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ABSTRACT
Objective: to explore the association between
loneliness and affective, cognitive, physical
and social factors for older persons in home care.
Design: descriptive cross sectional study.
Setting: random sample of home care clients
in Reykjavik area.
Subjects: 257 individuals were assessed
with the Minimum Data Set for Home Care (InterRAI-
HC) instrument.
Results: 20.3% of home care clients expressed
loneliness, 18.3% of men and 20.9% of women with
widowed persons being more likely to be lonely
than married persons, p=0.013, as were they who
assessed their health as being poor, p=0.042 .
Women with cognitive impairment were more likely
to be lonely, p=0.022 and they were more likely
to have depressive symptoms, p=0.025. Women who
took more than six medications were more likely
to be lonely (79.2% vs. 20.8%, p=0.018). Lonely
women took more neuroleptics (p=0.007) but lonely
males more hypnotics (p=0.046). Lonely women agreed
more with the statement that they would be better
of elsewhere (43.5% vs. 12.7%, p<0.0001). Being
mostly indoors was not associated with loneliness
and there was no association with use of formal
care services.
Conclusion: Loneliness was identified in
one fifth of persons in home care, more often
among widowed persons and women with cognitive
impairment and among those who assessed their
health as being poor. Sex difference was seen
with regards to affective symptoms and medication
use. Further studies are needed to understand
how the needs of lonely persons in home care can
be best met.
Key
words: loneliness, home care, elderly, primary,
health care
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INTRODUCTION
Older persons should be
able to stay at home as long as possible according to
policy statements on care of older persons and should
be offered places in a nursing home when needs are greater
than available support at home (1). Studies show that
people do well in nursing home setting when needs of
the individual are met. The opposite is true when the
wish of the individual is to stay at home rather than
in an institution (2). Because of this it is important
to explore both affective and somatic wellbeing of sick
older people living at home and assess if their needs
are being met and if not, whether wellbeing can be improved
by modifying the service.
A study on health, nursing
needs and quality of life of older people who got home
care from the Primary Health Service in 1997 showed
that 18% of the individuals had never been out of the
house for the last 30 days previous to the examination
and 24% had only been out of the house once during the
week. Only 18% had gone out of the house daily. This
study showed also that 21% of the individuals experienced
loneliness, 18% were bored and 19% showed a depressed
look. Being alone is prevalent, which is clear from
the fact that 27% were alone the whole day, but 39%
more than half the day(3). We cannot find any Icelandic
studies on loneliness in Icelandic professional papers.
Foreign studies show that being alone and loneliness
are associated with reduced quality of life (6). The
purpose of this paper is to explore more closely the
connection between loneliness and affective, somatic
and social aspects of older people in home care.
MATERIALS AND METHODS
This article is
further analysis of material that was published on health,
nursing needs and quality of life of older people who
got services from the Primary Health Service in 1997(3).
The purpose of this study was
to document health and nursing care needs of people
65 years of age and older who use the Primary Health
Service in the autumn of 1997 at primary health care
centers in Fossvogur, Hlíðasvæði,
Miðbær and Seltjarnarnes with the InterRAI
MDS-HC assessment(4).
The term Primary Home Health
Service refers to services from the primary health care
service in people's homes, provided by nurses, nurse's
assistants and doctors. The study includes all persons
in home care service at these primary health care centers
when the study started on September 1st 1997, altogether
347 persons. Participation rate was 75%. 52 refused
participating, 24 were in hospital, two had entered
a Nursing Home, three declined or were absent when the
study was to take place and nine died before they were
assessed. Altogether 257 individuals participated in
the study, 31 from primary health care center A, 68
from center B, 64 from center C and 94 from center D.
Informed consent was obtained
from the older persons but for those who could not consent
it was obtained from nearest relatives. Information
was obtained by talking to the individual him- or herself,
from medical records, from people delivering services
or from relatives. The study was approved by the Ethical
and Data Protection Committees in Iceland. Information
was transferred from a social security number to a research
number that was then used in analysis.
A nurse from the respective
primary health care centers collected information. Before
data collection started, everyone who collected information
had a one day course in the use of the InterRAI MDS-HC
instrument and was taught how to assess each and every
variable according to definitions, and a manual which
guides the assessment. Each assessment took between
one and one and a half hours.
Univariate analysis of the variables
in the MDS-HC assessment was done with respect to loneliness.
Variables that were significantly associated with loneliness
in that analysis were then put in to multi-variant analysis
to find independent associations with loneliness. Significance
level was P <0.05. SPSS statistical package
(version 11) was used for data analysis.
RESULTS
Of the total group who
got home health service, 20.3% experienced loneliness,
18.3% of men and 20.9% of women. Key information is
shown in Table 1. Widows and widowers were significantly
more likely to be lonely than people in marriage, p=0.013.
