Loneliness and Social Isolation among the Elderly: Are We Doing Enough?

One of the most prominent policy actions taken by the United Nations in recent years was to declare and bring out a related document, namely, the Decade of Healthy Aging 2021–2030, which includes four interconnected action areas for safeguarding the health and well-being of older people, their families, and their communities: (i) change how we think, feel, and act toward age and aging; (ii) ensure that communities foster the abilities of older people; (iii) deliver integrated care and primary health services tailored to older people; and (iv) ensure access to long-term care for older people.^[1]

Before proceeding further, it is important to mention and discuss briefly the reasons for focusing our editorial on the concepts of “loneliness” and “social isolation” in the elderly in the Indian context.

Although most developed countries such as the USA, many parts of Europe, and Japan have a significantly larger aging population compared with countries like India, as recently as December 2020, under 7% of Indians were aged 65 years and over.^[2] However, if we go by the cutoff age of 60 years, then nearly 9% of the population has crossed this mark in the 2011 census,^[3] which by the UN standards make India as an “aging nation.” This figure is expected to rise in a decade’s time when it is projected that adults aged 60 years and over will constitute over 13% of the population in India by 2031, and by 2050, the figure will be of over 500 million adults.^[2] Hence, this exponential growth of the elderly is of considerable concern and for which services need to gear up to, including mental health services.

In addition, in this rapidly industrializing and technologically advancing world, where globalization is spreading its tentacles far and wide, migration is a common enough phenomena nowadays. The current and most recent/previous generation migrating from rural to urban, from town to city, from India to abroad (i.e. international), etc., is a common, if not a routine, phenomena nowadays.^[1] This has led onto the fragmentation of the traditional family system, which was considered a bedrock of the Indian culture with its own strengths; details of which are discussed elsewhere.^[4,5] Furthermore, despite the persistence of traditional family structures and cultural norms that favor multigenerational households, a slow shift is occurring toward smaller families and different types of household, including living alone – as an elderly couple or by self.^[1] Due to this, “social isolation” and “loneliness” have become even more relevant concepts to be examined and addressed.

To briefly recapitulate, loneliness is a subjective feeling that one is lacking the social connections that are needed. It makes the person feel that one is abandoned or cut off from the people with whom they belong to despite having them around; the feeling of closeness, trust, and genuine affection is missing. Social isolation, on the other hand, is an objective physical state of being alone and out of touch with other people. This can lead to “loneliness” as one is more likely to feel lonely if one rarely interacts with others.^[6] However, there is only a weak correlation between these two concepts; socially isolated people are not necessarily lonely and vice versa.^[1]

It may be pertinent to mention that the document (the Decade of Healthy Aging 2021–2030) came out in 2021, in which the impact of the COVID-19 pandemic was felt to a significant extent on the mental health of people across the world, especially the elderly. The salience and significance of the terms “social isolation,” “loneliness,” “solitude,” etc., not only came into prominence, but their relevance and impact on mental health, especially of the elderly, were reestablished and reunderstood.^[1,6] The old age saying that “ man is a social animal” came back to the fore.

Nevertheless, even in the prepandemic period, there has been considerable research on the association and effect of both “loneliness” and “social isolation” in the elderly. High rates ranging from 20% to 34% of “loneliness” have been reported from across the world (USA, Europe, Latin America, and China); India is surprisingly not lagging behind, with prevalence varying from 18% to 44%.^[1] On the other hand, the prevalence of “social isolation” has also been comparable, ranging from 10% to 43% (USA, North America); India has a prevalence of 20%.^[1]

More specific India-based studies are also available: a prepandemic population-based survey (BKPAI survey) among the elderly reported social isolation in 19.3% and psychological distress in 23.4% of those surveyed.^[7] In the first wave (2017–2018) of the Longitudinal Aging Study in India study, 20.5% of adults aged 45 years and over reported moderate loneliness, while 13.3% reported severe loneliness.^[8] Nearly 1/5^th of the 1001 elderly participants (adults aged over 65 years) from the 10/66 Dementia Research Group reported feeling lonely.^[9]

There is ample evidence that demonstrates that both “loneliness” and “social isolation” are linked with increased physical morbidity (stroke and cardiovascular disease) and increased psychological morbidity (cognitive decline, dementia, depression, anxiety, and suicidal ideation) and mortality (suicide) with a lowered quality of life.^[1,6]

Hence, there is an urgent need for the management and intervention regarding “loneliness” and “social isolation” being experienced by the elderly. A PubMed search between 1985 and 2023 with key words “Loneliness” (all fields) AND “India” (all fields) generated 164 results, with only one study focusing on mediation for loneliness: A plethora of studies exploring the antecedents and consequences of loneliness among elderly are available with scanty research on interventions.

The WHO has advocated reduction of physical and psychological morbidity through face-to-face or digital interventions (cognitive behavior therapy, social skills training, and befriending), improvement of infrastructure (e.g. transport, digital inclusion, and built environment) and promoting age-friendly communities, and through laws and policies to address; for instance, agism, inequality, and the digital divide. They have advocated that a specific strategy for reducing social isolation and loneliness among the elderly should aim to (a) implement and scale up elective interventions to reduce social isolation and loneliness; (b) improve research and strengthen the evidence regarding what works; and (c) create a global coalition to increase the political priority of social isolation and loneliness among older people.^[1]

Keeping in view the high prevalence of both “social isolation” and “loneliness” in the elderly, well-thought-out interventions on the model as proposed by the WHO need to be developed, with the delivery being based as per the practical issues in a country like ours. Philip et al.^[3] have proposed a bottom-up approach, wherein community care, that is, primary care, forms the foundation and basis for addressing this aspect. This has been done as the largest care resource still currently remains the family/spouse, the informal caregivers, and “scaling up” of services with (re) establishment of social links/networks being the easiest at the community levels.^[3] As we discuss this, NIMHANS, Bengaluru, has taken up this initiative in providing e-training to 10,000 nonspecialized health-care workers and community caregivers for the identification of mental health issues and management of loneliness of the elderly in the community.^[10]

Although the well-being of senior citizens is mandated in the Constitution of India under Article 41, it is interesting to note that primary care is practically nonexistent, and even specialized care is inadequate.^[3] The readers are advised to read a recent review outlining and critically discussing the training and policy needs for providing geriatric care.^[3]

It is imperative that the government makes “care of the elderly” as its focus, especially as we seem to be sitting on a potential epidemic. Addressing the basic issues of “social isolation” and “loneliness” will be a step in the right direction. In some countries, till recently, these were neglected social determinants of health and had started becoming pressing public and policy health issues.^[1] The United Kingdom and Japan appointed a “loneliness minister” while the USA brought out a consensus report to address these concerns.^[1] The Indian Government and Policy Makers can take a leaf out of their book! Even the national associations (IAGMH, IPS, and IASP) can do their own bit in a concerted and probably focused (if not a joint) effort.

After all, one may prefer “solitude,” but no one voluntarily chooses “loneliness” and/or “social isolation:” the silent killers which our elderly have to face! As social psychiatrists, we should be contributing toward effectively managing these silent killers!