An integrative review of loneliness and quality of life in older adults who lived alone during COVID-19: considerations for supporting reconnection

Abstract

Background

Loneliness and decreased quality of life are associated with decreased life expectancy and are regarded as serious health concerns. Understanding the impact of the pandemic on older adults living alone is essential for informing strategies to decrease loneliness and improve quality of life following the COVID-19 pandemic and in future crises. This integrative review aimed to synthesise the qualitative and quantitative evidence on the factors of the pandemic that influenced loneliness and quality of life of older adults living alone, and examine associated interventions to support this population.

Methods

An integrative review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases (CINAHL Plus, MEDLINE with Full Text, APA PSYCArticles, Psychology & Behavioral Sciences Collection, Academic Search Premier and Proquest Coronavirus Research Database) were searched in February 2024 for peer-reviewed studies on community-dwelling older adults (60+) living alone during COVID-19. Screening and selection were completed in Covidence. The review included 53 articles (39 quantitative, 11 qualitative, and three mixed-methods) published between 2020 and 2023. Study quality was appraised using the Mixed Methods Appraisal Tool. Data were extracted into Excel and synthesised narratively across quantitative, qualitative, and mixed-methods studies to identify factors influencing loneliness, quality of life, and related interventions.

Results

Most studies were based on cross-sectional data and represented a broad international experience. Most studies reported increased loneliness and worsened quality of life during the pandemic. Loneliness was associated with isolation, intolerance of uncertainty and anxiety, however being accustomed to isolation, unity through adherence to pandemic measures, and socialising with neighbours were protective factors. Worsened quality of life was associated with poor sleep patterns, stigmatisation from being labelled as an ‘at risk’ population and feeling imprisoned at home. Protective factors included an appreciation for activities and connections, fostering creativity, engaging in hobbies and learning new skills. Lastly, interventions utilised technology via phone calls and socially assisted robots and were shown to help older adults.

Conclusions

Additional meaningful, engaging and accessible strategies are needed to support older adults who live alone during crises. This integrative review offers insight into global experiences of loneliness and quality of life among older adults living alone during the COVID-19 pandemic, with suggestions for effective intervention strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06887-5.

Introduction

The COVID-19 pandemic necessitated public health measures, such as social distancing, to restrict the spread of the virus [1]. Social distancing altered the social world for older adults [1], reducing opportunities for social contact and community participation [2]. This disruption was predicted to intensify feelings of loneliness in older adults [3], a trend that was established by early pandemic literature [4]. Loneliness has been described as the subjective feeling of being alone and disconnected [5, 6] from other people or community life and roles that bring meaning and purpose [7]. It has been frequently explored in older adults, in part due to the recognised negative impact on health and wellbeing [3]. Attention on loneliness in older adults became more salient during the pandemic due to perceived risks stemming from social distancing and lockdown mandates [8]. Enforced social isolation during the COVID-19 pandemic limited opportunities for face-to-face social contact and community participation, but the effects are likely to have ongoing impacts for those with limited resources and capacity to reengage and reconnect socially (due to frailty, low digital literacy, lack of transport, etc.) [9]. Therefore, the COVID-19 pandemic was expected to increase levels of loneliness.

As loneliness has been correlated to quality of life, this was also a key area of interest during the pandemic. Quality of life, a multidimensional construct that incorporates health, social relations and independence in the context of individual cultures and value systems [10, 11], has been frequently explored in older adults. This is because older adults experience a range of health, social and financial changes which can profoundly impact their quality of life [10]. As social isolation and loneliness are known to negatively impact quality of life [12], there was significant concern for the quality of life of older adults during the pandemic [13]. This concern was warranted as recent studies have demonstrated that older adults experienced reduced quality of life during the pandemic [13].

Living alone is a long identified risk factor for loneliness [3, 8, 14] and reduced quality of life [10]. Consequently, during the pandemic, older adults living alone were perceived as more vulnerable and in need of special attention [4]. Measures implemented during the pandemic, including social distancing, may have disproportionally affected this group of older adults. Exploring the experiences of older adults who live alone in relation to loneliness and quality of life during the COVID-19 pandemic provides valuable insights. These can then be used by health and social services to understand risk in future pandemics and to consider tailored interventions which may mitigate changes in loneliness and/or quality of life.

Current systematic reviews and meta-analyses investigating older adults and loneliness show that loneliness is a multifactorial problem requiring multifaceted solutions [15–19]. Interventions that combine social and psychological factors produce better outcomes than single-component efforts [15, 16, 18]. For example, the review by Patil and Braun [18] highlights that the most effective interventions increase social opportunities for connection and address internal cognitive dimensions of loneliness (e.g., modifying maladaptive thought patterns). This approach helps lonely older adults develop more stable interpersonal relationships and perpetuate social opportunities [18]. Another consistency between current reviews is the recognition that active engagement and meaningful connection are imperative [16]. Passive approaches (e.g., simply providing a service without personal engagement, or one-size-fits-all group activities) are less effective [18]. The importance of tailoring interventions to the participant’s interests and needs was highlighted through matching people by interests to avoid the “lonely stigma” of formal programs [15] or through ensuring participants play an active role (as in skill-building classes or therapy) [18]. However, during the COVID-19 pandemic, social distancing limited the accessibility of these types of interventions for older adults living alone, leading to the utilisation of technology-based interventions.

Several discrepancies emerge when comparing the literature on technology-based interventions. Some studies report significant benefits, for example, older adults taught to use video-chat report feeling more socially connected [18]. However, others find limited or no effects, possibly due to usability issues or lack of personal touch [15]. Additionally, Balki, Hayes [20] argue that newer technologies have low quality of evidence and mixed results. In the context of COVID-19 lockdowns and enforced social distancing, when face-to-face interactions were unavailable, these technology-based interventions were often the only means through which older adults living alone could stay connected [19]. However, their variable effectiveness underscores the importance of systematic and comprehensive evaluation to determine their impact on older adults living alone.

Living alone is correlated with higher mortality and often intersects with loneliness; however, previous reviews did not specifically target older adults living alone as a distinct group [15, 16, 18–21]. Furthermore, Donovan and Blazer [16] emphasised that despite recognition of “living alone” as a significant risk factor, interventions seldom focus on this population directly, often excluding them due to recruitment barriers or reliance on already-engaged older adults in community settings. While Nakou, Dragioti [17] specifically address older adults living alone, their outcomes are centred around increased loneliness and mortality risk, rather than quality of life and interventions utilised to support this population. Therefore, these discrepancy points to a crucial gap in the literature, around the experiences of loneliness and quality of life for older adults living alone, and the technological interventions utilised to support them.

