Loneliness among elderly people is a main concern across modern societies. Although loneliness is often debated together with social isolation, the latter implies a real absence of social connections, whereas the former results from a subjective feeling of social relations. However, because living alone can lead to loneliness, individuals can be at the same time isolated and lonely. Loneliness can be contrasted through many interventions, which can be distinguished in individual- and group-based types and may be done in-person or online. Although lonely patients are frequently seen in community services, a lot of them end up hospitalized. Social prescriptions are non-medical interventions designed to help care patients by linking clinical practice with social activities. The integration of health and social care in the European welfare systems has become a urgent priority for elderly people to improve their quality of care.

The World Health Organization (WHO) has recently recognized loneliness as a factor of big concern for public health in modern societies. Being considered a major risk factor for elderly people, the list of illnesses associated to loneliness is very lengthy (for instance, anxiety, cancer, dementia, depression, heart disease). The side effects induced by loneliness push for a growing usage of health and social services, with a high increase of societal costs. Elderly people are very prone to loneliness owing to their lower social connections induced by life changes like loss of mobility, retirement and disability. Notably, since employment implies social support and engagement, lifestyle and social environment may change very much after retirement and elderly people can find it more difficult to keep their social connections [4]. So, it is unsurprising to realize that loneliness has become a widespread concern among elderly individuals in Europe.

In this commentary we first sum up the debate on the definition of loneliness in literature. Second, we analyse the potential interventions to contrast loneliness thanks to positive means such as social prescribing. Last, we offer a proposal to integrate at best health and social care.

Definition

Loneliness is often debated together with social isolation in literature. Although the two concepts are quite different, they may have similar negative effects on human health. While social isolation implies a real state of limited social contacts, loneliness is related to a personal experience of feeling alone. Therefore, while loneliness is necessarily negative, a lot of elderly people could even prefer social isolation [4,5]. However, because living alone can eventually lead to loneliness, many subjects can be isolated and feel lonely as well. Finally, loneliness can be grouped in emotional and social subtypes [1,5,9]. The first refers to the absence of one or more intimate figures, the second results from a lack of a wider social network.

Potential interventions

The mitigation of the negative effects of loneliness is currently a strong societal challenge [1]. Although it has almost become an epidemic between elderly people in a lot of European nations [2], loneliness cannot be considered an unavoidable fact of life due to aging, so it can be contrasted through many interventions [3]. A lot of reviews have been already published on loneliness interventions [4,5,7,8], with different categorizations of them which yield heterogeneous results. Altogether, loneliness interventions can be distinguished in individual- and group-based types, with one‐to‐one home‐based befriending and large‐scale social groups as extreme examples [5,10]. Moreover, interventions may be done in-person or online by internet connections. Quite recently indicated by the WHO as a useful solution to contrast loneliness in elderly people, online interventions by internet can easily contribute to boost social connections, in particular for older adults with very limited mobility living on their own [8]. As to contents, interventions aimed at achieving physical and mental health benefits in lonely elderly people can vary widely, from psychological therapies to contacts with nature (for instance, blue and green spaces) and pet company [1]. Notably, mobile older adults are more likely to opt for recreational or physical group programs [6]. Finally, it is worth noting that the benefits of loneliness interventions are methodologically challenging to be proved through scientific evidence because the outcome measures of the organizational studies designed to assess different interventions compared to usual care are very uncertain so their results are hardly ever extendable to other settings.

