Living alone and all-cause mortality in community-dwelling adults: A systematic review and meta-analysis

Perceived Loneliness, Social Isolation, and Social Support Resources of Frail Older People Ageing in Place Alone in Italy

This paper presents some findings from the IN-AGE ("Inclusive ageing in place") study, which the authors carried out in 2019 in Italy. It explores the available social support resources for frail older people with functional limitations ageing in place alone, and possible links between their social isolation and perceived loneliness. The authors conducted qualitative/semi-structured interviews involving 120 participants aged 65 years and over, and used a mixed-methods analysis (quantitative/qualitative). The main results show the family as the main help resource for daily activities, but also for intimate confidences against social isolation, especially when said relatives live close. Family confidants are less present when seniors are supported by friends/neighbours or/and public services. Moreover, the family is valuable for decreasing loneliness, although not always. However, some older people feel particularly alone when they are supported by public services. Such a complex context draws attention on the need of support for frail seniors living alone and could provide insights for policymakers on adequate policies for preventing and managing loneliness and social isolation in later life. This is especially relevant when family (and other) resources are not available or scarce, also considering the opportunities offered by technology, which can help seniors remain socially connected to relatives, friends and their overall community.

Social isolation, regardless of living alone, is associated with mortality: the Otassha study

Introduction

Social isolation has been recognized as a contributing factor to negative health outcomes. Although living alone is associated with health-related outcomes, existing findings are inconsistent. It is not the act of living alone that may predict poor health, but rather social isolation that can lead to increased mortality risk. This study investigated the combined associations of social isolation and living alone with mortality among community-dwelling older adults.

Methods

We included older adults from Itabashi ward, Tokyo, who participated in comprehensive health checkups. Participants were categorized into four groups based on their social isolation status and living alone. The primary outcome was all-cause mortality, analyzed using Cox proportional hazards models.

Results

Of the 1,106 participants (mean age 73, 42% male), 4.5% experienced both social isolation and living alone. This combination was associated with a worse prognosis regarding all-cause mortality (hazard ratio (HR): 2.08 [95% confidence interval (CI), 1.08-4. 00]). Those who were socially isolated but not living alone also showed a trend towards higher mortality risk (HR: 1.41 [95% CI, 0.90-2.20]). Contrastingly, those who were not socially isolated and lived alone did not show an increased mortality risk (HR: 0.81 [95% CI, 0.44-1.49]).

Discussion and conclusion

Living alone is not inherently associated with a poor prognosis in older adults; however, social isolation was associated with a higher mortality risk. Healthcare providers should focus on enhancing social interactions and support for older adults because of their effects on health rather than solely addressing living arrangements to prevent adverse health events.

Smaller household size and higher prevalence of serious psychological distress in younger people and never-married people: a nationwide cross-sectional survey in Japan

Background

Small-member households are increasing worldwide. However, most previous studies have focused on older people and living alone. Using the latest national survey data, we investigated a dose-response relationship between household size and serious psychological distress (SPD).

Methods

We analyzed data from the 2019 Comprehensive Survey of Living Conditions in Japan. The study participants were 405,560 community-dwelling adults aged 20 or older. Household size was classified into 5 or more, 3 or 4, two, and one (i.e., living alone). SPD was defined as ≥13 points based on the Kessler 6-item Psychological Distress Scale. We used multivariable logistic regressions and included age, education, equivalent household expenditures, housing tenure, employment contract, smoking, and illness under treatment as covariates.

Results

After stratified analyses by age and gender, a dose-response relationship between smaller household size and more common SPD was significant for younger, but not for older people (p-trend was <0.001 in men aged 20-59 and women aged 20-39). After stratified analyses by gender and marital status, a dose-response relationship was significant only for the never-married group in both genders (p-trend was <0.001 in never-married men and women).

Conclusion

Smaller households were associated with higher prevalence of SPD in younger adults and in never-married individuals, regardless of gender. Our findings suggest a need to focus on younger people and never-married people to reduce the mental health risks due to small household sizes.