Consequently, this review sought to understand the factors contributing to loneliness and quality of life among older adults living alone during the pandemic and intervention strategies used to improve experiences. Specifically, this study explored:

1. What factors influenced older adults’ experiences of loneliness during the pandemic?

2. What factors influenced older adults’ quality of life during the pandemic?

3. What interventions were used to improve older adults’ loneliness or quality of life during the pandemic?

This information is important to enable proactive planning to support older adults living alone in future events.

Methods

Design

Drawing from Whittemore and Knafl [22], a five-stage integrative review was conducted to investigate primary research using quantitative, qualitative and mixed methods designs. An integrative review was determined as the best approach as it would enable a synthesis of existing knowledge, across various methodologies, and the ability to generate insights. In this methodology ‘insights’ enable researchers to see existing data from a new perspective [23]. Cronin and George [23] argue that such an approach “does not merely point researchers towards new landscapes but allows them to see existing ones from a different perspective” (p. 69). This approach seemed applicable in relation to understanding loneliness and quality of life – two extensively explored concepts – against the background of a health pandemic and with consideration for similar events in the future. Guidelines on Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) were followed [24]. The Mixed-Methods Appraisal Tool (MMAT) was used to assess quality and rigour of studies [25].

Search strategy

A search of the literature was undertaken between July 2023 to February 2024, using six electronic databases: CINAHL Plus, MEDLINE with Full Text, APA PSYCArticles, Psychology & Behavioral Sciences Collection, Academic Search Premier and Proquest Coronavirus Research Database. The search strategy was developed in consultation with a health librarian. One search, consisting of six steps was conducted using MESH headings, relevant terms and abbreviations, which was implemented in MEDLINE is shown in Table 1. Articles were manually searched at the full-text review stage for reference to subjects living alone.

Table 1.

Example search strategy – Medline

Step	Search term
1	TI (“older adults” OR elderly OR geriatric* OR aging OR ageing OR senior* OR “older people” aged 65 or 65+)
2	TI covid-19 OR coronavirus OR pandemic OR lockdown OR isolation
3	AB experience* OR perception* OR attitude* OR view* OR feeling* OR perspective*
4	1 and 2 and 3 (Limiters – published 01/01/2019-15/02/2024)
5	“social isolation” OR loneliness OR “social participation” OR “quality of life”
6	4 and 5

Inclusion and exclusion criteria

The search included all peer-reviewed primary research, published in English, which explored the perspectives and experience of loneliness or quality of life in community-dwelling older adults (60 + years) who lived alone during the COVID-19 pandemic [26]. Although the WHO designated COVID-19 a public health emergency between January 2020 and May 2023 [27], the review included studies published from January 2019 to February 2024 to accommodate reporting lags and capture emerging post-pandemic data. Articles were excluded if the experiences and perspectives of people who lived alone could not be articulated from the presented results. Reviews, conference presentations and editorials were excluded, and duplicates were removed. Citation tracking and reference list inspections were undertaken in the search for relevant papers. Quantitative and qualitative research papers were identified in peer reviewed systematic reviews and metanalyses for inclusion if appropriate. Database alerts were created to capture relevant new publications that should be added to the review following the initial search criteria. Grey literature was not included.

Study selection

In the literature search, 1189 studies were identified, after which 617 studies remained following deduplication. The title and abstract of each paper were screened against the inclusion criteria by two members of the research team using the Covidence software tool [28]. Discrepancies in inclusion votes were discussed to resolve conflicts. A total of 334 articles progressed to the full-text review stage. At the full-text review stage, delineation of the experience of older adults who lived alone was an important consideration as this was often not clear in the abstract screening stage. Full-text articles were reviewed comprehensively by one member of the team with sample checks completed by the other two researchers to ensure consistency. All studies were required to have a demographic table delineating the living arrangement of each participant so that findings could be attributed to those living alone or with others. A total of 280 articles were excluded at the full-text review stage, most commonly due to the data not specifying the loneliness and quality of life experiences of older adults who lived alone (Fig. 1). Data from 53 articles were extracted using Covidence software and assessed for quality using the MMAT.

Fig. 1.

Identification of studies via databases and registers

Quality appraisal

The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality across qualitative research, randomized controlled trials, non-randomized studies, quantitative descriptive studies, and mixed methods studies [29]. This approach has been widely cited as a tool for quality appraisal in sys and other systematic literature review types. The included studies were critiqued for design, clarity of research questions, sampling strategies outcome measures and interpretation of data. MMAT scores of 1–2 are categorised as low-quality, scores of 3–4 as medium-quality and scores of 5 as high-quality [25]. The MMAT was completed by one researcher with a sample cross-checked by another member of the research team.

Data extraction and synthesis

Data from included studies were extracted into Microsoft Excel. The data extracted included author, publication date, location of study, study aim and design, data collection period, participant description, methods and measures and findings on the experiences of loneliness, quality of life, and provided interventions for older adults living alone. While some studies included participants living both alone and with others, only those in which data for older adults living alone could be extracted were included. Extracted findings were subgrouped into three categories to enable synthesis specific to the research questions: (a) studies exploring loneliness, (b) studies exploring quality of life and (c) studies that provided interventions and reported outcome data for either loneliness or quality of life. Measures used to determine loneliness and quality of life were noted alongside categorised data (see Supplementary Table 1, Supplementary Table 2 and Supplementary Table 3).

Subgrouped data were analysed and synthesised to produce a narrative “insight” related to the study aim and research questions. The first step was to summarise findings from all including studies to the three research questions. Secondly, the data from the quantitative studies were explored to identify experiences of loneliness and quality of life during COVID-19 and to note any data on factors that related to changes in these variables from pre-COVID-19. Thirdly, results and included quotes in the included qualitative studies were analysed [30]. Similar findings were grouped and refined into themes related to research aims [30]. Multiple readings of the articles [22] were conducted by the research team to reach consensus on prominent findings. Narrative summary, based on the paper by Dixon-Woods, Agarwal [31] was used to integrate study results across the various methodological designs to provide key insights in relation to the research questions (see Supplementary Table 4). Step 1 involved systematically organising and describing the findings of included studies; Step 2 involved exploring patterns, relationships, and differences across studies; and Step 3 entailed developing an interpretive narrative to explain these findings within their theoretical and contextual frameworks [31].

Results

Overview of included studies

The 53 studies included in the review were published between 2020 and 2023 (Table 2). Fifty papers investigated the experiences of loneliness for more than 84,616 people living alone. Of these, 36 were quantitative studies, 10 were qualitative, and three were mixed methods. Seventeen studies investigated quality of life among older adults, including approximately 4234 older adults who lived alone. Eight of these studies were quantitative, seven were qualitative, and two were mixed methods. Of the 53 studies, only three studies were interventional [32–34]. Two intervention studies explored loneliness [32, 33] and two explored quality of life [33, 34]. All three studies provided a technology-based intervention.