Social prescribing

A lot of elderly patients experiencing loneliness are first seen in primary care settings [2]. Therefore, general practitioners (GPs) are fully conscious of the importance of loneliness and should be in the right place to contrast it in elderly people. However, GPs feel an absence of therapeutic options to constrain the negative effects of loneliness. Consequently, since loneliness is nowadays almost comparable to obesity and smoking as a mortality risk, a lot of elderly people living on their own are inevitably admitted through accident and emergency departments [9]. That is why social prescribing is increasingly considered a promising add-on approach to medical treatments [6]. Social prescriptions are non-clinical interventions which should help patients to enhance their health by linking traditional medical practice with the social services delivered in community. Because loneliness is a societal issue requiring holistic collaboration among health and social services [7], social prescriptions should contribute to fulfil the major needs of elderly individuals [4]. Social prescribing should also encourage to integrate health and social care by facilitating GPs to address lonely patients to the social activities in community that should meet at best their psychosocial needs. This approach should fill care gaps and enhance both mental and physical health of lonely patients. Since healthcare has a smaller impact than socioeconomic factors on lonely adults, a multi-objective approach should be the best strategy to target the multi-dimensional problem of loneliness in elderly people [8]. A ‘link worker’ fulfilling the need of a go-between clinicians and local community sectors could play a very important role [13]. In fact, by facilitating lonely patients to access social activities in their community, a link worker could really have a positive impact on their health [6]. Directly referred from primary care, the link worker should meet lonely patients on an individual basis so as to address them to the social services which might fulfil their needs at best [4,14]. Because a one-size-fits-all approach cannot be effective on the different causes of loneliness by definition, the link worker should choose the most indicated person-centered interventions for lonely patients [7,14]. Furthermore, the personal involvement of elderly patients in planning activities should be the best strategy to overcome their likely resistance against an external supporter [10]. Last but not least, because a ‘quick fix ‘to loneliness does not exist by definition, the link worker should follow up his/her patients besides the first intervention period so as to maintain the reduction of loneliness side effects in the long period.

Crucial issues

Elderly people suffer a growing number of chronic disorders that require a close integration among health and social services in modern societies. As a consequence, socioeconomic inequalities should be carefully considered nowadays because high-income people with high levels of education enjoy much better and longer life expectancies than low-income people with low education who started working at a younger age. So, we believe that policies such as earlier retirement for lower socio-economic groups should be widely adopted by European nations in the long run []. Without paying more attention to equity considerations, the attempts to enhance health for the socially disadvantaged populations could be ineffective or even lead to increase social inequalities [9]. All in all, increased longevity leads to growing age-related conditions such as loneliness. That is why taking care of the increasing number of elderly people living alone has become a big challenge for the welfare systems of most European countries. According to the WHO, the integration of health and social services should be the best solution to deal with this growing issue. Nowadays building bridges for integrated care plans in primary care and local community is considered a crucial strategy in developed countries [14]. Elderly people need a social environment framed to decrease loneliness thanks to social activities provided in community settings or directly at home. Involving older adults in social entertainments like community life (for instance, conferences and social clubs) and leisure time (for instance, movies and comedies) should contribute to postpone as long as possible their cognitive impairment and decrease their quality of life. In light of the strong evidence of resistance to external care by elderly patients owing to the threat of losing their independence, social workers should be fully conscious that accepting social care is a hard challenge for elderly people. Ultimately, a person-centered social care should be the best strategy to make feel lonely adults to be the leaders (and not the followers) of the interventions aimed at tackling their mental and physical decline.

Comment

An integrated management of health and social care in community has become a top priority to strengthen the quality of care provided to elderly people in this era of increasing burden of chronic illnesses, of which loneliness is a paramount example. Striving for dismantling any type of barriers that potentially weaken the coordination of services provided to elderly people who need multiple care, we think that a model for European welfare systems should be inspired by a whole integration of care across health and social services, ideally placed in the same organizations in primary care. Rather than obliging elderly patients and their carers to navigate through health and social systems, health care and social services should be designed around the patients in a societal perspective of ‘good dying’, supported by multidisciplinary and well-trained health and social workforces. Such a holistic approach should enhance a global competence larger than the sum of its parts in the welfare systems. Besides better coping with the growing needs of ageing populations, investing in integrated community care should increase also the efficiency of the European welfare systems in the long run. Indeed, a crucial goal according to the inevitable growth of age-related public expenditures.