Living alone 'raises death risk in elderly'

"Loneliness can shorten your life and make every day activities a struggle,” the Daily Mail has reported. The news is based on a US study that examined the relationship between loneliness, “functional decline” and death of older adults. It found that over six years of follow-up loneliness was associated with death and functional decline, such as reduced mobility and difficulty climbing stairs.

Despite the fact that this study found a link between loneliness, functional decline and death, it does not provide evidence that loneliness actually causes functional decline or death. There is likely to be a complex relationship between reported loneliness and other social, lifestyle, physical and mental health factors. This study was not able to explore this. Although the researchers tried to adjust their analyses for various factors that could have had an influence, it is possible that functional decline and death were due to other factors not measured in the study. Also, both loneliness and functional outcomes were self-reported, which may affect the reliability of the results.

Limited conclusions can be drawn from this relatively small study and the headline that loneliness can shorten your life is misleading.

If you are concerned about the loneliness, isolation or neglect of an elderly person, you may want to talk to your local authority’s adult social services department. Anyone with concerns about their mental wellbeing should talk to their GP. You can find information and support for older people from Age UK.

Where did the story come from?

The study was carried out by researchers from the University of California, US and was funded by grants from the US National Institute on Aging and the Health Resources and Services Administration. The study was published in the peer-reviewed journal Archives of Internal Medicine.

The Mail gives an accurate representation of this study’s findings, although the news does not recognise that this study cannot prove causation due to the complex relationship that is likely to exist between loneliness and other factors that could influence death or functional decline.

A second study in support of the findings and relating to living alone and an increased risk of death from heart disease was reported briefly in the Daily Express, and can be found in the same journal.

It should also be noted that the Daily Express illustrated the story with a picture of a solitary young man. This is at odds with the study, in which the average subject was female and over 70. The study did not suggest a higher risk of death in the stereotypical young male ‘loner’, as may have been the impression given in the Express.

What kind of research was this?

This was a longitudinal cohort study looking at the relationship between loneliness, functional decline and death in adults older than 60 years.

This type of study looks at the effect that particular exposures or risk factors (in this case, loneliness) have upon groups of people over time. This type of study is normally used to look at the effect of suspected risk factors that cannot be controlled experimentally. Although this study design can demonstrate associations, these studies cannot reliably prove causation due to the inability to control for other factors that could have an influence.

What did the research involve?

The researchers used data from the 2002 Health and Retirement Study, a national US study of people living in the community. The Health and Retirement Study looked at the relationships between health and wealth as people age, including a section on loneliness, stress and social support. The researchers analysed a sub-section of these participants, focusing only on those older than 60 years at time of enrolment (1,604 participants, average age 71). The researchers then examined the relationship between those reporting loneliness and the risk of worsening health and death in the following six years.

Loneliness is the subjective feeling of isolation, not belonging or lacking companionship. Loneliness was only assessed at the time of study enrolment and was determined from a questionnaire that measured three components of loneliness. These were whether participants:

• felt left out
• felt isolated
• lacked companionship

For each component subjects were asked if they felt that way:

• hardly ever (or never)
• some of the time
• often

Participants were classified as ‘lonely’ if they responded ‘some of the time’ or ‘often’ to any of the questions.

Researchers looked at the participants’ functional decline over a six-year period and whether the participants died in that time. Death was determined from interviews with family members and the National Death Index. Functional decline was determined at study start and at the end of follow-up by looking at four self-reported measures:

• difficulty in an increased number of ‘activities of daily living’, including dressing, bathing, transferring (for example, getting out of bed), eating and going to the toilet
• difficulty with an increased number of ‘upper body tasks’ (such as pushing large objects or lifting objects heavier than 10lb)
• a decline in walking 
• increased difficulty in stair climbing

The researchers analysed their results using statistical methods, adjusting the results for demographic differences, education and working status, the number of medical conditions and baseline activities of daily living levels.

What were the basic results?

Of the 1,604 participants, 59% were women, 18% lived alone and 43% reported feeling lonely. The key finding of this study was that loneliness was associated with an increased risk of death during follow-up: 22.8% of those reporting feeling lonely had died, compared with 14.2% of those who did not report being lonely (hazard ratio for death with reported loneliness 1.45, 95% confidence interval 1.11 to 1.88).

Loneliness was also associated with functional decline, with those reporting being lonely more likely to:

• have a decline in activities of daily living (experienced by 24.8% of those reporting feeling lonely compared with 12.5% of those who did not report loneliness, risk ratio 1.59, 95% confidence interval 1.23 to 2.07)
• develop difficulties with ‘upper body tasks’ (41.5% versus 28.3%, risk ratio 1.28, 95% confidence interval 1.08 to 1.52)
• experience decline in mobility (38.1% versus 29.4%, risk ratio 1.18, 95% confidence interval 0.99 to 1.41)
• have difficulty in climbing stairs (40.8% versus 27.9%, risk ratio 1.31, 95% confidence interval 1.10 to 1.57)

How did the researchers interpret the results?

The researchers conclude that among people over the age of 60, loneliness is a predictor of ‘functional decline’ and death. Lead researcher Carla Perissinotto is quoted as saying that “assessment of loneliness is not routine in clinical practice and it may be viewed as beyond the scope of medical practice.

“Our results suggest that questioning older persons about loneliness may be a useful way of identifying elderly persons at risk of disability and poor health outcomes”.

The authors conclude that “loneliness is a negative feeling that would be worth addressing even if the condition had no health implications”.

Conclusion

Overall, this relatively small study provides limited evidence that loneliness reported by those older than 60 years is associated with functional decline (disability) and an increased risk of death. It does not prove that loneliness causes functional decline or death. There is likely to be a complex relationship between reported loneliness and other social, lifestyle, physical and mental health factors, and the study is not able to explore this. Though the researchers attempted to adjust their analyses for various factors that could have had an influence, it is possible that functional decline and death were due to other factors that were not measured.

There are other important points worth noting, some of which the authors stated:

Loneliness was measured at a single point in time

Loneliness was measured at only one point in time, in 2002. This may not give a true indication of whether the participants were actually lonely, as it could have depended on events they were experiencing at that one point in time that may have changed for example the day, week or month after. Repeated measurements would have provided a more accurate representation of whether a person was lonely.

Potential classification bias

Participants were classified as ‘lonely’ if they reported feeling lonely ‘some of the time’. This also may not give a true reflection of whether someone is actually lonely. The scale used to assess participants’ loneliness was small and used only three options to answer.

Self-reporting

Loneliness and functional status were determined by self-reporting, which can make the results less reliable.

Self-selecting participants

The total eligible population for this study was 1,963. The authors report that 347 of the eligible participants declined to participate, 10 participants did not complete the loneliness questions, and two were lost to follow-up. They note that these 359 elderly people who did not participate were significantly older than those that did (average age 72.3 years versus 70.9 years) and were generally in poorer health, being more likely to have diabetes or current problems with activities of daily living. Therefore, this self-selection to participate in the study may mean that the findings are not representative of the general elderly population.

Population studied in the community

Finally, the participants all lived in the community, and the findings may not be applicable to those who live in care homes, for example.

Consequently, the headline that loneliness can “shorten your life” is misleading and is not supported by the results of this study.

If you are concerned about the loneliness, isolation or neglect of an elderly person, you may want to talk to your local authority’s adult social services department. Anyone with concerns about their mental wellbeing should talk to their GP. You can get information and support for older people from Age UK.