Predictors and subjective causes of loneliness in an aged population

Archives of Gerontology and Geriatrics 41 (2005) 223–233 www.elsevier.com/locate/archger

Predictors and subjective causes of loneliness in an aged population N. Savikko a, P. Routasalo a,b, R.S. Tilvis a,c, T.E. Strandberg c, K.H. Pitka¨la¨ a,c,* a

b

The Central Union for the Welfare of the Aged, Malmin Kauppatie 26, 00700 Helsinki, Finland University of Turku, Department of Nursing Science, Lemminka¨isenkatu 1, 20014 Turun yliopisto, Finland c University of Helsinki, Faculty of Medicine, Institute of Clinical Medicine, P.O. Box 340, FIN-00029 HUS, Finland Received 23 August 2004; received in revised form 14 February 2005; accepted 4 March 2005 Available online 23 May 2005

Abstract The aim of the study was to examine the prevalence and self-reported causes of loneliness among Finnish older population. The data were collected with a postal questionnaire from a random sample of 6786 elderly people (75 years of age). The response rate was 71.8% from community-dwelling sample. Of the respondents, 39% suffered from loneliness, 5% often or always. Loneliness was more common among rural elderly people than those living in cities. It was associated with advancing age, living alone or in a residential home, widowhood, low level of education and poor income. In addition, poor health status, poor functional status, poor vision and loss of hearing increased the prevalence of loneliness. The most common subjective causes for loneliness were illnesses, death of a spouse and lack of friends. Loneliness seems to derive from societal life changes as well as from natural life events and hardships originating from aging. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Loneliness; Aged population; Causes for loneliness

1. Introduction Loneliness in old age is a significant challenge for gerontological research and practice. Its prevalence in elderly populations has varied from 7% (Victor et al., 2000) to 49% (Holme´n et al., 1994), and about one-third of people aged 60 years and older (n = 1037) experienced loneliness in Finland in 1998 (Vaarama et al., 1999). * Corresponding author. Tel.: +358 9 3508 6037; fax: +358 9 3508 6010. E-mail address: [email protected] (K.H. Pitka¨la¨). 0167-4943/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2005.03.002

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The concept of loneliness has been interpreted in various ways (Victor et al., 2000). Some researchers define it as an individual’s subjective experience about lack of satisfying human relationships, and thus loneliness would be a negative feeling causing distress to an individual. Also depression is closely related to loneliness. However, being alone may be also experienced as a positive and creative state—solitude (Andersson, 1998). The concepts of loneliness, social isolation and living alone have often been used interchangeably, although they are distinct but interrelated concepts. Of these, living alone is the most straightforward concept, which may be measured by the household size (Victor et al., 2002). Social isolation relates to a number of contacts and integration of an individual into the surrounding social environment (Cattan and White, 2003). Yet, loneliness is a subjective feeling and the amount of it can only be described by the individual experiencing it (Wenger et al., 1996; Andersson, 1998; Tilvis et al., 2000). A person may suffer from loneliness even though he or she is surrounded by many people (Victor et al., 2002). Loneliness impairs the quality of life and implies poor prognosis in old age (Victor et al., 2000). There is also a strong relationship between depressive symptoms and loneliness (Mullins and Dugan, 1990; Prince et al., 1997; Holme´n et al., 1999), and loneliness predicts increased use of health services (Ellaway et al., 1999; Geller et al., 1999) and early institutionalization (Tijhuis et al., 1999; Tilvis et al., 2000). It has also been shown to predict cognitive decline (Fratiglioni et al., 2000; Tilvis et al., 2000) and it increases the risk of mortality (Penninx et al., 1997; Herlitz et al., 1998; Tilvis et al., 2000). Loneliness has been associated with old age (Holme´n et al., 1992, 1994; Holme´n, 1994; Fees et al., 1999), although the observations have been inconsistent (Holme´n et al., 1992; Mullins et al., 1996). While the gender differences have remained disputable (Holme´n et al., 1992; Andersson and Stevens, 1993; Holme´n, 1994; Andersson, 1998; Chang and Yang, 1999; Victor et al., 2000), the roles of widowhood (Holme´n et al., 1992; Dugan and Kivett, 1994; Samuelsson et al., 1998; Dykstra and De Jong Gierveld, 1999; Tijhuis et al., 1999; Van Baarsen et al., 1999) and living alone (Holme´n et al., 1992; Samuelsson et al., 1998) are well established. In addition, low level of education and poor income levels have been associated with loneliness in some studies (Chang and Yang, 1999; Dykstra and De Jong Gierveld, 1999). The association between poor subjective health and loneliness has been found in several studies (Holme´n et al., 1992, 1994; Mullins et al., 1996; Chang and Yang, 1999; Fees et al., 1999; Tijhuis et al., 1999; Van Baarsen et al., 1999; Tilvis et al., 2000). However, the data concerning the relationship between the functional status and loneliness have been inconsistent (Holme´n et al., 1993; Holme´n, 1994; Bondevik and Skogstad, 1998; Kim, 1999; Tijhuis et al., 1999). Those who have poor sight or hearing impairment feel lonely more often than those with better vision and hearing (Dugan and Kivett, 1994; Holme´n, 1994; Kramer et al., 2002). The previous study findings concerning the factors associated with loneliness have been partly inconsistent. This may be due to small sample sizes. In addition, to our knowledge, there are no studies comparing prevalence of loneliness among elderly people living in rural areas and cities and the factors older people consider the causes for their loneliness. This large-scale study was designed to examine the prevalence of loneliness in Finnish older population, and it aims to clarify the associations between the loneliness and the demographic and health related factors. An important goal is to find out what the elderly themselves consider to be the causes for their loneliness.

