Loneliness in the time of COVID-19: Impact on older adults.

Abstract

Social isolation is defined as the objective state of having few social relationships or infrequent social contact with others, (National Academies of Sciences et al., 2020) while loneliness is a subjective feeling of being isolated (National Academies of Sciences et al., 2020). Loneliness has gained the recognition as a global phenomenon and its impact has worsened with the COVID-19 pandemic. Recently this recognition influenced Japan's appointment of a “Minister of Loneliness” following increasing rates of suicide. Loneliness was also recognized as a national issue in the United Kingdom, where they appointed a “Minister for Loneliness” in 2018. Social isolation and loneliness are serious yet underestimated public health risks that affect a significant portion of the older adult population. In the United States (U.S.), approximately one-quarter of community-dwelling older adults are considered to be socially isolated, and 43% of them report feeling lonely (Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress et al., 2014). Social isolation and loneliness are major risk factors linked to poor physical and mental health status (Wu, 2020). Prior to the COVID-19 pandemic, loneliness and social isolation were acknowledged as public health issues linked to increased risk of morbidity and mortality. The effects of the COVID-19 pandemic have had an increasing negative effect on the number of older adults who are socially isolated and are a high-risk group for both COVID-19 and loneliness. The COVID-19 virus has shown worse outcomes and a higher mortality rate in older adults and those with comorbidities such as hypertension, cardiovascular disease, diabetes, chronic respiratory disease and chronic kidney disease (CKD) (Shahid et al., 2020). A significant percentage of older American adults have these chronic conditions, putting them at a higher risk of infection (Shahid et al., 2020). COVID-19 has also disproportionately affected older adults, including residents in nursing homes or long-term care facilities. Primary prevention especially for older persons with comorbidities is to practice social distancing, which can often translate to social isolation. For older persons, one of the negative outcomes of social isolation is loneliness. Loneliness can lead to depression, cognitive dysfunction, disability, cardiovascular disease and increased mortality rates (Morley & Vellas, 2020). Prior to the COVID-19 pandemic, the vast majority of community-dwelling older adults actively participated in social activities, such as attending senior centres, churches activities, traveling and many other social events. Due to social distancing guidelines, many of these services and programmes are restricted or no longer available. These restrictions would certainly increase social isolation and the feelings of loneliness for older adults. In the context of COVID-19, social isolation may be especially detrimental to family caregivers, given that the majority are older adults themselves and are already at increased risk of stress, anxiety and depression (Wu, 2020). The implementation of restrictions on social interaction have been adapted by nursing homes in many states across the U.S. This has led to the creation of guidelines in light of the increasing confirmed COVID-19 cases to ensure both the safety of nursing home residents and families. Strict outdoor and indoor visitation enforcing 6-feet barriers have been encouraged to reduce the risk of COVID-19 transmission. While there are exceptions that permit close contact, referred to as “compassionate care situations” and end-of-life visits, the majority of encounters have been encouraged to be virtual. Visits from family and friends are central to the care of residents, buffering against loneliness, anxiety and depression by providing continuity, advocacy and emotional support. Visiting can provide residents with a sense of meaning, worthiness and connectedness. The absence of strong social supports is therefore harmful to both the physical and psychological well-being of residents and can lead to increased morbidity and mortality risk. In the context of the COVID-19 pandemic, it may be particularly difficult to reconnect with others given the restrictions on in-person social gatherings. These even transient feelings of loneliness can have a negative effect on health (Morley & Vellas, 2020). As such, there could be dangerous unintended consequences if loneliness increases in response to the restrictive measures put in place to contain the spread of infections. Dying from COVID-19 is a harsh reality that hundreds of thousands have succumbed to amid this public health crisis, in part due to restrictions efforted in decreasing the spread of the virus. Limiting exposure and transmission to vulnerable aging population has negatively affected end-of-life discussions and lessened the chance to die with someone present. This has considerable social and existential consequences, both for the dying patient and for his or her relatives in their bereavement process. Celebration of hallmark anniversaries and holidays are events that many look forward to