J, Steptoe A. Loneliness, social isolation, and behavioral and biological health indicators in older adults. Health Psychol. 2011;30(4):377-385.

15. Hawkey LC, Masi CM, Berry JD, Cacioppo JT. Loneliness is a unique predictor of age-related differences in systolic blood pressure. Psychol Aging. 2006;21(1):152-164.

16. Momtaz YA, Hamid TA, Yusoff S, et al. Loneliness as a risk factor for hypertension in later life. J Aging Health. 2012;24(4):696-710.

17. Thurston RC, Kubzansky LD. Women, loneliness, and incident coronary heart disease. Psychosom Med. 2009;71(8):836-842.

18. Mayor S. Loneliness is associated with higher risk of stroke and heart disease, study finds. BMJ. 2016;353:i2269.

19. Lam CLM, Yu J, Lee TMC. Perceived loneliness and general cognitive status in community-dwelling older adults: the moderating influence of depression. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2017;24(5):471-480.

20. Segel-Karpas D, Ayalon L, Lachman ME. Loneliness and depressive symptoms: the moderating role of the transition into retirement. Aging Ment Health. 2018;22(1):135-140.

21. Barg FK, Huss-Ashmore R, Wittink MN, Murray GF, Bogner HR, Gallo JJ. A mixed-methods approach to understanding loneliness and depression in older adults. J Gerontol B Psychol Sci Soc Sci. 2006;61(6):S329-S239.

22. Muyan M, Chang EC, Jilani Z, Yu T, Lin J, Hirsch JK. Loneliness and negative affective conditions in adults: is there any room for hope in predicting anxiety and depressive symptoms? J Psychol. 2016;150(3):333-341.

23. Whisman MA. Loneliness and the metabolic syndrome in a population-based sample of middle-aged and older adults. Health Psychol. 2010; 29(5):550-554.

24. Segrin C, Burke TJ. Loneliness and sleep quality: dyadic effects and stress effects. Behav Sleep Med. 2015;13(3):241-254.

25. Kurina LM, Knutson KL, Hawkley LC, Cacioppo JT, Lauderdale DS, Ober C. Loneliness is associated with sleep fragmentation in a communal society. Sleep. 2011;34(11):1519-1526.

26. Luanaigh CO, Lawlor BA. Loneliness and the health of older people. Int J Geriatr Psychiatry. 2008;23(12):1213-1221.

27. Hawkley LC, Capitanio JP. Perceived social isolation, evolutionary fitness and health outcomes: a lifespan approach. Philos Trans R Soc Lond B Biol Sci. 2015;370(1669).

28. Theeke LA, Mallow J, Gianni C, Legg K, Glass C. The experience of older women living with loneliness and chronic conditions in Appalachia. Rural Ment Health. 2015;39(2):61-72.

29. Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(13):1009-1016.

30. Health and Retirement Study: a public resource for data on aging in America since 1990. University of Michigan website. http://hrsonline.isr.umich.edu/

31. Theeke LA. Predictors of loneliness in U.S. adults over age sixty-five. Arch Psychiatr Nurs. 2009;23(5):387-396.

32. Theeke LA, Mallow JA. The development of LISTEN: a novel intervention for loneliness. Open J Nurs. 2015;5(2):136-143.

33. Theeke LA, Mallow JA, Barnes ER, Theeke E. The feasibility and acceptability of LISTEN for loneliness. Open J Nurs. 2015;5(5):416-425.