Utility of Goal Attainment Scaling (GAS) in evaluating a multicomponent exercise programme for community-dwelling pre-frail older adults

OBJECTIVES

This study aimed to investigate the effectiveness of Goal Attainment Scaling (GAS) in assessing an intervention for pre-frail senior citizens. Additionally, the study aimed to explain how the GAS goals were established based on the International Classification of Functioning, Disability and Health (ICF) categories, including body function, activity and participation and environmental factors.

METHODS

In this study, 220 pre-frail older adults were randomly selected to participate in a controlled trial. The intervention group engaged in multicomponent exercise three times a week, once at a community health service location and twice at home. The control group received advice on physical activity but did not have supervised exercise. Participants in both groups selected individualised GAS goals from 23 goals developed based on ICF by focus group discussion. The study used generalised estimating equations to analyse the differences between the groups.

RESULTS

The study included 144 participants, 72 in the exercise group and 72 in the control group. The top three individualised goals for all participants were vestibular functions (53.5%), pain management (43.1%) and lifting and carrying objects (31.9%). Both groups saw a significant increase in GAS scores at week 8 and week 24 of the intervention (p<0.05), but the exercise group showed a more significant improvement (p<0.05). The participants living alone were associated with lower postintervention improvements in the GAS scores. In contrast, the participants who were using a smartphone were likely to get higher postintervention improvements in the GAS scores.

CONCLUSIONS

GAS can be a valuable tool for setting and evaluating individualised and meaningful goals in body functions, activity and participation and environmental factors. The multicomponent exercise interventions can help pre-frail older adults achieve their expected goals as measured by the GAS.

Association between living alone and all-cause mortality of young and middle-aged patients with acute myocardial infarction: analysis of the China Acute Myocardial Infarction (CAMI) registry

BACKGROUND

Lack of social support is a known predictor of the prognosis after acute myocardial infarction (AMI). Although as a common factor associated with social support, there are limited data on long-term prognostic impact of living status in young and middle-aged patients with AMI.

METHODS

We analyzed data from the China Acute Myocardial Infarction (CAMI) Registry, consecutive AMI young and middle-aged patients admitted at 108 hospitals in China between January 2013 and September 2014 were included. Eligible patients were assigned to living alone and not living alone groups based on their living status. The primary endpoint was 2-year all-cause mortality. The secondary endpoints included in-hospital mortality and 2-year major adverse cardiac and cerebrovascular events (MACCEs; a composite of all-cause mortality, MI, or stroke). Multilevel logistic and multilevel Cox regression models were used to evaluate the effect of living status on short-term and long-term outcomes.

RESULTS

A total of 8307 consecutive AMI young and middle-aged patients were included, 192 (2.3%) patients were living alone. Of the analyzed patients, living alone was associated with 2-year all-cause mortality and MACCEs among all analyzed patients after multivariate adjustment (adjusted hazard ratio [HR] = 2.171 [1.210-3.895], P = 0.009; adjusted HR = 2.169 [1.395-3.370], P = 0.001), but not with poorer in-hospital mortality.

CONCLUSIONS

The analysis suggested that living alone was associated with both 2-year all-cause mortality and MACCEs in AMI young and middle-aged patients but did not show an extra effect on the in-hospital mortality after covariate adjustment.

TRIAL REGISTRATION

Trial registration number: NCT01874691; Registered 31 October 2012.

Living alone and cancer mortality by race/ethnicity and socioeconomic status among US working-age adults

BACKGROUND

Previous studies have shown an association between living alone and cancer mortality; however, findings by sex and race/ethnicity have generally been inconsistent, and data by socioeconomic status are sparse. The association between living alone and cancer mortality by sex, race/ethnicity, and socioeconomic status in a nationally representative US cohort was examined.

METHODS

Pooled 1998-2019 data for adults aged 18-64 years at enrollment from the National Health Interview Survey linked to the National Death Index (N = 473,648) with up to 22 years of follow-up were used to calculate hazard ratios (HRs) for the association between living alone and cancer mortality.