Table 2.

Characteristics of included studies

Authors, (date), location	Study Design	Stated Primary Aims/s of study	Number of participants who lived alone (% of total sample)	Mean Age (Years) and Health Status		Loneliness	Quality of life (QoL)	Measures	Findings related to Loneliness and/or Quality of Life (QoL)		MMAT Overall Qualitya
Altay & Çalmaz (2023), Turkey	Descriptive correlational study	To determine the factors affecting the perception of loneliness and life satisfaction.	43 (20%)		70.17 N/A.	Y	Y	Loneliness Scale for the Elderly (LSE). Life Satisfaction Scale (LSS).	Emotional loneliness was not significantly different for those living alone compared to with others. Life satisfaction was lower for those who lived alone compared to those who lived with others.		Medium
Atzendorf & Gruber (2022), 25 European countries	Cross sectional study	To measure the medium-term consequences on the mental well-being of older people, and the differences between countries.	8590 (31%)		74.5 N/A	Y	N	Change in loneliness: respondents who reported feeling lonely often or some of the time were asked whether they felt lonelier (1) or less lonely/about the same (0) compared to the time before the outbreak of COVID-19.	Participants living alone had a significantly higher probability of feeling lonelier since the outbreak of the pandemic, especially in countries with high COVID-19 mortality rates.		Medium
Bailey et al. (2021), Ireland	Cross sectional study	To examine health trajectories and healthcare utilization while cocooning.	57 (38%)		79.8 Most participants showed signs of frailty, with only 13% classified as fit.	Y	Y	Non-validated questionnaire measuring access to essential services, mental health, physical health and attitudes and compliance to cocooning.	Participants were almost twice as likely to report loneliness if they lived alone. There was no association between poorer QoL and living alone.		High
Beridze et al. (2022), Sweden	Cross sectional study	To explore the indirect negative effects of COVID-19 restrictions (collateral damage) and the sociodemographic profile of highly susceptible older adults living in central Stockholm.	618 (50%)		78.2 N/A	Y	N	UCLA-3	Those who lived alone had a significantly higher likelihood of experiencing loneliness.		Medium
Bloom et al. (2022), UK	Qualitative research	To explore the first wave impacted the experience of well-being and health behaviours, and how these changed over time.	7 (58%)		81.5–85.8 IQR N/A	Y	N	Serial telephone semi-structured interviews (3 months apart)	Participants living alone emphasised increased loneliness and isolation compared to those living with others.		Medium
Briere et al. (2023), Canada	Cross sectional study	To examine factors associated with QoL and well-being among older adults within the context of the pandemic, including loneliness and social isolation.	713 (32%)		69.4 36.3% with no chronic health conditions.	N	Y	Older People’s QoL	Living situation was not associated with QoL		Medium
Castillo et al. (2021), Philippines	Qualitative research	To describe the meaning of experience of using social media technologies.	8 (100%)		62–71 range N/A	Y	Y	In depth-online interviews	Participants lived alone found comfort by communicating through technologies, which decreased loneliness and increased quality of life. Technology supported their enjoyment of lockdown by facilitating learning and social connection.		Medium
Cihan & Gökgöz Durmaz (2021), Turkey	Cross-sectional design	To determine social (loneliness) and psychological (fear) consequences.	12 (9%)		71.5 85.4% with chronic health condition.	Y	N	LSE - Loneliness Scale for the Elderly	Participants who lived alone reported more loneliness compared to those living with their spouse or children.		Medium
Czaja et al. (2021), USA	Randomised controlled trial	To examine the relationships between social network size, social support, social isolation and loneliness, and the factors that predict loneliness and social isolation.	300 (100%)		76.2 Health as rated as “good” (m = 3.03), based on a 5-point scale ranging from 1 = poor to 5 = excellent.	Y	N	Friendship scale - Social isolation UCLA (20-item). Lubben Social Network Index - Social network size	Greater social isolation and less social support were associated with greater loneliness in older adults living alone. Environmental factors (life space, social network size, and life engagement), and health (reported number of functional limitations, and number of reported health conditions) were significant predictors of loneliness and social isolation.		Medium
Dai et al. (2022), China	Cross sectional study	To examine changes in residential status and mental health one year after Wuhan’s social isolation policies.	87 (21%)		71.9 N/A	Y	N	UCLA (20-item)	Loneliness was significantly higher among widowed older adults than those who were married or lived with their children.		Medium
Derrer-Merk et al. (2022), UK	Qualitative research	To investigate the experience of belongingness and its impact on resilience.	17 (58%)		71.0 N/A	Y	N	Semi-structured in-depth interview schedule, at two-time points.	Participants who lived alone experienced challenged belongingness, which increased loneliness and impacted resilience.		Medium
Dhakal et al. (2023), USA	Cross sectional study	To assess how the frequency of four modes of contact (i.e., phone calls; electronic and social messaging, such as e-mails/texts/social media messages; video calls; and in-person visits) was associated with feelings of loneliness.	554 (28%)		77.0 N/A	Y	N	Loneliness: How often did you feel lonely in a typical week during the COVID-19 outbreak? Is this more often, less often, or about the same as a typical week before the COVID-19 outbreak started?	Those who lived with alone were more likely to report experiencing loneliness. Results suggest that ICTs may not decrease loneliness among older adults.		Medium
Dziedzic et al. (2021), Poland	Cross sectional study	To assess the prevalence of anxiety, depressive symptoms, irritability and loneliness, and analyse the relationships between loneliness, mental health, sociodemographics, and chronic diseases.	48 (22%)		65.2 N/A	Y	N	Polish R-UCLA (20 item)	People who lived alone reported higher levels of loneliness.		Medium
Emerson (2020), USA	Cross sectional study	To investigate the effects of social distancing, and identify behavioural and social communication changes.	177 (21%)		60–85 range N/A	Y	N	Non-validated survey measuring loneliness	Those living alone reported higher rates of loneliness.		Low
Falvo et al. (2021), Switzerland	Qualitative research – Phenomenology	To explore the lived experiences of individuals aged > 64 during the first COVID-19 lockdown (April-May 2020).	12 (63%)		75.0 N/A	Y	Y	Semi-structured phone interviews	Older adults living alone expressed concerns about how reduced social contact could negatively impact loneliness. Identifying older people as an at-risk population made older adults living alone feel stigmatized, discriminated, looked with suspicion, and even threatened.		Medium
