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Loneliness and Health in Later Life

Abstract and Keywords

Loneliness in old age is a very popular issue in the media although it is frequently looked at through the lens of prejudice and myth. There is no doubt that loneliness is a serious problem for older people and that, considering its association with adverse health outcomes, both from a mental and physical point of view, increased attention should be paid to this topic. The main findings about loneliness are: (1) it is a common subjective experience; (2) it is a negative condition for human beings; (3) the prevalence of loneliness is higher in southern European countries compared to northern European countries; (4) loneliness is more prevalent in young and older cohorts than in middle-aged adults; (5) loneliness is associated with several variables although the direction of the association, as cause or consequences, is far from clear; (6) most probably, personal and contextual variables have a bidirectional relationship. In this chapter we review the multiple variables associated with loneliness as well the diversity of possible consequences. Although there is abundant literature on loneliness, a deeper and more systematic knowledge of it will help to develop and implement more specific interventions to deal with the problem. The types of intervention that have been reported appear to be relatively inefficient and probably the subject must be addressed by innovative strategies from both a social as well as a psychological perspective.

Keywords: loneliness, health, outcomes, predictors, interventions

Introduction

Loneliness is a major issue in the ageing literature, but more importantly is a negative experience for human beings, contributing to poor quality of life across the globe. The experience of loneliness appears to be a very relevant issue from a social as well as a psychological point of view, and assumes particular relevance in old age. Beside the objective conditions that contribute to loneliness, the subjective experience is somehow universal and independent from an individual’s socio-economic conditions; this constitutes a challenge for those working in the ageing field. From a psychological perspective, in addition to investigating the causes of loneliness, one should devote time to understanding the consequences of loneliness for subjective well-being as well as physical and mental health. Withdrawing from work contexts, increasing loss of friends and family members due to death, and other age-related losses may lead to strong feelings of loneliness. Considering that loneliness may be a modifiable factor of distress in old age, it is crucial clearly to understand its determinants and consequences in order to organize interventions to prevent or buffer negative outcomes during the ageing process.

There is no universal definition of loneliness, although it is generally described as a perceived deprivation of social contact, the lack of people available or willing to share social and emotional experiences, a state where an individual has the potential to interact with others but is not doing so, or a discrepancy between the actual and desired interaction and intimacy with others (Gierveld 1998; Victor et al 2000). Whether loneliness is considered a social or a psychological problem, intervention will focus on facilitating social networks or working on emotional problems that contribute to feelings of loneliness and depression.

While loneliness describes the subjective feeling of living in the absence of social contacts or support, it can be contrasted with objective social isolation (Wenger et al 1996). This differentiation is widely recognized, and according to Gierveld (1987) there would be several cognitive processes that mediate between characteristics of the social network and the experience of loneliness. Several recent investigations show that it is the respondent’s evaluation of their relationship rather than the number of social contacts in a person’s social network that is (p. 382) important (Routasalo et al. 2006; Victor et al. 2000). A slightly different way of looking at this issue is to consider that loneliness may comprise two primary dimensions, both recognized as negative experiences: emotional and social isolation. The first refers to a lack of others to whom the individual can be emotionally attached and a lack of the experience of social bonding that is intuitively desired, whereas the second, social isolation, describes the actual number of people in a person’s social structure, referring to the lack of an acceptable social network (Weiss 1973).

Within emotional loneliness, Ditommaso et al. (2004) have proposed the concept of romantic loneliness. When the loss of an intimate relationship occurs—for example widowhood—older people became more vulnerable to loneliness, despite other conditions and circumstances. The simplest form of a network is a social dyad (e.g. spouse relationship), and the impact of losing a loved one, particularly in the case of a long-lasting marital relationship, is enormous. Not only may there be the loss of a partner to share intimate thoughts and feelings, but also the loss of a partner who may have given crucial support and encouragement in facing the challenges of the ageing process. Even when normal grief occurs people will probably have a lasting longing feeling of loneliness that makes the restoration process difficult, as well as potentially inhibiting re-engagement in daily activities and relationships with others. This is true even when the death of the spouse reduces the perceived burden due to a long period of care-giving. Most of the literature on bereavement in later life (e.g. Gallagher-Thompson et al. 2011) focuses mainly on the traumatic event of the death of a spouse and fails to look at loneliness as a negative outcome that deserves particular attention. The loss of a spouse cannot be treated only by reinterpretation of experience but requires a redefinition of the self and life, to discover a new meaning to invest in within the context of a reduced time in which to live.

