4/1/2015

1

THE HIDDEN RISK OF LONELINESS: ITS IMPACT ON MENTAL HEALTH

Patrick Arbore, Ed.D., Director & Founder, Center for Elderly Suicide Prevention & Grief Related Services –Institute on Aging, San Francisco

INSTITUTE ON AGING’S CENTER FOR ELDERLY SUICIDE PREVENTION Friendship Line for the Elderly

CESP’s Primary Service is the 24-hour Friendship Line for the Elderly – an Accredited hotline/warmline for people 60+ who are depressed, isolated, lonely, bereaved, substance abusers and/or suicidal and younger disabled adults

• (800) 971-0016 or (415) 752-3778

• Traumatic Loss Services

• Patrick Arbore, Ed.D. parbore@ioaging.org 415.750.4133

• For More Information IOA Connect – 415.750.4111

2

4/1/2015

2

US Population Living Alone

• The number of people living alone in 2010 was approximately 29 million – a 30% increase since 1980 (US Census Bureau, 1996)

• Some researchers found that elderly individuals who live alone are lonelier than age-matched individuals living with others despite comparable social interaction frequency and personal network adequacy

3

The Demography of Aging

• The older population (65+) numbered 41.4 million in 2011, an increase of 18% since 2000.

• Persons >65 have an average life expectancy of an additional 19.2 years (20.4 years for females and 17.8 years for males)

• 21.0% of persons 65+ were members of racial or ethnic minority

• Almost half of older women (46%) age 75+ live alone.

• The 85+ population is projected to increase from 5.7 million in 2011 to 14.1 million in 2040.

Wolfson, NEJM April 2001Chen and Landefeld in Medical Management of Vulnerable and Underserved Populations 2007

http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf

4

4/1/2015

3

Loneliness

• Loneliness affects millions of Americans either acutely or chronically

• Human beings are hardwired to connect with others

• Our need to belong is powerful and fundamental

• Everyday loneliness is painful when people are isolated from family members and/or friends

• Loneliness can evolve into depression

5

Why Focus on Older Adults?

Why are older adults different than younger adults?

Why should we care about loneliness?

6

4/1/2015

4

Medical Care for Older

Adults:

Challenges of Complexity

and

HeterogeneityPacala, JT. Grand Rounds UCSF 2011

7

Multiple Chronic Diseases

+

Problems in Other Domains

=

Functional Decline

The Challenge of Complexity:

8

4/1/2015

5

Loneliness

Theorist Harry Stack Sullivan wrote:

Loneliness is the worst emotional experience imaginable – He stated that the deepest emotional problems for people are loneliness, isolation and low self-esteem

9

Loneliness

• Loneliness is a feeling of longing and emptiness that is caused by the lack of emotional attachment and/or social ties

10

4/1/2015

6

Myths about loneliness

• It is a normal part of aging• It is synonymous with depression• It cannot occur if you live with others and have friends

• It does not exist in married couples

• It will go away if you join a social group

11

“In a real sense, through our own self-talk, we are either in the construction business or the wrecking business.” –Dorothy Corkville

12

4/1/2015

7

Loneliness

• Loneliness is different than being alone

• Some people prefer solitude

• Loneliness is a highly subjective and personal feeling

• Loneliness makes a person vulnerable to different situations – depression, use of drugs, higher blood pressure

13

Loneliness

According to Weiss (1973) loneliness can be described as a gnawing chronic disease without redeeming features – has been recognized as a strong correlate of depressive symptoms

14

4/1/2015

8

Living Together Loneliness

• Can result when there is a difference between expected and achieved contact

• More than ¼ of married people, the majority of them female, suffer from “living together loneliness”

• Germaine Greer wrote “Loneliness is never more cruel than when it is felt in close propinquity with someone who has ceased to communicate”

15

Loneliness

• Hawkley, et al (1999) proposed that there are three dimensions to loneliness: Isolation, connectedness, and belongingness

• Loneliness has been linked to physical illness, alcoholism and suicide

• Lonely individuals have been found to express pessimistic views, be low in positive affect and are more likely to be shy and less satisfied with life

16

4/1/2015

9

Loneliness

• Is one of the great dreads of our time

• Most of us have experienced it and most of us fear it

• During times when you are experiencing yourself as fragmented or incomplete, or “invisible” to those around you, and when that feeling is accompanied by self-doubt, then you are likely to experience being alone – not as solitude – but as loneliness

17

Ageism – Robert Butler

• Stereotyping of and discrimination against older people based on age

• Old people are categorized as senile, rigid in thought and manner, old-fashioned

• Younger generations see old people as different from themselves

• They cease to identify elders as human beings

18

4/1/2015

10

Loneliness

• Has been called an important public health issue – it has significant impact on the quality of life of older adults

• Some authors refer to loneliness as an epidemic

• A key element in loneliness is that it incorporates the entire self

• Loneliness is a time of excruciating awareness of one’s self and how one is situated in the world

