APPROXIMATELY 617 million adults were age 65 or older as of 2015, translating to 9% of the global population. By 2030, the population of older adults is expected to reach 1 billion (12%); by 2050, this is projected to increase globally to 1.6 billion (17%).1-3 As of 2016, older adults made up 15.2% of the US population.4 Generally, people are living longer due to factors such as improved health and dental care, immunizations, and better nutrition. Environmental changes such as safer housing, plumbing, and better air and water quality have also improved health outcomes.1-3
According to the World Health Organization, health refers to an individual's "state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."5 As such, living longer does not always equate to a high quality of life.6 Depression and decreased enjoyment of life are common in older adults who are lonely and experiencing chronic illnesses.6 This article discusses strategies to help older adult patients cope with loneliness, social isolation, and chronic illness in order to improve their health and quality of life.
Loneliness in older adults
Loneliness is broadly defined as feelings of sadness and despair that may result from being cut off from others or without company. In the literature, loneliness is described as a subjective feeling of distress from being alone.7,8 Individuals may feel alone with or without company. Like younger people, older adults are social beings who require intellectual stimulation and intimacy to enjoy a sense of belonging and to feel valued.7,8
Loneliness and social isolation are two distinct but interrelated processes.2,7,8 Social isolation is characterized as an objective physical separation from other people; for example, older adults who live alone and cannot socialize due to mobility limitations.7,8 Social isolation may also occur secondary to chronic illness, leading to the development of loneliness.2,7,8
Loneliness increases anxiety and is associated with feelings of powerlessness and a decreased sense of self-worth, as well as pulmonary, cardiovascular, endocrine, immune, musculoskeletal, and psychiatric pathologies in older adults, mediated in part through systemic stress responses.4,9-11 For example, older adults with diabetes may experience hyperglycemia from stress associated with loneliness. Similarly, isolated older adults may be less active, which can lead to obesity, decreased muscle mass, and increased fall risk. Maladaptive coping mechanisms such as smoking, substance use, overeating, and inactivity can also contribute to the development of these pathologies.4,9,10
Approximately 25% of adults age 50 and older experience loneliness and isolation.12 Older adults may have difficulty socializing while experiencing pain, fatigue, sleep disturbances, or problems with mobility, as well as psychosocial issues such as depression or the death or separation from a spouse or partner. Loneliness may be a separate diagnosis contributing to mortality in this population, but further research is needed.7,8
Loneliness and chronic illness
According to the National Council on Aging (NCOA), 80% of older adults in the US have one or more chronic illnesses, and approximately 77% have two or more.1 In older adults, chronic illness may lead to loneliness and social isolation. Older adults experiencing complications from physical illness and immobility are more likely to stay home rather than socialize, causing feelings of isolation and loneliness. They may also experience cognitive decline and dementia.10,13 However, older adults who are active and have regular social interactions have a lower incidence of various chronic illnesses.10,14 (See Major chronic conditions in older adults.)