Loneliness is a popular issue in the media, which frequently reports loneliness in later life, mostly in relation to a negative stereotype of older people. Dykstra (2009) writes about three loneliness myths: (1) loneliness is common only among the very old; (2) people in northern, more individualistic countries are more lonely than those in family-oriented, southern countries; and (3) loneliness has increased over the past decades. With regard to the first myth, it would appear that loneliness in later life is overestimated by others, and when reviewing the literature we can observe a U-shaped curve, with loneliness higher in the young-adult age group (ages 15–24), decreasing in middle age and increasing again among the oldest old, aged 80+ years. With regard to the second myth, concerning differential prevalence of loneliness along north–south lines, there is a general consensus about the higher rates of reported loneliness in southern and eastern European countries, thus negating the idea that people in individualistic countries from the north of Europe are lonelier (Dykstra 2009). Probable explanations are different individual characteristics, country differences, or some interaction of the two. The final myth about increasing loneliness was also not confirmed by existing data (e.g. Victor et al. 2002). In the subsequent examination of loneliness, myths will be debunked by the scientific literature reviewed in the next section of this chapter.

Recently Rokach (2012) has recognized loneliness as a social stigma. This author characterizes three different types of experiences of loneliness: (1) loneliness as a universal phenomenon, that is, fundamental to being human; (2) loneliness as a subjective experience influenced by personal and situational variables; and (3) loneliness as a complex and multifaceted experience, painful, severely distressing, and personal. Concerning explanations of loneliness, Dykstra (2009) points to three types of argument: social characteristics of the network; relationship standards and expectations; and poor self-esteem, which inhibits the individual from interacting with others or causes others to withdraw. While the first two (p. 383) arguments are more sociological in nature, the last is more psychological and appeals to personal characteristics as well as life history that may condition the experience of loneliness. This corroborates Rokach’s viewpoint on stigma, as people consider it a personal failure not to have an adequate social network and the intimacy they desire during the life course, reaching the end of life with few significant interpersonal connections.

There is a well established although not very clear association between loneliness, health outcomes, and mortality (e.g. Cacioppo et al. 2006; Momtaz et al. 2012) on the one hand, and social support and loneliness on the other (e.g. Routasalo et al. 2006). Uchino (2004) presents a comprehensive model relating social integration and social support with physical health, in which he introduced loneliness as a direct pathway by which social integration may influence mortality, something that has not been studied so far. This is a challenge that persists nowadays and we still need to establish clearly the difference between the concepts of loneliness and social isolation to reach a clear hypothesis with respect to the association of loneliness with physical health. The main findings from the revision of the literature on loneliness can be seen in Box 18.1.

This chapter begins by looking at the prevalence and major trends of loneliness in old age, with a commentary on the theoretical status of loneliness in causal networks. Next the variables associated with loneliness as predictors and as outcomes are reviewed, paying particular attention to physical and mental health issues. Finally, possible interventions to address deleterious effects of loneliness in old age are discussed.

Prevalence and Major Trends of Loneliness

The prevalence of loneliness varies widely between studies due to different conceptions of loneliness and methods of assessment, but overall findings suggest the importance of studying the determinants of both social isolation and perceived social isolation throughout the ageing process in culturally distinct community samples (Rokach, Orzeck, and Neto 2004).

(p. 384) The percentage of older people who often feel lonely in European countries as described by Walker and Maltby (1997) ranged from 5% in Denmark to 36% in Greece. Northern countries, including the UK, showed a lower rate of loneliness than Mediterranean countries, despite lower levels of social contact and a higher percentage of old people living alone. Similar findings were presented in a review by Dykstra (2009) that showed northern European countries reporting less loneliness than people in southern countries. Nevertheless, Mediterranean countries seem to have larger and stronger families from which one could expect closer relationships that might prevent loneliness. This discrepancy between people from the north and the south of Europe may be due to a different self-evaluation of loneliness, different expectations towards the role of family members or friends during the ageing process, or being more prone to complain about the availability of people in the network.