19

20

IsolationAccording to Ebersole & Hess –

• Is a response to conditions that inhibit ability or opportunity to interact with others or is a result of the desire not to interact

• Isolation increases vulnerability to disease, suicide and death

• Isolation can occur as a result of age, race/culture, frailty, poverty, appearance, sexual orientation or stereotypical thinking

4/1/2015

11

21

Social Isolation

• Social isolation has many causes and numerous defining characteristics – absence of supportive significant others; lacking purpose or challenges; aloneness imposed by others; withdrawal because of hearing deficits; feelings of rejection; limited mobility; vision impairment

• Older adults are particularly susceptible because of environmental structures, loss of family or friends, and inability to perform certain activities

Stereotypes of Aging

According to Cheng (2005):

• Be aware of ageism and gender stereotypes especially related to women who choose to live alone

• Not all older women who live alone report feeling isolated

22

4/1/2015

12

23

Emotional Isolation

• Involves needs for affiliation, degree of independence, and self-concept issues

• A person made to feel lonely through ostracism, social exclusion or bereavement feels threatened, anxious, and dysphoric –emotional states that promote attempts to reconnect for relief from their negative affect

24

Depression & Isolation

• When emotions go unexpressed, we can become depressed, irritable, and emotionally unavailable

• Some days depression and loneliness can trigger withdrawals – isolating versus reaching out

• Taking time for ourselves (solitude) is very different from isolation

4/1/2015

13

25

Depression & Isolation

• We may build walls around ourselves w/o knowing it

• We fear being judged by others (why isn’t he/she over it?) can keep us from opening up

• Withdrawing heightens the sense of isolation

26

Depression & Isolation

• Depression & isolation are part of the experience of grief

• In the midst of isolation and depression we may start to wonder “Why me?”

• By reaching out to others, we get the extra support that can help us through a trying time

4/1/2015

14

Should we Screen for Loneliness?

27

LONELINESS SCREENING

Question Hardly Ever

Some of the Time

Often

1. I feel left out 1 2 3

2. I feel isolated 1 2 3

3. I lack companionship

1 2 3

3-item Loneliness Scale:

Max score 9: higher score=more lonely

http://psychcentral.com/quizzes/loneliness.htm

YES!!28

4/1/2015

15

Evidence Based Data on Loneliness

According to Cacioppo (2006):

• The most frequently used measure of loneliness is the revised UCLA Loneliness Scale – a 20-item questionnaire measuring general feelings of social isolation and dissatisfaction with one’s social interactions

• Found that loneliness and depression both had substantial predictive value

29

Youtube video -- Cacioppo

• http://www.youtube.com/watch?v=_0hxl03JoA0

30

4/1/2015

16

Cacioppo’s Findings Continued

• Both loneliness and depressive symptoms are relatively stable features over a 3-year period

• These data suggest that loneliness and depressive symptoms have strong reciprocal influences in middle-aged and older adults

• It is important to recognize the specific and reciprocal influences of loneliness & depressive symptoms if we are to mitigate their impact on older adults’ well-being

31

Perissinotto’s Findings (2012)

• Lonely older subjects were more likely to experience decline in ADL

• Develop difficulties with upper extremity tasks

• Experience decline in mobility

• Experience difficulty in climbing

• Associated with an increased risk of death

32

4/1/2015

17

What Prevents Conversations about Loneliness, Depression & Grief?

1. Lack of a Vocabulary

2. Ageism

3. Resistance

33

Loneliness and Depression

• Research has suggested that loneliness can lead to depression which can cause physical and psychological problems including death by suicide

34

4/1/2015

18

Depression

According to Ebersol & Hess:

• Depression is the most common mental health problem of late life

• Approximately 15% of people >65 are affected by depression

• Remains underdiagnosed and undertreated among older adults

35

What is Grief?

• Grief is an emotional response to loss

• The psychological, behavioral, social and physical reactions to the perception of loss

• Natural and expectable

• Reaction to all types of loss

• Dependent upon the individual’s unique perception of loss

36

4/1/2015

19

Losses

• If losses are not grieved, “acting out” may occur – Strong feelings of loneliness, sadness, anger, sorrow and rage may be experienced but not expressed in a healthy manner

• Substances may be used to “medicate” strong feelings

• Losses accumulate as we age

37

Denial of Suffering

• One can disengage suffering and pain through the use of: alcohol – shopping – gambling –drugs – food – television – internet

• Suffering and pain are turned into technical matters requiring technical intervention

• The normal medical response to pain is to demand more drugs, doctors & hospitals

• Suffering manifests as depression, loneliness, substance abuse, suicidal ideation, anxiety, worry, hoarding and other mental health issues

38

4/1/2015

20

39

What Helps the Distressed Individual

• Being empathic

• Listen attentively

• Reflect feelings

• Create rapport

• Offer appropriate resources/referral

Social connectedness• “One of the National Strategy’s primary aims is to promote

opportunities and settings to enhance connectedness among persons, families, and communities.