RESULTS

Compared to adults living with others, adults living alone were at a higher risk of cancer death in the age-adjusted model (HR, 1.32; 95% CI, 1.25-1.39) and after additional adjustments for multiple sociodemographic characteristics and cancer risk factors (HR, 1.10; 95% CI, 1.04-1.16). Age-adjusted models stratified by sex, poverty level, and educational attainment showed similar associations between living alone and cancer mortality, but the association was stronger among non-Hispanic White adults (HR, 1.33; 95% CI, 1.25-1.42) than non-Hispanic Black adults (HR, 1.18; 95% CI, 1.05-1.32; p value for difference < .05) and did not exist in other racial/ethnic groups. These associations were attenuated but persisted in fully adjusted models among men (HR, 1.13; 95% CI, 1.05-1.23), women (HR, 1.09; 95% CI, 1.01-1.18), non-Hispanic White adults (HR, 1.13; 95% CI, 1.05-1.20), and adults with a college degree (HR, 1.22; 95% CI, 1.07-1.39).

CONCLUSIONS

In this nationally representative study in the United States, adults living alone were at a higher risk of cancer death in several sociodemographic groups.

BMI categories across different living arrangements

INTRODUCTION

Research on the prevalence of body mass index (BMI) categories across different living arrangements remains limited. We aimed to quantify the prevalence of BMI categories among those living alone (LA) and those not living alone (NLA).

METHODS

In this population-based cross-sectional study, we used individual-level data from the 2011-2021 Behavioral Risk Factor Surveillance System. Main outcomes were prevalence of BMI categories in LA and NLA, adjusted for age, gender, and race/ethnicity, and socioeconomic status, using logistic regression and model-predicted marginal prevalence to estimate BMI categories prevalence.

RESULTS

Between 2011 and 2021, we quantified BMI categories prevalence in 4,195,414 adults in the BRFSS, with 1,197,787 (28.5%) adults LA and 2,997,627 (71.5%) adults NLA. In comparison to NLA, LA consistently demonstrates lower adjusted obesity prevalence across genders and age groups, with the highest prevalence observed in the 45-64 age range, particularly within the 45-54 group (LA: 37.4%, 95% CI: 37.1-37.8%; NLA: 34.3%, 95% CI: 33.8-34.7%). Additionally, LA displays an overall lower adjusted prevalence of overweight compared to NLA, notably in the 18-34 and >64 age groups.

CONCLUSIONS

Heterogeneity in BMI categories prevalence exists between LA and NLA. Future studies and public health efforts should consider this heterogeneity.

The association of living alone and social isolation with sarcopenia: A systematic review and meta-analysis

BACKGROUND

Living alone can cause social isolation and is correlated with multiple adverse health outcomes. Evidence about the association of living alone and social isolation with sarcopenia is limited. This meta-analysis aims to investigate the correlation between living alone, social isolation, and sarcopenia.

METHODS

According to the PRISMA guidelines, we systematically searched Medline, Embase, Web of Science, and Scopus for literature published up to June 30, 2023. We conducted reference checking to supplement the references. Two investigators independently screened the references for eligibility and assessed the quality of the references. We included references involving data on living alone, social isolation, and sarcopenia. Two investigators recorded study data for meta-analysis and study characteristics.

RESULTS

Data regarding living alone and sarcopenia were available from 13 studies. Meta-analysis demonstrated that living alone is correlated with sarcopenia (odds ratio, 1.51; 95 % CI, 1.31-1.75; p < 0.001). The gender-stratified analysis demonstrated that women living alone are more likely to have sarcopenia (odds ratio, 1.81; 95 % CI, 1.32-2.48; p < 0.001) but not men (odds ratio, 1.24; 95 % CI, 0.56-2.74; p = 0.60). Data regarding social isolation and sarcopenia were available from five studies. Social isolation is also associated with sarcopenia (odds ratio, 1.70; 95 % CI, 1.51-1.92; p < 0.001). And subgroup analysis demonstrated that social isolation is a risk factor for sarcopenia (odds ratio, 1.79; 95 % CI, 1.55-2.06; p < 0.001).

