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Loneliness and emergency and planned hospitalizations among a community sample of older adults.

Journal: Journal of the American Geriatrics Society

Manuscript ID: JAGS-1320-BR-Dec-09.R1

Manuscript Type: Brief Reports

Date Submitted by the Author:

15-Feb-2010

Complete List of Authors: Molloy, Gerard; University of Stirling, Department of Psychology McGee, Hannah; Royal College of Surgeons in Ireland, Psychology O'Neill, Desmond; Trinity Centre for Health Sciences, Medical Gerontology Conroy, Ronan; Royal College of Surgeons in Ireland, Epidemiology

Key Words: loneliness, social support, health care use

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Running head: Loneliness and health care use

Loneliness and emergency and planned hospitalizations among a community sample of

older adults.

*Molloy GJ, PhD

Department of Psychology, University of Stirling, Stirling Scotland.

McGee HM, PhD

Division of Population Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland

O‟Neill D, MD

Department of Medical Gerontology, Trinity Centre for Health Sciences, Adelaide and Meath

Hospital, Dublin, Ireland & Centre for Ageing, Neuroscience and the Humanities, Trinity

College Dublin, Dublin Ireland.

Conroy RM, DSc

Division of Population Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland

*Corresponding author: Department of Psychology, Cottrell Building, University of Stirling,

Stirling FK9 4LA, UK; 2School of Psychology, University Aberdeen, Aberdeen AB24 2UB,

UK. Tel: + 44 (0) 1786 467655. Fax: +44 (0) 1786 467641. Email:[email protected]

Alternative: Professor Hannah McGee, Department of Psychology, Division of Population

Health Sciences, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2,

Ireland. Tel +353-1-4022418/28, Fax +353-1-4022764 Email: [email protected]

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Background: Loneliness is as an important prognostic risk factor for poor health among older

adults. There is some conflicting evidence showing that loneliness is associated with greater

health care use.

Objective: To examine whether loneliness is independently associated with both emergency

hospitalization and planned hospital inpatient admissions in a population sample of older adults.

Design: Nationally representative cross-sectional interviews in the Republic of Ireland and

Northern Ireland.

Setting: Private homes in the community.

Participants: Randomly selected older people in the community (aged > 65 years, N=2,033).

Main outcome measure: Emergency hospitalization and planned hospital admissions.

Results: Eleven percent of the sample had an emergency hospitalization and 15% had a planned

hospital admission. Forty-two percent reported being bothered by loneliness. A higher frequency

of loneliness was associated with emergency hospitalization only (Odds ratio = 1.29, 95% CI

1.08-1.55) and this association was independent of a range of potential confounds in multivariate

analysis.

Conclusion: In this community based sample of older adults greater loneliness was

independently associated with emergency hospitalization, but not planned inpatient admissions.

Key words: Loneliness, social isolation, health care use, emergency.

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Introduction

The need to belong hypothesis states that it is a fundamental human motivation to form

and maintain strong stable interpersonal relationships 1. There is a compelling body of evidence

showing that an absence of such social relationships i.e. social isolation, is associated with

subsequent morbidity and mortality with effect sizes that rival conventional risk factors such as

obesity and physical inactivity 2. The data showing that objective indicators of social isolation,

such as unmarried status, are associated with poorer health both etiologically and prognostically

are now in little doubt 3; however perhaps more intriguingly is the increasingly large body of

work showing that the subjective experience of social isolation or „loneliness‟ is also related to

poorer subsequent health outcomes, independently of objective indicators of social isolation 4-6

.

Loneliness has been defined as an unpleasant subjective state of sensing a discrepancy

between the desired amount of companionship or emotional support and that which is available

in the person's environment 7. Loneliness is correlated with biological, psychological and social

antecedents 8,9

and there has been accumulating evidence indicating that loneliness may be an

important independent prognostic risk factor for physical illness most notably cognitive decline

10,11 and poorer psychological well being

12,13. There is also evidence showing that higher levels

of loneliness are associated with stress related pathophysiological processes that precede the

development of disease such as neuroendocrine, cardiovascular and immunological responses 14

.

These findings suggest that the loneliness to health link is indeed biologically plausible.

