Loneliness in old age: what really helps

Sunday, half past ten in the morning. A daughter rings her mother, as she does every week. “How are you?” “Fine, fine. I’ve got everything I need.” In the background the television is talking; it has been on since breakfast. The call lasts six minutes: the weather, the knee, the grandchildren. When the daughter hangs up she has a sense that something is not right, but she cannot say what. At the other end her mother turns the sound down and thinks that this was the only voice meant for her today.

A great deal is written about loneliness in older people, often in ways that help nobody: as an epidemic, as the fault of children who do not ring, or as something a computer course would solve. The truth is more complicated and, at the same time, more useful.

In this post I would like to explain what loneliness in old age actually is, by which routes people arrive at it, and what research says about what really helps. Whether you are reading this for yourself or because of your mother, father or a neighbour, the same applies: no moralising, and no promises the data do not support.

Alone, lonely, isolated: three different things

Before asking what helps, we need to know against what. Three words are constantly mixed up in conversations about old age.

Solitude means being on your own. Nothing more. For many people, after decades of work, children and caring for others, solitude is exactly what they were waiting for. See solitude in the knowledge base.

Loneliness is the painful feeling of having less closeness than you need. It depends on the gap between what you have and what you want, not on the number of people. There is a short explanation under loneliness and a longer one in Loneliness is not solitude: the difference that changes everything.

Social isolation is a measurable lack of contact: you live alone, rarely see anyone, and have nobody to ring when something goes wrong.

These three can overlap, but they need not. A widower visited every day by one of his children may be deeply lonely. A woman who lives alone at the end of the village and speaks to her sister twice a week may not be lonely at all. If we treat them the same, we will offer one of them company she does not need and fail to give the other what he is missing.

That this is no marginal question was shown by a meta-analysis by Julianne Holt-Lunstad and colleagues from 2010. They pooled 148 studies with a little over 300,000 participants and found that people with stronger social ties were about 50 per cent more likely to be alive at the end of the follow-up period than those with weak ones. The figure describes averages across large groups and does not predict any one person’s fate, but it does say that relationships are not an ornament to a healthy life; they are part of it. More on this in Loneliness and health: what the research shows and what it doesn’t.

Age itself is not the cause

It is widely assumed that loneliness is a natural part of ageing. In a review article the Dutch sociologist Pearl Dykstra placed this among the myths. The data show that most older people are not lonely and that loneliness rises markedly only in very old age. Even then, not because of the years themselves but because of what accumulates with them: losses, illness, getting about with more difficulty.

This is an important distinction. If age is to blame, nothing can be done. If the circumstances that often accompany age are to blame, a good many of them can be shifted.

A second thing worth knowing: older people usually have a smaller circle than younger people, but that in itself is not a problem. The psychologist Laura Carstensen and her colleagues described how people, once they are aware that time is not unlimited, narrow their circle on purpose. They let superficial contacts go and give their time to those who truly matter to them. A smaller circle is therefore often a choice, not a loss.

The third finding surprises many. In a meta-analysis of factors in older adults’ loneliness, Martin Pinquart and Silvia Sörensen found that the quality of contacts counts for more than their number, and that contact with friends and neighbours was more strongly linked to lower loneliness than contact with family. This does not mean children are unimportant. It means that a call made out of duty does not do the same as coffee with a neighbour who comes because she wants to.

Widowhood and retirement: when everyday contact falls away

Two great changes in later life take away something you had never counted as contact.

Widowhood takes not only a person but also the witness to your everyday life: someone who knows how you take your coffee, and with whom you need not speak in order not to be alone. This is loneliness caused by one missing close bond, and no group fills it. Whoever tells a widowed parent to “get out and see people” means well but is answering the wrong question. Often half of social life falls away too, because the friends were mostly couples. I write about this in When a partner dies: who are you now without them and When a parent loses their partner: how to stand beside a widowed mother or father.

Retirement works more quietly. A job gave you not only a salary but also a reason to leave the house, people you met without arranging to, and the sense of being needed somewhere. All of that disappears on the same day. The first months can be pleasant; the emptiness often shows itself later, once the holiday feeling has worn off. More in Retirement, the loss of a role and the question of meaning.

What both changes have in common is that those around you see the event but not what left with it. So the first help often lies in someone naming it: “You are not missing company. You are missing him.” Or: “You are not missing the work. You are missing being expected somewhere.”