Social isolation has become more common among older adults.15 Social loneliness refers to a lack of community or friends, while emotional loneliness refers to a lack of strong connections to family.8,15 In a society that values physical appearance and beauty, older individuals may isolate themselves due to fears surrounding these youthful expectations (for example, in response to a loss of muscle tone and/or skin elasticity and turgor).16 A supportive social network helps protect older adults from depression and anxiety, decrease morbidity, and increase their lifespan.15 Consistent social interactions also decrease the risk of cognitive dysfunction and dementia in this population.6,11,17
According to the NCOA, patient falls account for most fractures and traumatic brain injuries in older adults.1,18 Chronic disease predisposes older adults to falls as does a sedentary lifestyle, which leads to loss of balance and weakness. Regular physical activity such as walking, swimming, or yoga can reduce social isolation, especially when these activities involve other people.11 However, isolation and loneliness may prevent older adults from participating in exercise and other activities outside the home.11 In fact, many consequences of loneliness are also risk factors. For example, low activity may be both a risk factor and a complication.11
Variables that contribute to social isolation in the chronic illness-loneliness continuum may include hypertension, dyslipidemia, hyperglycemia, physical inactivity, obesity, alcohol or tobacco use, retirement status, poverty, and healthcare disparities that limit access to care.1,4,16 Complications from heart disease, cancer, stroke, and diabetes account for approximately 66% of annual deaths among older adults in the US.1 Arthritis and visual and hearing impairments also represent major problems for this patient population and often contribute to social isolation.1,4,16,19
When chronic illness impairs the ability to perform activities of daily living (ADLs) or instrumental ADLs, older adults face challenges related to walking, toileting, bathing, navigating stairs, preparing meals, and driving.3,13 Chronic illness may also interfere with interactions with friends and family and in sexual intimacy with a romantic partner.3,10
Many older adults outlive their spouse, relatives, and friends and may be separated from their children. Losing a home or income contributes to social isolation.4,13,20 Additionally, older adults who belong to the LGBTQ+ community may be at an increased risk for loneliness because they may be single, without children, and coping with societal stigmas regarding sexual orientation or identity.21
As of 2016, approximately 12.3 million older adults live alone in the US, which can lead to social isolation.4 Men may be more susceptible to loneliness and isolation than women because women typically have larger support systems.18
Living alone often means taking care of a family home, and the inability to do so can lead to a loss of independence and self-esteem in older adults.11,15,22 Those who live alone are also at an increased risk for nutritional deficiencies due to a loss of socialization often associated with mealtimes.23
Approximately 25% of older adults suffer from depression, anxiety disorder, or dementia in the US, and about 5 million older adults have substance use disorders.1 In addition, adults over age 85 have the highest suicide rate of any age range.1,2,14 Support groups may be available, but socially isolated individuals are not always aware of them due to lack of exposure and interaction.24 Older adults may adapt to an everyday routine of being alone and subsequently lose interest in and energy for outside activities.24 They may feel too overwhelmed to break out of this routine.24
Nursing considerations
To combat loneliness, isolation, and poor health in older adults, a complete assessment is necessary. Nurses should conduct a health history interview, review medications, complete a head-to-toe physical assessment, and assess for cognitive impairment with the use of a valid screening tool. Psychosocial and physical evaluations allow healthcare professionals to understand a patient's physical and mental health and create goals to improve these areas. Routine assessment of older adults should include signs and symptoms of loneliness, social isolation, and depression.4,25
Standardized tools such as the University of California, Los Angeles (UCLA) Loneliness Scale and the Geriatric Depression Scale determine the severity of loneliness and depression in this population.26-28 The UCLA Loneliness Scale (Version 3) includes 20 items to determine loneliness and has been validated for use with older adults.26,27 The long-form Geriatric Depression Scale includes 30 items to evaluate for depression in older adults.28
Nurses should also inquire about patients' social support systems, financial stability, and any previous end-of-life care and documents such as a advance directives or healthcare powers of attorney. Nurses can then correlate their findings with evaluations of functional capacity, cognition, mood, fall risk, and polypharmacy.29 Care plans include a list of obtainable physical, environmental, nutritional, and social interventions, but, if older patients feel overwhelmed, they may not participate.11,30
The COVID-19 pandemic has had a substantial impact on quality of life in older adults and the general population.31 Additionally, comorbidities and limited social support systems in older adults have created barriers to quality of life in older adults.32 Management of chronic diseases can help older adults improve their quality of life, both physically and socially. For example, cardiovascular and pulmonary disorders can decrease energy levels and physical capabilities, and neurologic disorders can affect cognition and the ability to safely perform ADLs.10,17 Therefore, nurses should educate patients on the importance of adherence to disease management interventions for optimal function and quality of life.