In a recent study on cross-national differences in old people’s loneliness, from a large cross-national project on ageing issues, the Survey of Health, Ageing and Retirement in Europe (SHARE), Fokkema, Gierveld, and Dykstra (2012) corroborate the Dykstra (2009) north–south division in Europe by reporting lower rates of loneliness in Denmark, Switzerland, and the Netherlands, and higher rates in Greece, Spain, and Italy but also France. Central European countries such as the Czech Republic and Poland also show a higher prevalence of loneliness, joining the south with poor results.

All over the world studies report a high prevalence of loneliness in older people. Perissinotto, Cenzer, and Covinsky (2012) reported 43% of older people (60+ years) who participated in the longitudinal Health and Retirement Study in the USA to be feeling lonely. Park, Yang, Lee, Haley and Chiriboga (2012) found more than 50% of older Korean Americans experiencing loneliness. Momtaz et al. (2012) reported 29.3% experienced loneliness in a representative sample of older Malaysians. Theeke (2009) reported 20% of an older cohort feeling lonely in the US, ranging from 12% to 38%; and finally the estimated prevalence of loneliness in older people in China is 29.6% (Yang and Victor 2008).

There is a common perception that loneliness and isolation have become more prevalent, namely in Britain, as a result of the changes in the family structure, particularly post-Second World War. To confirm the veracity of this presumption, Victor et al. (2002) compared historical data with contemporary ones. The overall prevalence of loneliness ranged from 5% to 9% and showed no increase. The rates for specific age or gender groups were also stable. Reported loneliness among those living alone decreased from 32% in 1945 to 14% in 1999; similar results were also found in Dykstra’s (2009) research. According to Victor et al. (2002), rates of loneliness presented in others major British studies ranged between 5% and 16% in people 65 years and over, although it is recognized that a perceived stigma associated with admitting loneliness can result in the underestimation of these rates of loneliness. Paúl et al. (2006) found in a representative UK sample that feelings of loneliness were reported by 7% of older people, ranging from 3% in the group aged 65–69 years to 13% in the group aged 80+ years. More females (8%) than males (5%) reported feeling lonely. According to Dykstra (2009), loneliness seems to be common only in the group 75+ years old.

In Portugal the prevalence of people feeling lonely all of the time was 4.6% with 11.7% reported feeling lonely on a regular basis within an overall total of 16.3% people reporting loneliness, although only 7% of people presented with a limited social network (Lubben 1988, score <20). Loneliness varied by gender with more women feeling lonely (20.4%) than men (7.3%), and by educational level with more illiterate people (25.8%) reporting loneliness. The amount of people feeling lonely increased with age: 9.9% in the 50–64 years age (p. 385) group, 16.3% in the group aged 65–74 years, 20.9% in the group aged 75–84 years, and 26.8% in people aged 85 and over (Paúl and Ribeiro 2009).

A prevalence study on loneliness in the UK using data from the European Social Survey, including people aged 15 years and older, again showed a U-shaped distribution, confirming higher rates of loneliness in people under 25 years old and in people 65 years and over. Depression appears associated with loneliness for all age groups but physical health is associated with loneliness in young and middle-aged people, but not in older people. Curiously, for older people the quality of social relations is protective for loneliness, while for young people it is the quantity of social relationships that matters (Victor and Yang 2012). This study corroborates with that reported by Pinquart and Sörensen (2001), who also report a U-shaped association between age and loneliness, where the quality rather than the quantity of the social network is strongly correlated with loneliness. Friends and neighbours seem more effective in dealing with loneliness than family members. Gender (being a woman), having low socio-economic status and low competence, and living in nursing homes were also associated with higher loneliness. A growing tendency for developing feelings of loneliness in late-life was observed in a 28-year prospective study of Aartsen and Jylhä (2011) based on data from Tampere, Finland (TamELSA). Approximately one-third of people that did not experience loneliness at baseline later developed feelings of loneliness.

In a meta-analysis of research findings on loneliness in older adults, Pinquart and Sörensen (2001) concluded that 5–15% of older adults report frequent loneliness. Jones, Victor, and Vetter (1985) compared loneliness in rural and urban communities, finding a prevalence of 2% and 5% respectively. Females felt lonelier then men, and loneliness increased with age. An extensive study of Finns aged 74+ years found that 39.4% of the sample suffered from loneliness not associated with the frequency of contacts with children and friends, but rather with the satisfaction with these contacts (Routasalo et al. 2006). Some previous researchers suggested that the feeling of loneliness is more common among people aged 75+ than younger adults, but that the prevalence of loneliness levels off after the age of 90 years (Andersson 1998).

