Project objectives

An increasing number of older people in the UK are living alone and consequently an increasing number are at risk of being socially isolated. Social isolation has been identified as a risk factor for poor health (especially poor mental health) and lower wellbeing, including morbidity and mortality, loneliness, depression and cognitive decline. Older people who are socially isolated are also more vulnerable to the complicating effects of unforeseen events such as falls. Because older people who are isolated have smaller networks of relatives, neighbours and friends, they have less (unpaid/informal) support to fall back on to help meet their social care or other needs; and they may not access the appropriate formal health and social care services, which in turn could have harmful longer-term consequences.

Numerous interventions have been suggested as ways to reduce social isolation and develop the social networks of older people. However, the notion of social isolation itself, its drivers, and the pathways through which it affects health and wellbeing over time are not well-understood. In addition, the evidence base in support of these interventions is often hindered by weak methodologies and conceptual definitions.

The aim of this scoping study was to review the evidence on social isolation, its impact on health, wellbeing and service use, and the methodological challenges associated with the evaluation of interventions in this area. It was expected that the scoping study would inform the design of interventions and describe the characteristics of the individuals who may benefit from them.

Brief summary

An increasing number of older people are living alone and are at risk of being socially isolated in the United Kingdom. This is of concern because social isolation has been identified as a risk factor for poor health and reduced wellbeing, including mortality, depression and cognitive decline. Because older people who are isolated have smaller networks of relatives, neighbours and friends, they have less support to fall back on, to help meet their social care or other needs. They may not access to appropriate formal health or social care services, which in turn could have deleterious longer-term consequences.

This study examined the impact of social isolation and loneliness on physical health, mental health and wellbeing in old age. A scoping review was conducted between August 2013 and March 2014.

Methods

Nine databases were searched for empirical papers investigating the impact of social isolation and loneliness on a range of health outcomes in old age. The search yielded 11,736 articles, of which 128 were included in the scoping review (after filtering for relevance).

Findings

Research on the impact of social isolation and loneliness on health constitutes a large and growing body of literature. The 128 studies included in this review spanned a total of 15 countries, although over half of the papers focused on the United States. Social isolation and loneliness are overlapping but distinct concepts. Social isolation is often considered as an objective measure of social contacts and integration, whereas loneliness refers to the subjective negative feeling associated with a perceived lack of contacts. In fact, the research team found quite a wide variety of definitions and measurements in the literature reviewed. In terms of the issue being studied, over half of the 128 papers focused on loneliness.

The studies included in the review had varied objectives (Table 1) but half aimed to describe the association between isolation or loneliness and the health outcome studied. Although there have been a number of such descriptive studies, this topic has received relatively little attention in the intervention literature, with only seven per cent of the papers aiming to describe or evaluate an intervention at the time of writing. Most interventions had mixed results. For example, Routasalo and colleagues (2009) reported that a large proportion of participants had found new friends through a psychosocial rehabilitation programme and that their wellbeing levels increased significantly. However, their loneliness and social isolation scores were not affected by taking part in the programme, suggesting that there are other mechanisms at play. Similar results were found for group activities. A randomised control trial of a model of restorative home care on physical health and social support showed significant improvements in physical function but no changes in perceived levels of social support (Parsons et al. 2013).

Table 1. Overview of the objectives of the papers included in the scoping review

A wide range of health outcomes were examined in the papers included in the review. Overall, the review found a balance between mental health and physical health (35 per cent of the studies included for each type of outcome). The most commonly studied health outcome was depression, followed by cardiovascular health and wellbeing/quality of life. Across the 128 studies, only two did not find a detrimental effect of social isolation or loneliness on health.

The impact of social isolation and loneliness on health and wellbeing in old age was not uniform across population groups. Gender and age differences were the most researched factors in the sample of articles. In recent years, differences by socio-economic or ethnic backgrounds have been studied as well – although to a lesser extent.

Finally, a number of papers focused on specific groups who are at higher risk of isolation and loneliness and associated negative health outcomes. These groups include older people who are cancer survivors, unpaid carers, substance users, or people who are HIV-positive, and those with a history of institutionalization.

Gaps in evidence and implications for research and practice

The scoping review highlighted a number of gaps in the evidence base. First, the lack of consistency in the definitions and measures of isolation and loneliness is problematic as it limits considerably the comparability of the findings between studies, and therefore between settings, population groups and time periods. Very broad and general measures may not fully detect the impacts on physical and mental health of older adults, and could ultimately impair the design of effective interventions. Closer integration of the research on the drivers of loneliness and isolation and the research on their impact on health would allow future researchers to understand better which dimensions are crucial to include in their studies.

Second, only a third of the studies included in the scoping review used a longitudinal design to explain the health and wellbeing effects of social isolation and loneliness. Cross-sectional studies in this context can say nothing about the direction of causaIity. It means that relatively little is known about mechanisms of change or influence. Indeed, older people may become lonelier or more isolated, be chronically isolated or become so because of trigger events such as retirement or bereavement.

A better understanding of these mechanisms is necessary to help policy-makers, commissioners and service providers plan and design appropriate interventions.

Health and social care service use of isolated older people – potentially a particularly vulnerable group - is also under-researched. Available studies focusing on other population groups provide important insights for future research. For example, general practitioners, nurses and other frontline health and social care professionals potentially have a role to play (Wilson et al. 2011, van der Zwet et al. 2009) to support lonely people who (typically) have poorer access to adequate health information (Askeslon et al. 2011).