Loneliness may also be particularly important in understanding older adult‟s self-

management of health in the community, as it is argued that persistent feelings of loneliness can

lead to behavioural, emotional and cognitive dysregulation 9. One important set of outcomes to

understand in this context is the health care use of older adults. There are a limited number of


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studies that have examined links between loneliness and health care use. In a prospective study

of 232 heavy users of the emergency department (ED), continued use of the ED at follow-up was

associated with greater perceived loneliness at baseline 15

. In a cross-sectional study of 164 ED

users, loneliness scores were associated with the total number of ED visits over the previous year

16. Another study of 227 older women found that loneliness was associated with frequency of

physician visits and this was independent of socio-demographic factors and health status 17

. In

two separate studies that looked at the relationship between loneliness and frequency of general

practitioner (GP) consultations, no clear pattern emerged. One study found that loneliness was

significantly associated with frequency of consultation at the surgery, but not with the frequency

of home visits in a sample of 691 adults 18

, whereas the other study found no association between

loneliness and GP or other medical practitioner attendance in a sample of 1241 adults in the

community 19

.

One difficulty with interpreting this set of findings is the distinction between emergency

and planned health care use, which are very different behavioural phenomena. It is theoretically

more plausible to find associations between emergency health care use and loneliness, as planned

health care use may often be intentional planned preventive health care e.g. vaccination, which is

often though not always, characteristic of effective self-management of health in the community,

whereas emergency health care use can never be characterised in this way. Although some of

theses studies looked at emergency users only, GP consultations typically represent a

heterogenous range of emergency and planned attendances. It is important therefore to make this

distinction.

A potentially useful way of clarifying this issue is to examine both emergency and

planned hospital use separately in relation to loneliness. This type of analysis would show


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whether loneliness might be more reliably linked to certain types of health care use and could

potentially partly explain some previous conflicting results. In the present analysis we examined

whether loneliness was associated with emergency hospitalization and planned hospital inpatient,

i.e. overnight admissions in the previous year in a population survey of over two thousand older

adults20

.

Method

Participants were randomly selected community-dwelling older people identified by the

Register of Electors or postal address files in the Republic of Ireland (RoI) and Northern Ireland

(NI), respectively. Eligible participants were those aged 65 years and older living at private

residential addresses and able to participate in a research interview (response rates 73% (N=

2,033)). Participants were asked as part of structured interview if they used a hospital for medical

treatment in the last 12 months and whether visits were emergency hospitalizations or planned

inpatient, i.e. overnight, admissions . Loneliness was measured using a single item: “How often

in the last 12 months have you been bothered by loneliness?” This was measured on a 4 point

scale-Very Often, Quite Often, Not Very Often and Never. Depressive symptoms were measured

using the Hospital Anxiety and Depression scale (HADS) 21

. Social participation was measured

using 2 items: “Over the last month were you able to: Attend events outside of your home (e.g.

community or social event) and Visit friends or family in their own home.” This was measured

on a 4 point scale- Without difficulty, With some difficulty, With much difficulty, Unable to do.

Perceived social support was measured with three items: “How often would each of the

following types of support be available to you if you needed it? 1. Someone who makes you feel

loved and appreciated, 2. Someone whom you can confide in and who will give you advice or

information, 3. Someone who will help you with practical tasks like preparing meals, household


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chores or shopping?” Responses were one 5 point scale- None of the time, a little of the time,

some of the time, most of the time, most of the time, all of the time. Participants were asked “Do

you have any longstanding illness, disability or infirmity? By long-standing I mean anything that

has troubled you over a period of time or that is likely to affect you over a period of time?” This

is a standard ROI and UK census question about chronic illness. Full methodological details of

the study are available elsewhere20

. In our analysis we used univariate and multivariate binary

logistic regression (1= attended, 0 =did not attend).

Results

Eleven percent (217/2033) of the entire sample (N=2,033; Mean age 74.1 years, standard

deviation 6.8, 43% male, 55% with an longstanding illness or disability, and 44% married) had

an emergency hospitalization i.e. an attenadance at the emergency department (ED) and 15%

(312/2033) had a planned inpatient admission (PA) in the previous year. Fifty –eight percent of

the sample responded Never, 27% Not very often, 11% Quite often and 4% Very often to the

question „How often in the last 12 months have you been bothered by loneliness?‟ The

corresponding ED attendance for these 4 categories were 8.8%, 10.8%, 16.3 % and 19.5%

respectively and for PA the figures were 14.2%, 18.4%, 13% and 19.5%. Figure 1 compares the

odds of health care use for both ED and PA by comparing each of the loneliness categories with

the never lonely category. This shows that as the frequency of loneliness increased the odds of

ED hospitalization increased, but the odds of PA did not. Table 1 presents univariate and

multivariate logistic regression analysis that show the associations between ED hospitalization

and PA in the last 12 months, loneliness and other risk factors. Marital status and living alone

were not included in the same model due to multicollinearity. The table shows that greater

loneliness was associated with approximately 29% higher odds of ED hospitalization in the


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previous year in multivariate analysis. There was not a significant association between loneliness

and PA. The multivariate analyses show that the association between loneliness and ED

hospitalization was not changed by the addition of covariates into the model, including

depressive symptomatology, social participation and social support.