Considering the differentiation between social and emotional loneliness, Drennan et al. (2008) found that social and family loneliness were low among older people in Ireland but that a specific form of loneliness concerning close relationships with a partner or friends was relatively high. These authors used the SELSA-S scale (Ditommaso et al. 2004) to measure loneliness, and that instrument introduced a second dimension to emotional loneliness related to attachment and intimate relationships called ‘romantic loneliness’ as mentioned earlier.

The explanation of loneliness varies if we consider individual vs country level loneliness and also loneliness levels between countries. Authors report that cross-national loneliness is attributable to marital status (greater among those not married), lower socio-economic status, and poor health. Other variables in some countries (e.g. Spain) are the proportion of people that do not have living parents, or that are informal care-givers, or people that depend on informal family care (e.g. Czech Republic). Financial and health problems seem to be strong predictors of loneliness, although the most generally accepted association is between loneliness and social relationships. According to Fokkema et al. (2012), living alone is one of the main risk factors for loneliness.

Loneliness and Health in Later Life

Figure 18.1 Variables associated with loneliness in hypothetical causal networks.

Most of the studies on loneliness are cross-sectional, preventing the establishment of causal relations between loneliness and associated variables. The associations seem to follow expected trends with older people, women, those who have lost their spouse/partner, those (p. 386) with less education and income, those living alone, with poor health and a disability, being more prone to loneliness (see Figure 18.1). Although loneliness is more frequently viewed as an outcome of adverse conditions, it can also be looked at as a causal variable of deleterious outcomes on health and well-being. In the first hypothesis we have to consider which are the predictive variables associated with loneliness; in the second hypothesis we have to check which are the outcomes of loneliness, namely those concerning physical and mental health. Those reporting loneliness may have a less active life style and poor self-care, becoming more prone to disability and illness. Older persons with poor health may experience difficulties in maintaining social relationships because they cannot communicate properly, want to hide their condition, or simply because social contacts become more difficult, and thus they become socially isolated and lonely. In any event, loneliness appears a vulnerability factor in later life and according to Cacioppo, Hawkley, and Bernston (2003) loneliness is a powerful but little understood risk factor for broad-based morbidity and mortality.

Loneliness, in addition to being an objective condition, appears also to encompass subjective feelings accompanying the ageing process for a significant percentage of old people, independent of their social network and living arrangements. Moreover, alongside the macro socio-economic determinants of loneliness, which other variables may be associated with negative feelings of loneliness? The predictors of loneliness in a UK study were being divorced/separated or widowed and not having good quality of life (Paúl et al. 2006). Data confirmed the expected associations between loneliness, widowhood, self-perceived poor health, psychological distress, and cognitive deficit, but failed to show, when controlling for all the other variables in the model, the association with gender, age, living arrangements, social network, or the number of health problems, as found in other studies (e.g. Prince et al. 1997; Routasalo and Pitkala 2003). Some relevant associations between loneliness and usual predictors of social isolation (living arrangements, namely living alone and social network) became non-significant in the adjusted model of loneliness, with the exception of being a widow/widower that goes on being a predictor of loneliness, which is relevant both from a theoretical as well as a practical point of view. This finding suggests, on the one hand, the independence of both concepts of emotional and social isolation, and, on the (p. 387) other hand, the subjective and affective nature of loneliness in old age. A similar perspective was reported by Hughes et al. (2004), who found that objective and subjective isolation are modestly related, which reinforces the idea that the quantitative and qualitative aspects of social relationships are quite distinct.

According to Routasalo and Pitkala (2003), demographic factors (age, widowhood, institutional care, and living alone) appeared in a large number of cross-sectional studies, whereas social factors (low number of social contacts or lack of friends) appeared in only a few population-based studies or studies with small samples. In a subsequent paper Routasalo et al. (2006) showed that in addition to living alone, being depressed, reporting a feeling of being misunderstood, and the presence of unfulfilled expectations towards contacts with others are relevant predictors of loneliness.