Table 2 shows functional, cognitive and affective well
being with respect to loneliness. Persons with cognitive
impairment were significantly more likely to be lonely,
p=0.022. Women with loneliness were also more likely
to have associated depressive symptoms, p=0.025, but
such an association was not seen with men. Women with
more than six medications were significantly more likely
to be lonely (79.2% vs. 20.8%, p=0.018). Lonely women
were more likely to take neuroleptic medications (p=0.007)
but lonely men more likely to take hypnotics (p=0.046).
Of 48 lonely women, 60.4% assessed their own health
as being poor compared to 44.5% of those who were not
lonely, which was close to being significant, p=0.053.
Similar numbers for 11 lonely men were 54.5% vs. 38.8%
which is not a significant difference. The difference
is significant for the total group, p=0.042, and points
in the same direction for both sexes. There was no association
between getting out doors and being lonely. Thus those
who even never went out of the house for a month were
not more likely to be lonely. The number of hours from
formal services was no different with respect to loneliness.
For the variable "better off elsewhere", 43.5%
of women with loneliness were in that group, compared
to 12.7% of women without loneliness, p<0.0001. Similar
numbers for males were not significant, 18.2% vs. 14.3%.
|
Loneliness |
Without Loneliness |
| Sex |
|
|
| Total group |
59(20,3%) |
231(79,7%) |
| Female |
48(20,9%) |
182(79,1%) |
| Male |
11(18,3%) |
49(81,7%) |
| Age |
|
|
| No sex difference |
83,4(*6,3) |
82,7(*6,5) |
| Female |
83,6(*6,2) |
82,6(*6,2) |
| Male |
82,6(*6,8) |
83,1(*7,6) |
| Marital status |
|
|
| Male |
|
|
| Married |
2(6,9%) |
27(93,1%) |
| Widower |
5(27,8%) |
13(72,2%) |
| Divorced |
3 |
3 |
| Unmarried |
4 |
6 |
| Female |
|
|
| Married |
5(11,6%) |
38(88,4%) |
| Widow |
37(26,4%) |
103(73,6%) |
| Divorced |
3 |
7 |
| Unmarried |
3 |
33 |
* Standard deviation
No difference between sexes p=0,786
No difference between ages with respect to loneliness
p=0,48
No difference between sexes with respect to loneliness,
but widowed persons were significantly more likely to
be lonely than married p=0,013 Mantel Haenszel
Table1: Demographic factors
|
Loneliness |
Without Loneliness |
| IADL |
|
|
| Total group |
|
|
| Adjusted for sex and age |
10,4 |
9,8 |
| No difference between the total group
p=0.441 |
|
|
| male |
11,0 (*,7) |
|
| female |
9,3(*,4) |
|
| ADL |
|
|
| Total group |
|
|
| Self reliant ADL 270 |
|
|
| Help with ADL 27 |
|
|
| Male without ADL dysfunction |
9(81,8%) |
40(81,6%) |
| Male with ADL dysfunction |
2(18,2%) |
9(18,4%) |
| Female without ADL dysfunction |
43(89,6%) |
171(94,0%) |
| Female with ADL dysfunction |
5(10,4%) |
11(6,0%) |
| CPS |
|
|
| Total group |
|
|
| Without cognitive impairment 166 (55.9%) |
|
|
| Cognitive impairment 130 (44.1%) |
|
|
| (no information about 1) |
|
|
| |
|
|
| Males without cognitive impairment |
8(72,7%) |
24(50,0%) |
| Males with cognitive impairment |
3(27,3%) |
24(50,0%) |
| Females without cognitive impairment |
29(41,7%) |
110(60,4%) |
| Females with cognitive impairment |
28(58,3%) |
72(39,6%) |
| Depression Rating Scale: |
|
|
| Males without depressive symptoms |
6(54,5%) |
34(69,4%) |
| Males with depressive symptoms |
5(45,5%) |
15(30,6%) |
| Females without depressive symptoms |
18(37,5%) |
133(73,1%) |
| Females with depressive symptoms |
30(62,5%) |
49(26,9%) |
* Standard deviation. IADL=instrumental activities of
living, ADL=Activities of Daily Living, CPS=Cognitive
performance scale
Significant difference
between sexes p=0,024
No significance between sexes with respect to ADL dysfunction
and loneliness p=0.337
Females with cognitive impairment were more likely to
be lonely p=0,022
Females (but not males) who were lonely were more likely
to have depressive symptoms p=0.025
Table 2: Functional
and affective well being
DISCUSSION
One out of five
persons in home nursing care experiences the feeling
of loneliness. Similar to other studies, widowers and
widows are significantly more likely to be lonely than
married people and so are women with cognitive impairment
(6). Lonely women are more likely to express symptoms
of depression, take more than six medications, assess
their health as being poor and feel that they would
be better placed elsewhere than at home. The clinical
picture of the lonely women is much clearer than for
men. Lonely men are less functional in instrumental
activities of daily living and take more sleeping medications
but don't show other characteristics. Other studies
have shown strong association between age and loneliness
which was not seen in this study but in fact everyone
was already old and of similar age. Conflicting information
about association with sex is seen in studies but the
current study did not show difference between sexes.
