The effect of letter writing on a long-term care resident with loneliness

Abstract

Older adults living in long term care (LTC) facilities may experience increased isolation and loneliness. This was compounded with the Coronavirus Disease 2019 (COVID-19) pandemic. Loneliness and isolation increase the risk for physical, psychological, and social decline. This case report discusses the effect of a letter writing initiative on feelings of loneliness and connection in a long-term care resident. Personalized care is the standard in the long-term care setting and letter writing between two people can contribute to personalized meaningful care as evidenced by the example provided. Further research is needed to explore social connection and loneliness and methods to combat these issues with a personalized approach for different populations within LTC facilities.

Introduction

Loneliness and isolation in the older adult population is a growing concern.^{1 , 2} Long-term care residents may experience increased isolation and loneliness.^{3 , 4} With social distancing parameters and visitor restriction in long term care facilities (LTCFs) due to Coronavirus Disease 2019 (COVID-19), the risk for loneliness and isolation intensified.⁵ There are numerous well documented physical and psychological sequalae to loneliness and isolation such as cognitive and functional decline, poor health outcomes, increased rates of hospitalizations, and increased mortality.^{6 , 7} Growing evidence suggests engagement in meaningful activities can improve quality of life, mental health, and reduce complications such as frailty.^{8 , 9} Strategies to combat loneliness and promote connection in LTCFs have historically involved outside groups providing activities, music, and other events. Group gatherings within facilities were planned and encouraged by activity directors. Due to restrictions these types of activities were curtailed or modified during the pandemic. Evidence-based meaningful strategies to engage the older adult in the long-term care setting were needed even before the pandemic¹⁰ and continue as we progress to the endemic stage.

Person Centered Care is considered a priority in in long term care.^{11 , 12} Studies suggest person-centered care offers an evidence-based approach wherein health care workers can incorporate patient preferences, feelings, culture, and life history into patient interactions.¹³

One emphasis of person-centered care is nurturing relationships.^{14 , 15} Supporting relationship building can promote connection. Data suggest decreased feelings of social connection is linked to mental health issues including loneliness, cognitive decline, and depression.⁸

Case report

An 82-year-old female resident of a long-term care facility participated in a letter writing initiative. The initiative received Institutional Review Board Approval at the local university. The resident had lived in the facility for 5 years and was living in a room alone stating she had “problems finding a roommate because none of her roommates could talk to her.” Her family lived out of state and was only able to visit a couple of times a year. This was during the COVID-19 pandemic and visitors and outside activities were significantly curtailed. Once consent was obtained and prior to letters being sent, a pre intervention UCLA Loneliness Scale was completed.

The UCLA Loneliness Scale is an evidence based reliable and valid tool for use in the older adult.16, 17, 18, 19 Items within the scale have also been noted to suggest an association between loneliness and social connection.¹⁷ The UCLA Loneliness Scale comprises 20 separate questions ranked from 0 to 3 ranging from “I never feel this way”, “I sometimes feel this way”, “I rarely feel this way” to “I often feel this way”. Higher scores suggest a higher degree of loneliness. There have been several revisions of the scale as shorter versions (Fetzer, n.d.). Although the revised scales are shorter, specific questions on the original scale related to connection were of interest to the investigator and the original UCLA Loneliness Scale was utilized. For this resident, the pre intervention scale indicated a score of 33 out of a possible 60 points with a score greater than 30 indicating a moderate to high level of loneliness.¹⁸

A nursing student was assigned to the resident sent letters weekly for 10 weeks. After an introductory letter, the student also sent artwork, crafts, and other creative correspondence. With the introductory letter the student sent a self-addressed stamped envelope encouraging the resident to write back. The resident elected to send 4 letters to the student during the period of the intervention. After the 10-week period of letter correspondence, the UCLA loneliness scale was completed, and the resident scored 12 out of a possible 60 points. Of particular interest were three individual items within the scale.¹⁸ Table 1 details the question and resident responses.

Table 1.

Resident responses.

Item	Pre-Intervention	Post Intervention
“I am unhappy doing so many things alone”	I often feel this way	I rarely feel this way
“I lack companionship”	I often feel this way	I rarely feel this way
“I feel left out”	I often feel this way	I rarely feel this way

In a post interview the resident shared several insights regarding the letter writing initiative. She stated “So many do not have loved ones and to hear from young people is amazing. I enjoyed it immensely. I hope for this to continue even after the pandemic is over”. When asked about her favorite parts of the letter writing she indicated “getting mail” and our shared interests such as “faith, pets, and some television shows.” She also stated in a post interview the letters provided something to talk to the other residents who were receiving letters about, and she felt more “connected” to some of the other residents. This is an ongoing project. Anecdotal data from the facility and verbal statements suggest there was a potential clinical significance to the project for this and other residents.

Discussion

This initiative allowed older adults to connect without advanced technology and to potentially correspond in a way that had meaning to them in their young and middle adult years. Letter writing is a reflective, tangible activity taking time and purposefulness to send letters. Letter writing may represent a potential method to allow resident choice and promote person centered care. Although there are a growing number of older adults who are technologically adept, there remains a significant number of older adults (specifically those 75 years and older, less affluent, or with lower levels of educational attainment) who are unfamiliar or uncomfortable with technology.^{20 , 21} Older adults may lack access to technology or the skills necessary to utilize technology.²¹ Older adults may also face physical challenges making it difficult to manipulate devices as well as have a lack of confidence in using technological devices. Studies evaluating the impact of different types of social engagement and the benefit for different individuals are warranted. Further study of the 3 questions from the scale with significant change in response merit further investigation.

The letters prompted connection among shared interests. Further research is needed to identify the presence and consequences of social isolation and loneliness among long term care residents.^{4 , 22} Loneliness is multi-faceted. Distinct dimensions of loneliness and feelings of connection need to be explored among residents in LTCFs.^{20 , 23}

Conclusion

The case study presented points to the potential benefits to both participants with his low technological initiative. It is not cost prohibitive and is easily implemented. Although the letter writers were nursing students this type of project could be readily adapted by numerous types of individuals or groups within the community. Personalized care is the standard in the long-term care setting and letter writing between two people can contribute to personalized meaningful care as evidenced by the case study discussed. Further research is needed to explore social connection and loneliness and methods to combat these issues with a personalized approach for different populations within LTC facilities.