Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses

Causal Inference and Observational Research: The Utility of Twins

Valid causal inference is central to progress in theoretical and applied psychology. Although the randomized experiment is widely considered the gold standard for determining whether a given exposure increases the likelihood of some specified outcome, experiments are not always feasible and in some cases can result in biased estimates of causal effects. Alternatively, standard observational approaches are limited by the possibility of confounding, reverse causation, and the nonrandom distribution of exposure (i.e., selection). We describe the counterfactual model of causation and apply it to the challenges of causal inference in observational research, with a particular focus on aging. We argue that the study of twin pairs discordant on exposure, and in particular discordant monozygotic twins, provides a useful analog to the idealized counterfactual design. A review of discordant-twin studies in aging reveals that they are consistent with, but do not unambiguously establish, a causal effect of lifestyle factors on important late-life outcomes. Nonetheless, the existing studies are few in number and have clear limitations that have not always been considered in interpreting their results. It is concluded that twin researchers could make greater use of the discordant-twin design as one approach to strengthen causal inferences in observational research.

Depression and loneliness in Jamaicans with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is the commonest genetic disorder in Jamaica, and has life-long implications for those afflicted with it. It is well known that depression and loneliness may exist in those with chronic diseases, but the coexistence of depression and loneliness in people with sickle cell disease is not clear. The aim of this study is to determine the prevalence of and factors associated with depression and loneliness in the Jamaica Sickle Cell Cohort Study and its age and sex matched controls.

METHODS

277 patients with SCD and 65 controls were administered a questionnaire that studied demographics, disease severity, depression, and loneliness. Regression analyses were done to examine relationships between outcomes and associated variables.

RESULTS

Depression was found in 21.6% of patients and 9.4% in controls. Loneliness scores were also significantly higher in patients (16.9 +/- 5.1) than in controls (14.95 +/- 4.69). Depression was significantly associated with unemployment [OR = 2.9, p-value: < 0.001], whereas unemployment (p-value: 0.002), and lower educational attainment were significantly associated with loneliness.In patients with SCD, depression was significantly associated with being unemployed (OR 2.4, 95% CI 1.2,4.6, p-value:0.01), presence of a leg ulcer (OR = 3.8, 95% CI: 1.7, 8.4, p-value: 0.001), frequent visits (OR = 3.3, 95% CI: 1.2, 8.9, p-value: 0.019), and frequent painful crises (OR = 2.5, 95% CI: 1.1, 5.8, p-value: 0.035). Not being employed (Coef.: 2.0; p-value: 0.004) and higher educational attainment (tertiary vs. primary education, Coef.: -5.5; p-value: < 0.001) were significant associations with loneliness after adjusting for genotype.

CONCLUSIONS

Health workers need to actively look for and manage these problems to optimize their patients' total biopsychosocial care.

Perceived social isolation makes me sad: 5-year cross-lagged analyses of loneliness and depressive symptomatology in the Chicago Health, Aging, and Social Relations Study

We present evidence from a 5-year longitudinal study for the prospective associations between loneliness and depressive symptoms in a population-based, ethnically diverse sample of 229 men and women who were 50-68 years old at study onset. Cross-lagged panel models were used in which the criterion variables were loneliness and depressive symptoms, considered simultaneously. We used variations on this model to evaluate the possible effects of gender, ethnicity, education, physical functioning, medications, social network size, neuroticism, stressful life events, perceived stress, and social support on the observed associations between loneliness and depressive symptoms. Cross-lagged analyses indicated that loneliness predicted subsequent changes in depressive symptomatology, but not vice versa, and that this temporal association was not attributable to demographic variables, objective social isolation, dispositional negativity, stress, or social support. The importance of distinguishing between loneliness and depressive symptoms and the implications for loneliness and depressive symptomatology in older adults are discussed.