CONCLUSIONS

This meta-analysis revealed the association of living alone and social isolation with sarcopenia. Gender differences can help to screen high-risk groups of sarcopenia and reduce healthcare expenditures. As a further development of living alone, social isolation may play a more important role in sarcopenia than living alone.

Association between childhood adversities and premature and potentially avoidable mortality in adulthood: a population-based study

BACKGROUND

The association of childhood adversities with mortality has rarely been explored, and even less studied is the question of whether any excess mortality may be potentially preventable. This study examined the association between specific childhood adversities and premature and potentially avoidable mortality (PPAM) in adulthood in a representative sample of the general population. Also, we examined whether the associations were potentially mediated by various adult socioeconomic, psychosocial, and behavioral factors.

METHODS

The study used data from the National Population Health Survey (NPHS-1994) linked to the Canadian Vital Statistics Database (CVSD 1994-2014) available from Statistics Canada. The NPHS interview retrospectively assessed childhood exposure to prolonged hospitalization, parental divorce, prolonged parental unemployment, prolonged trauma, parental problematic substance use, physical abuse, and being sent away from home for doing something wrong. An existing definition of PPAM, consisting of causes of death considered preventable or treatable before age 75, was used. Competing cause survival models were used to examine the associations of specific childhood adversities with PPAM in adulthood among respondents aged 18 to 74 years (rounded n = 11,035).

RESULTS

During the 20-year follow-up, 5.4% of the sample died prematurely of a cause that was considered potentially avoidable. Childhood adversities had a differential effect on mortality. Physical abuse (age-adjusted sub-hazard ratio; SHR 1.44; 95% CI 1.03, 2.00) and being sent away from home (age-adjusted SHR 2.26; 95% CI 1.43,3.57) were significantly associated with PPAM. The associations were attenuated when adjusted for adulthood factors, namely smoking, poor perceived health, depression, low perceived social support, and low income, consistent with possible mediating effects. Other adversities under study were not associated with PPAM.

CONCLUSION

The findings imply that the psychological sequelae of childhood physical abuse and being sent away from home and subsequent uptake of adverse health behavior may lead to increased risk of potentially avoidable mortality. The potential mediators identified offer directions for future research to perform causal mediation analyses with suitable data and identify interventions aimed at preventing premature mortality due to potentially avoidable causes. Other forms of adversities, mostly related to household dysfunction, may not be determinants of the distal health outcome of mortality.

Association of living arrangements with all-cause mortality among older adults: a propensity score-matched cohort study

BACKGROUND

Many studies exist on the living arrangements and health status of older adults, but the findings have been inconsistent. Therefore, we examined the relationship between living arrangements and all-cause mortality in older adults.

METHODS

This perspective study was based on the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2011 to 2018. We used a sample aged 65 years and over included in the study in 2011. Propensity score matching was performed to minimize bias and Cox proportional hazards regression models were conducted.

RESULTS

A total of 7,963 participants were included. Of these, 1,383 were living alone, 6,424 were living with families, and 156 were living in nursing homes. In the propensity score-matched cohort, older adults living alone had a significantly lower risk of all-cause mortality than those living with families (hazard ratio 0.85; 95% confidence intervals 0.76 to 0.95). Living alone was prominently associated with a decline in mortality compared with living in nursing homes (hazard ratio 0.61; 95% confidence intervals 0.44 to 0.84). There was no significant difference in mortality between living in nursing homes and living with families (hazard ratio 1.19; 95% confidence intervals 0.89 to 1.60). Subgroup analyses indicated that there was no significant interaction with age, sex, education, or residence.

CONCLUSIONS

The risk of all-cause mortality was significantly lower in older adults living alone than in those living with families or living in nursing homes. This article's findings suggest the need to adopt multiple approaches to meet the needs of senior care services.

