Older persons' existential loneliness, as interpreted by their significant others - an interview study

Development and Validation of a New Measurement Scale for Existential Loneliness

This article deals with the development and initial validation of the Existential Loneliness Scale (ELS). An initial pool of 40 items, generated based on literature review, qualitative studies, and previously developed scales, was evaluated by the experts' judgment, so 30 items were retained and then administered to an Iranian sample of 433 youth and adult participants aged 20 to 85 years. Participants also completed other measures relevant for construct validity: Existential Loneliness Questionnaire (ELQ), De Jong Gierveld Loneliness Scale (DJGLS-6), Existential Anxiety Questionnaire (EAQ), Meaning in Life Questionnaire (MLQ), Beck Depression Inventory (BDI-13), and Satisfaction with Life Scale (SWLS). Exploratory factor analysis and parallel analysis showed strong evidence of unidimensionality. This result was also supported by confirmatory factor analysis test. Finally, 19 items were kept, which were free from DIF by gender and by marital status. The scale had high internal consistency (α = .95 and ω = .95) and adequate test-retest reliability with a 1-month interval (r = .74). Examination of the ELS' correlation with criterion measures indicated that the scale has good concurrent, discriminant, and convergent validity. Findings revealed the ELS as a reliable, valid, and suitable instrument to measure existential loneliness in the Iranian adult population.

'They're Going to Die at Some Point, but We're all Going to Die' - A Qualitative Exploration of Bereavement in Later Life

This article reports on a qualitative study to investigate what bereavement means to older people. Drawing upon 80 in-depth interviews collected from eight British and Australian retirement communities, our study revealed that facing bereavement while ageing includes experiences of losing both others and the wholeness of the self. Core themes identified how the experience of losing others can be compounded by ageing-related challenges, undermining older people's defence from bereavement and frustrating their fundamental meaning and being. The older people's dynamic responses were also captured, highlighting the importance of supporting their agency to deal with the deeper pain of loss. By extending the concept of bereavement in later life, we also called for a more grief literate culture to mitigate the multifaceted and often deeper distresses of bereavement that older people may face alongside ageing.

"It doesn't feel like exercise": a realist process evaluation of factors that support long-term attendance at dance classes designed for healthy ageing

Introduction

Dance can positively impact older people's health and wellbeing across cultures and socioeconomic groups, countering age-related physical, sensorimotor and cognitive decline.

Background/objectives

The RIPE (Really Is Possible for Everyone) Dance program aims to improve older people's physical, mental, cognitive and social wellbeing by integrating engaging dance sequences with evidence-based fall prevention exercises. We sought to identify what mechanisms support observed long-term participation in this program, including by people living with challenging health conditions.

Methods

Following a realist evaluation approach, we co-developed and tested program theories iteratively with participant interviewees (n = 20), dance teachers (n = 2) and via observation of a dance class. Initial data were dual-coded and emergent findings were interrogated by the research team. Findings were organised to express Program activities + Context + Mechanism = Process outcomes configurations.

Results

We identified four program theories comprising 14 mechanisms which explained long-term attendance: 1. RIPE Dance benefits my body and mind (trust in the program, belief in health benefits), 2. RIPE Dance helps me feel good about myself (self-efficacy, pride in achievement, psychological safety, defying expectations, feeling valued), 3. RIPE Dance creates camaraderie (social connection, mutual support, rapport with the teacher), and 4. RIPE Dance is uplifting (raised spirits, fun, synchrony, musical reactivity).

Conclusion

The RIPE Dance program provides effective and enjoyable 'exercise in disguise' for older people with diverse mobility profiles.

Significance/implications

This research confirms that participation in dance can contribute significantly to healthy, happy ageing. Findings detail program activities that were most strongly associated with process outcomes, offering guidance for further program development, implementation and scaling up.