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2. Methods 2.1. Population sample The data were gathered in the autumn 2002, from community-dwelling older people (75 years old). Six municipalities were selected representing various parts of Finland, rural areas and small and large cities. After permission from the local ethics committee, a postal questionnaire was sent to a random sample (n = 6786) in these municipalities from The Finnish National Population Register. The questionnaire was re-sent after 1 month to non-responders. According to statistics 5.1% of the sample (statistical and mailing delay) was dead and 10.5% were in permanent institutional care. In addition, there were 26 persons whose mailing address had changed and were therefore unknown. Thus, the number of the potential community-dwelling respondents were 5722 of which 4113 returned the questionnaire. The response rate for the community-dwelling elderly was 71.8%. In this article, we report only those who have given their response on both the question about loneliness and age and gender (n = 3915). 2.2. Questionnaire and analysis The questionnaire consisted of demographic variables (age, gender, marital status, education, former job, living conditions and income), health related variables (eight questions) and variables charting the self-reported causes of the loneliness (eight questions of which one was open question). Of the demographic variables, age and time of widowhood were divided into groups. Education was divided into three (1 = primary school or less, 2 = high school and 3 = college or university). Respondents were divided into three groups according to the area they were living in: those living in Helsinki (>0.5 million inhabitants) were considered to live in a large city, those living in population centers of cities with 35 000–80 000 inhabitants were considered to live in a small cities and those living in sparsely populated areas with farming as the main source of livelihood were considered to live in a rural area. Some categorizations were made to the health related factors. Health status was divided into two categories (1 [healthy] = those who considered themselves as healthy or quite healthy and 2 [sick] = those who considered themselves as sick or very sick). Handling day-to-day matters (such as shopping, going to the bank or post office) was divided into two categories (1 = daily or several times a week and 2 = once a week or less). Functional status was asked by question ‘‘How is your physical functioning at the moment?’’ with options 1 = very good, 2 = good, 3 = moderate, 4 = poor and 5 = very poor. Self-reported functioning was divided into three categories: (1 [good] = those who considered their functioning very good or good, 2 [moderate] = those who considered their functioning moderate, 3 [poor] = those who considered their functioning poor or very poor). This question has been piloted and found easy to understand for the older people. The loneliness was measured with the question: ‘‘Do you suffer from loneliness?’’ (1 = seldom or never, 2 = sometimes and 3 = often or always). This question has been identified as easy to answer within elderly population and it has prognostic value (Tilvis et al., 2000).

