Social isolation is a significant threat to the wellbeing of older people living in the community. The Australian Bureau of statistics predict that by 2021 there will be an increase of people living alone of between 52% and 113%¹ writes Enis Jusufspahic.

Social isolation is best understood as an absence of relationships with friends and family on an individual level, and with society on a broader level. The most important elements of social isolation are the individual’s subjective perception of loneliness as well as the extent to which they are able to call on their social network for ongoing support and support during a crisis ^{2 3}.

Australian and international research has demonstrated that the negative impact of social isolation depends not on the quantity of social interactions (the number of relationships and the frequency of social interactions), but on the satisfaction of a person’s need for social connection which points to the depth of the relationship – in other words, being able to establish and maintain a meaningful emotional connection.

It is persistent loneliness, rather than situational (passing) loneliness related to a particular event, such as a death of a friend, which impacts on the person’s wellbeing. A state of chronic social isolation is particularly dangerous, as it can create a persistent, self-reinforcing loop of negative thoughts, sensations and behaviours. Once established, this loop of negative thoughts is difficult to break the longer the person is in this state.

Why are older persons more at risk of social isolation?

Pre-existing social isolation is a risk factor for all people regardless of age; it is the key life events and events transitioning into old age that increase the risk of social isolation. These may include:

• Retirement;
• Loss of driver’s licence;
• Relocating to a new community;
• Sudden loss of functional ability;
• An increase in physical health problems or chronic conditions e.g. heart disease, stroke, chronic pain;
• Side-effects from medications;
• Losses in relationships, independence, work and income and mobility creating lack of stable social networks;
• Significant change in living arrangements; and
• Admission(s) to hospital ^{4 5}.

Impact of social isolation

Humans are inherently social animals. We have an expectation of being with others which we inherit from our parents and our early social environment that establishes a baseline for what we deem to be an adequate social connection. This explains why different people experience social isolation differently. If a person is not able to realise these needs for social contact over time, their brain chemistry changes. Indeed, developmental psychology has demonstrated the necessity of social contact for healthy brains. It affects our ability to regulate emotions related to our sense of self and belonging, and ultimately our growth needs – to realise one’s potential and to connect to others and help them realise their own potential. This negatively impacts the way a person interprets social interactions and may lead to a kind of self-reinforcing loop which perpetuates behaviours that lead to further social isolation.

Limited social networks impact health through three pathways:

1. Behavioural: Socially isolated people are more likely to be at nutritional risk and more likely to engage in risk taking behaviour, such as heavy drinking.

2. Psychological: Socially isolated people are at increased risk of cognitive decline due to lack of social connections. Similarly, people who are experiencing mental distress are at greater risk of social isolation due to difficulty in everyday functioning. Social Support programs which target socially isolated older people are far more effective if the person’s physical health and mental needs are addressed too.

3. Physiological: There is overwhelming evidence demonstrating negative health outcomes and increased risk factors for socially isolated older people. This includes:

• Greater risk of depression and anxiety for older people with multiple chronic health conditions;
• Increased number of falls;
• Increased risk for all-cause mortality;
• More likely to have dementia, coronary heart disease or stroke;
• Increased risk for rehospitalisation (4 to 5 times more likely); and
• Social isolation as predictor of institutionalisation.

It flows back the other way too. Physical ill health leads to social isolation, specifically for older adults:

• With sensory loss which impacts their ability to communicate;
• Who have four or more chronic health conditions;
• Who are incontinent; and
• With sleep complaints or insomnia⁶.

Groups at risk

Groups at greatest risk of social isolation include older people:

• Over the age of 85;
• With limited English language skills;
• From LGBTI community (stigma, discrimination);
• Who have caring responsibilities;
• Living in rural areas due to lack of services and transport; and
• In residential care.

Economically, one of the groups at most risk are older people on low incomes who are in the private rental market, as a large percentage of their income is spent on renting a property that offers limited tenure, that does not have to meet minimum housing standards and there is often difficulty in gaining permission to modify the premises to suit the person’s specific needs.