Sociodemographic features associated with the MoCA, SPPB, and GDS scores in a community-dwelling elderly population

BACKGROUND

An accurate evaluation of cognitive function, physical health, and psychological health is fundamental for assessing health problems in the elderly population, and it is important to identify the necessity of early therapeutic intervention. The objective of this study was to evaluate the states of mental and physical functions and to investigate the relationships between sociodemographic features and these functions in a community-dwelling elderly population.

METHODS

This community-based cross-sectional study was conducted in a suburban district of Shanghai, China. A total of 1025 participants aged 60-89 years underwent investigations of demographic and lifestyle features and a multidimensional geriatric evaluation comprising the Montreal Cognitive Assessment (MoCA), Short Physical Performance Battery (SPPB), and Geriatric Depression Scale (GDS).

RESULTS

The results of the multivariate linear regression models demonstrated that the MoCA and SPPB scores decreased with advancing age (all P < 0.01). However, the GDS score did not exhibit an age-related decrease (P = 0.09). Both sex and living alone influenced the MoCA score (P < 0.01 and P = 0.04, respectively), SPPB score (P < 0.01 and P = 0.04, respectively), and GDS score (P < 0.01 and P < 0.01, respectively). A higher education level was related to better MoCA and SPPB scores (all P < 0.01). Furthermore, age and sex had interactive effects on the MoCA score (P = 0.03) and SPPB score (P < 0.01). The kernel-weighted local polynomial smoothing curves exhibited similar trends.

CONCLUSIONS

It is imperative to develop a more sensitive evaluation of physical function, and to encourage various intellectually and emotionally stimulating social activity strategies to promote healthy aging, especially in elderly women and those living alone who have a low education level.

Tea intake or consumption and the risk of dementia: a meta-analysis of prospective cohort studies

Purpose

Dementia affects as many as 130 million people, which presents a significant and growing medical burden globally. This meta-analysis aims to assess whether tea intake, tea consumption can reduce the risk of dementia, Alzheimer's disease (AD) and Vascular dementia (VD).

Patients and methods

Cochrane Library, PubMed and Embase were searched for cohort studies from inception to November 1, 2022. The Newcastle Ottawa Quality Assessment Scale (NOS) was applied to evaluate the risk of bias of the included studies. We extracted the data as the relative risks (RRs) for the outcome of the interest, and conducted the meta-analysis utilizing the random effect model due to the certain heterogeneity. Sensitivity analysis were performed by moving one study at a time, Subgroup-analysis was carried out according to different ages and dementia types. And the funnel plots based on Egger's and Begger's regression tests were used to evaluate publication bias. All statistical analyses were performed using Stata statistical software version 14.0 and R studio version 4.2.0.

Results

Seven prospective cohort studies covering 410,951 individuals, which were published from 2009 and 2022 were included in this meta-analysis. The methodological quality of these studies was relatively with five out of seven being of high quality and the remaining being of moderate. The pooling analysis shows that the relationship between tea intake or consumption is associated with a reduced risk of all-cause dementia (RR = 0.71, 95% CI [0.57-0.88], I² = 79.0%, p < 0.01). Further, the subgroup-analysis revealed that tea intake or consumption is associated with a reduced risk of AD (RR = 0.88, 95% CI [0.79-0.99], I² = 52.6%, p = 0.024) and VD (RR = 0.75, 95% CI [0.66-0.85], I = 0.00%, p < 0.001). Lastly, tea intake or consumption could reduce the risk of all-cause dementia to a greater degree among populations with less physical activity, older age, APOE carriers, and smokers.

Conclusion

Our meta-analysis demonstrated that tea (green tea or black tea) intake or consumption is associated with a significant reduction in the risk of dementia, AD or VD. These findings provide evidence that tea intake or consumption should be recognized as an independent protective factor against the onset of dementia, AD or VD.

Living Alone Increases the Risk of Hypertension in Older Chinese Adults: A Population-Based Longitudinal Study

Background and Objectives

Cross-sectional studies have suggested a potential association between living alone and hypertension risk, but longitudinal evidence remains limited. We aimed to investigate the correlation between living alone, alterations in living arrangements, and hypertension risk among older adults utilizing a population-based longitudinal design.

