Loneliness and social isolation are different. Loneliness is the subjective, distressed feeling of being alone or separated while social isolation is the objective, physical separation from other people [1 - see references at the side]. It is possible for a person to be surrounded by others but feel lonely, or to be alone but not feel lonely.
The prevalence of loneliness
Globally, up to 50% of people aged over 60 are at risk of social isolation and approximately one-third will experience loneliness in their later life . There are over one million older people who are chronically lonely in the UK. Older people are often vulnerable to loneliness due to a wide range of factors such as widowhood, deaths of relatives or friends, poor functional status, lower income and retirement. The COVID-19 pandemic has placed them at additional risk as they would miss out on interactions in their communities.
The impact of loneliness on health
Loneliness has significant impacts on physical and mental health. It increases the likelihood of mortality in older people by 26% . Its effect is comparable to other well-established risk factors such as obesity and cigarette smoking. It is associated with an increased risk of developing stroke, hypertension, coronary heart disease, dementia, depression, and suicidal thoughts .
Loneliness is a significant risk factor of malnutrition
Loneliness is a significant risk factor for malnutrition [5,6,7]. A study showed that people over 65 living alone have a significantly lower body mass index compared with those living with their family. Socially isolated older people often experience reduced appetite, eat fewer meals in a day and have a lower intake of protein, fruits, and vegetables in their diet . It could be possibly because they become less motivated to shop, cook and eat. Furthermore, people living alone have fewer social cues to eat.
During the COVID-19 pandemic, older people are at increased risk of loneliness due to self-isolation, social distancing, shielding, and visiting restriction rules in hospital and care homes. Many older people are having their meals in their own rooms rather than in dining rooms. Additionally, food choices in hospital is different from the home environment and restriction of food brought into the hospital and care home by relatives and friends may contribute to poor oral intake in older patients. Community day centres, places of worship, dementia cafes and lunch clubs are temporarily closed as result of the lockdown. Older people staying at home may struggle with shopping and cooking but lack support to overcome these problems.
Tackling malnutrition and loneliness
The consequences of malnutrition can also be devastating. It increases risk of hospital admission, muscle wasting and falls, reduced ability to fight infection and impaired wound healing . Therefore, dietitians play an essential role in carrying out comprehensive nutritional assessment including psychosocial considerations to tailor interventions to suit the needs of the individuals. The Patient Association Malnutrition Checklist helps patients and health and social care staff identify the potential risk of malnutrition in older people. The Campaign to End loneliness has useful resource on how to identify or recognise the most lonely.
There are different ways to increase calories, protein and nutrient density in food and drinks to treat malnutrition. This can include adding 2-4 tablespoons of skimmed milk powder into one pint of full cream milk, adding cream, butter, cheese into mash, soup, and sauces. If food first and nourishing drink approaches fail to meet the goal of care, a trial of nutritional supplements could be trialled with a specific goal and timespan. For more food first ideas, please read BDA Malnutrition Food Fact sheet.
During the COVID-19 crisis, older people may find shopping and preparing meals difficult. Family, friends, or their carer can help them with shopping or ordering food for home delivery. Stocking up on longer-lasting convenience foods such as tinned, dried, and frozen foods can be useful. Please see our basic store cupboard ideas for more details. On the other hand, meals on wheels and other meal delivery services such as Wiltshire Farm Foods, Oakhouse Foods and Parsley box play a vital role in not only alleviating loneliness but also in improving dietary intake and helping prevent malnutrition in older people living alone .
Online technologies could be harnessed to provide social support networks and a sense of belonging. Regular telephone calls, messages, video calls using WhatsApp, Facetime, Facebook, Zoom, or Skype may help older people stay connected by widening their social circle or by increasing the frequency of contact with existing acquaintances. Writing letters, postcards or sending emails are good ways to connect with significant others.
Older people can receive support via contact with close family and friends, voluntary organisations, or health-care professionals. However, there is insufficient evidence to support the effectiveness of video calls for reducing social isolation and loneliness in older people . To create a social eating environment, arrangement of video calls to eat regularly with a friend, or family member could be made. Please visit the Age UK loneliness website for technology support advice and download How to stay connected in older age guide for more insights. The Silver Line offer telephone friendship service and connect older people with local support services, their number is 0800 470 8090.
A simple call can make a big difference in one’s life, have you been ringing your family regularly?
Senior Specialist Dietitian, South Tees Hospitals NHS Foundation Trust
Dove is a Senior Specialist Dietitian at South Tees Hospitals NHS Foundation Trust and PR Officer for the BDA’s Older People’s Specialist Group.