Lab test results can indicate chronic health issues; for example, low albumin levels may indicate poor nutrition, high blood urea nitrogen levels may indicate dehydration, and low hemoglobin levels may indicate anemia.33,34 Nurses should also promote hydration and a nutritious diet by encouraging patients to join family and friends for meals and exploring home food delivery or community transportation resources or ride-share opportunities to get to the grocery store.15,23
Based on the assessment, nurses may pursue various interventions, including social services such as the local Area Agency on Aging.35 They may also explore home healthcare service options for older home-bound patients. These professionals can subsequently assess and modify patient living conditions for safety, such as removing throw rugs, incorporating adequate lighting, and discussing emergency alert systems.3 If indicated, they should also discuss community adult day-care centers and local senior centers with patients and their families, as well as possible relocation to a retirement community, assisted living facility, or long-term-care facility, as well as encourage end-of-life discussions.3
Nurses and healthcare professionals are in a position to educate older adult patients about the social support available to them.3 Information about support networks such as exercise groups and community activities can be disseminated via newspapers, flyers, mail, social media, bulletin boards, and local TV.1,36 Technologic interventions can also be harnessed to reduce loneliness.11 For example, internet usage provides opportunities for social group interactions among homebound patients.11
Older adults may opt to participate in activities such as part-time employment, volunteer work, bingo, painting, walking, bowling, swimming, yoga, and joining a gym.30 Similarly, animal-assisted therapy (AAT) is a broad term to describe interactions between a person and a highly trained, sensitive animal to help with physical, emotional, and mental health. It represents another option for older adults in improving their quality of life and reducing loneliness.20,37,38 These animals may have scheduled visits with an individual, or the individual may own the animal. For example, AAT can be used to pair animals with older adults who require continuous rehabilitation for physical or cognitive function to build self-confidence and self-esteem.20,37,38 It may include dogs, cats, pigs, or horses. (See Benefits of AAT.)
Interprofessional teams are vital in creating comprehensive and integrated plans of care to address complex chronic health issues in older adults.20,22 Various healthcare professionals can help manage older adult patients, including (but not limited to) nurses, physicians, pharmacists, physical therapists, respiratory therapists, social workers, dietitians, and exercise instructors. Coordination of care enhances healthcare delivery and promotes optimal patient outcomes; for example, increased emphasis on competency among healthcare professionals to address the needs of older adult patients.20,22 Healthcare facilities should explore training and education in older adult care through simulation and professional development. Similarly, nursing programs could explore incorporating interprofessional simulation scenarios into the curriculum to address older adult care, as well as potential nursing specializations in older adult care.
Nurses should ensure their patients' assistive devices such as hearing and ambulatory aids are working properly. Additionally, patient environments should have optimal lighting, and nurses should provide patient education with a relaxing countenance and demeanor.39 (See Case study.)
Addressing the source
People are social beings. The best way to help older adults cope with loneliness and chronic disease is to address and manage the sources of physical and mental disorders. Loneliness and chronic illness are often intertwined, and nurses can support patients in managing their chronic conditions to improve quality of life and/or reduce loneliness. Spending time with older adults in a caring environment helps them achieve self-efficacy and lets them know they are valued.
* Provides companionship and reduces social isolation and loneliness among older adults.
* Creates purpose, as having an animal helps older adults feel valued and needed.
* Eases loneliness among older adults who are single or separated from a spouse due to divorce or death.
* Reduces BP, improves sleep patterns, and increases appetite.
* Reduces anxiety and improves cognitive function in older adults.
* Increases physical activity and promotes joint mobility.
* Distracts from issues related to chronic illness, such as pain, immobility, and social isolation.
* Increases social interactions; for example, walking a dog is one way to meet other people.
* Robopets, which are robots that look and move like living animals, may provide an alternative. Research indicates that robopets help older adults through engagement and interaction.
RD, 71, is a female with rheumatoid arthritis. She was referred for home healthcare services by her PCP after a recent fall. RD has pain and swelling in the joints of her hands and knees (pain level 4 on scale of 0 to 10, with 0 representing no pain and 10 representing the most pain imagainable) and generalized weakness. She has experienced a gradual increase in difficulty with mobility and meal preparation and has had two falls in the past year. Her medication regimen includes ferrous sulfate and p.r.n. acetaminophen. She lives alone since her partner of 30 years died unexpectedly last year and is estranged from her two adult children from a previous marriage. However, she remains close with her younger sister. She and her partner were teachers, as well as professional bowlers and coaches. Below is a sample care plan developed by the home healthcare nurse in collaboration with RD.
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