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Psychotherapy Casebook

Old Age and Loneliness

Editor’s Note

Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Meyer is an assistant professor of general internal medicine at the Medical University of South Carolina and medical director of Home Based Primary Care at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina. Dr Schuyler is a psychiatrist with a part-time private practice and a part-time job on the Geriatric Unit at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (deans915@comcast.net).

Potential conflicts of interest: None reported.

Disclaimer: The views herein are those of the authors and do not necessarily reflect the views of the Veterans Administration.

Old Age and Loneliness

As our nation ages, health care providers and many of their elderly patients are working to minimize risks of chronic illness and debilitation. Blood pressure and cholesterol control, cancer screening, and exercise are interventions patients expect to hear about. However, other less-recognized health risks also need attention. Loneliness and social isolation are common among the elderly and predict declining health and poor quality of life.

CASE PRESENTATION

Mr A is a 75-year-old man who has lived alone in a wooded rural area since his wife’s death several years ago. His past medical history includes orthostatic hypotension and unsteadiness, due to autonomic dysfunction, and peptic ulcer disease. Although he is independently competent in most activities, Mr A prudently stopped driving several years ago because of unsteadiness and fall risk due to his orthostatic hypotension. He relied on a paid caregiver or his daughter for transportation. When his daughter left on an extended business trip and his paid caregiver married and was less available, his social network became very thin.

During this period, Mr A took his medication erratically, seemed strident and impulsive when seen by visiting nurses, fell more often, and finally called a suicide help line reporting that he was contemplating shooting himself. He was briefly hospitalized. During the psychiatric intake interview, Mr A reported feeling lonely and a recent lack of motivation. His daughter was stunned by these events. “He has never done anything like this before,” she said, and resolved to re-engage in her father’s daily life. She also promised to manage the paid caregiver visits or to replace the caregiver. Since renewed attention was given to Mr A and his care, there has been no further mention of, or acts of, self-harm. There have been no recent falls.

DISCUSSION

Loneliness and social isolation result in numerous negative health consequences. In a 3-year study of aging people,1 loneliness was found to be a significant contributor to poor self-rated health scores. The study also found that self-rated health improved when loneliness lessened.1 Loneliness also affects mobility. Similar to approximately 40% of his fellow octogenerians, Mr A had experienced motor function decline associated with an age-related condition. Loss of motor function is a common consequence of aging and is associated with adverse health consequences. Among community-dwelling older persons, feeling alone and being alone are associated with more rapid further motor decline.2 The association of rapid motor function decline and loneliness persists after controlling for depression, cognitive impairment, and baseline disability.2 For 823 cognitively normal senior citizens who were tested annually, the risk of Alzheimer’s dementia was more than doubled in lonely elderly individuals compared to those who were not lonely.3 Loneliness is also closely associated with depressive symptoms and may work in synergy with depression to diminish well-being in older people.4

To decrease loneliness and social isolation, multiple intervention strategies have been created and studied among the elderly. Results suggest that a deeper understanding of the nature of loneliness in any individual’s situation is important in order to achieve a successful intervention.5 Is the problem actual social isolation like that of Mr A? Or perhaps loneliness is due to unfulfilled expectations for existing social interactions, like the perfunctory visits an elderly relative may receive in a nursing home or the hollow togetherness of the weekly nursing home bingo game. Sometimes the problem is defined by the lonely person’s own maladaptive social cognitions.

Elderly individuals may be able to describe their feeling of loneliness and suggest remedies for it. The following suggestions were inspired by interviews with 19 older people who each experienced some degree of loneliness.6 Family contacts can gain meaning when the older person performs tasks for family members, especially meal preparation. With more debilitated elderly relatives, transforming a nursing home visit into shared tea time, cocktail time, or a dinner out may also help transform the participants’ relationships. Offering a wide range of activities for a spectrum of abilities and tastes will increase the opportunities for an elderly individual to find like-minded people and an enjoyable project. Reading is a solitary, but active, pastime that allows the individual to stay in contact with the larger world, and it can diminish loneliness through a sense of connection. Gardening can provide a function and purpose, and there can be long-term satisfaction in watching the planned and created plot flourish. The full or shared responsibility of taking care of a pet can also result in satisfaction and companionship.

Planned activities for groups of elderly people are part of most senior center and nursing home schedules. However, many elderly individuals are reluctant to participate. On our nursing home unit, every attempt is made to create the ambience of a community. As a community, there are expected to be friendships and frequent communication among the 20 residents, as well as contact between residents and staff. When attention is called to a patient’s relationship with other residents, the response may be, “They are all demented, so we have very little in common. I don’ t talk with anyone.” When a resident remains isolated from others, he/she often does not participate in the community activities offered. This lack of participation, combined with minimal social contacts, can produce a picture of social isolation little different from that encountered in aging outpatients.

SUMMARY

Loneliness among the elderly is common, both in outpatient and inpatient settings. Although loneliness escapes listing in the DSM-IV and does not appear on most primary care intake questionnaires, it is associated with depression, poor health status, decreased mobility, and cognitive decline. Problem-solving strategies to combat loneliness are important clinically. Health status can improve if loneliness is diminished through companionship, satisfying family relations, and activities with a sense of purpose.

REFERENCES

1. Nummela O, Seppänen M, Uutela A. The effect of loneliness and change in loneliness on self-rated health (SRH): a longitudinal study among aging people [published online ahead of print November 17, 2010]. Arch Gerontol Geriatr. PubMed doi:10.1016/j.archger.2010.10.023

2. Buchman AS, Boyle PA, Wilson RS, et al. Loneliness and the rate of motor decline in old age: the Rush Memory and Aging Project, a community-based cohort study. BMC Geriatr. 2010;10(1):77. PubMed doi:10.1186/1471-2318-10-77

3. Wilson RS, Krueger KR, Arnold SE, et al. Loneliness and risk of Alzheimer disease. Arch Gen Psychiatry. 2007;64(2):234-240. PubMed doi:10.1001/archpsyc.64.2.234

4. Cacioppo JT, Hughes ME, Waite LJ, et al. Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychol Aging. 2006;21(1):140-151. PubMed doi:10.1037/0882-7974.21.1.140

5. Masi CM, Chen HT, Hawkley LC, et al. A meta-analysis of interventions to reduce loneliness [published online ahead of print August 17, 2010]. Pers Soc Psychol Rev. doi:10.1177/1088868310377394 PubMed

6. Pettigrew S, Roberts M. Addressing loneliness in later life. Aging Ment Health. 2008;12(3):302-309. PubMed doi:10.1080/13607860802121084

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