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Self-reported causes of the loneliness were examined from two groups, from those who felt themselves often or always lonely and from those who felt loneliness sometimes. Causes of loneliness were asked by the question ‘‘What do you feel are the causes of your loneliness?’’ with seven statements each with yes/no options and one open-ended with a possibility to answer if there were other causes for loneliness. Data were examined with statistical variables, such as frequencies and percentages. Three loneliness groups were compared with the Chi-square test for categorical variables and logistic regression analysis was used to determine which variables independently predicted having feelings of loneliness often or always. p  0.05 was considered statistically significant.

3. Results 3.1. Characteristics of the population The mean age was 81.1  4.49 (standard deviation (S.D.)) years and women outnumbered men. About half of the respondents were widowed and most of them (78%) had lost their spouse more than 6 years ago (Table 1). The majority of the population had low level of education (primary school or less 57%), and two in five had worked in the office-, service- or mental work (42%). Of the respondents, 93% lived at own home and over half lived alone, 55% were living in a small and 31% in a large city, and 14% in the rural area. Almost three in four considered their income as moderate. The health was considered good or quite good by 66% of the respondents, about one in four needed help daily, but almost 61% of the respondents evaluated that they had handled day-to-day matters outside their home more frequently than once a week. Functional status was assessed as poor among 20% of the individuals, and nine in ten were able to read and hear the normally spoken words, 17% reported having the hearing aid. 3.2. Relationship of loneliness to demographic and health related factors Of the respondents, slightly more than 5% felt themselves often or always lonely, and 39% suffered from loneliness at least sometimes (Table 1). Those living in a large city felt less often lonely than those living in small cities or in rural areas. Feelings of loneliness were more common in the oldest age groups and among women (Table 1). Widowhood enhanced the risk of loneliness, especially among those who were recently (6 years) widowed. Loneliness was more common among persons with low than higher level of education, and among those with poor income. The former job was also associated with loneliness so that those who had worked in heavy physical work (farming, stock raising, forestry, housekeeping, factory-, mine- or construction worker) suffered more often from loneliness than those with other work background. Respondents living alone or in a residential home suffered more from loneliness than those living with someone else or in their own homes. Those who considered themselves as healthy or their functional status as good felt less lonely than those who considered themselves in a worse condition (Table 2). Also those

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Table 1 Demographic factors and loneliness Loneliness All: 3915, % (n)

Seldom or never: 2374 (61%), %

Sometimes: 1339 (34%), %

Often or always: 202 (5%), %

Age (years) 79 80–89 90

44 (n = 1723) 50 (n = 1957) 6 (n = 235)

65 58 51

32 36 36

3 6 13

Gender Female Male

69 (n = 2720) 31 (n = 1195)

57 69

38 26

5 5

Marital status Married Single Separated or divorced Widowed

36 9 6 49

(n = 1347) (n = 336) (n = 256) (n = 1929)

77 63 59 49

22 34 34 43

1 3 7 8

Time being widowed 1 2–5 6

4 (n = 82) 18 (n = 329) 78 (n = 1426)

34 45 50

51 43 43

15 12 7

Education Primary school or less High school College or university

57 (n = 2163) 24 (n = 901) 19 (n = 758)

57 63 71

38 32 25

5 5 4

Income Good Moderate Poor

24 (n = 918) 73 (n = 2678) 3 (n = 108)

71 58 35

25 37 48

4 5 17

Former job Farmer Factory worker Office worker Other

18 17 42 23

(n = 675) (n = 625) (n = 1589) (n = 883)

54 59 60 67

40 36 35 27

6 5 5 6

Living at Home Residential home

93 (n = 3545) 7 (n = 287)

62 46

33 41

5 13

Living with Alone With spouse With some one else

59 (n = 2243) 35 (n = 1284) 6 (n = 237)

51 80 65

42 19 31

7 1 4

Domicile Rural areas Small city Large city

14 (n = 472) 55 (n = 1959) 31 (n = 1112)

55 60 63

39 35 32

6 5 5

Chi-square test, p-value

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p = 0.050

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Table 2 Health related factors and loneliness Loneliness

Chi-square test, p-value All: 3915, % (n) Seldom or Sometimes: Often or never: 2374 1339 (34%), % always: (61%), % 202 (5%), % p  0.001

Health status Healthy Sick

66 (n = 2510) 34 (n = 1322)

68 48

29 42

3 10

Daily outdoor activities Yes No

81 (n = 3096) 19 (n = 753)