Childhood loneliness as a predictor of adolescent depressive symptoms: an 8-year longitudinal study

Childhood loneliness is characterised by children's perceived dissatisfaction with aspects of their social relationships. This 8-year prospective study investigates whether loneliness in childhood predicts depressive symptoms in adolescence, controlling for early childhood indicators of emotional problems and a sociometric measure of peer social preference. 296 children were tested in the infant years of primary school (T1 5 years of age), in the upper primary school (T2 9 years of age) and in secondary school (T3 13 years of age). At T1, children completed the loneliness assessment and sociometric interview. Their teachers completed externalisation and internalisation rating scales for each child. At T2, children completed a loneliness assessment, a measure of depressive symptoms, and the sociometric interview. At T3, children completed the depressive symptom assessment. An SEM analysis showed that depressive symptoms in early adolescence (age 13) were predicted by reports of depressive symptoms at age 8, which were themselves predicted by internalisation in the infant school (5 years). The interactive effect of loneliness at 5 and 9, indicative of prolonged loneliness in childhood, also predicted depressive symptoms at age 13. Parent and peer-related loneliness at age 5 and 9, peer acceptance variables, and duration of parent loneliness did not predict depression. Our results suggest that enduring peer-related loneliness during childhood constitutes an interpersonal stressor that predisposes children to adolescent depressive symptoms. Possible mediators are discussed.

A pilot study assessing social support among cancer patients enrolled on clinical trials: a comparison of younger versus older adults

Purpose:

This study tested the logistical feasibility of obtaining data on social support systems from cancer patients enrolled on clinical trials and compared the social support of older adults (age ≥65) and younger adults (<50 years of age) with cancer.

Methods:

Patients had to be eligible for a phase II or phase III oncology clinical trial and enter the study prior to treatment. Patients filled out the Lubben Social Network Scale (LSNS) at baseline. The Symptom Distress Scale (SDS) and single-item overall quality of life (QOL) Uniscale were assessed at baseline and weekly for 4 weeks.

Results:

There was no significant difference in overall mean Lubben social support levels by age. Older patients had more relatives they felt close to (85% versus 53% with 5 or more relatives, P = 0.02), heard from more friends monthly (84% versus 53% with 3 or more friends, P = 0.02), less overall symptom distress (P = 0.03), less insomnia (P = 0.003), better concentration (P = 0.005), better outlook (P = 0.01), and less depression (P = 0.005) than younger patients.

Conclusions:

Younger subjects reported worse symptoms, a smaller social support network, and fewer close friends and relatives than older subjects. Having someone to discuss decisions and seeing friends or relatives often was associated with longer survival.

Evaluation of quality of life in people with aphasia using a Dutch version of the SAQOL-39

PURPOSE

To examine the quality of life (QoL) of people with aphasia and to study the influence of variables such as age, time post onset and (degree of) social support on the QoL of aphasic persons.

METHOD

We compared the scores of an aphasic population (N = 43) with those of a healthy control group (N = 43) and of a group of patients with brain lesions without neurogenic communication disorders (N = 43) on a Dutch version of the Stroke and Aphasia Quality of Life-scale (SAQoL-39) and on a social support questionnaire. In half of the aphasic group, the SAQoL-39 was re-administered 8 months after the first testing.

RESULTS

People with aphasia obtained significantly lower scores for QoL measures compared with both other groups. Especially, communicative and psychosocial factors seem to influence these results. Older people with aphasia scored lower than younger persons and women tend to evaluate their QoL somewhat more negatively than men. Persons who had aphasia for more than 6 months tended to have higher QoL-scores compared with those who had become aphasic more recently. After 8 months, the retested group scored significantly higher on communication and on psychosocial functioning than on first testing.

CONCLUSIONS

Gathering information on QoL after suffering from stroke and from aphasia can lead to a better understanding of the problems involved. The clinical use of instruments such as the SAQoL-39 can probably contribute to a more patient oriented rehabilitation, whereby the focus not only lie in improving linguistic skills but also on reducing the impairments and the handicaps that accompany aphasia and thus on increasing QoL.

