The epidemiology of social isolation and loneliness among older adults during the last years of life

Abstract

Background: Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life.

Objectives: To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life.

Design: Nationally representative, cross-sectional survey.

Setting: Health and Retirement Study, 2006-2016 data.

Participants: Adults age > 50 interviewed once in the last 4 years of life (n = 3613).

Measurements: We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest.

Results: Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment.

Conclusions: Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.

Keywords: cognition; end of life; loneliness; palliative care; social isolation.

Figure 1.

The Interrelationship of Loneliness and Social isolation. *r<0.20 represents a low correlation between the two social markers which has been reported in prior national studies [3].

Figure 2.

The Prevalence of (A) Social Isolation and (B) Social Isolation Subscales by Time Prior to Death. Points in (A) represent the mean weighted prevalence of social isolation in 3 month time intervals prior to death. Bars represent 95% confidence intervals. In (A) and (B) lines represents social.

Figure 3.

The Prevalence of Frequent Loneliness by Time Prior to Death. Points represent the mean weighted prevalence of frequent loneliness in 3 month time intervals prior to death. Bars represent 95% confidence intervals. The line represents loneliness modeled by time prior to death, adjusted for age at death, sex, race/ethnicity, and education. Gray shading above and below the line represents modeled 95% confidence intervals.

Figure 4.

The Adjusted Prevalence of (A) Social Isolation and (B) Loneliness by Key Sociodemographic, Medical, and Functional Covariates. Rates represent the model-based probabilities adjusted for age at death, sex, race/ethnicity, education, comorbidities, and number of ADL impairments. Error bars represent the 95% confidence intervals. All displayed comparisons reached a significance threshold of p<0.05 or less. Full model results are provided in Supplementary Materials.