Loneliness Across the life-span Jolanthe de Koning PhD student at the University of Bath PhD focus: Social well-being and active lifestyles of older adults in rural Britain Overview of academic literature Thursday 10 th of July 2014

Contents 1.Definitions: What is loneliness? What is social isolation? 2.Prevalence (in the UK) 3.Health consequences Evidence on link with alcohol use/abuse 4.What increases the risk of loneliness? 5.Life-course approach: Childhood influences Gender differences Life-time events & personality 6.What protects against loneliness? 7.Which interventions work? 8.Discussion points

Definitions Social isolation = the lack of/infrequent contact with family, friends or neighbours (<weekly, or <monthly) (Victor, 2009) Loneliness = the feeling of a mismatch between social contact that you desire and social contact that you have. (Victor, 2009) Practitioners often see this distinction Social network type = the pool of social resources an individual routinely draws from (e.g. family, friends, diverse, congregant and restricted) (Litwin & Siovitz-Ezra, 2010) Social network position = the place within a social network; i.e. in the centre, or at the periphery. (Locke et al., 2010) It is important to treat SI and Loneliness as different phenomena.

Social isolation: 310 Dutch adolescents, followed from age (Witvliet et al., 2010) Isolated from cliques: 19%, 15%, 16% age 11, 12, 13, respectively An American poll in 2011: 22% of teenagers log onto a social media site 10/day or more English older adults, 52+yrs, (ELSA: Jivraj et al., 2012) 5% overall socially isolated (< weekly contact) 7% for men, 3% for women (ns. different) Prevalence

Loneliness: 2,091 American adolescents, yrs (Woodhouse et al., 2011) 17% felt lonely 2,393 British children and adults, 15-97yrs, 2006 data (Victor & Yang, 2012) Highest in under 25s (9%) and over 55s (9%), lowest for 25-55s (5%)

Social isolation 4,432 English adults, 50+ yrs (ELSA, 2-waves, Kamiya et al., 2010) Social ties not linked to CVD risk factors (blood tests) 4004 Dutch adults, 65+ yrs (10-yr study, Holwerda et al., 2012) No link with mortality – except if also lonely Solitude can be chosen and valued (Qualitative, Wenger & Burholt, 2004) Studies including ‘participation’ (e.g. ELSA, Shankar et al., 2012) Social isolation linked with earlier mortality Health consequences

Loneliness In younger years… 310 Dutch adolescents, followed from age (Witvliet et al., 2010) Clique isolation led to depression, only if also feeling lonely 10,576 American adolescents (3-waves, Goosby et al., 2013) Depression (strongest association) Poorer self-rated health & incr. risk factors for CVD (weaker associations) In later life… Depression, one-way (229 Americans, 50+, 5yrs; Cacioppo et al., 2010) Poorer cognitive function (6,034 English, 65+, 4yrs; Shankar et al., 2012) Doubled risk of Alzheimer’s (823 Americans, 65+, 6yrs; Wilson et al., 2007) CVD risk factors (229 Americans, 50+, 5-yrs; Hawkley et al., 2010) All-cause mortality for men (4004 Dutch, 65+, 10yrs; Holwerda et al., 2012) Out-patient service use (153 frail Swedish, 65+; Taube et al., 2014) Health consequences

No strong evidence of a link with isolation or loneliness Social isolation 1,563 American 10 th grade students (Huang et al., 2014) Frequency of social network site use & no. of close online friends not related Instead, influence via pictures of drinking behaviours 791 American adults, followed from to yrs (Moos et al., 2010) More friends who are / approve of heavy drinking – more risk of risk-drinking Social network type 3005 American adults aged (Shiovitz-Ezra & Litwin, 2012) Less resourceful network more linked to risk Loneliness No link in older age (Dutch, v.d.Berg et al., 2013; US, Shiovitz-Ezra & Litwin, 2012) Alcohol use/abuse?

In younger years… 832 American children, at age 9, 11 and 15 (Schinka et al., 2013) Higher family income – more chance of low, stable loneliness, less chance of both high-increasing and decreasing loneliness. Better age 7 social skills – greater chance of low, stable loneliness Higher age 7 depression – more risk of high increasing and persistent loneliness Higher age 7 aggression – more risk of high increasing loneliness 20 American adolescents (Locke et al., 2010) With autism more lonely vs. peers What increases the risk of loneliness?