Moderating effect of apolipoprotein genotype on loneliness leading to depressive symptoms in Chinese older adults

OBJECTIVE

Depressive symptoms, which are both common and heritable, are important indicators of the extent of general well-being and health in old age. Identifying risk factors for depressive symptoms may lead to improved intervention and effective prevention. Both the presence of the apolipoprotein (APOE) genotype and loneliness are associated with later life symptoms of depression, and all three share a neuroendocrine signature, namely altered activity in the hypothalamic-pituitary-adrenal axis. The authors expected a positive association of loneliness with depressive symptoms, a negative link between APOE epsilon2 with depressive symptoms, and a significant genotype-environment interaction between loneliness (the social environment) and APOE epsilon2 on symptoms of depression.

DESIGN

This was a cross-sectional observational study.

SETTING AND PARTICIPANTS

A population-based sample of 979 Chinese people from Taiwan aged 54 years and older was examined.

MEASUREMENTS

A short-form of the Center for Epidemiologic Studies of Depression Scale was used and the genotype of APOE was obtained.

RESULTS

The interaction between loneliness and APOE epsilon2 was found to be negatively associated with depressive symptoms in adjusted regression models. Loneliness was also positively correlated with symptoms of depression.

CONCLUSIONS

These data suggest that the APOE epsilon2 genotype decreases vulnerability to symptoms of depression in the presence of a social stressor, namely loneliness in this case, and has implications for the enhancement of well-being among older adults. Future studies are needed to delineate the mechanism underlying this gene-environment interaction.

Loneliness and cortisol: momentary, day-to-day, and trait associations

In attempts to understand the social determinants of health, strong associations have been found between measures of loneliness, physiological stress processes, and physical and mental health outcomes. Feelings of loneliness are hypothesized to have implications for physiological stress processes, including activity of the hypothalamic-pituitary-adrenal (HPA) axis. In a community sample of young adults, multilevel modeling was used to examine whether trait and state feelings of loneliness were related to changes in levels of the stress-sensitive hormone cortisol, and whether the associations between loneliness and cortisol were mediated or moderated by the presence of concurrent depression or high levels of chronic life stress. Results indicated that trait loneliness was associated with a flattening of the diurnal cortisol rhythm. In addition, both daily and momentary state variations in loneliness were related to cortisol. Prior day feelings of loneliness were associated with an increased cortisol awakening response the next morning and momentary experiences of loneliness during the day were associated with momentary increases in cortisol among youth who also had high chronic interpersonal stress. Results were significant after covarying current depression, both chronic and momentary reports of stress, and medical and lifestyle covariates. This study expanded on prior work by investigating and revealing three different time courses of association between loneliness and HPA axis activity in young adults: trait, daily and momentary.

Loneliness and risk of mortality: a longitudinal investigation in Alameda County, California

We investigated the prospective impact of self-reported loneliness on all-cause mortality, mortality from ischemic disease and mortality from other cardiovascular diseases. We tested these effects through GEE binomial regression models applied to longitudinal data from the Alameda County Study of persons aged 21 and over arranged into person-years. Controlling for age and gender, the chances of all-cause mortality were significantly higher among respondents reporting that they often feel lonely compared to those who report that they never feel lonely. Frequent loneliness was not significantly associated with mortality from ischemic heart disease but more than doubled the odds of mortality from other ailments of the circulatory system in models controlling for age and gender. Subsequent models showed that physical activity and depression may be important mediators of loneliness-mortality associations. Finally, we find support for the contention that chronic loneliness significantly increases risk of mortality but also find reason to believe that relatively recent changes in feelings of loneliness increase risk of mortality as well.