• Connectedness is a common thread that weaves together many of the influences of suicidal behavior and has direct relevance for prevention.

• Accordingly, CDC has adopted as its theme “Promoting individual, family, and community connectedness to prevent suicidal behavior” to define this area of prevention.

• We define connectedness as the degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups.

http://www.cdc.gov/violenceprevention/suicide/prevention.html

Excerpt from: Strategic Direction for the Prevention of Suicidal Behavior: Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior

40

4/1/2015

21

How Do We Recognize Loneliness?

• Does the person initiate contact?

• Is the person anxious, withdrawn, apathetic, or hostile? Does the person provoke to get attention?

• Does the person cling to others or attempt to detain them?

• Is the person eager for visitors and distressed when they leave?

• Does the person exhibit contempt for his or her condition for self?

41

Recognition of Loneliness

• Can be hidden or may be disguised as a physical symptom, such as discomfort, fatigue, anxiety, tension, withdrawal

• People may appear restless, uneasy or uncomfortable

• Lonely people may choose to stay at home, go back to bed, or go to sleep

42

4/1/2015

22

Loneliness Interventions

• Ask about loneliness

• Spend time with the person in silence or in conversation

• Assist the person in keeping contact with people important to them

• Explore the nature of loneliness with the person

• Develop community support for the person

43

The Path of Compassion:Cultivating Kindheartedness

Compassion is defined as the emotional response when perceiving suffering and involves an authentic desire to help alleviate that suffering.

Empathy, as defined by researchers, is the visceral or emotional experience of another person’s feelings.

Empathy is the basis of true compassion since it makes us aware of the difficulties others face and their suffering.

44

4/1/2015

23

Five Insights to Contemplate

1. Everything changes.

2. All we actually ever “have” is the present moment.

3. Our thoughts are just thoughts, not always reality.

4. We are part of an interconnected web of life.

5. What we practice becomes stronger.

45

46

4/1/2015

24

47

What We Can Do

• Connect with people -- Telephone contact

• Connections are paramount to caring for people who are lonely – assist them with keeping contact with people who are important to them

• Be as present as possible with people who are lonely

• Empathize with people’s losses and suffering

48

4/1/2015

25

Active Listening – Empathetic Listening

• Listen with the third ear – hear what is being said between the lines and without words – what the speaker feels and thinks

• Especially important to listen with your whole self to people who may have mental health issues – people with mental health issues may be extremely sensitive to how people engage them

49

What We Can Do For Ourselves

Anne LaMott in Stitches (2013) writes:

“Daily rituals, especially walks, even forced marches around the neighborhood, and schedules, whether work or meals with non-awful people, can be the knots you hold on to when you’ve run out of rope”

50

4/1/2015

26

Take Care of You

51

A Poem by Inge Meldgaard

ForgottenOnce upon a time in September,

When Springtime’s tender blooms burst forth,

The joyous poet did write

A tale to remember,

Of brilliant colours,

Softest perfumes,

Birds in flight,

Wondrous

Light.

52

4/1/2015

27

Poem Continued

When morning came, the poet awoke

To feel the prison chains of truth,

To find that he’d been dreaming

Of former days, of youth.

Health and strength now gone,

The old man weeps.

No one sees

His tears

Fall.

53

Any Questions???Contact Information:

Patrick Arbore: parbore@ioaging.org

415.750.4133

54

4/1/2015

28

References

Brady, M. (2003). The wisdom of listening.

Cacioppo, J.T., et al (2006). Loneliness as a specific risk factor for depressive symptoms: Cross Sectional and Longitudinal Analyses.

Psychology and aging, 21(1), 140-151.

Cacioppo, J.T. & Patrick, W. (2008). Loneliness: Human nature and the need for social connection.

55

References

Cheng, Ching-Yu (2006). Living alone. Journal of Gerontological Nursing.

Gillick, M. (2006). The denial of aging.

Greenspan, M. (2004). Healing through the dark emotions.

Lamott, A. (2013). Stitches: A handbook on meaning, hope and repair.

Real, T. (1997). I don’t want to talk about it.

Segal,L. (2013). Out of time: The pleasures and perils of ageing.

56

4/1/2015

29

References

Schachter-Shalomi, Z. (1997). From age-ing to sage-ing.

Smith, J.M. (2012). Loneliness in older adults. Journal of Gerontological Nursing, 38(8).

Wright, L.M. (2005). Spirituality, suffering, and illness: Ideas for healing.

Yalom, I.D. (2008). Staring at the sun: Overcoming the terror of death.

57

References

Perissinotto, C., Cenzer, I., and Covinsky, K. (2012). Loneliness in older persons: A predictor of functional decline and death. Arch Intern Med, 172(14), 1078-1083

58