Perspectives on existential loneliness. Narrations by older people in different care contexts

The aim was to explore existential loneliness in different long-term care contexts as narrated by older people. A qualitative secondary analysis was performed of 22 interviews with older people in residential care, home care, and specialized palliative care. The analysis started with naive reading of interviews from each care context. As these readings showed similarity with Eriksson's theory of the suffering human being, the three different concepts of suffering were used as an analytic grid. Our result indicates that suffering and existential loneliness are interrelated for frail older people. Some situations and circumstances that trigger existential loneliness are the same in the three care contexts while others differ. In residential and home care, unnecessary waiting, not feeling at home and not being encountered with respect and dignity can trigger existential loneliness while seeing and hearing others suffering can give rise to existential loneliness in residential care. In specialized palliative care, feelings of guilt and remorse are prominent in relation to existential loneliness. In conclusion, different healthcare contexts have various conditions for providing care that meet the existential needs of older people. Hopefully our results will be used as a basis for discussions in multi-professional teams and among managers.

A Re(Defining) Moment: Eulogizing Good Death in the Face of COVID-19

Master narratives of "Good death" that render the circumstances surrounding COVID-19 fatalities as inherently "Bad" exacerbate the profound layers of grief people are experiencing as a result of the pandemic. This (re)defining moments essay engages autoethnographic writing and eulogy as methods to resist such master narratives. In particular, the author re-stories the loss of Katherine, a beloved one who died of COVID-19 "alone" in a hospital. The eulogy opens opportunities for sensemaking and (re)framing that allow the author and others to move from questioning why our loved ones have to die alone to asking how we resist master narratives of Good death and lonely dying. In particular, the ceremonial narrative counter-stories Good death by exploring alternative understandings of dying alone and through honoring the many ways that Katherine dedicated her life to "accompanying" those experiencing loneliness in the face of suffering.

Process of inner change in advanced age: a qualitative study of older adults in their early 90 s

BACKGROUND

The number of nonagenarians is growing globally. The promotion of mental wellbeing is increasingly important. The aim of this study was to explore mental wellbeing and psychological experiences of older adults in their early 90 s who were living at home.

METHODS

We conducted a qualitative study using semi-structured face-to-face interviews with 20 older adults in their early 90 s. A thematic analysis, according to Braun and Clarke, was used to analyze data.

RESULTS

An inner process of older adults in their early 90 s was revealed; its three themes were the "reality of aging," "seeking emptiness of the mind," and "still moving on." Older adults in this study experienced functional decline, regret, and loneliness. They were tired of life and nearly gave up. Emptying their minds helped them reset their attitudes and find a way to move on. After realizing that negative thinking did not help anything, they focused on what they could do and their daily routines. Perceived social usefulness validated participants' self-worth. However, a few were consistently active without negative perceptions of aging.

CONCLUSION

Understanding the psychological process and mental wellbeing in later life aids in the development of practical healthcare policies to assist the growing oldest-old population in cope with age-related challenges and improve their mental wellbeing.

An exploration of person-centred approach in end-of-life care policies in England and Japan

Background

Increasing evidence has suggested that a person-centred approach (PCA) is beneficial not only for improving care outcomes but also for mitigating the pressure on public health systems. However, policy implementation gaps have prevented the translation of this complex framework into useful practical, ethical and moral stances for end-of-life care (EOLC). This article aims to explore the meaning and implications of person-centredness in EOLC policy discourses.

Methods

By perceiving policy documents as a medium embodied with socio-political and cultural norms, we analysed how PCA in EOLC is constructed within specific socio-cultural contexts and the implications of these contexts on resultant care. Focusing on England and Japan, we conducted a critical policy analysis to examine and compare key policy and legal documents released between 2000 and 2019 in these two post-industrial and socio-culturally distinctive countries.

Results

Our analysis found that the PCA is mobilised in policy discourses primarily through three interconnected dimensions: individual, relational and existential. While acknowledging that both countries have developed varied policy and legal mechanisms to emphasise holistic and integrated care with respect to these three dimensions, we also identified significant gaps in the pol icies both within and between England and Japan. They include ambiguity in defining patients’ best interests, fragmented support for social and family care and the neglect of existential needs.

Conclusions

This cross-cultural analysis has revealed the complex nature of discourses around PCA in English and Japanese EOLC policies, which often concentrate on the multifaceted aspects of experiences as one approaches the end of life. Despite this, we argue that a more holistic construction of PCA is needed in EOLC policies not only in England and Japan but also more broadly, to encapsulate the richness of end-of-life experiences.