Self-esteem modulates medial prefrontal cortical responses to evaluative social feedback

Self-esteem is a facet of personality that influences perception of social standing and modulates the salience of social acceptance and rejection. As such, self-esteem may bias neural responses to positive and negative social feedback across individuals. During functional magnetic resonance imaging scanning, participants (n = 42) engaged in a social evaluation task whereby they ostensibly received feedback from peers indicating they were liked or disliked. Results demonstrated that individuals with low self-esteem believed that they received less positive feedback from others and showed enhanced activity to positive versus negative social feedback in the ventral anterior cingulate cortex/medial prefrontal cortex (vACC/mPFC). By contrast, vACC/mPFC activity was insensitive to positive versus negative feedback in individuals with high self-esteem, and these individuals consistently overestimated the amount of positive feedback received from peers. Voxelwise analyses supported these findings; lower self-esteem predicted a linear increase in vACC/mPFC response to positive versus negative social feedback. Taken together, the present findings propose a functional role for the vACC/mPFC in representing the salience of social feedback and shaping perceptions of relative social standing.

Loneliness predicts increased blood pressure: 5-year cross-lagged analyses in middle-aged and older adults

Loneliness is a prevalent social problem with serious physiological and health implications. However, much of the research to date is based on cross-sectional data, including our own earlier finding that loneliness was associated with elevated blood pressure (Hawkley, Masi, Berry & Cacioppo, 2006). In this study, we tested the hypothesis that the effect of loneliness accumulates to produce greater increases in systolic blood pressure (SBP) over a 4-year period than are observed in less lonely individuals. A population-based sample of 229 50- to 68-year-old White, Black, and Hispanic men and women in the Chicago Health, Aging, and Social Relations Study was tested annually for each of 5 consecutive years. Cross-lagged panel analyses revealed that loneliness at study onset predicted increases in SBP 2, 3, and 4 years later (B = 0.152, SE = 0.091, p < .05, one-tailed). These increases were cumulative such that higher initial levels of loneliness were associated with greater increases in SBP over a 4-year period. The effect of loneliness on SBP was independent of age, gender, race or ethnicity, cardiovascular risk factors, medications, health conditions, and the effects of depressive symptoms, social support, perceived stress, and hostility.

Effects of internet use on health and depression: a longitudinal study

Background

The rapid expansion of the Internet has increased the ease with which the public can obtain medical information. Most research on the utility of the Internet for health purposes has evaluated the quality of the information itself or examined its impact on clinical populations. Little is known about the consequences of its use by the general population.

Objective

Is use of the Internet by the general population for health purposes associated with a subsequent change in psychological well-being and health? Are the effects different for healthy versus ill individuals? Does the impact of using the Internet for health purposes differ from the impact of other types of Internet use?

Methods

Data come from a national US panel survey of 740 individuals conducted from 2000 to 2002. Across three surveys, respondents described their use of the Internet for different purposes, indicated whether they had any of 13 serious illnesses (or were taking care of someone with a serious illness), and reported their depression. In the initial and final surveys they also reported on their physical health. Lagged dependent variable regression analysis was used to predict changes in depression and general health reported on a later survey from frequency of different types of Internet use at an earlier period, holding constant prior depression and general health, respectively. Statistical interactions tested whether uses of the Internet predicted depression and general health differently for people who initially differed on their general health, chronic illness, and caregiver status.

Results

Health-related Internet use was associated with small but reliable increases in depression (ie, increasing use of the Internet for health purposes from 3 to 5 days per week to once a day was associated with .11 standard deviations more symptoms of depression, P = .002). In contrast, using the Internet for communication with friends and family was associated with small but reliable decreases in depression (ie, increasing use of the Internet for communication with friends and family purposes from 3 to 5 days per week to once a day was associated with .07 standard deviations fewer symptoms of depression, P = .007). There were no significant effects of respondents’ initial health status (P = .234) or role as a caregiver (P = .911) on the association between health-related Internet use and depression. Neither type of use was associated with changes in general health (P = .705 for social uses and P = .494 for health uses).

Conclusions

Using the Internet for health purposes was associated with increased depression. The increase may be due to increased rumination, unnecessary alarm, or over-attention to health problems. Additionally, those with unmeasured problems or those more prone to health anxiety may self-select online health resources. In contrast, using the Internet to communicate with friends and family was associated with declines in depression. This finding is comparable to other studies showing that social support is beneficial for well-being and lends support to the idea that the Internet is a way to strengthen and maintain social ties.