Discussion

Our findings show that loneliness was associated with emergency hospitalization among

older community dwelling adults, whereas planned hospital inpatient admission was not. This

association was independent of a range of potential confounds, perhaps most interestingly

depression, social participation and social support. This confirms that loneliness appears to be

more than a component of depression or a dearth of social contact and social support. It is

important to acknowledge that the present cross-sectional data cannot determine direction of

causality, however there is evidence suggesting that loneliness is as heritable as major

personality traits such as neuroticism or agreeableness 9, which would lend support to the

proposal that loneliness could potentially predict emergency health care use rather than vice

versa.

There are a number of other limitations to the present study, mainly constraints due to the

nationally representative sampling approach undertaken. These are the self-report methodology

and the retrospective recall over the previous year, which may be prone to memory bias; the lack

of information on the reasons for health care use; and the single-item loneliness measure.

However, given the scarcity of population based data linking loneliness to health care use among

older adults, the present findings are clearly important in demonstrating that the association is

more likely to be observed with emergency rather than planned health care use.


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As loneliness was not associated with planned inpatient admissions it appears that

intentional and planned health care needs are not different between those who are lonely and

those who are not, whereas emergency health care use was different between those who are

lonely and those who were not. Those who are lonely may therefore have greater health care

needs. Persistently lonely individuals may be less able to cope effectively in managing their

health due to the behavioural, emotional and cognitive regulatory deficits that are key features of

loneliness 9. It is possible that in an emergency, those who are lonely can not source practical

social support in the community and some of the emergency health care use may be

inappropriate in that particular health problems may have otherwise been resolved in the

community; however reasons for emergency hospitalization and planned admissions were not

sought in this study. It is also possible that lonely individuals have more deleterious stress

related pathophysiological responses when a health threat occurs 14

and this may also partly

account for the greater emergency health care use. Future studies should examine whether

loneliness is associated with inappropriate emergency health care use among older adults in

order order to elucidate these issues.

Conclusion

Promoting the most efficient possible use of emergency services for increasing numbers

of older people is a high priority for health services worldwide, but many of these focus on more

clearly medical components of well-being, or else look at policies and procedures which promote

admission avoidance or facilitate discharge. Although interventions for loneliness22

have not yet

been shown to be effective in older populations, the findings of this study should prompt

renewed scrutiny of loneliness as a marker of vulnerability in opportunistic or population-based


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screening, as well as studies which further our understanding of the dynamics of loneliness and

possible measures to alleviate its impact on wellbeing.

Reference List

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mechanisms. Psychosom Med. 2002;64:407-417.

(7) Blazer DG. Self-efficacy and depression in late life: a primary prevention proposal. Aging

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(8) Boomsma DI, Cacioppo JT, Muthen B, Asparouhov T, Clark S. Longitudinal genetic

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(13) Cacioppo JT, Hughes ME, Waite LJ, Hawkley LC, Thisted RA. Loneliness as a specific

risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychol

Aging. 2006;21:140-151.

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cardiovascular, and inflammatory stress responses in middle-aged men and women.

Psychoneuroendocrinology. 2004;29:593-611.


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(15) Genell AK, Rosenqvist U. Heavy users of an emergency department--a two year follow-

up study. Soc Sci Med. 1987;25:825-831.

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(17) Cheng ST. Loneliness-distress and physician utilization in well-elderly females. Journal

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(20) McGee H, O'Hanlon A, Barker M et al. One Island -Two Systems. A comparison of

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Table 1

Associations Between Health Care Use In The Last 12 Months, Loneliness And Other Risk Factors.

Emergency health care use in the last 12 months Planned admission in the last 12 months

Odds ratio (95% CI)

Univariate

Odds ratio (95% CI)

Multivariate 1*

Odds ratio (95% CI)

Multivariate 2

Odds ratio (95% CI)

Univariate

Odds ratio (95% CI)

Multivariate

Loneliness (higher scores = greater loneliness) 1.37 (1.17-1.59) 1.29 (1.08-1.55) 1.30 (1.09-1.56) 1.09 (0.94-1.25) 1.09 (0.92-1.28)

Longstanding illness, disability (1= yes, 0=no) 1.81 (1.34-2.43) 1.35 (0.98-1.87) 1.35 (0.98-1.88) 1.69 (1.31-2.17) 1.64 (1.25-2.15)

