Try out PMC Labs and tell us what you think. Learn More. Loneliness is a common source of distress, suffering, and impaired quality of life in older persons.
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We examined the relationship between loneliness, functional decline and death in adults over age 60 in the United States. This is a longitudinal cohort study of participants in the psychosocial module of the Health and Retirement Study HRSa nationally representative study of older persons. Baseline assessment was in and follow-up occurred every two years until Subjects were categorized as not lonely if they responded hardly ever to all three questions and lonely if they responded some of the time or often to any of the three questions. The primary outcomes were time to death over 6 years, and functional decline over 6 years on 4 measures: difficulty on an increased of activities of daily living ADLdifficulty in an increased of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing.
Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADLs, Loneliness was associated with an increased risk of death Among participants who were older than 60, loneliness was a predictor of functional decline and death.
In older persons, health outcomes, such as worsening disability and death, are influenced not just by biomedical factors, but also by psychosocial distress. For example, several studies link depression to higher risks of disability and mortality 2 — 3. Other studies have shown that measures of social isolation--the of social contacts and the amount of social engagement—are associated with poor health outcomes.
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Yet, these quantitative measures of relationships may not adequately capture the distress that an individual may subjectively feel. The concept of loneliness is only starting to be recognized as a separate entity from social isolation and depression and therefore few studies have examined it as an independent risk factor. Loneliness is an important contributor to human suffering, especially in the elderly, where prevalence rates may be higher. While persons who are lonely are more likely to experience depressive symptoms, feelings of loneliness are only weakly associated with enjoyment, energy and motivation—emotions that are central to a diagnosis of depression.
For example, it is possible for persons who live alone to not feel lonely, while some who are married or living with others will still experience loneliness. The subjective distress of loneliness may be a more important measure of suffering and quality of life rather than objective measures of social isolation.
Given the of health and social issues that health care providers must prioritize, the identification and amelioration of loneliness may seem to be outside of the scope of medical practice.
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Yet, by separating suffering and distress into medical and non-medical spheres, providers may be missing a key risk factor for poor health. To quantify the prevalence of loneliness and determine whether older persons who are lonely are at risk for poor health outcomes, we used the Health and Retirement Study HRSa national, population-based study of community living older adults.
After adjusting for common measures of medical risk, we examined the impact of loneliness on mortality and several measures of worsening disability that are of particular importance in older persons. The HRS is a population-based longitudinal study examining the relationships between health and wealth changes as people age. In addition to the primary survey, the HRS administers modules on additional topics to randomly selected participants. Our analytic cohort was limited to participants over the age of In14, Of the remaining 12, eligible participants, The subjects who were excluded were ificantly older The primary predictor variable consisted of a 3-item loneliness questionnaire which measures three components of loneliness: whether subjects feel left out, isolated, or lack companionship.
Both the 3-item loneliness scales and the R-UCLA have been validated and are able to be self-administered. For each component, subjects are asked if they feel that way hardly ever or neversome of the time, or often. Our primary analysis used a dichotomous measure of loneliness because we believed each item in the scale better represented different ways a person might express loneliness rather than additive components of loneliness. However, we performed sensitivity analyses examining alternative definitions for the outcome.
Third, we analyzed the items as a continuous scale, giving one point for each component answered some of the time and two points for each item answered often. Outcomes studied included time to death, and among survivors, functional decline over 6 years on 4 measures. Time to death was determined from interviews with family members and the national death index.
Loneliness in older persons: a predictor of functional decline and death
We used four measures of functional decline: 1 difficulty in increased of ADLs, 2 difficulty in increased of upper extremity tasks, 3 decline in walking, 4 and increased difficulty in stair climbing. For ADL function, participants were asked if they had difficulty in any of the 5 ADLs: bathing, dressing, transferring, toileting, and eating. For upper extremity tasks, subjects were asked whether they had difficulty extending their arms above their shoulders, pushing or pulling large objects or lifting or carrying weights heavier than 10 pounds. A decline was defined as difficulty in more tasks in compared to For mobility, participants were asked about difficulty with 4 tasks: running or jogging a mile, walking several blocks, or walking one block.