Healthcare Professionals' Perceptions of Loneliness amongst Older Adults: A Qualitative Study

BACKGROUND

Loneliness amongst older adults is linked to poor health outcomes and constitutes a public health issue worldwide. Healthcare professionals' perceptions could influence the strategies they implement in order to prevent, detect and manage loneliness amongst older adults. The aim of this study was to describe and understand healthcare professionals' perceptions of loneliness amongst older adults.

METHODS

A descriptive qualitative study. Twenty-six Spanish healthcare professionals with experience caring for older adults participated in the study. Data were collected between November 2019 and September 2020 using focus groups and in-depth interviews. Data were analysed following a content analysis method using ATLAS.ti software.

RESULTS

Healthcare professionals' perceptions of loneliness amongst older adults is represented by three themes: (1) "when one's personal life and social context lead to loneliness"; (2) "from abandonment to personal growth: the two faces of loneliness"; and (3) "loneliness as a health issue that needs to be addressed".

CONCLUSIONS

Healthcare professionals perceive loneliness as a multifactorial, subjective experience that can trigger different coping mechanisms and negatively affect older people's health. Healthcare professionals consider that a greater involvement of the whole society is needed in order to fight loneliness amongst older adults as a public health issue.

A Conceptual Review of Loneliness in Adults: Qualitative Evidence Synthesis

The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness.

A gradual separation from the world: a qualitative exploration of existential loneliness in old age

This study sought to explore qualitatively experiences of existential loneliness (EL) in 80 older people living in retirement communities across the United Kingdom and Australia. Qualitative semi-structured interviews permitted in-depth exploration of issues such as biographical narrative, close relationships, loss, feelings of loneliness and retirement living. It was our intention to conduct a large-scale, deep-listening exercise that would provide further clues about EL in older people and the circumstances that give rise to such feelings. Data provided rich insight into older people's inner lives. Core themes identified loss of close attachments, lack of physical touch and intimacy, deterioration of health and body, and lack of an emotional language through which to express EL as central to older people's experiences. Furthermore, there was a suggestion that the move to retirement living was for many people inextricably connected to their experience of EL. Our data further support and extend the notion that EL can be thought of as a gradual sense of separation from the world and that ageing intensifies a myriad of social, emotional and physical circumstances that prompt its emergence. This sense of existential isolation need not be thought of as exclusive to those experiencing extreme frailty or who face death imminently – our data pointed to a clear and gradual emergence of EL throughout later life.

Empowering communities with health promotion labs: result from a CBPR programme in Malmö, Sweden

Health promotion is thus not only a participatory practice, but a practice for empowerment and social justice. The study describes findings from a community-based participatory and challenge-driven research program. that aimed to improve health through health promotion platform in an ethnically diverse low-income neighbourhood of Malmö, Sweden. Local residents together with lay health promoters living in the area were actively involved in the planning phase and decided on the structure and content of the program. Academic, public sector and commercial actors were involved, as well as NGOs and residents. Empowerment was used as a lens to analyse focus group interviews with participants (n=322) in six co-creative health-promoting labs on three occasions in the period 2017-2019. The CBPR interview guide focused on the dimensions of participation, collaboration and experience of the activities. The CBPR approach driven by community member contributed to empowerment processes within the health promotion labs: Health promotors building trust in social places for integration, Participants motivate each other by social support and Participants acting for community health in wider circle. CBPR Health promotion program should be followed up longitudielly with community participants to be able to see the processes of change and empowerment on the community level.

Quality of Care in a Nursing Home as Experienced by Patients with Dementia

Background

Dementia care is one of the most rapidly growing areas in health care. Despite this, relatively little is known about the experiences of persons with dementia in relation to quality of care.

Objective

The aim of this study was to describe how persons with dementia in nursing homes experience the quality of care.

Design

A cross-sectional design was used.

Setting and Participants

The study was conducted in a nursing home in Norway. A total of 33 persons with dementia participated.

