For years, Linda Fried offered older patients who complained of being lonely what seemed to be sensible guidance. "Go out and find something that matters to you," she would say.
But her well-meaning advice didn't work most of the time. What patients really wanted were close relationships with people they care about, satisfying social roles and a sense that their lives have value. And this wasn't easy to find.
We need "new societal institutions that bring meaning and purpose" to older adults' lives, Fried recently told a committee of the National Academies of Sciences investigating loneliness and social isolation among older adults. (Fried is a geriatrician and dean of the Mailman School of Public Health at Columbia University.)
The panel's deliberations come amid growing interest in the topic. Four surveys by Cigna, AARP, the Kaiser Family Foundation and the University of Michigan have examined the extent of loneliness and social isolation in older adults in the past year. And health insurers, health-care systems, senior housing operators and social service agencies are launching or expanding initiatives.
Notably, Anthem (health benefits company in the USA) is planning a national rollout to Medicare Advantage plans of a program addressing loneliness developed by its subsidiary CareMore Health, said Robin Caruso, CareMore's chief togetherness officer.
UnitedHealthcare is making health navigators available to Medicare Advantage members at risk for social isolation. And Kaiser Permanente is starting a pilot program that will refer lonely or isolated older adults in its Northwest region to community services, with plans to eventually bring it to other regions, said Lucy Savitz, vice president of health research at Kaiser Permanente Northwest.
The effectiveness of these programs and others remains to be seen. Few have been rigorously evaluated, and many assume increased social interaction will go a long way toward alleviating older adults' distress at not having meaningful relationships. But that isn't necessarily the case.
"Assuaging loneliness is not just about having random human contact; it's about the quality of that contact and who you're having contact with," said Vyjeyanthi Periyakoil, an associate professor of medicine at Stanford University School of Medicine.
A one-size-fits-all approach won't work for older adults, she and other experts agreed. Instead, varied approaches that recognise the different degrees, types and root causes of loneliness are needed.
Types of loneliness
Loneliness comes in different forms that call for different responses. According to a well-established framework, "emotional loneliness" occurs when someone feels the lack of intimate relationships. "Social loneliness" is the lack of satisfying contact with family members, friends, neighbours or other community members. "Collective loneliness" is the feeling of not being valued by the broader community.
Some experts add another category: "existential loneliness," or the sense that life lacks meaning or purpose.
Carla Perissinotto, associate chief for geriatrics clinical programs at the University of California at San Francisco, has been thinking about the different types of loneliness recently because of her 75-year-old mother, Gloria. Widowed in September, then forced to stay home for three months after hip surgery, Gloria became profoundly lonely.
"If I were a clinician and said to my mother, 'Go to a senior centre,' that wouldn't get at the core underlying issues: my mother's grief and her feeling, since she's not a native to this country, that she's not welcome here, given the political situation," Perissinotto said.
What has helped Gloria is "talking about and giving voice to what she's experiencing," Perissinotto said. Also, friends, former co-workers, family members and some of Perissinotto's high school buddies have rallied around Gloria.
"She feels that she's a valuable part of her community, and that's what's missing for so many people," Perissinotto said.
"Look at the older people around you who've had a major life transition: a death, the diagnosis of a serious illness, a financial setback, a surgery putting them at risk," she said. "Think about what you can offer as a friend or a colleague to help them feel valued."
Listening to older adults and learning about the type of loneliness they're experiencing is important before trying to intervene. "We need to understand what's driving someone's loneliness situation before suggesting options," Perissinotto said.
Root causes of loneliness
One of the root causes of loneliness can be the perception that other people have rejected you or don't care about you. Frequently, people who are lonely convey negativity or push others away because of perceived rejection, which only reinforces their isolation.
In a review of interventions to reduce loneliness, researchers from the University of Chicago noted that interventions that address what they call "maladaptive social cognition" - distrust of other people, negativity and the expectation of rejection - are generally more effective than those that teach social skills or promote social interactions. Cognitive behaviour therapy, which teaches people to recognise and question their assumptions, is often recommended.
Relationships that have become disappointing are another common cause of loneliness. This could be a spouse who has become inattentive over time or adult children or friends who live at a distance and are rarely in touch.
"Figuring out how to promote quality relationships for older adults who are lonely is tricky," Holt-Lunstad said. "While we have decades of research in relationship science that helps characterise quality relationships, there's not a lot of evidence around effective ways to create those relationships or intervene" when problems surface.
Other contributors to loneliness are easier to address. A few examples: Someone who has lost a sense of being meaningfully connected to other people because of hearing loss - the most common type of disability among older adults - can be encouraged to use a hearing aid. Someone who can't drive anymore and has stopped getting out of the house can get assistance with transportation. Or someone who has lost a sibling or a spouse can be directed to a bereavement program.
"We have to be very strategic about efforts to help people, what it is they need and what we're trying to accomplish," Holt-Lunstad said. "We can't just throw programs at people and hope that something is better than nothing."
She recommends that older adults take mental stock of the extent to which they feel lonely or socially isolated. Am I feeling left out? To what extent are my relationships supportive? Then, they should consider what underlies any problems. Why don't I get together with friends? Why have I lost touch with people I once spoke with?
"When you identify these factors, then you can think about the most appropriate strategies to relieve your discomfort and handle any obstacles that are getting in the way," Holt-Lunstad said.
WHERE TO GET HELP:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call 111.
If you need to talk to someone, the following free helplines operate 24/7:
DEPRESSION HELPLINE: 0800 111 757
LIFELINE: 0800 543 354
1737 NEED TO TALK? Call or text 1737
SAMARITANS: 0800 726 666
YOUTHLINE: 0800 376 633 or text 234