Why Loneliness Interventions Are Unsuccessful: A Call for Precision Health

Determinants of social loneliness among older adults in job retirement and the role of emotional expressivity

OBJECTIVES

The study examined the possibility that a mediating role of positive and negative emotional expressivity may contribute to understanding the associations between social loneliness and its previously identified predictors (i.e. health, age, sex, and social living situation).

METHOD

Self-reported assessments were collected from community-dwelling Swedish residents (aged 65 and above) in job retirement. Structural equation modeling with manifest variables was applied to cross-sectional data (N = 601) to analyze two competing models; one main-effect regression model, examining the predictive effect of emotional expressivity (along with health and sociodemographics) on social loneliness, and one mediation model, examining the mediating effect of emotional expressivity (using the bootstrapping technique provided in Mplus).

RESULTS

The results indicated that the mediation model fit the data considerably better than the main-effect regression model (Δχ2 [Δdf = 8] = 72.69, p < 0.00001), and demonstrated a good fit on its own, with CFI = 0.986 and RMSEA = 0.030. This suggests that emotional expressivity contributes to the understanding of the connection between social loneliness and its previously identified predictors.

CONCLUSION

Recognizing the significance of emotional expressivity has the potential to enhance our understanding of loneliness in older adults, both in theory and in practice.

Efficacy of relational agents for loneliness across age groups: a systematic review and meta-analysis

BACKGROUND

Loneliness is a serious public health concern. Although previous interventions have had some success in mitigating loneliness, the field is in search of novel, more effective, and more scalable solutions. Here, we focus on "relational agents", a form of software agents that are increasingly powered by artificial intelligence and large language models (LLMs). We report on a systematic review and meta-analysis to investigate the impact of relational agents on loneliness across age groups.

METHODS

In this systematic review and meta-analysis, we searched 11 databases including Ovid MEDLINE and Embase from inception to Sep 16, 2022. We included randomised controlled trials and non-randomised studies of interventions published in English across all age groups. These loneliness interventions, typically attempt to improve social skills, social support, social interaction, and maladaptive cognitions. Peer-reviewed journal articles, books, book chapters, Master's and PhD theses, or conference papers were eligible for inclusion. Two reviewers independently screened studies, extracted data, and assessed risk of bias via the RoB 2 and ROBINS-I tools. We calculated pooled estimates of Hedge's g in a random-effects meta-analysis and conducted sensitivity and sub-group analyses. We evaluated publication bias via funnel plots, Egger's test, and a trim-and-fill algorithm.

FINDINGS

Our search identified 3,935 records of which 14 met eligibility criteria and were included in our meta-analysis. Included studies comprised 286 participants with individual study sample sizes ranging from 4 to 42 participants (x̄ = 20.43, s = 11.58, x̃ = 20). We used a Bonferroni correction with αBonferroni = 0.05 / 4 = 0.0125 and applied Knapp-Hartung adjustments. Relational agents reduced loneliness significantly at an adjusted αBonferroni (g = -0.552; 95% Knapp-Hartung CI, -0.877 to -0.226; P = 0.003), which corresponds to a moderate reduction in loneliness.

CONCLUSION

Our results are currently the most comprehensive of their kind and provide promising evidence for the efficacy of relational agents. Relational agents are a promising technology that can alleviate loneliness in a scalable way and that can be a meaningful complement to other approaches. The advent of LLMs should boost their efficacy, and further research is needed to explore the optimal design and use of relational agents. Future research could also address shortcomings of current results, such as small sample sizes and high risk of bias. Particularly young audiences have been overlooked in past research.

Contributions of loneliness to cognitive impairment and dementia in older adults are independent of other risk factors and Alzheimer's pathology: a narrative review