Social and emotional aging

The past several decades have witnessed unidimensional decline models of aging give way to life-span developmental models that consider how specific processes and strategies facilitate adaptive aging. In part, this shift was provoked by the stark contrast between findings that clearly demonstrate decreased biological, physiological, and cognitive capacity and those suggesting that people are generally satisfied in old age and experience relatively high levels of emotional well-being. In recent years, this supposed "paradox" of aging has been reconciled through careful theoretical analysis and empirical investigation. Viewing aging as adaptation sheds light on resilience, well-being, and emotional distress across adulthood.

Familial resemblance for loneliness

Social isolation and loneliness in humans have been associated with physical and psychological morbidity, as well as mortality. This study aimed to assess the etiology of individual differences in feelings of loneliness. The genetic architecture of loneliness was explored in an extended twin-family design including 8,683 twins, siblings and parents from 3,911 families. In addition, 917 spouses of twins participated. The presence of assortative mating, genetic non-additivity, vertical cultural transmission, genotype-environment (GE) correlation and interaction was modeled. GE interaction was considered for several demographic characteristics. Results showed non-random mating for loneliness. We confirmed that loneliness is moderately heritable, with a significant contribution of non-additive genetic variation. There were no effects of vertical cultural transmission. With respect to demographic characteristics, results indicated that marriage, having offspring, more years of education, and a higher number of siblings are associated with lower levels of loneliness. Interestingly, these effects tended to be stronger for men than women. There was little evidence of changes in genetic architecture as a function of these characteristics. We conclude that the genetic architecture of loneliness points to non-additive genetic influences, suggesting it may be a trait that was not neutral to selection in our evolutionary past. Sociodemographic factors that influence the prevalence of loneliness do not affect its genetic architecture.

Psychological distress after stroke and aphasia: the first six months

Objective: We explored the factors that predicted psychological distress in the first six months post stroke in a sample including people with aphasia.

Design: Prospective longitudinal observational study.

Setting and subjects: Participants with a first stroke from two acute stroke units were assessed while still in hospital (baseline) and at three and six months post stroke.

Main measures: Distress was assessed with the General Health Questionnaire-12. Other measures included: NIH Stroke Scale, Barthel Index, Frenchay Aphasia Screening Test, Frenchay Activities Index, MOS Social Support Scale and social network indicators. Logistic regression was used to identify predictors of distress at each stage post stroke; and to determine what baseline factors predicted distress at six months.

Results: Eighty-seven participants were able to self-report on measures used, of whom 32 (37%) had aphasia. 71 (82%) were seen at six months, including 11 (16%) with aphasia. Predictors of distress were: stroke severity at baseline; low social support at three months; and loneliness and low satisfaction with social network at six months. The baseline factors that predicted distress at six months were psychological distress, loneliness and low satisfaction with social network (Nagelkerke R2 = 0.49). Aphasia was not a predictor of distress at any time point. Yet, at three months post stroke 93% of those with aphasia experienced high distress, as opposed to 50% of those without aphasia (χ2 (1) = 8.61, P<0.01).

Conclusions: Factors contributing to distress after stroke vary across time. Loneliness and low satisfaction with one’s social network are particularly important and contribute to long-term psychological distress.

Job insecurity and change over time in health among older men and women

OBJECTIVES

We estimated associations between job insecurity and change over time in the physical and psychological health of older adult men and women.

METHODS

We conducted secondary analyses of longitudinal data from men and women (N = 190) born between 1935 and 1952 in the Chicago Health, Aging, and Social Relations Study. We used multivariate regression techniques to test the association of job insecurity with changes in physical health (self-reported global health, resting blood pressure, and urinary catecholamines [epinephrine]) and psychological health (depressive symptoms, hostility, loneliness, and personal stress). We controlled for individual characteristics and baseline measures of the outcomes.

