Suffering in silence: A global epidemic

This blog is the collaborative work of BGS President-Elect Prof Tahir Masud and his team Aneesha Chauhan, final year medical student, University of Oxford and Sanja Thompson consultant physician, Geratology department, University of Oxford.

Everyone has experienced loneliness. Acutely, it is a transient, often mild experience that is relieved by meaningful social interaction. However, we are living in an epidemic of chronic loneliness. More than three quarters of GPs in the UK say they see between 1 and 5 lonely people a day. Furthermore, recent prevalence data revealed that 30% of the elderly are “sometimes lonely” with 9% suffering from severe loneliness. It is being increasingly recognised that loneliness is a pathological state, with its own epidemiology, risk factors, presentations, and increased mortality and morbidity.

Well known risk factors for loneliness in older people include living alone, the loss of a partner, poor social networks and resources, low socioeconomic status, and poor physical and mental health. With research suggesting that loneliness is a bigger killer than obesity within the older population, and a risk factor for early institutionalization, cognitive decline and increased use of health services, the exact mechanisms behind its poor prognosis are still being investigated.

Unsurprisingly, loneliness is associated with poor lifestyle behaviours that have their own adverse effect on mortality, such as alcohol abuse and smoking – which are often reinforcing, creating a vicious cycle. However, the direct effects are also being delineated, and are more far-reaching than perhaps expected. Loneliness is associated with raised cortisol levels, hypertension and increased cardiovascular disease. It increases pro-inflammatory gene activity, and causes immune system dysfunction. It is associated with impaired sleep and memory, cognitive decline, and in the older population, it doubles the risk of Alzheimer’s disease. Results from animal studies confirm the detrimental impact of social isolation, and are being used to further investigate the underlying disease processes.

In the UK, over 1 million older adults admit they feel lonely often or all the time – a number set to increase given the changing demography. Despite modern day communication technologies, nearly half of the older population report that either television or pets are their mainstay of company. The widespread nature of loneliness and its impact has led researchers to dub it the ‘next big public health issue’. Perhaps it’s a little belated – Mother Teresa said that ‘the most terrible poverty is loneliness’ – however, it’s only now that we are beginning to identify loneliness as a major health issue.

As with any public health issue, the association between cause and effect must be understood in order to tackle the problem. Strategies to combat loneliness may potentially benefit physical and mental health, and quality-of-life as well as improving social interaction. However, the subjective nature of loneliness is complex. Not surprisingly, there is truth behind the saying ‘feeling of being alone in a crowded room’. Loneliness is not merely a function of solitude; objective and subjective isolation are two different, quantifiable entities. Objective isolation includes parameters such as living situation and social network, whilst subjective isolation involves measuring patient-reported feelings of isolation or remoteness. A recent meta-analysis by Holt-Lunstad et al (2015) suggested that they are both independently associated with adverse health outcomes, although few studies have measured both of these parameters simultaneously – and those that exist often show conflicting data regarding their relative effects. In the future, the prevalence of loneliness should be examined on a larger scale, using both objective and patient-reported outcome measures. Defining their relative importance is essential in identifying the independent pathways by which they influence health, and confirming any causality. Therefore, one of the key steps in aiding recognition of the lonely geriatric population is the identification of a valid and reliable tool to measure both objective and social isolation. This would guide future research into appropriate primary and secondary interventions.

Evidence suggests that loneliness reduction interventions should be individualised to the target population, and may include a combination of 4 primary strategies: 1) improving social skills, 2) enhancing social support, 3) increasing opportunities for social interaction, and 4) addressing maladaptive social cognition. Once again, this is an area where there is a paucity of academically rigorous data and prospective, randomised controlled trials into the efficacy and cost-effectiveness of such interventions are needed.

Filling the gaps in research would be the first step in setting up a successful public health strategy, starting with the identification of potential treatment target groups, and the strategies that work best for each specific patient population. The Campaign to End Loneliness, led by 5 partner organisations including Age UK, was set up in 2011 to create a large scale network that can allow research and intervention to be carried out. The British Geriatrics Society has an important role to play in these developments, and we hope to work closely with these organisations to further raise awareness that loneliness is an important public health threat.