In later years… Older age… not by itself. Often assumed, but not always so. 999 British adults, 65+yrs (Victor, 2005) Pathway 1: continued long-established (68%) Pathway 2: late-onset (23%) Pathway 3: decreasing (10%) Female gender... Or are they more likely to admit? Women more likely to report (2,393 British, 15-97yrs, Victor & Yang, 2012) Higher loneliness for women (8,688 English, 50+, Shankar et al., 2011) Widowhood… one of the strongest predictors. Strongest predictor (2,295 Dutch, 65+yrs, 7-yr study, Dykstra et al., 2005) Pervasive sense of loneliness (39 bereavement studies, Neaf et al., 2012) What increases the risk of loneliness?

Health & Physical function… a two-way relationship American adults, 50+yrs, 6-year study (Luo et al., 2012) Loneliness both affected and was affected by functional limitations Cognition and psychological factors ‘Cognitive discrepancy theory’ (Cacioppo et al., 2010) Tendency not to ask for help (30 adults, 75+yrs, Wenger & Burholt, 2004) Low optimism, 10-year study (416 men, 70+yrs, Ruis-Ottenheim, 2012) Low income 7,780 English adults, 50+yrs (ELSA: Demakakos et al., 2006) A major correlate of loneliness What increases the risk of loneliness?

Loneliness in adulthood affected by… 3,980 Dutch adults aged (2-waves, Mers and Jak, 2013). Both parents’ reliability, closeness and supportiveness Conflicts and violence with father (not mother) 7,446 American adults aged (retrospective survey, Palgi et al., 2012). Traumatic events (affecting self* and others) that happen up until adulthood (e.g. being abused by others, or a significant other’s death, substance abuse) Not related to loneliness if happened after age ,576 American adolescents (3-waves; Goosby et al., 2013) Loneliness in childhood increases risk of adult depression and poor self-rated health (and thus loneliness in adulthood). Life-course approach: Childhood influences

Childhood influences: 3,750 Norwegian adults, 40-80yrs (Nicolaisen & Thoresen, 2014) Bullied in childhood & Conflicts between parents (men) Economic problems in childhood family (women) 2,645 Irish adults, 65+yrs (Kamiya et al., 2013) Poor childhood SES (men and women) Parental substance abuse (men) Later life influences: 3,750 Norwegian adults aged 40-80yrs (Nicolaisen & Thoresen, 2014) Partners death in later years (men more than women) Divorce in later years (women) Life-course approach: Gender differences

137 Centenarians in the US (Hensley et al., 2012) +/- ve events had an indirect effect on loneliness through neuroticism. -ve events only predicted loneliness if competence was also low. 699 Norwegian adults 67-79yrs (5 year follow-up, Nicolaisen & Thoresen, 2012) Mastery (influencing one’s own life situation) protective against loneliness, for those with and without physical limitations. Having a partner strongly protective, only if without physical limitations. Age, gender, self-rated health not predictive of loneliness. Life-course approach: Life-time events & personality

Parenting Reliability, closeness, supportiveness (3,980 Dutch, 21-85yrs, Mers & Jak, 2013) Better age 7 social skills (832 Americans, 9, 11, 15yrs, Schinka et al., 2013) Social engagement 2,393 British children and adults, 15-97yrs (Victor & Yang, 2012) In younger years, quantity of social engagement is protective In mid- and later- life, quality of social engagement is protective Health & Confidence Health improvements decreased loneliness over time (999 British, 65+, Victor & Bowling, 2012) Confidence to overcome life’s difficulties protected against loneliness, despite physical limitations. (699 Norwegian, 67-79yrs, Nicolaisen & Thoresen, 2012) What protects against loneliness?

Reviewers’ conclusions: One-to-one, informal referrals to other services (Findley, 2003) Groups with education or support element/ not one-to-one (Cattan et al., 2005) Interventions addressing maladaptive social cognition (Masi et al., 2011) Recent review of 17 studies (Hagan et al., 2014) A community-based Mindfulness Based Stress Reduction (MBSR) programme None of the 3 one-to-one interventions showed long term effectiveness Effective new technology interventions: – Web-based communication (e.g. Skype) in care-home setting – Games console with a partner (e.g. the Wii) in private home setting – Contact with a living or robotic dog Which interventions work?

A. Should policy, health professionals, local practitioners etc… B. How could they…. (for different age groups) Help with avoiding/overcoming negative life-time events? Help with increasing people’s positive life-time events? Help increase peoples’ confidence in their ability to deal with life’s challenges? Provide accessible counselling to reduce negative personality traits? Help stimulate a nurturing and supportive home / school environments? Help increase social engagement in older age? Help overcome & deal with bereavement? Discussion points