Fingerman et al. (2022), USA	Cross sectional study	To examine how living alone was associated with daily social contact and emotional well-being.	79 (35%)		78.3 Moderately good physical health (M = 3.48 on a 1–5 scale).	Y	N	Day Reconstruction Method (DRM) - morning, noon, evening. Social engagement - in person, via phone, electronically Emotion ratings: gratitude, contentment, loneliness, sadness, stress (Likert scale)	Participants who lived alone experienced more positive emotions (contentment, gratitude) when they saw someone in person compared to people who did not have in-person contact. Individuals who live alone experienced more negative emotions (loneliness, sadness, and stress) when they talked to someone on the phone compared to people (a) who lived alone but did not talk with others on the phone or (b) who live with others regardless of phone contact.		Medium
Fiocco et al. (2021), Canada	Qualitative research – Phenomenology	To investigate the lived experience of community-dwelling older adults during the first six months of COVID-19.	6 (27%)		72.2 68% reported a medical condition, including anxiety, depression, chronic pain, hypertension and diabetes	Y	Y	Semi-structured interviews	Participants who lived alone, especially those without existing family and “social bubbles”, experienced more isolation and loneliness due to the inability to connect with others. Participants living with others in larger spaces benefited from this living arrangement. Some participants enjoyed the solitude to foster creativity and spirituality or expressed gratitude for small pleasures and opportunities for human touch.		Medium
Fuller & Huseth-Zosel (2022), USA	Mixed methods	To explore shifts in perceptions of loneliness in unique geographic contexts, prior to and during social distancing recommendations.	41 (54%)		82 N/A	Y	Y	UCLA-3. Qualitative interview which encouraged explanation of responses to the UCLA-3.	Change in loneliness did not vary for those living alone. For those experiencing decreased or no change in feelings of loneliness, two themes arose: accustomed to being alone (i.e., feeling comfortable with solitude or being used to independence) and staying connected using phones/technology (i.e., to stay connected through phone calls, videochat, social media, and texting). Participants reported struggling to being forced into isolation as opposed to making their own choice to be alone.		Medium
García-Esquinas et al. (2021), Spain	Cohort study	To describe the differences in health behaviours, mental health and physical health, prior to and 7–15 weeks into lockdown.	3041		74.5 Overall physical health remained moderate with chronic conditions including, diabetes (n = 499), hypertension (n = 1571), cardiovascular disease (n = 221), cancer (n = 203) and depression (n = 337).	Y	Y	Loneliness UCLA-3 (ES) Direct measure Likert QoL Cantril Ladder (life satisfaction); Short Form Survey 12-Item (SF-12). Interviews Pre-pandemic face-to-face interview. Telephone interview during lockdown.	Living alone and feeling lonelier were predictors of unhealthy changes in SF-12 mental component scores and poor sleep. Percentage of older adults living alone without daily contact with family or friends halved during the pandemic. In one cohort, no increases in lonely feelings in older adults living alone were observed during the study period.		Medium
Gezgin Yazici & Ökten (2022), Turkey	Cross sectional study	To examine the relationship between sociodemographic characteristics, and loneliness and insomnia.	77 (19%)		70.3 Most participants had no psychiatric disorders (91%), though chronic physical conditions were common (74%), and most took regular medications (76%).	Y	N	UCLA-3. Non-validated Survey investigating sociodemographics. Insomnia severity index.	The relationship between living environment (alone/with family/caregiver) and both loneliness and insomnia were not significant.		Low
Goodman-Casanova et al. (2020), Spain	INTERVENTION STUDY: Randomised controlled trial.	To explore the impact of confinement on adults with mild cognitive impairment or mild dementia, and the impact of an assistive integrated technology that provided education and resources.	24 (26%)		73.3 Health status was found to be optimal in 89/93 respondents (96%), with no COVID-19 symptoms.	N	Y	Non-validated telephone-based survey with open and closed ended questions.	Those who lived alone experienced poorer mental health, well-being and sleep. Assistive technology supported cognitive stimulation and reduced carer burden.		Medium
Grohé et al. (2022), Germany	Qualitative research	To describe how home-living older adults with depression experience COVID-19.	18 (90%)		78.2 All participants had at least one pre-existing physical condition (e.g., cardio vascular diseases, respiratory diseases, vision problems, bladder problems).	Y	Y	Unstructured interviews	Older adults living alone with depression felt disconnected and experienced loneliness before and during COVID-19. Reported only minimally impacted but, also pined over lost opportunities for social and physical contact, which increased loneliness. Older adults living alone viewed circumstances as unchangeable, and passively accepted negaitve experiences. Reframing isolation as a common experience of “cocooning” provided a sense of autonomy and togetherness.		Low
Guner et al. (2023), Turkey	Cross sectional study	To assess the impact of loneliness on death anxiety.	16 (5%)		68.3 N/A	Y	N	Loneliness Scale of Elderly (LSE)	Participants who lived alone had higher LSE general and sub-dimension (emotional loneliness/social loneliness) scores than those who lived with others.		Medium
Heidinger & Richter (2020), Austria	Longitudinal study (pre- and peri-pandemic)	To provide a direct comparison of reported loneliness before and during COVID-19.	408 (46%)		73.0 Most participants rated their health as good or very good (60%), while few reported poor (n = 68) or very poor health (n = 11).	Y	N	German 6-Item De Jong Gierveld loneliness scale (DJGLS)	Participants living with at least one person reported to be less lonely than participants who were living alone at both the pre- and peri-COVID-19. The anticipated increase in loneliness was significant among those living with at least one other person but not among those living alone.		Medium
Holaday et al. (2022), USA	Cross sectional study	To determine whether feelings of loneliness, sadness, or social disconnection differed by race or ethnicity, and whether access to the internet or primary care was associated with less loneliness or feelings of disconnection.	1706 (21%)		65+ (mean age not specified). N/A	Y	N	Two questions: “Since the coronavirus outbreak began, have you felt more lonely or sad, less lonely or sad, or about the same?” and “Since the coronavirus outbreak began, have you felt more socially connected to family and friends, less socially connected to family and friends, or about the same?”	People who lived alone experienced higher loneliness and sadness, especially if they had access to the internet, but did not experience higher feelings of social disconnection.		Medium
Hughes et al. (2022), USA	Cross sectional study	To examine the psychosocial health effects of restrictions.	141 (39%)		65+ (mean age not specified). N/A	Y	N	Loneliness Single question: “In general, to what extent are the restrictions making you feel lonely?”	People living alone were more likely to feel lonely.		Medium
Johansson-Pajala et al. (2022), Sweden	Cross sectional study	To investigate the effect on experiences of anxiety and loneliness among older people living in residential care facilities or receiving home care services.	61,297 (74%)		85.5 26.5% of participants self-rated health to be poor or worse	Y	N	Loneliness Single Question: Does it happen that you are troubled by loneliness?	Living alone (with home care services) was the most influential factor affecting increased likelihood of loneliness.		Low