Research Design and Methods

The study included 8 782 older adults (≥65 years) without hypertension from the Chinese Longitudinal Healthy Longevity Survey. Participants were surveyed during the 2008 and 2011/2012 waves and were subsequently followed up in the next wave. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, or a self-reported diagnosis of hypertension by a physician. Cox proportional hazards model was used to explore the association between living alone and hypertension. Additionally, we analyzed how switching living arrangements during the follow-up period affects hypertension.

Results

During a median follow-up of 2.8 (1.7-3.0) years, 2 750 hypertension events occurred. Compared with living with family, the hazard ratio (HR) (95% confidence interval [CI]) of living alone was 1.19 (1.06-1.33) for hypertension. Similarly, persisting in living alone during follow-up increased the risk of hypertension compared to continuing to live with family (HR 1.24; 95% CI: 1.06-1.45). Compared to married participants who continued to live with family, widowed/divorced participants who transitioned from living with family to living alone experienced a higher risk of hypertension (HR 1.21; 95% CI: 1.00-1.47). Stratified analyses showed that living alone was only associated with an increased hypertension risk for participants aged >80, men, and rural residents.

Discussion and Implications

Living alone at baseline or persisting in living alone during follow-up correlated with increased hypertension risk. Divorced or widowed individuals who transitioned from living with family to living alone were still at risk. These results indicate that social support and living arrangements may be important in preventing hypertension in older adults.

[Determinants of Problem Drinking by Regional Variation among Adult Males in Single-Person Households: Geographically Weighted Regression Model Analysis]

PURPOSE

This study aimed to identify regional differences in problem drinking among adult males in single-person households and predict the determinants.

METHODS

This study used data from the 2019 Community Health Survey. Geographically weighted regression analysis was performed on 8,625 adult males in single-person households who had been consuming alcohol for the past year. The Si-Gun-Gu was selected as the spatial unit.

RESULTS

The top 10 regions for problem drinking among adult males in single-person households were located in the Jeju-do and Jeollanam-do areas near the southern coast, whereas the bottom 10 regions were located in the Incheon and northern Gyeonggi-do areas. Smoking, economic activity, and educational level were common factors affecting problem drinking among this population. Among the determinants of regional disparities in problem drinking among adult males in single-person households, personal factors included age, smoking, depression level, economic activity, educational level, and leisure activity, while regional factors included population and karaoke venue ratio.

CONCLUSION

Problem drinking among adult males in single-person households varies by region, and the variables affecting each particular area differ. Therefore, it is necessary to develop interventions tailored to individuals and regions that reflect the characteristics of each region by prioritizing smoking, economic activity, and educational level as the common factors.

Living Alone and Suicide Risk in the United States, 2008‒2019

Objectives. To evaluate the association between living alone and suicide and how it varies across sociodemographic characteristics. Methods. A nationally representative sample of adults from the 2008 American Community Survey (n = 3 310 000) was followed through 2019 for mortality. Cox models estimated hazard ratios of suicide across living arrangements (living alone or with others) at the time of the survey. Total and sociodemographically stratified models compared hazards of suicide of people living alone to people living with others. Results. Annual suicide rates per 100 000 person-years were 23.0 among adults living alone and 13.2 among adults living with others. The age-, sex-, and race/ethnicity-adjusted hazard ratio of suicide for living alone was 1.75 (95% confidence interval = 1.64, 1.87). Adjusted hazards of suicide associated with living alone varied across sociodemographic groups and were highest for adults with 4-year college degrees and annual incomes greater than $125 000 and lowest for Black individuals. Conclusions. Living alone is a risk marker for suicide with the strongest associations for adults with the highest levels of income and education. Because these associations were not controlled for psychiatric disorders, they should be interpreted as noncausal. (Am J Public Health. 2022;112(12):1774-1782. https://doi.org/10.2105/AJPH.2022.307080).