A Paradigm shift – loneliness as a root cause of symptom distress among older adults

The prevalence of symptoms such as pain, fatigue, depression, and insomnia is high at older ages and these symptoms commonly co-occur.^{1, 2} Traditional approaches to symptom management rely heavily on pharmacologic therapies. Decades of research have demonstrated that analgesics such as opioids, anti-inflammatory agents, and antidepressants have limited benefit and increase the risk of falls, delirium, and other harms stemming from polypharmacy and multimorbidity.³ Even over the counter therapies like NSAIDs are often contraindicated due to risks of gastrointestinal bleeds or renal impairment. Moreover, medical approaches often address each symptom individually without considering their interdependent nature. It is no surprise then that reducing the burden of symptom distress among older adults is a source of frustration among patients, families, and clinicians alike.

When possible, addressing the root causes of symptom distress is a more rational, and likely safer approach. In this issue of the Journal of the American Geriatrics Society, Powell and colleagues point us to a root cause approach to reducing symptoms among older adults through attention to social and emotional factors like loneliness. Using longitudinal data from the Health and Retirement Study, including 5,974 community-dwelling older adults and up to three longitudinal waves of data, they find that individuals reporting baseline loneliness had higher odds of reporting pain (aOR 1.22, 95% CI 1.08,1.37), fatigue (aOR 1.47, 95% CI 1.32, 1.65), depression (aOR 2.33, 95% CI 2.02, 2.68), and the cluster of these three symptoms (aOR 2.15, 95% CI 1.74, 2.67) in subsequent waves. Notably, this increased risk was apparent even among those reporting loneliness only “some of the time,” and was present to a greater degree among older adults experiencing “frequent” or “severe” loneliness. These data build on prior studies showing that the feeling of loneliness is a powerful predictor of pain,^{4, 5} other symptoms,⁶ use of polypharmacy, and the use of high-risk medications.⁷

That loneliness is strongly related to quality of life may not come as a surprise to clinicians or the general public. Loneliness is increasingly recognized as a public health concern in the United States since a 2020 National Academy of Sciences report summarized decades of research demonstrating both its high prevalence and its detrimental health effects.⁸ A 2018 survey by the AARP Foundation found that more than one-third (35 percent) of adults aged 45 and older are lonely.⁹ Additionally, a 2018 study by the Kaiser Family Foundation found that 22 percent of adults in the United States say they “often or always feel lonely, feel that they lack companionship, feel left out, or feel isolated from others”, numbers that are substantially higher among persons of low income.¹⁰

A growing body of neurophysiologic and clinical evidence has demonstrated that loneliness is a powerful predictor of poor health outcomes including cognitive impairment, functional decline, and death.^11–16 These adverse outcomes may be mediated by the influence of loneliness on the intermediate development of symptom distress (pain, fatigue, depression, as seen in Powell et al.) and the impact of these symptoms on declining cognition and function, which can then further worsen loneliness.^{13, 17–19} Reinforcing the growing evidence of the power of the mind-body connection, longitudinal studies on the impact of ageism and self perception of ageism indicate that negative perceptions of the aging process substantially increase risk of illness and death.^20–22 The health and social implications of loneliness have worsened during the COVID-19 pandemic because of social distancing that further isolates older adults.^23–26 Indeed, loneliness has become a nearly universal experience across age groups, communities, and cultures during the pandemic, upending stigma around discussing this sensitive topic and demonstrating to many the physical and mental toll loneliness can have on our health.

Powell et al’s results thus add to a growing body of evidence identifying loneliness as a powerful predictor of adverse outcomes. This creates an opportunity to shift our clinical paradigm in symptom management by incorporating social interventions (Table 1). As a first step, clinical teams and health systems should routinely ask about and identify loneliness among patients, particularly those experiencing pain, depression, or fatigue. Complicated surveys are not needed; loneliness can be quickly identified through a single question or brief scales.^{13, 27} Clinicians often worry about screening for conditions without having a clear next evidence-based intervention. This is a valid concern, yet screening for loneliness is different than other medical screenings in at least two ways. First, identifying loneliness is unlikely to lead to harm. To the contrary, patients often appreciate being provided the time and space to discuss challenges of loneliness. Helping individuals process complex emotional experiences of loneliness which may stem from grief, changes in living situation, or health challenges, can be therapeutic.^{28, 29} In our experience, asking about loneliness builds trust and human connection.