Khan & Kadoya (2021), Japan	Longitudinal pre-post survey	To determine whether older people suffered from loneliness more than younger people. To investigate the socio-demographic and psychological factors that led to loneliness.	851 (20%)		50.3 Participants reported moderately positive subjective health (M = 3.24 on a 5-point scale).	Y	N	Loneliness: UCLA 3-item. Single question “How often do you feel lonely”.	Living alone is a significant predictor of loneliness among older people. While loneliness in younger people was more pervasive, the magnitude of increase was higher among older people. Household income and financial satisfaction were associated with loneliness among older people during COVID-19. At both time points, age, subjective health status, and feelings of depression are strongly associated with loneliness.		Medium
Lee et al. (2021), Singapore	Longitudinal	To examine the psychological, physical activity, and financial impact of a 2-month lockdown, and to identify factors associated with adverse outcomes.	39 (8%)		73.8 Diabetes (n = 153), hypertension (n = 429), hyperlipidaemia (n = 333), cardiovascular disease (n = 109), chronic kidney disease (n = 67)	Y	N	UCLA 3-item	Individuals living alone were more likely to experience a clinically significant increase in loneliness scores.		Medium
Lee et al. (2021), USA	INTERVENTION STUDY: Mixed methods	To examine the Caring Callers (telephone reassurance service) impact on homebound older adults, and discuss the feasibility of its procedures, assessments, and implementation.	10 (67%)		74 Low overall self-rated health (M = 1.25 on a 0–4 scale), indicating perceptions of health between poor and fair.	Y	N	Loneliness: 20 items using a four-point rating scale. Semi-structured interviews.	Participants living alone with limited social support expressed program’s positive impact on alleviating feelings of loneliness and elevating their spirits.		Medium
Lehtisalo et al. (2021) Finland	Cross sectional study	To describe how the first phase of the COVID-19 pandemic affected older persons who are at risk of developing dementia.	196 (32%)		68.2 54.3% of participants reported having two or more chronic conditions, 25.3% reported one, and 20.4% reported none.	Y	N	Self-report if loneliness was similar to before the pandemic, decreased or increased.	Participants living alone reported a statistically significant increase in feelings of loneliness compared to those who lived with others.		Medium
Llorente-Baroso et al. (2021), Spain	Qualitative research	To understand experiences of the Internet and internet communication tools in addressing social isolation, loneliness and distance from loved ones.	13 (48%)		Aged 60+ (mean age not available). N/A.	Y	Y	Focus groups with people aged 60+	Participants with high education levels and digital literacy who spent lockdown alone did not report feeling lonely. Participant s with lower education levels reported more loneliness. Participants who experienced loneliness acknowledged that they expected the situation would be temporary, so they felt better at the beginning of lockdown. Technology (e.g., WhatsApp group communication) provided “an escape from their loneliness” and facilitated closeness with loved ones. Participants with lower educational background and living alone showed a higher emotional weakness supporting a link between low educational background and lower QoL.		Medium
MacDonald & Hülür (2021), Switzerland	Micro longitudinal: 2019 + 2020 follow-up	To examine the effect of lockdown on subjective well-being and loneliness before and during COVID-19.	39 (39%)		71 Mean number of health conditions was 4.12.	Y	N	Participants indicated on a slider with positive/negative affective states how they felt during the last day (in 2019) or week (during COVID-19 lockdown) - Based on Watson et al., (1988)	Participants who lived alone reported lower levels of loneliness.		Low
McKinlay et al. (2021), UK	Qualitative research	To examine factors that threatened and protected wellbeing during social distancing restrictions.	8 (40%)		79 Fourteen participants reported a physical health condition, including hypertension, diabetes, arthritis, high blood pressure and cancer.	Y	Y	Semi-structured interviews	Some participants living alone described a pre-existing familiarity with isolation from widowhood or retirement, so lockdown did not prompt a dramatic change in daily routines or social habits. Slowing the pace of life on an individual and societal level gave more time alone to reflect. Although some participants had described a loss of leisure during lockdown, many had found time for new hobbies, reading, crafts, gardening, and learning a new language.		Medium
Melei & Linder (2022), USA	Cross sectional study	To explore how social participation (habits/routines) changed, the differences in perceptions of social participation, and differences the COVID-19 Quality of Life (COV19-QoL) scale by demographics, access to health care, and lifestyle routine.	50 (22%)		65–86 (no mean provided) High blood pressure (58.7%), cancer (18.3%), heart disease (16.5%), type II diabetes (13.9%), COPD (7.4%), chronic kidney disease (3.5%), and weakened immune system due to transplant (1.7%). 25.7% reported no medical conditions.	N	Y	COV19-QoL Scale (Repišti et al., 2020).	There was a small but significant difference in COV19-QoL scores between individuals who lived alone and those who lived with others.		Medium
Mistry et al. (2022), Bangladesh	Cross sectional study	To assess changes in the prevalence of loneliness and identify its correlates.	104 (5%)		Aged 60–69 years (77.8%), 70–79 years (16.9%), and aged 80 years or older (5.3%). 58.9% had at least one pre-existing non-communicable disease.	Y	N	UCLA 3-item	The prevalence of loneliness remained stable or slightly increased from 2020 to 2021 among participants without a partner and those living alone.		Medium
Mistry et al. (2022), Bangladesh	Cross sectional study	To investigate the prevalence of loneliness and its associated factors.	79 (8%)		60–69 years old (n = 803), 70 years+ (n = 229). 58.9% suffering from non-communicable diseases.	Y	N	UCLA 3-item	Participants living alone were 2.5 times more likely to experience loneliness.		Medium
Neves et al. (2023), Australia	Qualitative research	To explore how older Australians who were lonely pre-pandemic managed lockdowns in Victoria, Australia (one of the longest lockdowns in the world).	32 (100%)		77.5 N/A	Y	N	Diaries - with reflective prompts	L living alone intensified feelings isolation and being unsupported. COVID-19 amplified feelings of loneliness, spreading them more consistently throughout the day. However, bedtime remained to be most challenging time. Digital connection was beneficial when participants felt valued (i.e., gaming online with grandchildren or assisting with homework via video). Some participants wrote that their house became a space of imprisonment and confinement, reminding them of loneliness.		High