Health related factors that are significantly associated
with loneliness in more than one study include somatic
functional loss, poor health assessed by the individual,
depression, anxiety, sensory loss and cognitive impairment(6).
Lonely people took more sleeping and anxiolytic medications(9)
and are inclined to abuse alcohol(10). Apart from anxiety
and sensory loss we identified these same factors. Our
study did not look at alcohol abuse specifically. The
results of this study are supported by almost the same
prevalence of loneliness found in the ADOCH study 28,
18.4% compared to 20.3%.
The concepts of loneliness,
social isolation and living alone are often used inter-
changeably. They are specific concepts but associated
and it is important to distinguish loneliness from other
related concepts as loneliness seems to have independent
prognostic power(11, 12). Depression is also closely
related to loneliness. Individuals may suffer from loneliness
even if they are among other people and an isolated
person can on the other hand be satisfied with his or
her position and feel well (6). Living alone is a simple
concept and easy to assess and social isolation can
be defined from number of interactions and from integration
of the person into his or her community. The diagnosis
of depression is based on diagnostic criteria. Loneliness
is on the other hand a subjective feeling and the degree
of loneliness can only be described by the one who experiences
it.
A Swedish study shows that one
third of people 75 years of age and older experienced
loneliness at least sometimes (13, 14). Another study
from Finland showed that 36% of people older than 60
years of age experienced loneliness often or sometimes(15).
Thus prevalence of loneliness among those who have home
health service is not that different from people without
such a service. Those who have Home Health Service are
often with impaired mobility in addition to loneliness
and do not have the same opportunities to get out as
others. That may increase the seriousness of loneliness.
Loneliness predicts reduced
survival (11, 16, 17), and increase likelihood of permanent
Nursing Home placement (11, 12). A study from Iowa,
USA, looked at 3,000 individuals and followed them for
four years(7). Loneliness increased significantly the
likelihood of Nursing Home placement and this association
held when corrected for age, education, income, cognitive
and physical function and social network which are factors
that also link to the risk of permanent Nursing Home
placement(7). Are there any studies that look at interventions
towards lonely older people? Can we avert or improve
loneliness? Few studies have assessed this question
among older people (18). One small US randomized study
assessed phone support but did not demonstrate benefit
(19). Few studies have had control groups and have been
unable to show benefit for various interventions such
as regular phone calls (20, 21), group therapy (22),
pet treatment (23, 24, 25) and bereavement therapy.
It is likely that individualized interventions are needed
where the persons themselves are given the possibility
of choosing an intervention(27). Interventions should
rather be directed towards strengthening good networks
that people may already have rather than to try to establish
new contacts. The quality of network and communication
matters more than frequency or intensity, and what matters
is that people have others to confide in and can feel
close to as a human being(8).
It is the strength of this study
to use an international reliable assessment tool which
links to various variables that could be associated
with loneliness and the study group is characteristic
of the primary home health service in Reykjavik. Weakness
of the study is that the study group is only moderately
large which reduces a bit the likelihood of finding
potential association between loneliness and some of
the factors that others have shown.
To conclude, loneliness
is a significant and prevalent issue among those who
get assistance from the primary health service in Reykjavík.
If loneliness persists then it is linked to increased
likelihood of depression (6) and if it is deep then
it is a strong risk factor for permanent Nursing Home
placement (10, 11). It is thus in accordance with policy
making on matters relating to older people to try to
find ways to deal with this issue but with as good quality
of life and the approach should be personalized. Studies
are needed to evaluate the value of day care and respite
care in relieving loneliness. Finally, studies are needed
to explore the potential mitigating effect of permanent
placement on loneliness. If that would be the case,
then the policy to support people at home would have
to take that information into account.
ACKNOWLEDGEMENT
Special thanks for
the access to the research material to
Hlíf Guðmundsdóttir, Fanney Friðbjörnsdóttir,
Maríanna Haraldsdóttir, Þórunn
Ólafsdóttir, Anna Birna Jensdóttir,
Ingibjörg Hjaltadóttir, Ómar Harðarson
og Hrafn Pálsson.
This study was supported by Primary Health Care, VASS
and the Icelandic Gerontological Research center.
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