RESULTS

Men who experience job insecurity rate themselves in significantly poorer physical health and have higher blood pressure and higher levels of urinary catecholamines compared with men who do not experience job insecurity and women who do. Women who experience job insecurity show higher depressive symptoms and report more hostility, loneliness, and personal stress compared with women who do not experience job insecurity and men who do.

DISCUSSION

The correlation between job insecurity and health is different in men and women but may be clinically significant in both populations and is a potentially important threat to older adults' health and well-being.

Measuring social isolation among older adults using multiple indicators from the NSHAP study

OBJECTIVES

The National Social Life, Health, and Aging Project (NSHAP) data contain multiple indicators of social connectedness, social participation, social support, and loneliness among older adults. We suggest that these indicators can be combined to measure two aspects of social isolation: social disconnectedness (i.e., physical separation from others) and perceived isolation (i.e., feelings of loneliness and a lack of social support). We use the NSHAP data to create scales measuring social disconnectedness and perceived isolation and examine their distribution among older adults.

METHODS

We assess the reliability of the scales using Cronbach's alpha and item-total correlations and perform confirmatory factor analysis to test the model against the data. Finally, we test differences in scale means across subgroups to assess the distribution of social disconnectedness and perceived isolation among older adults.

RESULTS

We find that 17 indicators combine into two reliable scales. The social disconnectedness scale has a two-factor structure, including the restricted social network dimension and the social inactivity dimension. The perceived isolation scale also comprises two dimensions: lack of support and loneliness. We find that social disconnectedness does not vary across age groups, but the oldest old feel more isolated than the young old. Social disconnectedness and perceived isolation are greater among those who have worse health. Discussion The creation of scales measuring social disconnectedness and perceived isolation provides one way to utilize the wide variety of indicators of social isolation collected in the NSHAP study. Although individual indicators of social connectedness or isolation are useful in their own right, these scales provide parsimonious, continuous variables that account for a variety of aspects of social isolation, which may be especially useful for inclusion in multivariate analyses predicting health outcomes.

Women, loneliness, and incident coronary heart disease

OBJECTIVE

To examine associations between loneliness and risk of incident coronary heart disease (CHD) over a 19-year follow-up period in a community sample of men and women. Loneliness, the perceived discrepancy between actual and desired social relationships, has been linked to several adverse health outcomes. However, no previous research has prospectively examined the association between loneliness and incident CHD in a community sample of men and women.

METHODS

Hypotheses were examined using data from the First National Health and Nutrition Survey and its follow-up studies (n = 3003). Loneliness, assessed by one item from the Center for Epidemiologic Studies of Depression scale, and covariates were derived from baseline interviews. Incident CHD was derived from hospital records/death certificates over 19 years of follow-up. Hypotheses were evaluated, using Cox proportional hazards models.

RESULTS

Among women, high loneliness was associated with increased risk of incident CHD (high: hazard ratio = 1.76, 95% Confidence Interval = 1.17-2.63; medium: hazard ratio = 0.98, 95% Confidence Interval = 0.64-1.49; reference: low), controlling for age, race, education, income, marital status, hypertension, diabetes, cholesterol, physical activity, smoking, alcohol use, systolic and diastolic blood pressures, and body mass index. Findings persisted additionally controlling for depressive symptoms. No significant associations were observed among men.

CONCLUSIONS

Loneliness was prospectively associated with increased risk of incident CHD, controlling for multiple confounding factors. Loneliness among women may merit clinical attention, not only due to its impact on quality of life but also its potential implications for cardiovascular health.

Predictors of loneliness in U.S. adults over age sixty-five

The purpose of this study was to examine sociodemographic and health-related risks for loneliness among older adults using Health and Retirement Study Data. Overall prevalence of loneliness was 19.3%. Marital status, self-report of health, number of chronic illnesses, gross motor impairment, fine motor impairment, and living alone were predictors of loneliness. Age, female gender, use of home care, and frequency of healthcare visits were not predictive. Loneliness is a prevalent problem for older adults in the United States with its own health-related risks. Future research of interventions targeting identified risks would enhance the evidence base for nursing and the problem of loneliness.