Ottoni et al. (2022), Canada	Mixed Methods	To determine how individual, interpersonal and neighbourhood characteristics influence social connectedness.	21 (68%)		72 26% rated their health as excellent, 71% rated their health as good/fair, 3% rated their health as poor.	Y	Y	Loneliness: UCLA 3-item. Interviews: explored participants’ typical day, current social and physical activities, perceived impacts of physical distancing, challenges to maintain desired social and physical activities and strategies to overcome these challenges.	Findings were consistent with older adults living alone and older adults living with others. Participants initiated social connections within their immediate neighbourhood by actively seeking walking partners, engaging in face-to-face interactions in hallways, and utilizing communal spaces within buildings. The apparent ease and accessibility of these interactions contributed to a sense of connection, which alleviated loneliness despite the pandemic’s constraints. Participants suggested these losses negatively impacted their well-being.		Medium
Parlapani et al. (2020), Greece	Cross sectional study	To investigate the psychological impact of COVID-19 and sleep disturbances, and potential predictors of loneliness.	20 (19%)		69.9 N/A.	Y	N	Greek De Jong Gierveld Loneliness Scale (DJGLS)	Participants living alone showed higher levels of loneliness, where intolerance of uncertainty and anxiety were significant.		Low
Portacolone et al. (2021), USA	Qualitative study	To investigate (a) How are older adults living alone with cognitive impairment managing during the early stages of the pandemic? (b) What are their priorities, concerns, and coping strategies? (c) What services and supports are important to them? (d) Are they experiencing a sense of precarity?	24 (100%)		81 Medical diagnosis of Alzheimer’s disease, mild cognitive impairment or dementia, or a score of ≤ 24 on the Montreal Cognitive Assessment.	Y	N	Ethnographic interviews	Older adults living alone experienced loneliness and extreme isolation, contributing to their precarity.		Medium
Richardson et al. (2023), UK	Cohort study	To investigate the prevalence of loneliness and its risk and protective factors (i.e.-pandemic social contact and technology-mediated contact).	147 (39%)		75+ Self-assessed health for age: 14.3% excellent, 57.3 good, 22.4 fair, poor 6.1	Y	N	Direct loneliness measure: “Do you feel lonely?”	Living alone was associated with 2.7 times increase in perceived loneliness.	Medium
Röhr et al. (2020), Germany	Cross sectional study	To investigate the mental wellbeing in the old age population during COVID-19. To inspect associations of mental wellbeing with sociodemographic factors, aspects of the personal life situation during lockdown and attitudes towards COVID-19 as well as resilience.	341 (34%)		75.5 N/A.	Y	N	UCLA 3-item.	There was no difference in levels of loneliness for participants who lived alone compared to those living with others.		Medium
Saraiva et al. (2021), Brazil	Cohort study	To investigate the relationship between life-space mobility and QoL in older adults with and without frailty.	85 (15%)		80 Health conditions: 33% diabetes, 26% heart failure, 17% cancer, 9% chronic obstructive pulmonary disease, frailty 33%	N	Y	UCLA 3-item. Non-standardised single question “How is the COVID-19 pandemic affecting your QoL?“.	Living alone did not predict a significant impact on QoL.		Medium
Savage et al. (2021), Canada	Cross sectional study	To investigate loneliness during the first wave of COVID-19.	1449 (30%)		65–79 89.7% of participants self-reported health status as excellent/very good/good, 10.1% as fair/poor, and 0.2% did not know.	Y	N	Single item: “In the past seven days, which statement best applies?” (I did not feel lonely; I felt lonely 1 or 2 days; I felt lonely several days; I felt lonely most days; I felt lonely every day).	Living alone was associated with loneliness in both women and men; although the association was greater in men, possibly due to smaller social networks.		Low
Seifert & Hassler (2020), Switzerland	Longitudinal pre-post	To investigate the association between subjective loneliness and different time phases.	527 (27%)		72.7 N/A.	Y	N	6-Item De Jong Gierveld loneliness scale (DJGLS) (de Jong Gierveld and Van Tilburg, 1999)	Individuals living alone were more likely to report greater loneliness.		Medium
Stolz et al. (2021), Austria	Cross sectional study	To assess the association between restriction measures and loneliness.	Total sample not clearly reported (30%) 557 + 388		Older adults 60+ N/A	Y	N	UCLA 3-item	The probability of feeling lonely decreased substantively (from 30% to 40% during lockdown, to 10% at the end of the observation period) among older adults who lived alone.		Medium
Strutt et al. (2022), Australia	Cross sectional study	To examine the impacts of physical and emotional health, emotion regulation, quality of life, social networks and loneliness, diet and exercise habits, health service utilization, grandparenting, and technology use.	61 (30%)		70.6 Participants reported a mean Physical Health score of 15.85 on the WHOQoL-BREF, indicating moderate physical quality of life.	Y	Y	WHOQoL-BREF Quality of life Lubben Social Network Scale (LSNS-6). De Jong Gierveld Loneliness Scale (DJGLS). Grandparenting questionnaire (developed by authors).	Living alone was associated with higher social and total loneliness scores. Living alone was associated with significantly lower WHOQOL-BREF-Social Relationships scores and WHOQOL-BREF Environment scores but not with any other mental health, quality of life or social variable.		Medium
Takashima et al. (2020), Japan	Qualitative research	To explore the perceptions of restrictions.	9 (38%)		78.2 N/A	Y	N	Focus groups	Participants who lived alone reported emotional loneliness and identified that losing connections with neighbours exacerbated loneliness and anxiety about living alone.		High
Van Assche et al. (2023), Belgium	INTERVENTION STUDY: Qualitative research	To explore the experiences of older adults with mild cognitive impairment with a socially assistive robot (SAR), and its effects on loneliness, and meaningful time use and activities.	4 (100%)		83 N/A	Y	Y	Semi-structured interviews following two-week interaction with SAR.	For older adults who lived alone, the robot felt like a welcome distraction, and saw the time spent as useful, enjoyable and fulfilling. Most time was spent during the latter parts of the day, and it often was a replacement for less productive activities, like watching television.		Medium
van Tilburg et al. (2021), The Netherlands	Cohort study	To assess the impact of reduction of social contacts, personal losses, and general threat experiences in society on well-being.	672 (40%)		73 Self-rated health was included as a control variable and did not interfere with the analysis.	Y	N	de Jong Gierveld short scales for emotional and social loneliness – 6-items (De Jong Gierveld & Van Tilburg, 2010)	Social loneliness and emotional loneliness were associated with not living with a spouse or partner.		Medium
Wilson-Genderson et al. (2022), USA	Longitudinal cross sectional	To examine predictors of change in loneliness experienced.	664 (27%)		60.79 N/A	Y	N	UCLA 3-item. Perceived social support – 4 items. Social isolation – 1 item.	Participants living alone reported higher loneliness scores. Women experienced less loneliness prior to the pandemic than men, however women experienced a greater increase in loneliness during the pandemic.		Medium
Wong et al. (2022), Hong Kong	Cohort study	To describe changes in loneliness, mental health problems, and attendance to scheduled medical care.	83 (14%)		70.9 Most participants (65.9%) reported 2–4 chronic conditions, and a further 34.1% reported living with four or more.	Y	N	Chinese 6-item De Jong Gierveld Loneliness Scale (DJGLS)	Living alone was associated with increased social loneliness and overall loneliness.		Medium

