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Commentary on: Holwerda TJ, Beekman AT, Deeg DJ, et al. Increased risk of mortality associated with social isolation in older men: only when feeling lonely? Results from the Amsterdam Study of the Elderly (AMSTEL). Psychol Med 2012;42:843–53.
Implications for practice and research
Clinicians should have heightened awareness and inquire about feelings of loneliness when providing care for older adults.
More studies are needed to further elucidate gender-based differences on the relationship between loneliness and mortality.
The demographic imperative indicates aging of the western hemisphere. Whereas some older adults would prefer continued employments until late in life, chronic-health conditions1 would force many into premature retirements. Without an efficient coping mechanism, related-social isolation and loneliness could emerge. Loneliness is defined broadly as a distressing feeling of individuals’ subjective experience about lack of satisfying relationships which can only be evaluated and quantified by the individual experiencing the ‘feeling of loneliness’.2 ,3 Whereas available data support fewer network supports for older men, the differential interactions of gender with feeling of loneliness are yet to be fully elucidated, and their effects on mortality are poorly understood. The interaction of this relationship with social isolation is also not known.
Using the Amsterdam Study of the Elderly, the authors investigated whether increased risk of mortality was associated with social isolation and feeling lonely in older men and women. The study used a prospective cohort of 4004 of older adults aged 65–84 years with a 10-year follow-up of mortality data. Structured clinical interviews were used to assess social isolation and loneliness. Mortality was validated through the registers of the municipality of Amsterdam or one to which participants relocated during the study period. Final regression analysis discounted the effects of important a priori surrogates for mortality such as psychiatric disorders, medical conditions, cognitive functioning, functional status and sociodemographic factors.
After 10 years of follow-up, the authors observed significantly higher death rates in men than in women who experienced feelings of loneliness at baseline, but not with social isolation; not withstanding adjustments for a priori explanatory variables that included social isolation, feelings of loneliness remained a significant predictor of mortality (HR 1.3, 95% CI 1.04 to 1.63). Supported by this evidence, the authors concluded that feelings of loneliness rather than social isolation factors were important predictors of mortality in older men.
Difference in population growth favours a higher proportion of women survivors than men, but gender differences in feelings of loneliness among older adults remain poorly understood. Whereas, women survivors are often able to maintain an active lifestyle and community network of families and friends, widowed men often undergo a rapid physical and psychological deterioration.4 For men who spent a lifetime of dependency on their spouses for instrumental activities of daily living and a social network of friends, family and church members, the death of a spouse can give way to a psychological predicament that they are ill-equipped to confront. Unstable health conditions and associated loss of control over others, and on the remaining life course may coincide with the appreciation for the inevitability of mortality. To survive such unhealthy convergence, an alternate coping mechanism must replace the old structure. Failure of this would further task individual physical and psychological well-being. While these predicaments may be prejudiced by the richness of pre-existing spousal relationships, ability to grieve and accept the loss of a spouse and become engaged with the remaining social networks may affect the perception of loneliness. Additionally, self-perceived poor physical and psychological well-being and the internalisation of the feeling of loneliness may influence consequent health trajectories including mortality.
Interestingly, feelings of loneliness are directly related to self-perceived health status, an established surrogate for mortality.5 In spite of such feelings by older adults, often, they fail to engage appropriate healthcare services.6 The authors’ findings are consistent with established tenets, and add directionality to the dialogue on the consequence of loneliness in older adults. These findings will guide future interventions to combat the feeling of loneliness and its consequences in older adults.
Competing interests None.
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