Table 1.

Clinical framework for addressing loneliness

Process	Strategy	Rationale/Tips
1. Identify Loneliness	Health systems, clinical teams, and clinicians can identify loneliness: - Single question: “How often have you felt lonely in the past month?” [27] - Scales: UCLA 3-item scale, De Jong Gierveld Scale Clinical conversations: - “I’ve noticed that many people have felt lonely during the COVID-19 pandemic, is that something you have experienced?”	- Individuals with many social relationships or those who are married can still feel lonely - Loneliness can be a sensitive or stigmatized topic; use clinical judgement to determine the best assessment tool
2. Discuss potential causes and help process emotion	- Identify social losses or health contributors: Death of a spouse, relative, or friends; change in living situation; reduced opportunity to socialize; sensory, cognitive, or functional impairment - Help process emotion (e.g. NURSE framework) [29] - Ask if patients want help in addressing this need	- Providing space to discuss loneliness and process related emotions can be therapeutic. Not all patients are ready to or want to discuss loneliness. - Identifying contributors can point to creative solutions
3. Individualized approach to clinical and social interventions	- Direct interventions: Change perceptions of loneliness (e.g. psychoeducation, meaning-making, social skills training) or enhance social connections (e.g. peer program, telephone warm-lines, intergenerational volunteering, virtual events) [31] - Indirect Interventions: Address modifiable medical (e.g. pain, hearing or vision loss, functional impairment) or social contributors (e.g. technology access or comfort, limited transportation, living in isolation, poverty)	- Involve other disciplines who may be knowledgeable of interventions and local resources (psychology, social work, chaplaincy) - Interventions may involve strengthening existing coping strategies or relationships - Establish referral networks to community organizations - It is okay not to have an immediate solution and to think about options over time
4. Address related medical needs	- Individuals experiencing loneliness may have higher rates of pain, depression, polypharmacy, and other health conditions.	- Loneliness may be a common pathway to clusters of symptoms - Review medications to determine if there are opportunities to deprescribe

Second, loneliness causes substantial immediate emotional distress and leads to physical and cognitive decline. An individualized approach to addressing social needs can be effective as we wait for the evidence on interventions to “catch up.”^{30, 31} Indeed, geriatric and palliative care clinicians often identify creative or out-of-the box solutions to try to improve health when evidence is lacking. The COVID-19 pandemic stimulated several promising interventions aimed at strengthening engagement and meaningful social connection.³² These include peer support interventions, senior centers, friendship lines, zoom convenings, technology classes, intergenerational volunteer work, and others.^32–34 Clinicians caring for older adults can help patients connect to community organizations focused on re-integrating older adults into the life of the community and reducing loneliness including area Agencies on Aging, AARP, National Council on Aging, Alzheimer’s Association, and local senior centers.¹³ By involving patients in the process of brainstorming potential solutions, clinical teams may be able to match local community resources with individual needs. Health systems can establish partnerships with local community organizations.^{35, 36} In addition to helping to enhance social connections, interventions can identify modifiable barriers to socializing, including hearing, vision, or functional impairments, as well as financial limitations reducing access to transportation or community programs. In parallel to immediate clinical efforts, future research is needed which specifically tests the role of social interventions in relieving pain, fatigue, depression and other outcomes among older adults.

Clinicians are on the frontlines of witnessing and responding to suffering stemming from poverty, cultural divides, ageism and stigma, fragmented health care systems, and a disrupted social safety net. These needs transcend disease-directed medical care. Loneliness exemplifies an experience at the intersection of medical and social needs, that when left untended, can intensify pain, depression, fatigue, and subsequent functional and cognitive decline. Consequently, assessment and treatment of symptoms must be interpreted in the context of the social drivers of distress. Efforts to relieve loneliness may improve quality of life while helping to avoid medications that can be ineffective or harmful.⁷ And, addressing loneliness as a risk factor may be as or more important than other routinely screened and addressed risk factors such as hypertension, diabetes, and obesity.¹⁷ As a healthcare community we should therefore advocate for prioritizing social needs and the reimbursement policies which make spending time on these topics feasible. Geriatrics and palliative care clinicians can be leaders in addressing our patients’ fundamental need for human connection. It is time to act and reconnect.