Results

Respondents’ mean age was 86.7 years. More than 80% reported their health as bad/neither good nor bad. Concerning their satisfaction with staying in the nursing home, two in ten were satisfied. Nearly half answered that they received or sometimes received good help and support when anxious. More than 50% reported that they only sometimes received or never received good help and support when they felt lonely. The majority perceived that the nurses came/or sometimes came when needed (79%) and that the nurses had time/sometimes had time to talk with them (73%).

Conclusion

This study reveals that the voice of persons with dementia must be listened to, in order to increase the quality of care in nursing homes. The challenge concerning how living in nursing homes can be more satisfying must be addressed by leaders and nurses in nursing homes, as well as researchers. Special attention must be paid to anxiety, loneliness, and going outdoors.

Dying alone and lonely dying: Media discourse and pandemic conditions

BACKGROUND AND OBJECTIVES

This paper explores current concerns and practice related to older people dying alone in Intensive Care Units, care homes, and at home through media discussions during the Covid-19 pandemic and before. It addresses the historically-situated concept of a good death and a bad death and suggests why dying alone, whether completely alone or without significant others physically present, may be considered a bad death.

METHODS

As evidence for collective fears about dying alone, we explored the treatment of these deaths in media using headline examples from the US New York Times and the English Guardian newspaper from the 19th century through Sept. 2020.

RESULTS

A search of the New York Times located 39 articles with either lonely dying or lonely death in the headline. The Guardian had 25 articles with use of the term, but unlike the New York Times, no obituaries were included. Although the deaths profiled were deemed unusual, deaths by suicide were only minimally classed as dying alone. The condition of dying alone is represented as a stigmatised death. Themes addressed: 1) dying alone is a nonnormative event; 2) this death matters; and 3) where people die alone, societies should honour the death and learn from it.

DISCUSSION AND IMPLICATIONS

Contemporary dying involves conditions for which we are unprepared as a society. We seldom address our civic obligations to each other. Few people have discussed their wishes about their preferences in dying and whether and how they want to be accompanied at their death, if possible. This is an invisible constraint of modern healthcare. Because of limited discussions and preparation, these deaths may lead to disenfranchised grief for the mourners. Cultural and societal responses to lonely dying are important in easing the emotional burden of dying alone, helping individuals prepare for this possibility and better integrating death with the life course. Recommendations include inclusion of accompaniment/nonaccompaniment at death as part of advance care planning and mitigation if this condition occurs. It is essential for individuals to find their own still point of acceptance within competing societal narratives of privileging the self in dying alone and the value of social connection.

Overcoming existential loneliness: a cross-cultural study

BACKGROUND

Moving into a long-term care facility (LTCF) can reduce the ability for older adults to engage in meaningful roles and activities and the size of their social network. These changes and losses can lead them to experience existential loneliness (EL)-the intolerable emptiness and lack of meaningful existence resulted from the losses they have experienced. While EL has often been understood as a universal human experience, it has primarily been studied in people from Western cultures; little is known about how EL may be experienced by and manifested in people from Eastern cultures. Hence, this qualitative study aimed to describe the experience and coping of EL in Hong Kong Chinese and Swedish older adults living in LTCFs.

METHODS

A qualitative study using Thorne's (2004) interpretive description was conducted. Thirteen Chinese and 9 Swedes living in LTCFs in Hong Kong, China and Malmo, Sweden, respectively were interviewed about their experience of EL in two series of semi-structured interviews. Data were analyzed using thematic analysis.

RESULTS

The core theme of "overcoming EL" described the participants' experience of EL, which came about through the combined process of "Feeling EL" and "Self-Regulating". Both Chinese and Swedish participants had similar experience with EL. Realizing that they did not want to living with EL anymore, they coped by reframing their experience and identifying new meaning in their life.

CONCLUSIONS

The study findings suggested that early and clear counselling support that help older adults to define new meaning in life may help them cope. In addition, more opportunities should be available at the LTCFs to promote quality relationships, enable older adults to reflect on their lives with pride, and support their ability to do the things they enjoy.

Spouses' existential loneliness when caring for a frail partner late in life - a hermeneutical approach

Purpose: Spouses are in a vulnerable situation when caring for a frail partner late in life. Exploring their existential loneliness can be a way to understand more about their existential needs.