64 47

32 41

4 12

Need for daily help Yes No

26 (n = 970) 74 (n = 2750)

45 67

44 30

11 3

Handling day-to-day matters Several times a week 61 (n = 2317) Once a week or less 39 (n = 1475)

68 50

29 41

3 9

Functional status Good Moderate Poor

23 (n = 898) 57 (n = 2177) 20 (n = 790)

79 60 43

20 37 42

1 3 15

Sees to read Yes No

93 (n = 3413) 7 (n = 263)

62 43

34 44

4 13

Hears normal talk Yes No

88 (n = 3124) 12 (n = 439)

62 48

34 41

4 11

Hearing aid Yes No

17 (n = 531) 83 (n = 2614)

59 61

36 34

5 5

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p  0.001

p = 0.567

who had outdoor activities or did not need daily help felt less lonely than those without these characteristics. The respondents who handled day-to-day matters (such as shopping, going to the bank or post office) more than once a week suffered less from loneliness than those who handled matters once a week or more rarely. Individuals with good vision or hearing suffered less from loneliness than those with poorer senses. The use of a hearing aid was not, however, significantly related to loneliness. 3.3. Predictors of loneliness Independent predictors of loneliness were assessed with logistic regression model including all those factors significantly associated with loneliness in bivariate analyses. Independent predictors were poor functional status, widowhood, poor income, living alone, and poor health (Table 3). Also female gender had independent predictive value, but high age (80 years) lost statistical significance in logistic regression model.

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Table 3 Predictors of loneliness in logistic regression model (R2 = 0.055)

Poor functional status Widowhood Poor income Living alone Poor health Female gender High age a b

ORa

Upper 95% CIb

Lower 95% CIb

4.53 2.84 2.28 1.77 1.49 1.55 0.73

2.99 1.88 1.28 1.18 0.98 1.08 0.52

6.85 4.28 4.07 2.68 2.28 2.22 1.03

Odds ratio. Confidence interval.

3.4. Self-reported causes of loneliness Those feeling lonely reported several causes for their loneliness (Table 4). The most common were illnesses (81%), death of a spouse (79%) and lack of friends (67%). Meaningless life was an especially common cause among those feeling ‘‘often or always lonely’’ (74%). Also the absence of relatives was a common cause. In both groups, those Table 4 Self-reported causes of suffering from loneliness Cause of loneliness

Loneliness All: 1388, % (n)

Sometimes: 1194, %

Often or always: 196, %

Own sickness Yes No

81 (n = 840) 19 (n = 202)

82 91

18 9

Death of the spouse Yes No

79 (n = 603) 21 (n = 158)

81 85

19 15

Lack of friends Yes No

67 (n = 524) 33 (n = 256)

79 87

21 13

Absence of relative Yes No

56 (n = 363) 44 (n = 289)

79 86

21 14

Meaningless life Yes No

48 (n = 307) 52 (n = 336)

71 91

29 9

Family matters Yes No

24 (n = 157) 76 (n = 499)

86 82

14 18

Living conditions Yes No

19 (n = 131) 81 (n = 572)

82 83

18 17

Chi-square test, p-value

p = 0.003

p = 0.312

p = 0.014

p = 0.024

p  0.001

p = 0.218

p = 0.847

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who felt themselves often or always and those who felt sometimes loneliness, about one in five considered that living conditions (e.g., living apart from other settlements, poor transportation system) and family matters (e.g., unemployment of the family member, serious illness or alcoholism) were the causes for their loneliness. In addition, there were several other things in both groups that were mentioned, for example, illness of spouse, ageing, retirement, children’s pressing life, death of a family member or new living environment.