Perceived social isolation and cognition

Social species, from Drosophila melanogaster to Homo sapiens, fare poorly when isolated. Homo sapiens, an irrepressibly meaning-making species, are, in normal circumstances, dramatically affected by perceived social isolation. Research indicates that perceived social isolation (i.e. loneliness) is a risk factor for, and may contribute to, poorer overall cognitive performance, faster cognitive decline, poorer executive functioning, increased negativity and depressive cognition, heightened sensitivity to social threats, a confirmatory bias in social cognition that is self-protective and paradoxically self-defeating, heightened anthropomorphism and contagion that threatens social cohesion. These differences in attention and cognition impact on emotions, decisions, behaviors and interpersonal interactions that can contribute to the association between loneliness and cognitive decline and between loneliness and morbidity more generally.

The effect of the traditional living arrangement, anpakkori, on depressive symptoms in elderly people residing on jeju island

OBJECTIVE

We examined the effect of anpakkori, a traditional living arrangement, on depression among elderly people on Jeju Island in Korea.

METHODS

A total of 593 subjects were assessed using a sociodemographic questionnaire developed by the authors, the Korean version of Geriatric Depression Scale (KGDS), the Social Support Scale, and the Activities of Daily Living/Instrumental Activities of Daily Living scales (ADL/IADL). Subjects were classified into three groups: those residing with their adult children, those living individually, and those living in the traditional Jeju anpakkori living arrangement.

RESULTS

The prevalence of depression in this study was 53.1%, and the traditional Jeju living arrangement, anpakkori, was significantly correlated with the presence of depressive symptoms (p=0.005)[odds ratio (OR)=1.88, 95% confidence interval (CI)=1.16-3.06].

CONCLUSION

Living in the traditional Jeju way may not be as good for establishing family solidarity as is living with adult children. Moreover, elderly individuals prone to depression tended to live in this anpakkori living arrangement. Careful psychological and social support systems that might prevent the development of depressive symptoms should be provided for those who live in anpakkori living arrangements.

Unmet needs and depressive symptoms among low--income older adults

Previous studies have found that declining health, decreased social interaction, and inadequate financial resources were significant risk factors for late-life depression, and social support from families and friends and religiosity were significant protective factors. In this study, we examined if low-income older adults' perceived unmet need for home- and community-based services for many aging-associated problems would be independently associated with their depressive symptoms, controlling for these known risk and protective factors. We interviewed a total of 213 community-residing older adults to assess their depressive symptoms, using the Geriatric Depression Scale (GDS), and unmet needs in the areas of personal assistance, instrumental and environmental support, emotional support, and other facilitative/enabling services. We found that the number of unmet needs was significantly positively associated with these older adults' depressive symptoms, although it explained only a small proportion of the variance of the GDS scores. Future research and practice implications are discussed.

Loneliness, social support networks, mood and wellbeing in community-dwelling elderly

OBJECTIVE

Both loneliness and social networks have been linked with mood and wellbeing. However, few studies have examined these factors simultaneously in community-dwelling participants. The aim of this study was to examine the relationship between social network, loneliness, depression, anxiety and quality of life in community dwelling older people living in Dublin.

METHODS

One thousand two hundred and ninety-nine people aged 65 and over, recruited through primary care practices, were interviewed in their own homes using the GMS-AGECAT. Social network was assessed using Wenger's typology.

RESULTS

35% of participants were lonely, with 9% describing it as painful and 6% as intrusive. Similarly, 34% had a non-integrated social network. However, the two constructs were distinct: 32% of participants with an integrated social network reported being lonely. Loneliness was higher in women, the widowed and those with physical disability and increased with age, but when age-related variables were controlled for this association was non-significant. Wellbeing, depressed mood and hopelessness were all independently associated with both loneliness and non-integrated social network. In particular, loneliness explained the excess risk of depression in the widowed. The population attributable risk (PAR) associated with loneliness was 61%, compared with 19% for non-integrated social network. Taken together they had a PAR of 70%

CONCLUSIONS

Loneliness and social networks both independently affect mood and wellbeing in the elderly, underlying a very significant proportion of depressed mood.