Male sex (1= yes, 0=no) 0.96 (0.72-1.28) 0.93 (0.68-1.27) 0.95(0.70-1.29) 1.43 (1.12-1.82) 1.49 (1.15-1.94)

Age (>80, 1= yes, 0=no) 1.28 (0.93-1.77) 1.15 (0.81-1.63) 1.13 (0.80-1.60) 1.14 (0.86-1.51) 1.16 (0.85-1.58)

Married (1= yes, 0=no) 1.04 (0.78-1.38) 1.31 (0.93-1.85) ------------------- 1.10 (0.86-1.40) 1.03 (0.77-1.38)

Living alone (1= yes, 0=no) 0.90 (0.68-1.20) --------------------- 0.73 (0.52-1.02) --------------------- ---------------------

Education (higher scores > education) 0.84 (0.73-0.97) 0.88 (0.76-1.01) 0.88 (0.77-1.02) 1.05 (0.96-1.15) 1.08 (0.99-1.18)

Depressive symptoms (higher scores >

symptoms)

1.13 (1.07-1.21) 1.04 (0.96-1.12) 1.03 (0.96-1.12) 1.05 (0.99-1.11) 0.96 (0.90-1.03)

Social participation (higher scores <

participation)

1.13 (1.07-1.20) 1.08 (1.01-1.16) 1.08 (1.00-1.16) 1.11 (1.05-1.17) 1.10 (1.03-1.17)


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Perceived social support (higher scores >

support)

1.03 (0.98-1.08) 1.05 (1.00-1.11) 1.05 (0.99-1.10) 1.02 (0.98-1.06) 1.04 (0.99-1.08)

* Did not include living alone due to multicollinearity with marital status.


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1

1.24

1.97

2.48

1

1.36

0.9

1.46

0

0.5

1

1.5

2

2.5

3

Never Not very often Quite often Very often

Emergency (Em) Planned (Pl)

Em CI: 0.88-1.74Pl CI: 1.03-1.78

How often in the last 12 months have you been bothered by loneliness? Odds ratio of health care use in the last year. CI: 95% Confidence interval

Em CI: 1.30-2.99 Pl CI: 0.58-1.38

Em CI: 1.41-4.38 Pl CI: 0.84-2.54


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Figure 1.

Associations Between Loneliness And Emergency And Planned Hospital Use In The Previous 12 Months.


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ACKNOWLEDGMENTS

We thank other Healthy Aging Research Programme staff and Steering Group members

who contributed in this research: Ms. Rebecca Garavan, Dr. Frances Horgan, Dr Karen

Morgan, Dr. Emer Shelley (Royal College of Surgeons in Ireland (RCSI)), Dr Claire

Donnellan, Dr. David Hevey (Trinity College Dublin), Professor Richard Layte

(Economic and Social Research Institute (ESRI)), Dr. Vivienne Crawford, Mr. John

Dinsmore, and Professor Bob Stout (Queens University Belfast). We thank Professor

James Williams (ESRI) and Dr. Donal McDade (Social and Market Research) for

coordinating community interviews in the Republic of Ireland and Northern Ireland,

respectively. We also sincerely thank research participants for their time and cooperation.

Professor Marie Johnston (University of Aberdeen, Scotland) and Professor Paul Baltes

(RIP) (Max Planck Institute for Human Development, Germany/University of Virginia)

have been external advisors to the Healthy Aging Research Programme, and we

acknowledge their support.

Financial Disclosure(s): This research was supported by a Programme Grant from the

Irish Health Research Board to Professor Hannah McGee (principal investigator, RCSI),

Professor Des O’Neill (Trinity College Dublin), Dr. Tony Fahey (ESRI) and Professor

Bob Stout (co-investigators).

Conflict of Interest Disclosures:

Elements of

Financial/Personal

Conflicts

*Author 1

GJ Molloy Author 2

HM McGee Author 3

D O’Neill Etc.

RM Conroy

Yes No Yes No Yes No Yes No

Employment or Affiliation X X X X

Grants/Funds X X X X


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Honoraria X X X X

Speaker Forum X X X X

Consultant X X X X

Stocks X X X X

Royalties X X X X

Expert Testimony X X X X

Board Member X X X X

Patents X X X X

Personal Relationship X X X X

Author Contributions:

Hannah McGee, Ronán Conroy and Des O’Neill were involved in the study concept and

design. Gerard Molloy and Hannah McGee were involved in the acquisition of data. All

authors were involved in analyses and interpretation of data and preparation of the

manuscript.

Sponsor’s Role: None.


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