Method: A hermeneutic approach was used. Multistage focus group interviews were conducted with two groups consisting of five spouses, respectively, who met three times each. To work with the text, an approach was adapted where quotations are converted into poems in a linguistic manner.

Results: Existential loneliness can be understood as the following: 1) being in a transition from us to merely me, 2) being forced to make decisions and feeling excluded, 3) navigating in an unfamiliar situation and questioning oneself, and 4) longing for togetherness but lacking the energy to encounter other people. The main interpretation is that existential loneliness emerges when one is in moments of inner struggle, when one is forced to make impossible choices, when one is approaching and is in limit situations, and when one is experiencing the endless loss of the other.

Conclusion: For health care professionals to achieve a holistic picture, person-centeredness can be a way to make the spouses’ existential needs visible and to provide support based on their needs.

Exploring Existential Loneliness Among Frail Older People as a Basis for an Intervention: Protocol for the Development Phase of the LONE Study

BACKGROUND

International research concerning end-of-life issues emphasizes the importance of health care professionals (HCPs) being prepared to deal with existential aspects, like loneliness, in order to provide adequate care. The last phase of life is often related to losses of different kinds, which might trigger feelings of isolation in general and existential loneliness (EL) in particular. There is a large body of research concerning loneliness among older people in general, but little is known about the phenomenon and concept of EL in old age.

OBJECTIVE

This study aims to describe the framing, design, and first results of the exploratory phase of an intervention study focusing on EL among older people: the LONE study. This stage of the study corresponds to the development phase, according to the Medical Research Council framework for designing complex interventions.

METHODS

The LONE study contains both theoretical and empirical studies concerning: (1) identifying the evidence base; (2) identifying and developing theory through individual and focus group interviews with frail older people, significant others, and HCPs; and (3) modeling process and outcomes for the intervention. This project involves sensitive issues that must be carefully reviewed. The topic in itself concerns a sensitive matter and the study group is vulnerable, therefore, an ethical consciousness will be applied throughout the project.

RESULTS

The results so far show that EL means being disconnected from life and implies a feeling of being fundamentally separated from others and the world, whether or not one has family, friends, or other close acquaintances. Although significant others highlighted things such as lack of activities, not participating in a social environment, and giving up on life as aspects of EL, the older people themselves highlighted a sense of meaningless waiting, a longing for a deeper connectedness, and restricted freedom as their origins of EL. The views of HCPs on the origin of EL, the place of care, and their own role differed between contexts.

CONCLUSIONS

The studies focusing on identifying the evidence base and developing theory are published. These results will now be used to identify potential intervention components, barriers, and enablers for the implementation of an intervention aimed at supporting HCPs in encountering EL among older people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/13607.

"Homeless in life" - loneliness experienced as existential suffering by older adults living at home: a caring science perspective

BACKGROUND

Due to physical impairments and functional limitations, older adults receiving home care can be considered especially vulnerable to loneliness. To understand how society can provide support that enhances vulnerable individuals' quality of life, it is important to explore loneliness and its underlying causes in older adults.

AIMS

To contribute to a deeper understanding of caring science theory, the aim of this study was to use a caring science perspective to explore and understand experiences of suffering from loneliness in older adults receiving home care. The research questions are as follows: What phenomena are associated with the experience of suffering from loneliness in older adults receiving home care? How can this experience be understood?

METHODOLOGY

A hermeneutical approach was used. The material was collected through interviews with 17 older adults about their quality of life, including their experiences of loneliness. The texts were interpreted through latent content analysis.

FINDINGS

The findings resulted in one main category and three subcategories. The main category was as follows: Being homeless in life-loneliness expressed and primarily stemming from existential suffering. The subcategories were as follows: Loss of communion with one's partner or other loved ones, Loss of meaningful social activities due to isolation and Loss of health due to frailty and vulnerability. All categories were described and implications for practice discussed.

CONCLUSION

This study contributes to an understanding of experiences of suffering from loneliness in older adults receiving home care, with relevance for the healthcare context as well as for what a community or society should focus on when addressing these important issues.