Loneliness – a key outcome?

Of course, the title should be “Preventing loneliness“, because loneliness is a bad outcome.

Rehabilitation’s goal has always been to ‘improve quality of life’, but that is difficult to quantify not least because, when in a situation, people may change their opinion (a phenomenon termed ‘response recalibration’ to make it sound better!). A second oft-stated goal is to ‘improve social participation’, but again this is difficult to measure, not least because different people want different degrees and types of social participation. Loneliness captures the person’s opinion, and is measurable, and so one can measure how badly a service is performing by measuring loneliness.

Loneliness is, unsurprisingly, more common in people with disability, and several (probably many) articles show this. (here and here and here) Moreover, caregiver loneliness is an independent variable influencing caregiver burden in a population of caregivers to patients with traumatic brain injury. So rehabilitation services, which have as their focus of attention a person’s disabilities, should be concerned about reducing loneliness.

Loneliness has been distinguished from social isolation, which personalises the concept: “Loneliness arises from a discrepancy between desired and actual level of social connection, …” This definition was in a discussion on how Covid-19 is emphasising the importance of the social determinants of health; it is interesting how the effects of the pandemic are rippling out.

Loneliness is not only an influence on quality of life. Loneliness is associated with less good health. For example, a systematic review found that social isolation, loneliness, and living alone were all associated with an increased mortality rate of 26% (loneliness) to 32% (living alone). A more recent review confirmed adverse effects on health.

Loneliness can also be measured. An interesting systematic review found over 50 measures of concepts related to loneliness, and classified them on two axes. The first was concerned with the focus of a measure along a continuum between structure (of social relationships/networks) and function (of the relationships). The second was the degree of subjectivity (the person’s opinion) incorporated in the measure. A short, three-item measure has been proposed.

Can loneliness be reduced? One pilot trial (n = 66), in people with hearing impairment has investigated the effect of adding exercise and education on socialisation to an existing programme. No additional benefit on loneliness was detected, but it was probably underpowered. A systematic review identified 39 studies (in 2016), noting that although it suggested a benefit, the evidence was weak. A quick search today revealed many protocols. One recent trial investigated an intervention to increase self-efficacy. There was some effect on loneliness.

A bit more on loneliness within this site can be found here.

To conclude. People seen in rehabilitation are at increased risk of loneliness, which will reduce quality of life and health status, including an increase mortality risk. We need to research interventions, and we need to measure loneliness as an important outcome, perhaps better than quality of life which undergoes response recalibration, and so is a poor measure.

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