Loneliness significantly contributes to cognitive impairment and dementia in older adults. Loneliness is a distressing feeling resulting from a perceived lack of social connection (i.e., a discrepancy between desired and actual social relationships), while social isolation is a related term that can be defined by number and type of social relationships. Importantly, loneliness is distinct from social isolation in that it is associated with a distressing self-perception. The primary focus of this narrative review is the impact of chronic loneliness on cognitive impairment and dementia among older adults. Loneliness has a significant association with many factors that are related to worse cognition, and therefore we include discussion on health, mental health, as well as the physiological effects of loneliness, neuropathology, and potential treatments. Loneliness has been shown to be related to development of dementia with a hazard ratio (HR) risk comparable to having a single APOE4 gene. The relationship of dementia to loneliness appears to be at least partially independent of other known dementia risk factors that are possibly associated with loneliness, such as depression, educational status, social isolation, and physical activity. Episodic memory is not consistently impacted by loneliness, which would be more typically impaired if the mild cognitive impairment (MCI) or dementia was due to Alzheimer's disease (AD) pathology. In addition, the several longitudinal studies that included neuropathology showed no evidence for a relationship between loneliness and AD neuropathology. Loneliness may decrease resilience, or produce greater cognitive change associated with the same level of AD neuropathology. Intervention strategies to decrease loneliness in older adults have been developed but need to consider key treatment targets beyond social isolation. Loneliness needs to be assessed in all studies of cognitive decline in elders, since it significantly contributes to the variance of cognitive function. It will be useful to better define the underlying mechanism of loneliness effects on cognition to determine if it is similar to other psychological factors related to excessive stress reactivity, such as neuroticism or even depression, which are also associated with cognitive decline. It is important from a health perspective to develop better strategies to decrease loneliness in older adults.

Personalized medicine in old age psychiatry and Alzheimer's disease

Elderly patients show us unfolded lives with unique individual characteristics. An increasing life span is associated with increasing physical and mental disease burden. Alzheimer's disease (AD) is an increasing challenge in old age. AD cannot be cured but it can be treated. The complexity of old age and AD offer targets for personalized medicine (PM). Targets for stratification of patients, detection of patients at risk for AD or for future targeted therapy are plentiful and can be found in several omic-levels.

Nature-based social interventions to address loneliness among vulnerable populations: a common study protocol for three related randomized controlled trials in Barcelona, Helsinki, and Prague within the RECETAS European project

BACKGROUND

The negative effects of loneliness on population health and wellbeing requires interventions that transcend the medical system and leverage social, cultural, and public health system resources. Group-based social interventions are a potential method to alleviate loneliness. Moreover, nature, as part of our social and health infrastructure, may be an important part of the solutions that are needed to address loneliness. The RECETAS European project H2020 (Re-imagining Environments for Connection and Engagement: Testing Actions for Social Prescribing in Natural Spaces) is an international research project aiming to develop and test the effectiveness of nature-based social interventions to reduce loneliness and increase health-related quality of life.

METHODS

This article describes the three related randomized controlled trials (RCTs) that will be implemented: the RECETAS-BCN Trial in Barcelona (Spain) is targeting people 18+ from low socio-economic urban areas; the RECETAS-PRG Trial in Prague (Czech Republic) is addressing community-dwelling older adults over 60 years of age, and the RECETAS-HLSNK trial is reaching older people in assisted living facilities. Each trial will recruit 316 adults suffering from loneliness at least sometimes and randomize them to nature-based social interventions called "Friends in Nature" or to the control group. "Friends in Nature" uses modifications of the "Circle of Friends" methodology based on group processes of peer support and empowerment but including activities in nature. Participants will be assessed at baseline, at post-intervention (3 months), and at 6- and 12-month follow-up after baseline. Primary outcomes are the health-related quality-of-life according to 15D measure and The De Jong Gierveld 11-item loneliness scale. Secondary outcomes are health and psychosocial variables tailored to the specific target population. Nature exposure will be collected throughout the intervention period. Process evaluation will explore context, implementation, and mechanism of impact. Additionally, health economic evaluations will be performed.

DISCUSSION

The three RECETAS trials will explore the effectiveness of nature-based social interventions among lonely people from various ages, social, economic, and cultural backgrounds. RECETAS meets the growing need of solid evidence for programs addressing loneliness by harnessing the beneficial impact of nature on enhancing wellbeing and social connections.

TRIAL REGISTRATION

Barcelona (Spain) trial: ClinicalTrials.gov, ID: NCT05488496. Registered 29 July 2022. Prague (Czech Republic) trial: ClinicalTrials.gov, ID: NCT05522140. Registered August 25, 2022. Helsinki (Finland) trial: ClinicalTrials.gov, ID: NCT05507684. Registered August 12, 2022.

Use of home and community-based services and loneliness in older people with functional limitations: a cross-sectional study

BACKGROUND

Loneliness is one of the major health problems among older adults. Among this population, home and community-based services (HCBS) have become increasingly popular. Despite its health benefits, little is known about the relationship between HCBS use and loneliness in older people with functional limitations. We aim to explore the characteristics of loneliness among older people with functional limitations and examine the association between HCBS use and loneliness in China.

