Structured Opportunities for Connection to Improve Aging-related Loneliness

Background It has been suggested that humans have a basic need to belong.1 Social relationships are fundamental to emotional fulfillment, behavioral adjustment and cognitive function. While social integration is critical to human development across the life span, it is particularly important in later life, a time when social relationships often decrease.2 In recent decades, changes and fragmentation in family structure have increased the number of persons living alone, albeit well recognized that 'being alone' is not synonymous with loneliness.3 Loneliness is defined as a subjective, unwelcome feeling of lack or loss of companionship; a mismatch between quantity and quality of social relationships.4 Loneliness encompasses feelings of isolation, disconnectedness and/or not belonging. It often leads to emotional distress and may be associated with detrimental effects on both mental and physical health outcomes.5 Worldwide, prevalence rates of loneliness range from 2% - 61% across both institutional and community settings. Both loneliness and social isolation have been declared as profound threats to health and well-being.6 Recently, a national survey conducted with over 20,000 participants to quantify loneliness and its correlates, estimated that loneliness affects 33% of the US population over the age of 55. While there is some evidence that rates of loneliness decrease with age,7 the negative effect of loneliness on physical health and cognition validates the importance of identifying older adults at risk of loneliness and providing interventions that may reduce attributable poor health outcomes.

One interventional approach, popularized in the 1970's in the UK and Scandinavia, for addressing loneliness and social isolation is 'social prescribing', a model that enables healthcare practitioners to refer patients to non-clinical services and community-based activities to support well-being.12 Social prescribing employs a community-based, person-centered model in which a health coach tailors the social activity 'prescription' to support individuals in better understanding their own needs and taking action to improve their health and well-being. Often key to implementation of the 'prescription' are Link Workers who suggest personalized plans to patients and follow-up with patients to monitor engagement and outcomes.13 The aim of social prescribing is to equip physicians with alternative interventions that can reduce unnecessary prescriptions and referrals, while empowering patients to take greater responsibility for their health by connecting with available community resources to reduce loneliness and increase social relationships. Despite popularity and perceived potential benefits, the scientific rigor and validated evidence regarding social prescribing is sparse and very few studies have included comparison groups to support an inference of direct causation.14,15 In 2020, Roland et. al.16 concluded that current evidence fails to provide sufficient detail to judge either success or value of social prescribing.

Preliminary Data Given reported variation in prevalence of loneliness in age-specific, US populations, we conducted a preliminary cross-sectional study to estimate the prevalence of loneliness in the population of persons aged ≥ 55 years in the Endeavor Health catchment area. Four data collection sites were identified; patients scheduled for medical outpatient visits, laboratory testing or imaging procedures were approached in the respective waiting rooms and invited to complete a brief survey. The only demographic data collected was each patient's age group, i.e. 55-64, 65-74,75-84, ≥85 years. The selected instrument to measure loneliness was the validated, short form of the DeJong Gierveld Loneliness Scale (DeJong scale), designed to measure overall, emotional and social loneliness. Additionally, a single-item screener question,11 'How often do you feel lonely?' was also included to allow for response comparison to the DeJong scale. Endeavor Health Institutional Review Board non-human subjects research determination as a quality improvement project was obtained.

With a range of 28 to 69 completed surveys per site, a sample size of 204 was reached. Based on a total DeJong score of ≥3 (moderate loneliness), the estimated prevalence of loneliness in this sample was 28.7% (range by site: 18%-43%). Using the single-item screener the prevalence of loneliness was 33.8% based on a response of feeling lonely occasionally or more often.

Study Aims This collaborative study, conducted by Mather Institute and Endeavor Health, seeks to develop and test a social prescription model to reduce loneliness and support well-being among older adults receiving primary care at Endeavor Health in Evanston, Illinois. The objective of this pilot study will be to address the feasibility, uptake, sustainability and impact of primary care-initiated social prescribing among community-dwelling older individuals.