QoL Quality of life, MMAT Overall Quality - High (5), Medium (3–4), Low (1–2)

The studies were completed in a wide range of locations, most commonly the USA (n = 11), Canada (n = 4), UK (n = 4) and Turkey (n = 4). While all studies investigated older adults, some studies explored the experiences of older adults with particular health conditions, such as mild cognitive impairment or mild dementia [34, 35], chronic conditions [36], frailty [37], and clinical depression [38]. A summary of the papers comprised in this review and their corresponding MMAT score (majority of studies were of medium quality n = 46, 85%) are displayed in Table 2.

Of the quantitative studies evaluating loneliness (n = 35), 77% (n = 27) used standardised measures (see Table 2). The most commonly used was the UCLA Loneliness Scale 3-item version [39]. Fifteen studies used non-standardised measures such as single-item questions, for example “in general, to what extent are the restrictions making you feel lonely?” [40], or “how often do you feel lonely?” [41]. Loneliness was explored in 11 qualitative studies. This information was obtained through semi-structured interviews (n = 10), unstructured interviews (n = 1), focus groups (n = 2), or diary data (n = 1). Quality of life was explored using six standardised assessments and two non-standard measures (see Table 2). Quality of life outcomes emerged naturally from interviews (n = 93), unstructured interviews (n = 1), and focus groups (n = 1).

Insight 1: Heightened sense of loneliness

Most studies demonstrated a heightened sense of loneliness among older adults residing alone during the COVID-19 pandemic [1, 2, 35, 36, 40], [42–64]. Factors such as reduced social interactions [61, 65–67], intolerance of uncertainty and anxiety [35, 68], and isolation from neighbours [61], were described to explain exacerbated feelings of loneliness. Additionally, the association between living alone and loneliness was evident in both older women and men, with a more pronounced effect observed in men [3]. However, women who initially reported lower levels of loneliness pre-COVID-19, experienced a more substantial increase in loneliness during the pandemic compared to men [69]. The experience of heightened loneliness in older adults living alone is demonstrated in the quote below:

“I’m lonely. I’m not seeing family. I’m not seeing friends. I haven’t been anywhere since about the end of October. I had Christmas on my own, my birthday on my own. Everyone else’s birthdays, I couldn’t go to celebrate. It’s been hard. (.) I think being shut in all the time and just being on your own, it does make you, not nervous but apprehensive.” [63, p.10].

Despite the demonstrated influence of COVID-19 on loneliness, the findings also indicated that living alone is associated with a general predisposition towards increased loneliness, irrespective of external factors such as those introduced by the pandemic. Specifically, Heidinger and Richter [51] revealed higher loneliness levels in older adults living alone compared to older adults living with others, yet this did not show a significant increase from pre- to post-COVID-19. Some studies proposed that this consistency in loneliness levels may be attributed to older adults living alone being accustomed to isolation, which protects against further negative effects of mandated social distancing requirements [49, 51, 70, 71].

“Yet again, I swing my legs out of the bed with a certain amount of apprehension. What will the day bring? Whatever it brings, I will face it alone” [72, p.126].

However, divergent findings emerged, which suggested decreased loneliness or no change in loneliness in older adults living alone. The decrease in loneliness experienced by older adults living alone was suggested to stem from a shared experience of “togetherness” in isolating as a society [38, 54, 59], or the ease with which they initiated and connected socially with their immediate neighbours in hallways and driveways [73, 74]. In contrast, a subset of studies did not identify an association between living alone and heightened loneliness [75, 76], and emotional loneliness [77].

Insight 2: Significantly poorer quality of life

Most studies reported that older adults living alone experienced significantly poorer quality of life [34, 60, 73, 77, 78]. A minority of studies did not demonstrate a link between quality of life and older adults living alone [37, 43, 79]. The specific quality of life effects of the pandemic on those living alone were demonstrated by Strutt et al. [60], who reported decreased scores in both the Social Relationships domain and the Environment domain of the WHOQOL-BREF quality of life assessment. Additionally, Garcia-Esquinas et al. [80], highlighted that unhealthy changes in sleep quality were more common among those who lived alone. Furthermore, being identified as an “at-risk” population had the effect of some older adults feeling stigmatised [66] and imprisoned in their homes [35, 72]. For example, the explication below highlights how the restriction of community activities and engagement led to the felt sense of deprivation:

“I felt deprived because of no symphony, no seniors club, no entertainment, no library because I love my volunteering” [74, p.10].

While older adults who lived alone generally reported experiencing lower quality of life [34, 60, 73, 77, 78], some positive aspects were reported. Positives gleaned by those living alone during the pandemic included appreciating activities and small social connections [1, 73], and fostering creativity, engaging in hobbies and learning new skills [67, 71]. These contributed positively to quality of life. For example, the quote below demonstrates how gratitude was expressed towards social distancing mandates for the opportunity to complete accumulated tasks.

“I found the whole thing easy because I got jobs done…yeah, jobs that I had been waiting to do for so long, so I was grateful for the lockdown” [74, p.6].

Insight 3: Technology - hindrance or help?

Three interventional studies explored strategies for older adults living alone during COVID-19 restrictions [32–34]. These studies demonstrated that technology can foster connection for older adults living alone. Van Assche et al. [32] trialled a socially assistive robot and reported that the technology provided a useful, enjoyable and fulfilling distraction that replaced less productive activities such as watching television. The simple intervention of regular phone calls [33, 34] alleviated loneliness and elevated participants’ spirits. Non-intervention studies supported these notions by describing the role of technology in facilitating connection and comfort [70, 81, 82] particularly when interactions were valued and meaningful, such as helping grandchildren with homework [72] or remotely attending religious services [35]. The quotation below depicts how some participants valued the social media platforms for enabling increased connection amidst social distancing mandates:

“I am grateful [for Facebook] that I even had more time to communicate with friends now, because I’m being locked down” [81, p.5].

However, heterogeneity emerged in the studies, with some highlighting the negative impact of technology on loneliness and quality of life. For example, Dhakal, Koumoutzis [47] and Neves et al. [72] depicted how technology heightened feelings of loneliness in older adults living alone, due to the experience of technological modalities as daunting and the absence of support from family and friends. Additionally, some studies described how older adults who lived alone reported experiencing negative emotions when communicating via phone calls [1], and when accessing the internet [51]. Neves et al. [72] reiterated that superficial or less meaningful digital connections increased feelings of disconnection and loneliness. For example, when the connections became shorter, particularly during periods of home-schooling and remote working, feelings of isolation were exacerbated [72].

