Connecting with other people is fundamental for wellbeing. Sadly this is something the elderly often lack, social prescribing is one way this problem can be helped.
What is loneliness?
Most people have experienced feelings of loneliness. It often occurs during life transitions such as changing schools, moving to a new city or country or when an elderly person outlives their spouse and friends. Loneliness is often stigmatised, trivialised or ignored but when loneliness becomes a chronic condition, the impact can be far more serious than many people realise. Loneliness is emerging as a public health issue and the UK now has a designated loneliness minister to tackle the issue.
Elderly people are especially vulnerable to loneliness. According to Age U.K., more than 2 million people in England over the age of 75 live alone. 1.4 million elderly people saying they feel lonely with more than one million elderly people say they go for over a month without speaking to a friend, family member or neighbour. Covid-19 and the national lockdowns exacerbated loneliness and social isolation (7).
Loneliness is not the same as social isolation. Social isolation is the lack of social contacts and having few people to interact with. A person can live alone and not feel lonely or isolated. Loneliness is an individuals personal, subjective sense of lacking desired affection, closeness, and social interaction with others (8). A person may be surrounded by other people but still feel lonely. This is common with elderly people in care homes or hospitals who are surrounded by others yet still experience chronic loneliness (9).
To truly overcome loneliness requires a sense of belonging which is only achieved through reciprocal connections. Lonely people need to feel they are contributing towards the connection to create a sense of belonging not just being the recipient of help (9).
Why is connection important?
Studies on Blue Zones, areas around the world where people routinely live to 100 in good health, have found one of the important factors for their longevity and good health is ābelongingā. These Blue Zones place great emphasis on family, on community connections or being part of a faith-based group. As a result, the elderly in these communities have a feeling of purpose in life, a reason for waking up each morning as the feel loved and needed (6).
Humans have thrived as a species through connection with others. As hunter-gatherers people needed each other to stay alive. Loneliness doesnāt just make people feel unhappy, it makes people feel unsafe both mentally and physically. Evolutionary instincts brought prehistoric people together to work together for food, shelter, and protection. The mental distress people experience when feeling lonely or isolated is a warning to re-engage or face danger. Short term loneliness can be beneficial as it highlights the need for social connection, but chronic loneliness is harmful to all areas of health and wellbeing.
Just as physical pain serves to protect the body, loneliness protects the social body. It lets us know that social connections are diminishing. According to psychologist John Cacioppo, the brain goes on high alert for social threats and can produce a hyper-reactivity response to perceived negative behaviours in other people. This induces feelings that interactions are unpleasant which can result in self-preservation behaviour of retreating further from people which increases loneliness (9).
How does loneliness impact health?
Loneliness is linked to worse cardiovascular health, lower quality of life, decreased cognitive function, higher depression rates, mental health issues and decreased life span (2). A 2017 a meta-analysis of forty systemic reviews of mainly observational studies, identified a significant association between loneliness and increased all-cause mortality (1).
Until recently the cellular mechanisms by which loneliness caused declining health were not well understood. A research team lead by psychologist John Cacioppo carried out studies that identified that loneliness creates inflammation and a less effective immune response though over expression of genes involved in inflammation and decreased expression of genes involved in antiviral responses (3). The team called this phenomenon āconserved transcriptional responses to adversityā or CTRA (4).
The team then studied gene expression in leukocyte immune cells (white blood cells), that are involved in protecting the body from bacteria and viruses. The study didnāt just focus on humans but also included the highly social primate species, rhesus macaques (3).
The leukocyte cells from the lonely monkeyās and humans showed as expected CTRA, increased inflammation and decreased antiviral immune responses. New information was also revealed about a reciprocal relationship between loneliness and leukocyte gene expression suggesting each can help propagate the other over time (3). Loneliness predicted future CTRA gene expression measured a year or more later and CTRA gene expression also predicted loneliness. These results were specific to loneliness and could not be explained by depression, stress, or social support (4).
The team then investigated social experiences and CTRA gene expression in rhesus macaques. The lonely monkeys also had higher CTRA gene expression as well as higher levels of the stress hormone norepinephrine. Norepinephrine can stimulate blood stem cells in bone marrow to make more immature monocyte immune cells (a type of Leukocyte) that have high levels of inflammatory gene expression and low levels of antiviral gene expression which finally explained CTRA gene expression in white blood cells (4).
Loneliness results in flight-or flight stress signalling, which increases the production of immature monocytes which up regulates inflammation genes and impaired viral response. The danger signals activated in the brain by loneliness affect the production of white blood cells, the shift in monocytes output may propagate loneliness and contribute to its health risks (3).
Could social prescribing help the lonely elderly?
One potential intervention in helping to reduce loneliness in the elderly is social prescribing. Social prescribing, also known as community referral, enables health professionals to refer people to a link worker (community connector or navigator). Link workers take time to get to know the individuals needs finding out what matters to them and then connect them to a range of local, non-clinical services. Social prescribing recognises that peopleās health and wellbeing are determined by a range of social, economic, and environmental factors. It seeks to address peopleās needs in a holistic way and to support individuals to take greater control of their own health (5).