Hearing and mobility: obstacles we mistake for character

Two things cause loneliness in old age more often than we think, and we rarely recognise them because they look like something else.

The first is hearing. Someone who hears poorly cannot follow a conversation in company, especially when several people speak at once or there is background noise. For a while they ask “what did you say?”, then it becomes embarrassing and they start nodding. In time they stop going to lunches, because it is tiring and humiliating. The family sees a person who has “withdrawn” or “become odd”. In fact they cannot hear. A systematic review of research led by Aishwarya Shukla found a link between hearing loss and greater loneliness and social isolation in most of the studies included. Whether a hearing aid also reduces loneliness, research does not yet say with one voice. It does make conversation easier, and that is the condition for everything else. If you suspect poorer hearing in yourself or a parent, the first step is a conversation with the GP.

The second is mobility. A third floor with no lift, a bus that runs twice a day, a knee that will not last as far as the shop, fear of falling on an icy path. The world does not shrink because the person does not want to go out, but because every outing has become an expedition. Encouragement does not help here; transport does. In many Slovenian municipalities there are free transport schemes for older people run by volunteer drivers; you can ask about these and about home help at the municipality or the local social work centre.

Both obstacles share one feature: the loneliness that grows out of them is not an emotional difficulty to be worked through. It is a practical problem that has to be removed first. Only then can you see how much loneliness is left.

What research shows about what helps

The most frequently cited study in this field is a meta-analysis published in 2011 by Christopher Masi, Hsi-Yuan Chen, Louise Hawkley and John Cacioppo. They reviewed programmes for reducing loneliness and divided them into four groups: programmes that increase opportunities for contact, programmes that strengthen social support, programmes that teach social skills, and programmes that work with the thoughts through which a lonely person interprets themselves and others.

Among the randomised trials, that is, those with the most rigorous design, the last group did best. The authors’ explanation is that long-lasting loneliness changes expectations: a person starts looking for signs of rejection in others, duly finds them, and withdraws before anyone has actually rejected them. The mere opportunity for contact does not break this loop, because the person brings the conviction of being superfluous along on the outing too.

These findings need to be read with care, and the authors say so themselves. The average effect in the randomised trials was small. Only a handful of studies worked with thoughts. The meta-analysis covered people of all ages, not just older people, and the programmes differed greatly from one another. So it does not follow that socialising does not help, or that a lonely older person mainly needs therapy. Something more modest follows: that more contact alone is often not enough, and that it is worth looking at what the person thinks about those contacts as well.

It is complemented by an older systematic review by Mima Cattan and colleagues, which looked specifically at programmes for older people. The most convincing results came from group activities with educational or supportive content, aimed at a particular group of people, where participants had a say in what happened. For one-to-one home visits the picture was less clear. This does not mean a visit has no value. It means that research captures it less well, and that a group you belong to does something a single visitor cannot.

In Slovenia this role is played by pensioners’ associations, intergenerational centres, the university of the third age, choirs, hiking clubs and volunteer fire brigades. What they have in common is that a person goes there not “for company” but for something, and that they are missed when they do not turn up.

Why “go and see people” does not work

The sentence is well meant and almost always misses. It tells the person that the solution is simple and that it is their own fault if they do not use it. It also assumes the problem is one of opportunity, when it often lies in what research describes as changed expectations.

“Mum, the association has an outing on Thursday. Why don’t you go?”
“What would I do there. They all know each other already.”
“But Marija always invites you.”
“She invites me because she feels sorry for me.”
“What if she invites you because she’d like to sit with you?”
“I don’t know. It’s a long time since I thought anyone would want that.”
(This dialogue is composed; it does not describe a real person.)

The last sentence is the heart of it. The obstacle is not the outing and it is not Marija. The obstacle is a belief that has hardened over years of being alone: that you are a burden to others and that they invite you out of politeness. Persuasion does not change that belief. Sometimes it is loosened by a question that offers a different explanation, and by one experience that confirms it.

Another common obstacle is pride. A generation that grew up with the sentence “I won’t be a nuisance to anyone” finds it hard to say “I am lonely”. So it says “I’m fine” or “I’ve got everything I need”. The word loneliness carries shame, and the direct question “Are you lonely?” will as a rule get the answer “no”. You learn more from “Who have you talked to this week?” or “Which part of the day is the longest?”

An exercise: one person, one obstacle, one hour

The exercise is meant for you if you are the one who is lonely. If you are reading because of a parent, you can do it together, but let them give the answers.