Discussion

This review examined the impact of social distancing mandates on loneliness and quality of life for older adults living alone during the COVID-19 pandemic (2020–2023). In total, 53 studies from five continents were identified, revealing that the experiences of older adults, including those that live alone, was of international interest during a global pandemic. The expansive volume of literature is somewhat unsurprising as older adults who live alone have been identified as an ‘at risk’ population [83] prior to the COVID-19 pandemic. During COVID-19 and the time that has followed, the academic community has comprehensively examined the lived experiences of older adults across the globe, likely because of the anticipated risks to the health and wellbeing of this population [8, 10, 14, 83]. Our synthesis has demonstrated that many older adults living alone experienced a heightened sense of loneliness and significantly poorer quality of life during COVID-19 and in the time that has followed, as predicted. These findings provide a snapshot of the decline in wellbeing and increase in vulnerability that exists for older people during and following a significant global event. Our findings align with a number of government reports from around the world acknowledging the need to address the ‘lasting impacts’ of COVID-19 on loneliness and social isolation and the subsequent and consequential influence on wellbeing [84–87].

Despite the high level of concern about the wellbeing of older adults, there was limited interventional research conducted with those who lived alone during COVID-19. Three intervention studies [32–34], all-encompassing some element of technology, were trialled with mixed results suggesting that technology was both a hindrance and help. While technology was the primary mechanism of providing social support during social distancing mandates, the efficacy of technology in mitigating loneliness exhibited mixed findings. Research both pre- and during COVID-19 has emphasised that technology needs to be meaningful, personalised to the older person’s needs, support usual activities, and be relatively easy to use [72, 88–90]. The introduction of technology to support older adults in their own homes has also been reported to require ongoing technical and problem-solving support [89, 91]. These are considerations that need to be built into future technological interventions.

This review presents data to show the globally-felt human experience of enforced social isolation for people who lived alone. With this information, governments, health and community services can anticipate the needs of this group, in the case of future pandemics or other involuntary loss of social connection. This planning is critical in a country like Australia, which experienced catastrophic bushfires pre-COVID-19 and widespread flooding post-COVID-19. The combination of natural and health disasters has slowed the natural return to social and community life, exacerbated by the loss through natural disaster of community facilities (such as libraries, galleries and cafes) that were the focal point for common-interest groups [92]. Thus, the impact of COVID-19 is ongoing, and reconnection has not been simple. A proactive approach to addressing the needs of vulnerable people is warranted. With an already strained healthcare system, we propose the consideration of a pro-active social model of health, social prescribing, as a strategy to support reconnection, as desired, for older adults.

Social prescribing programs have increasingly been utilised to mitigate social isolation and loneliness [93], and may address specific concerns in older adults living alone [94]. Social prescribing is a person-centered and scalable approach that addresses health and social needs not addressed by routine medical care [95]. By supporting people to gain equal access to and participate in social institutions, relationships and systems [96], social prescribing by its nature encourages social integration, which in turn plays a pivotal role in enhancing resilience and mitigating the adverse effects of isolation [97]. Holistic and integrated care is provided to service users through the collaboration of health, social and community services to leverage existing community assets [95].

The link worker model of social prescribing may be particularly advantageous as service users can obtain more one-on-one support and personalised care to address complexities and nuances of an individual’s specific health issues [98]. Link workers bridge the gap between referrers (i.e., GPs, social workers) and individuals to facilitate the integration of social and community-based interventions into a personalised healthcare plan, which typically involves promoting participation in nature-based, physical and community activities, and providing information and supporting practical needs, including the application of technology [99, 100]. There is a real opportunity for this model to support older Australians living alone by providing the necessary individualised support to build confidence and address the social determinants that may act as barriers to older persons re-integrating into society. Additionally, social prescribing may enable link workers to support older adults living alone by acquiring technology skills to address the technological divide in any future social distancing mandates. For example, technology training interventions may support older Australians living alone by developing the skills to utilise different modalities for connection [90]. Therefore, there is a need to further explore social prescribing strategies that address loneliness and promote quality of life in older adults.

Strengths and limitations

Capturing the breadth of international research of various study designs provides a diverse picture of the experience of older adults worldwide. However, these experiences are somewhat conceptualised to the extremes of the pandemic situation and to the local health response to the crisis. For example, residents of Melbourne, Australia experienced one of the longest lockdowns in the world [101], while Swedish citizens had no lockdown policy enforced [102]. The inclusion of a variety of study designs in this integrative review provides summary data of quantitative studies, supported by personal and individual narratives captured in qualitative studies. It is important to note that many of the studies provided real-time data on the outcomes of interest in this study, but these were frequently not presented against pre-COVID-19 health and wellbeing levels. The review was limited to English-language papers and, despite a rigorous search approach, it is possible that not all relevant literature was identified. The exclusion of grey literature may be considered a limitation of this study. Although this review assessed study quality using the MMAT, we did not place any restriction on inclusion based on this score. The intent was to summarise the extent of literature available regardless of methodological quality. Consequently, readers should further explore individual studies in the interpretation of their presented data.

The study is also limited to experiences of older adults during a set time period and it is unknown whether older adults have returned to pre-COVID-19 levels in relation to the health outcomes explored in this study in addition to social connectedness and other elements of community-based living. Lastly, there are some limitations to the generalisability of our findings in terms of gender and geographic location. As examples, it has been acknowledged that women experienced lower rates of quality of life during the pandemic and this was not specifically explored in this paper. Likewise, it is plausible that older adults in urban and rural locations may have experienced loneliness and quality of life differently, further potentially influenced by neighbourhood design and proximity of other people. This was also not explored in this study.

Future research

Longitudinal studies are required to examine post-COVID-19 experiences and interventions to support older people to reconnect with society. Social prescribing may be one opportunity to support this process. Additionally, it is recommended that future studies assess key moderating variables, such as age and health status [103]. Accounting for these factors would enhance the robustness and clarity of findings.

Conclusion

The COVID-19 pandemic highlighted the vulnerabilities of older adults living alone, exacerbating feelings of loneliness and diminishing quality of life. While technology served as a critical tool for connection, its effectiveness varied, underscoring the need for tailored interventions that prioritise accessibility and ease of use. There is a need to proactively consider how to support older adults who live alone in future health or climate events. Social prescribing is a promising, proactive solution which could facilitate personalised support and foster meaningful connections.

Authors’ contributions

MB, CA and JRB: Conceptualization, methodology design, and manuscript drafting.MH, MB and CA: Data extraction, analysis, MH and TP: Literature search and review, data synthesis, Quality appraisal and manuscript development. All authors: critical revision and refinement of the manuscript. All Authors reviewed the manuscript.

Funding

We did not receive any financial support for the research.

Data availability

The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s)).

Declarations

Competing interests

The authors declare no competing interests.