Association of Loneliness, Social Isolation and Health Problems in the Elderly

Introduction: Humans develop themselves and their personalities to survive and adapt to live with other humans in society as social beings. Healthy social relationships are essential for mental and physical health while disrupting social interactions can lead to loneliness and social isolation. This narrative review describes health problems in the elderly, especially depression and cardiovascular disease as a result of loneliness and social isolation. Methods: PubMed database was searched for studies written in English. Keywords to search the journals and ebooks are “loneliness”, “social isolation”, “depression”, “cardiovascular disease” and “old age”.Results: Loneliness and social isolation can occur in all age groups. It is more common in old age, where 50% of the population aged 60 years and over are at risk of experiencing social isolation and one-third experiencing loneliness. This should be of particular concern because it is a risk factor for increased morbidity and mortality in this population. This increased risk is greater than smoking, obesity, and physical inactivity. This situation is closely related to the increased incidence of depression and cardiovascular disease which are the main co-morbidities in the elderly. Conclusions: Problems of loneliness and social isolation that are not handled properly can increase the use of health services in the elderly, so special attention is needed to prevent adverse impacts on physical and mental health and reduce unnecessary use of health services.

Keywords: Loneliness, Social Isolation, Depression, Cardiovascular Disease, Old Age.

Introduction

Humans are social creatures who constantly interact with other humans and the surrounding environment. This situation forces humans to constantly develop themselves and their personalities in order to survive and adapt to other humans in society. As social beings living in groups in everyday life, we certainly cannot escape mutual communication and social interaction[1]. Healthy social relationships are essential for mental and physical health, while disruption to social interaction can lead to loneliness and social isolation. Loneliness and social isolation can occur in all age groups. However, it is more common in the elderly[2].

With advances in public health and medical technology, as well as improvements in sanitation, the average life expectancy of people aged 60 years and over has increased globally, resulting in a projected 56% growth in the population of 901 million to 1.4 billion in 2030[2]. Data from Badan Pusat Statistik (BPS) states that the number of elderly people in Indonesia has increased from 18 million people (7.6%) in 2010 to 27 million people (10%) in 2020. This figure is expected to continue to increase to 40 million people (13.8%) in 2035, where 50% of the population aged 60 years and over are at risk of experiencing social isolation and one third experience loneliness[2],[3]. This should be of particular concern because it is a risk factor for increased morbidity and mortality in this population. This increased risk is greater than smoking, obesity and physical inactivity. This situation is closely related to the increased incidence of depression and cardiovascular disease which are the main co-morbidities in the elderly, resulting in high utilization of health services[1],[2],[4],[5].

This narrative review describes health problems in the elderly, especially depression and cardiovascular disease as a result of loneliness and social isolation.

Loneliness and Social Isolation in Older Age

According to Valtrota and Hanratty[2], loneliness is divided into social and emotional loneliness. Social loneliness is defined as a subjective feeling that is negatively related to the lack of relationships/ wider social networks as the root of loneliness. Meanwhile, emotional loneliness is caused by a lack of interest in social relationships caused by internal factors such as personality and psychological factors[2],[5].

Teresa Seeman[1], defines social isolation as separation from relationships, contact, and interaction with family members, friends, or the wider community. This state creates a feeling of emptiness. Individuals who are involved with positive social relationships tend to have less influence over daily problems. Conversely, those without social relationships will be isolated and neglected. This lack of contact with others tends to build and maintain a negative perception of oneself, lack of satisfaction with life, and often lack of motivation[1],[5].

There are some risk factors for increased loneliness and social isolation in old age, including physical, psychological, social, spousal bereavement/divorce, childlessness, failed marriages, and neglect of family members as well as lack of social engagement after leaving work (Tabel 1.)[3],[6],[7].

Tabel 1.Risk factors for loneliness, social isolation and social vulnerability [7]

Sociodemographic risk factors	Medical risk factors	Social risk factors
Increased ageFemale sexLow incomeLiving in long-term careLiving in isolated rural areasLiving in low-income urban areas	MultimorbidityHearing or vision lossHearing and vision lossCognitive impairmentFunctional impairmentFrailty	Living aloneLiving far from familyLack of transportationFew friendsCaregiver of an elderly relativeLife changes: change of residence, shrinking of social network, loss of a spouse, declining health, and loss of driver's license

Every individual will experience loneliness at some stage of their life to some degree, research has highlighted that the elderly are very vulnerable to experiencing loneliness and social isolation. Approximately 50% of individuals aged over 60 years are at risk of experiencing social isolation and one-third experience loneliness[2]. In addition, social isolation and loneliness are not completely interrelated, meaning that there are older people who can be socially isolated but not lonely, or lonely but not socially isolated, some older people experience social isolation and loneliness, while others experience neither.[6].

Health Problems in the Elderly as the Impact of Loneliness and Social Isolation

Loneliness and social isolation are risk factors for all causes of morbidity and mortality with similar results to other risk factors such as smoking, lack of exercise, obesity, and high blood pressure[8]. In addition, loneliness is also associated with decreased resistance to infection, cognitive decline, and mental health conditions such as dementia and depression[9],[10],[16]. A longitudinal study in Ireland on the elderly showed that loneliness is a major mediator between social isolation and depression. In addition, a longitudinal study in Amsterdam shows that loneliness and social isolation can independently affect the process of developing depressive symptoms. Similar findings in another study in Ireland show that loneliness and social isolation can independently influence depression[10].

Experiences of social isolation and loneliness can negatively impact physical and mental health, as well as increased utilization of health services (Table 2.)[2],[6],[7].

Table 2.Adverse outcomes associated with loneliness and social isolation [7]

Physical health	Mental health	Health services
Increased mortalityIncreased fallsIncreased cardiovascular diseaseIncreased serious illnessIncreased functional declineIncreased malnutrition	Increased depressionIncreased dementiaDecreased life satisfactionIncreased elder abuse	Increased emergency department visitsIncreased physician visitsIncreased hospital readmissionsIncreased long-term care admissions

Depression and Cardiovascular

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