In a Portuguese sample of older community dwellers, Paúl and Ribeiro (2009) show that being widowed, perceiving one’s own health as poor or very poor, having psychological distress, and cognitive decline were associated with loneliness. Other predictors of social loneliness were greater age, poorer health, living in rural areas, and lack of contact with friends. Family loneliness was predicted by rural setting, being male, having a lower income, being widowed, having no access to transportation, infrequent contact with children and relatives, and being a care-giver at home. Marital status, particularly being widowed, never married, or divorced, predicted romantic loneliness. The authors concluded that the quality of social and family relations might not buffer the older person from the experience of romantic loneliness, which means that loneliness is clearly a multifaceted and complex experience that can affect old people both socially and emotionally.

According to Prince et al. (1997), loneliness was more common among people living alone; lacking supportive neighbours, or contact with friends; upset with their relationship with a child; and for women older than 82 years. Better-quality housing was associated with less loneliness. They did not find any association between loneliness and not having children, or frequency of contact with relatives. The correlation of depressive symptoms seemed similar over the life course, although their prevalence could be different across age (Nolen-Hoeksema and Ahrens 2002). These authors showed a decreasing level of depression and loneliness in people aged 65–75 compared with younger subjects (25–35 or 45–55 years), although loneliness correlates significantly with depression in all age groups.

In short, most of the studies reviewed here report an increasing risk of loneliness in older people and in women (e.g. Jones et al. 1985; Prince et al. 1997; Routasalo et al. 2006; Uchino 2004). Other variables, such as widowhood, education, or income, are less consensual.

Loneliness and health

As mentioned previously, loneliness is associated with both subjective and objective health outcomes (Andersson 1998; Tomaka, Thompson, and Palacios 2006). In a revision of a large number of cross-sectional studies conducted to determine the correlates of loneliness, Routasalo and Pitkala (2003) presented the strength of association between loneliness and health factors in older people. According to these authors, the most closely associated factors, as shown in several population-based studies, were the impairment of physical functioning, poor health, anxiety, sensory impairment, depression, and mortality. Illness and (p. 388) disability may limit social interaction and foster the feeling of loneliness, which seems particularly likely during older age. Recently, a special issue of the Journal of Psychology presented several papers linking loneliness to various health conditions such as rheumatic disease, fibromyalgia, and depression, among others (Rokach 2012).

More recently, in another revision of relevant studies on loneliness with the purpose of showing the medical impact and biological effects of loneliness, Luanaigh and Lawlor (2008) concluded that loneliness has been negatively associated with physical health (e.g. poor sleep, systolic hypertension, heart disease), depression, and poorer cognition. Additionally, social isolation predicts morbidity and mortality from cancer, cardiovascular disease, and a host of other causes (Hawkley and Cacioppo 2003). In a study of the effects of types of social network, perceived social support, and loneliness on the health of older people, Stephens et al. (2011) concluded that loneliness was moderately related to total social support but strongly predicted mental and physical health.

As for the number of health problems, Mullins et al. (1996), though utilizing a more objective measure of disability in their study, reported no relationship between health concerns and feelings of loneliness. These authors suggested that functionally disabled people generally receive more care and attention than those whose poor health status is self-perceived, but not necessarily manifest; it may also indicate that formal services are more accessible to disabled people, permitting greater social contact. A face-value interpretation of the findings is that attitudes about health may be a more important variable in loneliness than actual health conditions.

Overall, the association between loneliness and health outcomes is widely accepted (e.g. Cacioppo et al. 2003; Hawkley et al. 2003; Hawkley and Cacioppo 2003; Uchino 2004). Cacioppo and Hawkley (2003) identified three pathways linking loneliness to disease: health behaviour and life styles, excessive stress reactivity, and inadequate or inefficient physiological repair and maintenance processes.

Perissinotto et al. (2012) studied the association between loneliness as a predictor of functional decline and death. Based on the results of a multivariate analysis adjusted for demographic variables, socio-economic status, living situation, depression, and various medical conditions, the authors concluded that subjects feeling loneliness were more likely to experience a decline in activities of daily living, develop difficulties with upper extremity tasks, experience decline in mobility, or experience difficulty in climbing stairs. Loneliness was associated with a 1.45 increase in the risk of death compared with people who were not lonely. The association of loneliness with the rate of motor decline in older people living in the community was studied by Buchman et al. (2010), who found that for each 1-point increase in the level of loneliness at baseline, motor decline was 40% more rapid. So they found that loneliness and being alone were independent predictors of motor decline. The association between loneliness and motor decline persisted, even after controlling for depressive symptoms, cognition, and baseline disability, among other factors.