as a time to reminisce and create memories with family and friends. For the ageing population these events are often even more treasured. The choice to limit these celebrations, restricting in-person gatherings has muted many occasions of joy, further dampened by the reality of every day rising death rates and infections. These once routine visits were anticipatory events for individuals living in residential facilities. This lack of opportunity to spend time with loved ones will undoubtedly have short term and long-term impact on these families. The sense of loss and missing out on celebrations is a natural emotional experience for older adults who have not been able to participate in these events. Older adults are often elevated to the status as the core of one's family and missing the opportunity to celebrate with them creates a void that is irreplaceable. Multiple creative ways have been utilized to simulate real-life contact and thus potentially addressing social isolation and feelings of loneliness in a time of physical distancing. The increased use of virtual platforms, visual and audio communication may facilitate older people to remain connected. As families endeavour to bridge the gap with creative use of technology, most of the interventions to combat the negative effects of social isolation and loneliness has been left to the staff that care for our older adults. With the restrictions on space in healthcare facilities, and visiting policy, this has changed the daily role of healthcare workers and what constitutes care. The healthcare worker role, especially nurses, has been expanded to include an open channel of communication, providing updates, bearer of hopeful and disappointing news. Nurses in and out of the frontlines should have heightened awareness of how social isolation and multi-morbidity influences an increased risks for contracting the virus and how they contribute to poorer health outcomes for patients infected with COVID-19. In many ways the social view of an emphasized role of nurses is not new. However, the impact of COVID-19 had exalted the nurse's role to one of honour, providing what is most needed, physical presence and care to reduce the feeling of social isolation and loneliness. Globally, nurses and healthcare workers are celebrated, because they have been recognized to doing what they have always done “stepping up to the plate” in times of crisis. In this process there is a social recognition of an increased in value of their role, as opposed to what is often seen as the tasks of a daily shift. Of the many life-altering lessons, one that should be considered is ways to integrate our healthcare delivery to maintain social connections, not just in crisis. The importance of external contact and involvement of family and friends is a critical part of recovery and maintenance of health. The nurse is often the last one in the room, and the primary liaison between family and sick individuals. These duties are being performed while working long hours, keeping registry of symptoms, continued testing, rapid decision-making process, additional to regular day-to-day duties. In the most intimate role, nurses have reported administering final rites, reducing the fear of interaction with family member who is dying, and fostering a process of absorbing pain while providing hope. The short-term impact is to lessen the feeling of social isolation and loneliness for these individuals. However, as noble as that responsibility is, a strategic approach is needed to combat the effects of loneliness. The natural response to individuals who are sick is to surround them with care, love and support. Care and support are often expressed in physical presence and frequent reminders of this, are helpful to the healing process. The importance of social connections, especially for those who are sick or vulnerable has been undervalued. Efforts should be taken to include the consideration of social connections in one's care plan since the lack thereof is contrasted with the lack of care. Loneliness and social isolation are realties that impact many facets of life. However, when forced by social expectations and demands to reduce health risks, addressing the impact on mental health is equally critical. One of the lessons of the COVID-19 pandemic is the need for integrated holistic care. There are multiple guidelines to implement clinical and scientific approach to protect older adults, including prevention of infections, receiving the yearly flu vaccine, and practicing good hygiene to reduce their predisposed risks. Fragmented care may be efficient; however, treating the whole body, fully addressing their physical and mental health should be the way we approach care. What remains missing is a collaborative mental health approach to preserve their emotional well-being during this process. In considering these guidelines, there should be a multifaceted approach to preserve dignity, and reduce the negative health outcomes of loneliness and social isolation that will continue long after the COVID-19 pandemic. Editorials are opinion pieces. This piece has not been subject to peer review and the opinions expressed are those of the authors. None.