4. Discussion 4.1. Findings Feelings of loneliness were reported by 39% of our Finnish elderly population, 5% of the sample suffered from loneliness often or always. Loneliness was more common among older people living in rural areas than those living in big or small cities. In multivariate analyses, the most powerful predictors of loneliness were poor functional status, widowhood and poor income. The most common subjective causes for suffering from loneliness were one’s own illnesses, death of a spouse and lack of friends. The strength of this study is in its being a large, diverse and representative sample of elderly people. Thus, our study has a high statistical power to clarify some inconsistent results from previous studies and the results of this study may be generalized to cover the whole elderly population in Finland. High response rate (71.8%) supports the reliability of this study. To our knowledge, our study is the first to report the causes for feeling lonely evaluated by the elderly themselves. However, the feelings of loneliness depend on cultural context. In Scandinavian countries comparable proportion of elderly individuals suffer from loneliness but older people in Southern Europe experience more frequently loneliness than elderly people in Northern countries (Eurobarometer, 1993). Thus, our finding may not be representative of other populations. One reason for the elderly living in the countryside suffering from loneliness more often may be because of the migration constantly happening in Finland. This leads to disintegration of small rural communities as the young move to the cities and elderly people are left behind. This may reduce social contacts especially when a person’s functional status is impaired and one is no longer able to participate in outdoor activities or to visit friends. Findings concerning the relation between the aged and loneliness in previous studies have been inconsistent. According to this and one previous study (e.g., Fees et al., 1999) loneliness seems to increase with age. However, in another study, loneliness leveled off after 90 years of age (Holme´n et al., 1992; Holme´n, 1994). Our multivariate analyses suggest that factors other than age itself explain the experience of loneliness. Our study also gives support to the argument that women suffer from loneliness more often than men (see also e.g., Andersson, 1998; Victor et al., 2000). There may be several reasons for this. First, women may be allowed to express their feelings more openly than men (Tijhuis et al., 1999). Second, women may value the human relationships more than men (Berg et al., 1981). Third, women live longer which exposes them to widowhood and other losses

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(Tijhuis et al., 1999). Our results suggest that associated features of female gender, irrespective of the widowhood, have an influence on the experience of loneliness. Loneliness seems to decrease with better education or income. The same trend has been found in a few previous studies (Chang and Yang, 1999; Dykstra and De Jong Gierveld, 1999), and it has been thought that those with higher education and income would have a broader social network (Dykstra and De Jong Gierveld, 1999). To our knowledge, the relationship between the former work and loneliness has not been examined in previously. According to our results those who had worked in heavy physical work suffered the most from loneliness in old age. Lower social class may be the explanation. In our study, it was found that the loss of health or functional status as well as vision or hearing was related to increased feelings of loneliness. This has been found in a number of previous studies (e.g., Holme´n et al., 1993; Dugan and Kivett, 1994; Holme´n, 1994; Mullins et al., 1996; Kim, 1999; Van Baarsen et al., 1999; Tilvis et al., 2000; Kramer et al., 2002). Obvious reason could be one’s decreasing capacity to keep up with social contacts when health deteriorates. However, Bondevik and Skogstad (1998) found that dependence on the ADL-support might also decrease loneliness, because outside help provides more social contacts. It is of note that the instrument used to measure loneliness partly measured the number of social contacts as well (Cutrona and Russell, 1987). Our logistic regression model explained only 5.5% of the variance of loneliness. One reason for this may be the emotional nature of the feeling of loneliness. Certain external factors such as widowhood, living alone or poor functional status certainly have their effect on suffering from loneliness but internal expectations and perceived quality of relationships may explain even more of that feeling (Victor et al., 2000). In previous studies, subjective causes of loneliness in the elderly have not received much attention. Our findings are supported by epidemiological studies of the associations with loneliness, but the present analyses show that there are many other causes for old-age loneliness than those investigated in previous studies. One’s own illness and death of a spouse were identified as the most common causes for loneliness, and this accords with the associations between health status, widowhood and loneliness. A significant finding was the importance that respondents gave to lack of friends and experience of meaningless life as the causes for their loneliness. Notable, too, was the significance attached to their living conditions and family matters. 4.2. Conclusions The proportion of older people suffering from loneliness in Finland is high (39%). Because loneliness is known to be associated with many detrimental factors (e.g., depression, early institutionalization, cognitive impairment, increased mortality) this problem deserves further attention. On one hand, loneliness seems to be connected with natural events such as losses and widowhood, and factors associated with aging (e.g., poor health and functional impairment). On the other hand, loneliness of older people may also be associated with poor level of income leading to isolation, or societal changes such as the migration of younger people from the countryside to cities.

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Acknowledgement This study was made possible by financial support from the Finnish Slot Machine Association.

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