It seems that the association of disability with loneliness varies with gender. Korporaal, van Groenou, and van Tilburg (2008) found that one’s own disability as well as spousal disability were related to higher levels of social loneliness. For men only, their wives’ disability was related to higher levels of social loneliness, whereas for women their own disability was related to higher levels of social loneliness. These findings suggest that we must be attentive not only to the effect of disability in social loneliness but also to differential effects in partners, particularly for men that are at elevated risk when their wife is disabled. Thus marriage (p. 389) may not be a protective factor for loneliness when one of the partners is disabled. Golden et al. (2009) also found higher rates of loneliness in women, widows, and people with a physical disability. Loneliness increases with age whenever explanatory models are not adjusted for variables related to age, such as gender or poor health. Jones et al. (1985) found a highly significant association between loneliness and disability in rural as well as in urban older people, independently of age. El-Mansoury et al. (2008) studied loneliness in women with rheumatoid arthritis in the Netherlands and Egypt and concluded that loneliness was higher in Egypt than in the Netherlands. Affection is the variable that better explains loneliness in both countries, and the authors suggest that family is important in Egypt but perhaps not as important in the Netherlands, where lower social support is more common.

In regard to mental health, loneliness has been identified as a primary issue affecting seniors, and numerous studies have confirmed the close relationship between loneliness and depression in old age (Alpass and Neville 2003; Cacioppo et al. 2006; Cheng, Fung, and Chan 2008), particularly among very old women (Paúl and Ribeiro 2008). In several study findings, the main consequences of loneliness are described as decreased well-being and depression. Heikkinen and Kauppinen (2004) reported that loneliness, together with other variables including a large number of chronic diseases, poor self-rated health, poor functional capacity, poor vision, and perceived negative changes in life, predicted depressive symptomatology. In a study focused on the association between loneliness, psychological distress, and disability in later life, Paúl et al. (2006) found that those older people feeling lonely had the highest percentage of psychological disturbance (55%). In a later study Paúl and Ribeiro (2008) found that women feeling loneliness had the highest percentage of psychological disturbance (65.8%). Greater loneliness was also related to increased psychiatric morbidity, increased physical impairment, low life satisfaction, small social networks, and the lack of a confidant. According to the findings of Bowling et al. (1989), the two variables most likely to distinguish between lonely and non-lonely older people were increased psychiatric morbidity and decreased life satisfaction. The consequences of loneliness are mainly decreased well-being and depression. The associations between disease, disability, and demographic variables and loneliness, as well as its mental health consequences, are not completely understood.

When questioning the association between loneliness and health/disability, one cannot omit depression from the equation due to a strong association between both conditions. Evidence shows that loneliness is a powerful predictor of depression but both constructs are clearly different and explained by different sets of determinants; as for loneliness, the predictors are marital status (divorced/separated and widowed) and poor self-perceived quality of life. For depression, the single most important predictor is loneliness and the number of health problems, limitations due to illness, not knowing the neighbours, and poor quality of life (Paúl, Ayis, and Ebrahim 2007).

Research has revealed poorer self-rated health as being related to greater loneliness among older people, as well as a close relationship between depression and loneliness (Mullins et al. 1996). People with poor physical and mental health may restrict their social contacts and activities outside their homes, or people feeling lonely may become more careless (Routasalo and Pitkala 2003). In either case, this finding may have important indicators for health and social professionals who assist older people in the community in adjusting to health-related changes, depression resulting from loneliness, or both. As for cognitive deficits, they appear to be associated with loneliness but again we cannot assume it as a cause (p. 390) or consequence of experiencing loneliness. Alpass and Neville (2003) stress the association between loneliness and chronic illness and self-rated health in older adults and depression. They found no relation between diagnosis of illness and depression but a clear association of loneliness and depression.

Implications for Practice

Huge changes in the conception of work and retirement, new familial arrangements that extend to diverse networks, the compression of morbidity, the massive use of new technologies of information and communication, and the encouragement of social participation of ever more active people will all probably contribute to a lessening of social isolation contributing to loneliness. Will this hinder loneliness and its impact? Probably not and so the remaining variables of a more individual nature associated with loneliness need to be addressed from a psychological point of view.