Social prescribing is designed to support people with a wide range of social, practical, or emotional needs usually provided for by voluntary or community organisations connected to link workers through social activities and social groups such as gardening, singing, crafting, learning, befriending, technology lessons or menās sheds. This initiative is supplemented by investment in community projects such as cafes, art spaces or gardens that can become a social point for social prescribing (5).
Social prescribing is supported by a growing body of evidence that shows it can lead to a range of positive health and wellbeing outcomes. Studies have pointed to improvements in quality of life, emotional and mental wellbeing and reduced levels of anxiety and depression. However, there are weaknesses as many of the studies are small scale, do not have control groups, focus on progress rather than outcomes or relate to individual interventions rather than the social prescribing model (5).
Social prescribing has generally not had the primary aim of addressing loneliness. To address this gap the British Red Cross in collaboration and funded by the Co-op partnership, delivered a national prescribing service for lonely people (10).
The social prescribing service consisted of paid link workers and volunteers who developed supportive relationships with the lonely service users, assessing their needs and providing individualised care. These three components were considered critical in loneliness interventions. Support was provided for 12 weeks and concentrated on building lonely peopleās confidence so that they were then able to use the community activities and services such as crafting groups, adult learning, and leisure facilities (10).
The social prescribing service helped to reduce service usersā loneliness and provide other benefits such as improved wellbeing and confidence. The results are interesting as it was the service users under 50 years old that were more likely to experience improvements in loneliness. This is due to younger peopleās loneliness being related to lack of social connections while elderly peopleās loneliness is often entrenched (due to self-preservation mode), arises from the death of friends and spouses, or from a loss of functional ability to engage in activities (10).
A key finding was that 60% of service users reported a worsening of their loneliness after finishing the 12 weeks service. One reason was that service users were unable to continue attending community activities because they were reliant on link workers/volunteers for transport (10).
Social prescribing could be a very effective tool in helping to reduce chronic loneliness in the elderly provided there are enough link workers and transport is available to help the less mobile elderly. Consideration needs to be taken about including behaviour interventions to change how lonely elderly people think about other people, helping them to understand that they are in a self-preservation mode and how to come out of it so that they can happily engage in community activities.
Ultimately we all want connection with each other and our community. Nothing can replace a feeling of belonging, sharing and laughing with each other. Unfortunately in our society the elderly do not have as much access as they should to these human needs, but social prescribing can be an antidote to that. There are even social prescribing projects which involve gardening- a wonderful way to connect both with nature and other people.
References
- N. Leigh-Hunt, D. Bagguley, K. Bash, V. Turner, S. Turnbull, N. Valtorta, W. Caan, An overview of systematic reviews on the public health consequences of social isolation and loneliness,Public Health, volume 152, 2017,Pages 157-171.
- Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. Health & Social Care in the Community. 2015;25(3):799-812. doi:10.1111/hsc.12311
- Allen S. Loneliness triggers cellular changes that can cause illness, study shows. University of Chicago News. https://news.uchicago.edu/story/loneliness-triggers-cellular-changes-can-cause-illness-study-shows. Published 2015. Accessed August 6, 2022.
- Loneliness triggers cellular changes that can cause illness, study shows. Science Daily. https://www.sciencedaily.com/releases/2015/11/151123201925.htm. Published 2015. Accessed August 7, 2022.
- Ewbank L. What is social prescribing?. KingsFund. https://www.kingsfund.org.uk/publications/social-prescribing. Published 2020. Accessed August 7, 2022.
- Buettner D. Power 9Ā® – Blue Zones. Blue Zones. https://www.bluezones.com/2016/11/power-9/. Accessed August 9, 2022.
- Loneliness in older people. nhs.uk. https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/feelings-and-symptoms/loneliness-in-older-people/. Published 2021. Accessed August 8, 2022.
- Rossall P, Iparraguirre J, Davidson S. Loneliness at local and neighbourhood level. Age UK. https://www.ageuk.org.uk/contentassets/972087f6d82841569c55d96a86e0dd87/age_uk_loneliness_risk_index_summary-july2015.pdf. Published 2015. Accessed August 7, 2022.
- Adams T. John Cacioppo: āLoneliness is like an iceberg ā it goes deeper than we can seeā. the Guardian. https://www.theguardian.com/science/2016/feb/28/loneliness-is-like-an-iceberg-john-cacioppo-social-neuroscience-interview. Published 2016. Accessed August 7, 2022.
- Foster A, Thompson J, Holding E et al. Impact of social prescribing to address loneliness: A mixed methods evaluation of a national social prescribing programme. Health & Social Care in the Community. 2020;29(5):1439-1449. doi:10.1111/hsc.13200
