JAMDA xxx (2016) 1e2
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Loneliness in Nursing Homes Kaisu H. Pitkala MD, PhD * Department of General Practice and Primary Health Care and Helsinki University Hospital, Unit of Primary Health Care, University of Helsinki
Loneliness is a geriatric syndrome associated with impaired health, poor quality of life, cognitive decline, and increased mortality.1e4 Loneliness has been deﬁned as a subjective feeling, a discrepancy between a person’s own expectations and one’s actual social network.5 Therefore, one can suffer from loneliness even if surrounded by others.6 Feelings of loneliness are common among older people. Approximately 4% to 9% of community-dwelling older people suffer from constant loneliness, and an additional one-third may experience some degree of loneliness.7,8 However, very little is known about the prevalence of loneliness in nursing homes even though residents in such institutions are suggested to be at risk for loneliness.7 One Norwegian study showed that 54% of cognitively intact nursing home residents suffer from loneliness.9 However, cognitively intact residents are a minority among nursing home residents.10 Due to the lack of studies, we know little about loneliness among nursing home residents. However, this problem in long-term care should be addressed for several reasons. Many characteristics common among nursing home residents, such as female gender, low income, recent losses of loved ones, disabilities, poor health, and cognitive decline, are those also associated with loneliness.7 Moving to a nursing home can signiﬁcantly affect a resident’s human relationships.8 The frequency of visits by family and friends usually decreases. The setting also affects the possibilities for intimacy of relationships. Although residents may meet new peers and staff in the nursing home, such people seldom replace old friends. In fact, observing other people socializing around them may make residents feel like bystanders, which can deepen their loneliness even more. For many older people, moving into a nursing home means the loss of a partner. Autonomy and control over one’s own life is compromised in institutional settings.11 Is loneliness in nursing homes different? Dependency on other people’s help may mean feeling like one is an object of other people’s actions. All people need reciprocity, both giving and receiving,11 which can be difﬁcult to achieve in institutional settings. Residents may feel useless and that their life is meaningless when they no longer have signiﬁcant roles to play.11 Furthermore, sexuality and the need for touch does not disappear in old age.12 In nursing homes, opportunities to meet one’s intimate needs for closeness and touch are limited. Moreover, feelings of loneliness for residents unable to look back on their lives with feelings of fulﬁllment may differ from
* Address correspondence to Kaisu H. Pitkala, MD, PhD, University of Helsinki, PO BOX 20, 00014, Finland. E-mail address: [email protected]
ﬁ. http://dx.doi.org/10.1016/j.jamda.2016.04.007 1525-8610/Ó 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
those of residents who are satisﬁed with their life-course.13 Some older people may suffer from existential loneliness, a devastating feeling of death anxiety.14 Death is ever-present in nursing homes, and the pervading feeling is that those who enter nursing homes have little time left. Is it possible to alleviate loneliness among nursing home residents? A few randomized studies have tackled this problem in nursing homes.15 Internet training16 or cognitive behavioral therapy17 appeared to have no effect on loneliness, whereas some interventions that use animals or robots may alleviate loneliness.18,19 However, neither robots nor even pets will suit all, as many older people long for human relationships. The physical environment also may play a major role in how residents interact with each other.20 A Finnish intervention conducted among community-dwelling older people showed improvement in lonely older people’s well-being, health, cognition, and mortality.21e23 Since the original trial, this intervention has also proved successful in assisted living facilities and among those with dementia.24 This group intervention is based on empowering older people to make friends with each other, peer support, and valuing older people’s own resources, as well as supporting their mastery and self-efﬁcacy: elements proven successful in self-management interventions for older people.11 More studies exploring loneliness in nursing homes are urgently needed. Loneliness is probably common and it affects residents’ quality of life. However, very little is known about its prognostic signiﬁcance in nursing home settings or how to tailor interventions for this heterogeneous population. References 1. Routasalo P, Pitkälä K. Loneliness among older individuals. Clin Rev Gerontol 2004;13:303e311. 2. Boss L, Kang DH, Branson S. Loneliness and cognitive function in the older adult: A systematic review. Int Psychogeriatr 2015;27:541e553. 3. Holt-Lunstad J, Smith TB, Baker M, et al. Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspect Psychol Sci 2015;10: 227e237. 4. Kuiper JS, Zuidersma M, Oude Voshaar RC, et al. Social relationships and risk of dementia: A systematic review and meta-analysis of longitudinal cohort studies. Ageing Res Rev 2015;22:39e57. 5. Peplau LA, Perlman D. Perspectives on loneliness. In: Peplau LA, Perlman D, editors. Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York: Wiley-Interscience; 1982. p. 123e134. 6. Routasalo P, Savikko N, Tilvis RS, et al. Social contacts and loneliness among aged individuals. A population-based survey. Gerontology 2006;52:181e187. 7. Savikko N, Routasalo P, Tilvis RS, Pitkala KH. Loneliness among older people. Arch Gerontol Geriatr 2005;41:223e233. 8. Grenade L, Boldy D. Social isolation and loneliness among older people: Issues and future challenges in community and residential settings. Aust Health Rev 2008;32:468e478.