Policies and programmes to prevent loneliness and prevent or delay disability among older people are needed to foster positive outcomes of the ageing process. Several possible psychosocial interventions to diminish loneliness and to promote well-being in later life will be discussed. According to Masi et al. (2010), there are four primary intervention strategies to cope with loneliness: (1) improving social skills; (2) enhancing social support; (3) increasing opportunities for social contact; and (4) addressing maladaptive social cognition. So mostly social interventions are envisaged for loneliness, again probably targeting more social isolation than loneliness. Community intervention promoting sociability between older people, inter-generational solidarity, and avoiding social isolation enhance the quality of life of old people, and diminish feelings of loneliness to some extent. Stevens (2001) presents an educational programme on friendship enrichment for older women to combat loneliness. The main goal was empowerment: by helping women clarify their needs in friendship, analyse their current social network, set goals in friendship, and develop strategies to achieve goals, loneliness might be averted. There was some evidence in improving existing friendships and reducing loneliness. With a similar perspective, Andrews et al. (2003) assessed the satisfaction of users of a local home-visiting befriending service in the UK that provided the opportunity to develop a new social bond. Users reported friendly reciprocity between themselves and the volunteers that visited them weekly. Evidence from this study attests to the value of befriending in ameliorating the effects of social isolation even though some operational aspects (e.g. matching volunteer with user) could be improved. Fostering solidarity between generations by all available means, as encouraged by the World Health Association (2002) and recently the EY2012EC initiative (EY2012 Coalition 2012), will result in lessening loneliness among older people.

Cattan, White, and Learmouth (2005) reviewed studies between 1970 and 2002 to check the efficacy of interventions targeting social isolation and loneliness among older people. They found thirty studies classified according to (1) ‘group interventions’ (n = 17); (2) face-to-face interventions (n = 10); (3) ‘service provision’ (n = 3); and (4) ‘community development’ (n = 1). Only a third of the studies were effective; these utilized group activities with an educational or support input. The literature review supports educational and social activity group interventions to alleviate social isolation and loneliness among older people. (p. 391) The effectiveness of home visiting and befriending was not clearly demonstrated. The integrative meta-analysis revealed that single-group pre-post and non-randomized comparison studies were the most successful interventions in reduction of loneliness and focused maladaptive social cognition. Fokkema and van Tilburg (2007) reviewed several interventions in the Netherlands and concluded that the effect of loneliness reduction is not clear, although some seem to have at least a preventive effect, avoiding increased feelings of loneliness as observed in control groups.

Although some major studies in the field of loneliness (e.g. ENRICHD Investigators 2001; National Institute of Health 2001) did not find a reduction in mortality after intervention to reduce patient depression and increase social support levels, the authors believe that post-intervention measurement periods of weeks or months allow little time for observing any pathophysiological or health outcome, as loneliness may unfold over several years (Cacioppo and Hawkley 2003).

Interventions oriented to people at risk of emotional isolation (particularly widows) should be more available (Paúl and Ribeiro 2009). Along with social interventions that focus mostly on social isolation, older people will benefit from psychological interventions helping them to cope with widowhood, psychological distress (mainly depression), and the challenges of declines associated with ageing (see Christensen et al. 2009, for a review) that are in turn associated with feelings of loneliness. The stress model can help in understanding the deleterious effect of loneliness. We have to be attentive to psychological signs of helplessness and low self-esteem that frequently coexist with loneliness, provoking double burden and deleterious consequences for the ageing process.

From a psychological point of view, intervention should focus on coping mechanisms used by those community-dwelling individuals who feel significant levels of loneliness to enhance its effects. As pointed out earlier, one possible explanation of loneliness is lower self-esteem that could lead to avoidance or inhibition of social contacts and difficulties in close relationships, resulting in poor social networks. Psychological interventions in face-to-face or group settings may help people to raise self-esteem and learn to deal with others, thereby enlarging their social networks; this in turn will help their ability to cope with loneliness. Reminiscence therapy is reported to be effective in lessening the feeling of loneliness (Chiang et al 2010). The authors explain that memory is used as a therapeutic intervention to help validate a sense of self. The authors demonstrated that the group therapy built a strong sense of belonging and cohesion among participants that decreased the feelings of loneliness in another study, a follow up study of institutionalized males.

Although there is an abundant literature on loneliness, a deeper and more systematic knowledge about it from a psychological perspective will help to develop and implement more specific interventions to deal with the problem and increase quality of life in older adults.

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