METHODS

We used a cross-sectional data from the 2018 China Health and Retirement Longitudinal Study, which includes a nationally representative sample of Chinese residents aged 65 and older with functional limitations. Logistic regression models were used to examine the associations between HCBS use and loneliness, and we further used propensity score matching to address potential sample selection bias.

RESULT

In China, 46% of older people with functional limitations felt lonely and only 22% of older people with functional limitations reported using HCBS in 2018. Compared with participants who did not receive HCBS, those who received HCBS were less likely to report loneliness (OR = 0.81, 95% CI = 0.63, 0.99, p = 0.048), and the results remained significant after addressing sample selection bias using propensity score matching.

CONCLUSION

Our results showed that loneliness was common among Chinese older people with functional limitations, and the proportion of HCBS use was low. There was robust evidence to support that among older people with functional limitations, HCBS use was associated with decreased loneliness. Further policies should promote the development of broader HCBS use for older people with functional limitations to reduce their loneliness.

PROTOCOL: In-person interventions to reduce social isolation and loneliness: An evidence and gap map

This is the protocol for an evidence and gap map. The objectives are as follows: This EGM aims to map available evidence on the effects of in-person interventions to reduce social isolation and/or loneliness across all age groups in all settings.

Factors associated with loneliness in immigrant and Canadian-born older adults in Ontario, Canada: a population-based study

BACKGROUND

While loneliness is common in older adults, some immigrant groups are at higher risk. To inform tailored interventions, we identified factors associated with loneliness among immigrant and Canadian-born older adults living in Ontario, Canada.

METHODS

We conducted a cross-sectional analysis of 2008/09 data from the Canadian Community Health Survey (Healthy Aging Cycle) and linked health administrative data for respondents 65 years and older residing in Ontario, Canada. Loneliness was measured using the Three-Item Loneliness Scale, with individuals categorized as 'lonely' if they had an overall score of 4 or greater. For immigrant and Canadian-born older adults, we developed separate multivariable logistic regression models to assess individual, relationship and community-level factors associated with loneliness.

RESULTS

In a sample of 968 immigrant and 1703 Canadian-born older adults, we found a high prevalence of loneliness (30.8% and 34.0%, respectively). Shared correlates of loneliness included low positive social interaction and wanting to participate more in social, recreational or group activities. In older immigrants, unique correlates included: widowhood, poor health (i.e., physical, mental and social well-being), less time in Canada, and lower neighborhood-level ethnic diversity and income. Among Canadian-born older adults, unique correlates were: female sex, poor mental health, weak sense of community belonging and living alone. Older immigrant females, compared to older immigrant males, had greater prevalence (39.1% vs. 21.9%) of loneliness.

CONCLUSIONS

Although both groups had shared correlates of loneliness, community-level factors were more strongly associated with loneliness in immigrants. These findings enhance our understanding of loneliness and can inform policy and practice tailored to immigrants.

Understanding the psychological experiences of loneliness in later life: qualitative protocol to inform technology development

OBJECTIVES

Loneliness is a public health issue impacting the health and well-being of older adults. This protocol focuses on understanding the psychological experiences of loneliness in later life to inform technology development as part of the 'Design for health ageing: a smart system to detect loneliness in older people' (DELONELINESS) study.

METHODS AND ANALYSIS

Data will be collected from semi-structured interviews with up to 60 people over the age of 65 on their experiences of loneliness and preferences for sensor-based technologies. The interviews will be audio-recorded, transcribed and analysed using a thematic codebook approach on NVivo software.

ETHICS AND DISSEMINATION

This study has received ethical approval by Research Ethics Committee's at King's College London (reference number: LRS/DP-21/22-33376) and the University of Sussex (reference number: ER/JH878/1). All participants will be required to provide informed consent. Results will be used to inform technology development within the DELONELINESS study and will be disseminated in peer-reviewed publications and conferences.

Relative Importance of Incivility and Loneliness in Occupational Health Outcomes

Researchers have studied loneliness as a modern health epidemic which is associated with myriad negative health effects, yet the literature lacks evidence of loneliness' correlates, including incivility, in the workplace. This paper not only replicates previous work on incivility, a pervasive interpersonal workplace stressor, it also contributes novel findings on the relative importance of loneliness in explaining variance in occupational health outcomes. We tested hypotheses using two cross-sectional datasets containing data from the general working population (Sample 1) and state corrections supervisors (Sample 2). Through relative importance analyses, including relative weights analysis, we found that both general and workplace loneliness explain substantial variance in several outcomes (e.g., emotional exhaustion, depression symptoms, and turnover intentions) relative to the variance explained by workplace incivility. When controlling for perceived work stress, general loneliness appears to be more important than incivility in explaining variance in emotional exhaustion, job satisfaction, and depression symptoms.