The scoping review revealed a paucity of research on specific population sub-groups, despite evidence of ethnic and socio-economic differences in the impact of loneliness and isolation on health. It should also be noted that the available evidence focuses almost exclusively on individual-level analyses. We suggest that to understand the scope and magnitude of the impact of loneliness and isolation on health, future research should further take into account environmental factors such as the nature and characteristics of communities and neighbourhoods where older people live.

Finally, only very little published work on interventions was identified, clearly indicating a gap that makes it hard to develop evidence-based practice. As the findings of longitudinal studies become available, potential causal mechanisms have to be considered in the design of these interventions. Clear conceptual models of loneliness and isolation are also needed, as the target populations for the intervention will respond differently to interventions aimed at reducing different dimensions of loneliness or isolation.

As noted by Hawkley and Cacioppo (2010), a crucial question is whether modifying the feeling of loneliness can have an impact on health. To date, the available evidence is scarce and this should be a priority for future research.

Detailed findings from the review will be available shortly (Courtin E, Knapp M (2014) Health and wellbeing consequences of social isolation and loneliness in old age: a scoping review, Ageing and Society, submitted).

References

1. Askeslon N, Campo S, Carter K (2011) Completely Isolated? Health information seeking among social isolates, Health Education and Behavior, 38, 2, 116-122.
2. Hawkley LC, Cacioppo JT (2010) Loneliness matters: a theoretical and empirical review of consequences and mechanisms, Annals of Behavioral Medicine, 40, 218-227.
3. Parsons JGM, Sheridan N, Rouse P, Robinson E, Connolly M (2013) A randomized controlled trial to determine the effect of a model of restorative home care on physical function and social support among older people, Archives of Physical Medicine and Rehabilitation, 94, 6, 1015-1022.
4. Routasalo PE, Tilvis RS, Kautiainen H, Pitkala KH (2009) Effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: randomized controlled trial, Journal of Advanced Nursing, 65, 2, 297-305.
5. van der Zwet J, Koelewijn-van Loon MS, van den Akker M (2009) Lonely patients in general practice: a call for revealing GPs’ emotions? A qualitative study, Family Practice, 26, 6, 501-509.
6. Victor C, Scambler S, Shah S, Cook D, Harris T, Rink E, et al. (2002) Has loneliness amongst older people increased? An investigation into variations between cohorts,Ageing and Society, 22, 5, 585-597.
7. Wilson DM, Harris A, Hollis V, Mohankumar D (2011) Upstream thinking and health promotion planning for older adults at risk of social isolation, International Journal of Older People Nursing, 6, 4, 282-288.

Plain English summary

An increasing number of older people are living alone and are at risk of being socially isolated in the United Kingdom. This is of concern because social isolation has been identified as a risk factor for poor health and reduced wellbeing, including mortality, depression and cognitive decline. Because older people who are isolated have smaller networks of relatives, neighbours and friends, they have less support to fall back on, to help meet their social care or other needs. They may not access to appropriate formal health or social care services, which in turn could have harmful longer-term consequences.

This study examined the impact of social isolation and loneliness on physical health, mental health and wellbeing in old age. A scoping review was conducted between August 2013 and March 2014.

Key points from the review included:

• Loneliness and social isolation are increasingly recognised as risk factors for poor health and reduced wellbeing. Almost all the studies reviewed found a detrimental effect of isolation or loneliness on health. Health risks associated with isolation and loneliness have been compared to the well-established detrimental effects of smoking and obesity;
• Depression and cardiovascular health are the most often researched outcomes, followed by wellbeing;
• Definition and measurement in this area both remain complex and contested. Causal links and mechanisms are difficult to demonstrate and further investigation is needed;
• There is a paucity of research focusing on the health and social care use of isolated older people and interventions.

The review suggested that future research should aim to “connect the dots” between the literature on the risk factors for loneliness and social isolation and the research on their impact on health and wellbeing.

Dissemination

An article has been submitted to a peer-reviewed journal (awaiting decision).

Published articles

1. NIHR School for Social Care Research (2014) Health and wellbeing consequences of social isolation and loneliness in old age, Research Findings 59, NIHR School for Social Care Research, London.
   http://www.sscr.nihr.ac.uk/PDF/Findings/RF59.pdf

Presentations

1. Emilie Courtin, Social isolation, loneliness and health in old age: a scoping review, NIHR School for Social Care Research and Campaign to End Loneliness’ Research Showcase: Research showcase: Loneliness, prevention and wellbeing, 17 April 2015.
   http://www.sscr.nihr.ac.uk/PDF/SSCRpresentations/Loneliness/CourtinKnapp.pdf
2. https://youtu.be/SbqIJncAaEo

Impact

The research has contributed to discussions of the evidence base on social isolation as part of an event co-hosted by the NIHR School for Social Care Research and the Campaign to End Loneliness. Around 200 people attended the one-day conference on Loneliness, Prevention and Wellbeing at LSE in London on 17 April 2015 from a range of (predominantly non-academic) backgrounds.

The study provides an improved understanding of the evidence base on the health and wellbeing consequences of social isolation and loneliness for older people, and is contributing to ongoing discussions on potential research studies to address evidence gaps between the School, the Campaign to End Loneliness and the Department of Health.

This project was funded by the National Institute for Health Research School for Social Care Research (project number T976/EM/LSE8).

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Social Care Research, NIHR, NHS or the Department of Health.