Living Alone, Socially Isolated or Lonely—What are We Measuring?

M any older adults live alone. For example, in the United States, over 45 % of women over the age of 75 years live alone. Much attention has been placed on older adults who are living alone, because of the recent studies that have shown that both loneliness and social isolation are associated with poor health outcomes. These studies have also suggested that living alone is not necessarily indicative of having poor social support or of feeling lonely. While it may be reasonable to believe that living alone is a good proxy for these types of social measures, there is increasing recognition that the measures of social well-being are complex concepts and go beyond simply describing the situational facts of a person’s life. In actuality, social isolation and loneliness are complex self-perceptions that may not be fully captured by whether or not someone lives alone. This demands that as clinicians, we must dig deeper into a patient’s personal perspective. For example, measures of loneliness go beyond just asking about whether a person has social contacts, but also ask about the subjective feeling of feeling left out, isolated or not belonging. Accordingly, this raises the question of whether we should consider living alone as a risk factor for poor health outcomes and if this risk is adequately measured by asking if a patient lives alone, or if we must concomitantly include composite measures of social isolation and loneliness. In this issue of JGIM, Ennis et al. report on the association of living alone with hospitalization in community-dwelling elders. In this retrospective longitudinal cohort study, Ennis et al. followed 2,636 participants over 65 years of age from the Adults Changes in Thought (ACT) study for an average of 8.4 years. The main measures examined included hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs). After adjusting for several factors, the authors concluded that living alone was associated with a lower risk for all-cause (OR=0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. The authors also concluded that dementia did not modify any of their findings. Asking about living alone may be a useful starting point for understanding an individual’s social support. However, when placed in the context of studies that have shown detrimental effects of social isolation and loneliness, Ennis’ findings imply that this question alone does not offer a complete picture of an individual’s social milieu. This study by Ennis et al. is one of several recent studies attempting to clarify the intricacies of social support—a term that may encompass some or all of the concepts of living alone, loneliness, and social isolation. While some studies approach the experience of social isolation as unidimensional and describe it as the lack of interaction with social contacts, others have developed composite measures that incorporate both the quality and quantity of social relationships. These inconsistencies in terminology and methodology can make it difficult to understand what is actually being measured and the significance of the conclusions reached. This challenge of understanding exactly what is being measured when older adults are described as living alone is apparent in this study. In addition to asking whether patients lived alone, the authors also used a composite measure of social support, (the Interpersonal Support Evaluation List or ISEL), which provides a global measure of perceived social support across four domains (belonging, self-esteem, appraisal, and tangible help). Since the ISEL measure includes the concepts of social isolation and loneliness together, it is difficult to determine whether these factors individually had an effect on the risk of hospitalization. The authors found that subjects who lived alone scored slightly lower on the social support measure than those living with others, but the absolute difference was strikingly small. Yet, it is clear that many persons who live alone have effective social support, while many who live with others have poor social support. In our research on the effects of loneliness on functional decline and death, we found a remarkably similar relationship between living alone and loneliness. While those who lived alone were more likely to report loneliness, many who live alone are not lonely and many who live with others still feel lonely. Living alone by itself is clearly an insufficient measure of social well-being and connectivity. The significant limitations of living alone as a measure of social support is probably a major reason why Ennis et al. did not find that living alone was a risk factor for hospitalization. Another difficulty in examining the association of living alone with health outcomes is the possibility of confounding by functional status. Older persons often choose to move in with family or others when they develop functional impairments that make independent living difficult. These Published online August 5, 2014