1. Write down three people you would like to talk to more often. Not the ones you “ought” to ring, but the ones after whom you feel lighter. They may be people with whom contact has lapsed.
2. Next to each name, write what stands in the way. Be precise: I can’t hear him well on the phone, I have no transport, we fell out last time, I don’t want to be a burden, I don’t know what I would say.
3. Choose the person with the smallest obstacle and write the obstacle down as a task. “I can’t hear well on the phone” becomes “I’ll invite her round for coffee”. “I don’t know what I would say” becomes “I’ll say she came to mind”.
4. Agree a fixed time. Every Tuesday at ten, not “let’s be in touch”. A fixed time removes the question of whether you are disturbing them and gives the week a point you can look forward to.
5. After three weeks, check one thing: whether the day you speak is different from the others. If it is, add a second name from the list. If not, change the person; do not give up the exercise.

For the wider picture of who else is in your circle and whom you can turn to for what, it helps to draw a map of your support network.

If you are reading this as a son or daughter

First: your parent’s loneliness is not a measure of your love. You can ring every day and they will still be lonely, because they miss a husband, colleagues or a body that used to obey. Your call matters, but it is not a cure for everything.

What you can do is less, and more precise, than it seems. Check the practical obstacles: when their hearing was last tested, how they get to the shop, whether they can use the phone you bought them. Prefer a shorter contact at a fixed time to a long visit whenever you remember. Instead of “you must get out more”, ask what they used to enjoy doing and with whom. And allow them a role: a person who only receives help feels like a burden, while a person who teaches you to bake potica or tells you what work was like in 1978 has something to give.

Look after yourself as well. If you are caring for a parent and feel guilty that it is never enough, that is not a sign you are doing too little. It is a sign you are carrying something one person cannot carry alone.

Where this does not apply

This post treats loneliness as something to be reduced. There are some important exceptions.

First, chosen solitude is not a problem. Someone who likes being alone, reads, gardens and speaks to someone twice a week does not need a programme. Children sometimes mistake their own distress at seeing a parent living alone for the parent’s. Ask before you fix.

Second, loneliness can be a mask for something else. Withdrawing from company, listlessness and giving up things that once brought pleasure are also signs of depression, which we often overlook in older people; I write about this in Depression in older people: when we mistake it for age itself. Withdrawal can also be an early sign of memory problems, when a person gives up company because they can no longer follow the conversation or are afraid of forgetting something. In both cases the first port of call is the GP, not a club.

Third, part of loneliness is not personal but environmental. If there is no bus, if the pension is too small for a coffee in town, if all the neighbours have moved away, then the person does not need to change their thinking; they need transport, money and neighbours. To put it down to their attitude would be unjust.

And fourth, the research on what helps is more modest than we would like. The effects of programmes are small, the studies varied. Anyone who promises you a reliable way out of loneliness is promising more than we know.

When to seek help

Talking to a professional makes sense when loneliness lasts for months and does not ease despite contact, when it is bound up with a loss that will not shift, or when you notice that you see pity in every invitation and duty in every call. It is with precisely these beliefs that conversation has the best chance of changing something.

As a therapist in training under supervision in marriage and family therapy, I work within relational family therapy, which is interested in how older experiences of closeness and abandonment are repeated in present relationships. Sessions take place in person in Ljubljana, and I also work with English-speaking clients. Older people can come themselves, and so can adult children who do not know how to stand beside a parent without burning out.

If loneliness brings thoughts that life no longer has any point, or that it would be better if you were not here, do not carry that alone. In Slovenia the Samarijan confidential helpline is available 24 hours a day on 116 123, the mental distress helpline (Klic v duševni stiski) between 7 pm and 7 am on 01 520 99 00, and in immediate danger call 112.

What to remember

• Solitude is a state, loneliness a feeling, social isolation a lack of contact. An older person who lives alone is not necessarily lonely, and one who has a visitor every day may be.
• Loneliness is not caused by age itself but by what comes with it: widowhood, retirement, poorer hearing, getting about with more difficulty. Each route needs its own answer.
• Hearing and transport are practical obstacles. Remove them first, and only then judge how much loneliness is left.
• Research suggests that more contact alone is often not enough; quality counts, and so does what the person thinks about those contacts. The effects of programmes are small, so no grand promises.
• “Go and see people” rarely helps. A fixed time, a group where you are missed and a role in which you have something to give work better.