Older men are at greater risk of social isolation, as the peak age for men living alone is 35 to 65 years; for women, it is 65 to 80 years⁷. Overall, older men are less connected socially and, as such, are at greater risk of suicide⁸.

Wellbeing and the LOCAL community

Health is not just about an individual’s wellbeing; a holistic understanding of health includes the social, emotional, spiritual and cultural well-being of the whole community⁹. This is in line with Malsow’s hierarchy of needs which explains that individuals can only realise themselves as a member of a community. A person’s perception of their community is very important to their sense of overall wellbeing. It is measured as:

• A feeling that the people in the area are trustworthy; as well as
• A feeling of belonging to the area; and
• Accessible transport as an enabler to build and maintain social connections.

Neighbourhoods are a key source of security, identity and support for older people whose daily activities are often concentrated in a few fixed locations. Public spaces need to be age-friendly in order to facilitate meaningful participation in work, family and community life, and provide opportunities for lifelong learning.

Active ageing, wellness and enablement

The World Health Organisation defines active ageing as a process of optimising opportunities for health, participation and security in order to enhance quality of life for people as they age¹⁰. This signals a move away from the traditional medical model (which emphasises dependency and care) towards a rights-based approach founded on optimising possibilities in later life.

Targeted interventions after a critical event or life transition were found to be highly effective motivators¹¹, as well as a multi-pronged approach which takes into account the person’s mental, social and physical wellbeing and reconnects older people to their social networks or assists them to develop new connections in addition to support services.

The most effective interventions are group based, with an educational component that targets a specific population. For instance, a study in a residential care found that chair-based exercise helps reduce anxiety and depression in people with dementia¹². The enablement approach includes learning about the person and involving them in the design and implementation of support services.

Numerous studies have demonstrated that increased levels of social support leads to increased quality of life and that social engagement prevents decline and facilitates recovery. One hundred and forty eight studies looked at the influence of social relationships on mortality and found a 50% increased likelihood of survival for people who had stronger social relationships.

Older persons’ mental health policy direction

Unfortunately, the Australian mental health system is overwhelmingly skewed towards providing acute and continuing psychiatric care to people aged between 12 and 64 ¹³. The Fourth National Mental Health plan acknowledges that older people require more coordination, specialised in-home mental health services, as well as in-patient services.

And the Roadmap for National Mental Health Reform stresses the significance of the life stage approach – namely the availability of prevention and intervention supports appropriate to each person’s life-stage and circumstances which includes older people¹⁴.

Enablement and wellness have the greatest potential for alleviating social isolation of older people because both emphasise solutions that build on a person’s functional capacity and foster links with their local community.

Enis Jusufspahic is the Community Care Development Officer at Inner Sydney Social Development Council

¹ Who’ll be Home Alone in 2021?, ABS, 2006
² The Lonely Society?, Mental Health Foundation, 2010
³ A Pate, Social Isolation, COTA Victoria, 2014
⁴ Depression and anxiety disorders in older people Fact Sheet 17, Beyond Blue
⁵ A Pate, Social Isolation, COTA Victoria, 2014
⁶ N Nicholson, A Review of Social Isolation, The Journal of Primary Prevention, 2012
⁷ Who’ll be Home Alone in 2021?, ABS, 2006
⁸ A Pate, Social Isolation, COTA Victoria, 2014
⁹ Üstün & Jakob, Re-defining ‘Health’, Bulletin of the World Health Organization, 2005
¹⁰ What is “active ageing”?, World Health Organisation (WHO)
¹¹ A Pate, Social Isolation, COTA Victoria, 2014
¹² What works to promote emotional wellbeing in older people, Beyond Blue, 2015
¹³ Mental Health Council of Australia, Priorities outside the NHHN reforms, Position Paper, 2011
¹⁴ The Roadmap for National Mental Health Reform 2012–22