A decline was defined as a decrease in the distance able to jog or walk over the 6 years. Lastly, for stair climbing, participants were asked whether they had difficulty climbing several flights of stairs, or one flight of stairs. A decline was defined as a decrease in the of flights of stairs able to climb.
Demographic characteristic such as age, race and education level were obtained by self report. Income was measured by asking the subject to report the total household income in the calendar year. Net worth was measured by asking the subject to report assets and debts. Living arrangements were measured by assessing whether the subject lives in urban or rural area, and whether the subject lives alone. Comorbid conditions, including hypertension, diabetes, cancer, chronic lung disease, cardiac disease, and stroke were assessed by asking Lonely elderly women in pa subjects if a physician had ever told them that they had the condition.
work with the HRS has provided evidence of the validity of these comorbidity questions by demonstrating that they strongly predict mortality. Frequent physical activity was defined as engaging in light or vigorous exercise three or more times per week. If subjects reported ever smoking they were classified as smokers, and if they reported currently drinking any quantity of alcohol they were classified as drinking alcohol.
Subjects were also asked to rate their hearing and vision, and those who rated the measure as fair or poor were classified as having an impairment. To determine whether loneliness was associated with a higher risk for death, we used proportional hazards model. The primary predictor was whether or not the subject was lonely and the outcome was time to death. To examine the association between six-year functional decline and loneliness modified Poisson regression analyses were conducted for each of the 4 functional decline outcomes. Our outcome for the functional measures was whether or not the subject declined rather than time to decline because functional measures were assessed every 2 years, creating only 3 time points.
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Multivariate analyses for both the mortality and functional outcomes were adjusted for demographic variables age, race, gender, marital statussocioeconomic status education, income, and net worthworking status, living arrangement, depression, the of baseline ADL difficulties and each of the medical conditions in Table 1.
Our mortality analysis also adjusted for baseline upper extremity tasks, mobility, and stair climbing difficulties. We tested interactions for age, gender, and depression, but these were not ificant. We also repeated our analyses excluding subjects with depression. These were similar to our original analyses. Baseline characteristics of the 1, study participants are presented in Table 1. Lonely elderly women in pa mean age of the participants in the study was Subjects who were lonely were slightly older Subjects were also more likely to be female, had lower SES across all measures, were more likely to smoke, have most comorbid conditions, have greater baseline functional impairment, have sensory impairments, and were less likely drink alcohol, engage in frequent physical activity.
While lonely subjects were more likely to live alone, the majority of lonely persons lived with someone. Moreover, while lonely subjects were more likely to be depressed, most lonely subjects were not depressed. Loneliness was associated with increased risk of death over the 6 year follow-up period The association between loneliness and death remained ificant even after adjusting for demographics, SES, depression and other health and functional measures HR 1.
Loneliness was associated with all measures of functional decline in unadjusted analysis and after adjusting for potential confounders including demographic variables, SES measures, depression, comorbidities and other baseline health and functional measures table 2.
For ADL decline The association between loneliness and decline in mobility We conducted additional analyses in which we used different definitions of loneliness. First, we classified subjects as moderately lonely if they reported having at least one of the loneliness items at least some of the time and severely lonely if they reported having at least one of the loneliness items often.
The adjusted risk of mortality and of functional decline across all 4 measures was similar for those moderately or severely lonely. Second, we classified subjects as moderately lonely if they reported one symptom at least some of the time, and severely lonely if they reported two or more symptoms at least some of the time. In adjusted analyses, there was a stepwise increase in the risk of ADL decline with increasing loneliness.
For the remaining outcomes, the adjusted risk for moderately and severely lonely were similar. When we scored loneliness as a continuous scale, stepwise increases in loneliness were associated with a higher risk on each outcome except mobility. Loneliness is a common source of suffering in older persons. We demonstrated that it is also a risk factor for poor health outcomes including death and multiple measures of functional decline.
It persisted after ing for a large of confounders including illness severity and depression.