Understanding and Addressing Older Adults' Loneliness: The Social Relationship Expectations Framework

Loneliness is an experience resulting from a perceived discrepancy between expected and actual social relationships. Although this discrepancy is widely considered the "core mechanism" of loneliness, previous research and interventions have not sufficiently addressed what older adults specifically expect from their social relationships. To address this gap and to help situate research on older adults' loneliness within broader life span developmental theories, we propose a theoretical framework that outlines six key social relationship expectations of older adults based on research from psychology, gerontology, and anthropology: availability of social contacts, receiving care and support, intimacy and understanding, enjoyment and shared interests, generativity and contribution, and being respected and valued. We further argue that a complete understanding of loneliness across the life span requires attention to the powerful impacts of contextual factors (e.g., culture, functional limitations, social network changes) on the expression and fulfillment of older adults' universal and age-specific relationship expectations. The proposed Social Relationship Expectations Framework may fruitfully inform future loneliness research and interventions for a heterogeneous aging population.

Head versus heart: social media reveals differential language of loneliness from depression

We study the language differentially associated with loneliness and depression using 3.4-million Facebook posts from 2986 individuals, and uncover the statistical associations of survey-based depression and loneliness with both dictionary-based (Linguistic Inquiry Word Count 2015) and open-vocabulary linguistic features (words, phrases, and topics). Loneliness and depression were found to have highly overlapping language profiles, including sickness, pain, and negative emotions as (cross-sectional) risk factors, and social relationships and activities as protective factors. Compared to depression, the language associated with loneliness reflects a stronger cognitive focus, including more references to cognitive processes (i.e., differentiation and tentative language, thoughts, and the observation of irregularities), and cognitive activities like reading and writing. As might be expected, less lonely users were more likely to reference social relationships (e.g., friends and family, romantic relationships), and use first-person plural pronouns. Our findings suggest that the mechanisms of loneliness include self-oriented cognitive activities (i.e., reading) and an overattention to the interpretation of information in the environment. These data-driven ecological findings suggest interventions for loneliness that target maladaptive social cognitions (e.g., through reframing the perception of social environments), strengthen social relationships, and treat other affective distress (i.e., depression).

Loneliness in Myanmar's older population: A mixed-methods investigation

OBJECTIVES

Little is known about loneliness in lower- and middle-income countries. This study investigates loneliness in the older population of Myanmar using a mixed-methods approach.

METHODS

To identify predictors of loneliness, hierarchical regression models were used to analyze data from the Myanmar Aging Survey 2012 (N = 3,618, 57% women). In a mixed-methods sequential explanatory design, quantitative data were integrated with qualitative data from semi-structured interviews with older adults in Myanmar in 2019.

RESULTS

The prevalence of loneliness varied by between-person characteristics. Health impairments, lower income, being widowed, not having children, and living with fewer household members were each associated with loneliness. Qualitative findings suggested that the physical presence of family members was especially protective against loneliness. Religion had mixed associations with loneliness, depending on the type of religious practice, demographic characteristics, health status, and community engagement.

DISCUSSION

The findings contribute to a better understanding of individuals' experiences of loneliness and may inform the design of interventions to prevent loneliness in Myanmar and globally.

A Psychometric Analysis of the 20-item Revised University of California Los Angeles Loneliness Scale Among Korean Older Adults Living Alone

The current study aimed to explore the factor structure of the Korean version of the Revised University of California Los Angeles loneliness scale for the Korean older adult population. Analyses were based on a cross-sectional cohort of 1,041 community-dwelling older adults (age ≥65 years) living alone in one Korean city. Exploratory factor analysis (EFA) was conducted to determine the underlying structure of the scale, and confirmatory factor analysis (CFA) was used to ascertain the validity of the outcomes. For reliability, Cronbach's alpha was computed. Based on EFA and CFA results, a two-factor structure was found. The first factor reflected "intimate loneliness" and the second "relational loneliness." Derived factors demonstrated satisfactory reliability (>0.8). The two factors of loneliness identified in this study could be considered when attempting to treat loneliness among older adults. Nevertheless, future studies should confirm the findings of this study and evaluate aspects of validity beyond factorial validity to further support the conceptual separation of the two identified factors. [Research in Gerontological Nursing, 14(6), 305-316.].