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9. Drageset J, Kirkevold M, Espehaug B. Loneliness and social support among nursing home residents without cognitive impairment: A questionnaire survey. Int J Nurs Stud 2011;48:611e619. 10. Pitkala KH, Pietila A, Hosia H, Teramuraet AL. Eight year trend in opioid use among institutionalized older people in Helsinki. J Am Med Dir Assoc 2015;16: 973e978. 11. Vernooij-Dassen M, Leatherman S, Rikkert MO. Quality of care in frail older people: The fragile balance between receiving and giving. BMJ 2011;342:d403. 12. Roelofs TS, Luijkx KG, Embregts PJ. Intimacy and sexuality of nursing home residents with dementia: A systematic review. Int Psychogeriatr 2015;27:367e384. 13. Erikson EH, Erikson JM. The Life Cycle Completed: Extended Version. New York: W. W. Norton & Company, Inc; 1998. p. 112e113. 14. Ettema EJ, Derksen LD, van Leeuwen E. Existential loneliness and end-of-life care: A systematic review. Theor Med Bioeth 2010;31:141e169. 15. Dickens AP, Richards SH, Greaves CJ, Campbell JL. Interventions targeting social isolation in older people: A systematic review. BMC Public Health 2011;11:647. 16. White H, McConnell E, Clipp E, et al. A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults. Aging Ment Health 2002;6:213e221. 17. Winningham RG, Pike NL. A cognitive intervention to enhance institutionalized older adults’ social support networks and decrease loneliness. Aging Ment Health 2007;11:716e721.
18. Banks MR, Willoughby LM, Banks WA. Animal-assisted therapy and loneliness in nursing homes: Use of robotic versus living dogs. J Am Med Dir Assoc 2008; 9:173e177. 19. Robinson H, Macdonald B, Kerse N, Broadbent E. The psychosocial effects of a companion robot: A randomized controlled trial. J Am Med Dir Assoc 2013;14: 661e667. 20. Rule BG, Milke DL, Dobbs AR. Design of institutions: Cognitive functioning and social interactions of the aged resident. J Appl Gerontol 1992;11: 475e488. 21. Routasalo PE, Tilvis RS, Kautiainen H, Pitkala KH. Effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: Randomized controlled trial. J Adv Nurs 2009;65: 297e305. 22. Pitkala KH, Routasalo P, Kautiainen H, Tilvis RS. Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: A randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2009;64:792e800. 23. Pitkala KH, Routasalo P, Kautiainen H, et al. Effects of socially stimulating group intervention on lonely, older people’s cognition: A randomized, controlled trial. Am J Geriatr Psychiatry 2011;19:654e663. 24. Circle of friends. Available at: http://www.vtkl.ﬁ/ﬁn/toimimme/ystavapiiri_ toiminta/circle_of_friends/. Accessed February 24, 2016.