Predictive value of age for coping: the role of self-efficacy, social support satisfaction and perceived stress

OBJECTIVES

The present study was prompted by the lack of agreement on how coping changes with age. We postulate that the effect of age on coping is mediated by coping resources, such as self-efficacy, perceived stress and social support satisfaction.

METHOD

The participants in the study were community dwelling and aged between 22 and 88 years old. Data were collected using the General Self Efficacy Scale, the Social Support Questionnaire, the Perceived Stress Scale, the Geriatric Depression Scale, the Social Readjustment Rating Scale (life-events) and the Way of Coping Checklist.

RESULTS

We performed path analyses for two competitive structural models: M1 (age does not directly affect coping processes) and M2 (age directly affects coping processes). Our results supported a modified version of M2. Age was not found to predict either of two coping strategies: problem-focused coping is predicted by self-efficacy and social support satisfaction; emotion-focused coping is predicted by social support satisfaction and perceived stress.

DISCUSSION

Changes in coping over the lifespan reflect the effectiveness with which a person's adaptive processes deal with age-associated changes in self-referred beliefs and environment perception.

Loneliness predicts reduced physical activity: cross-sectional & longitudinal analyses

OBJECTIVE

To determine cross-sectional and prospective associations between loneliness and physical activity, and to evaluate the roles of social control and emotion regulation as mediators of these associations.

DESIGN

A population-based sample of 229 White, Black, and Hispanic men and women, age 50 to 68 years at study onset, were tested annually for each of 3 years.

MAIN OUTCOME MEASURES

Physical activity probability, and changes in physical activity probability over a 3-year period.

RESULTS

Replicating and extending prior cross-sectional research, loneliness was associated with a significantly reduced odds of physical activity (OR = 0.65 per SD of loneliness) net of sociodemographic variables (age, gender, ethnicity, education, income), psychosocial variables (depressive symptoms, perceived stress, hostility, social support), and self-rated health. This association was mediated by hedonic emotion regulation, but not by social control as indexed by measures of social network size, marital status, contact with close ties, group membership, or religious group affiliation. Longitudinal analyses revealed that loneliness predicted diminished odds of physical activity in the next two years (OR = 0.61), and greater likelihood of transitioning from physical activity to inactivity (OR = 1.58).

CONCLUSION

Loneliness among middle and older age adults is an independent risk factor for physical inactivity and increases the likelihood that physical activity will be discontinued over time.

Loneliness: a concept analysis

TOPIC

Loneliness is a universal human experience recognized since the dawn of time, yet it is unique for every individual. Loneliness can lead to both depression and low self-esteem.

PURPOSE

This article explicates the concept of loneliness through the examination of its conceptual definition and uses, defining attributes, related concepts, and empirical referents.

SOURCES OF INFORMATION

Literature review using hand search and database were used as sources of information.

CONCLUSION

Because loneliness is commonly encountered in nursing situations, the information provided will serve as a framework for assessment, planning, intervention, and evaluation of clients.

Engagement in persons with dementia: the concept and its measurement

PURPOSE

The aim of this article is to delineate the underlying premises of the concept of engagement in persons with dementia and present a new theoretical framework of engagement.

SETTING/SUBJECTS

The sample included 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia.

METHODOLOGY

The authors describe a model of factors that affect engagement of persons with dementia. Moreover, the authors present the psychometric qualities of an assessment designed to capture the dimensions of engagement (Observational Measurement of Engagement). Finally, the authors detail plans for future research and data analyses that are currently underway.

DISCUSSION

This article lays the foundation for a new theoretical framework concerning the mechanisms of interactions between persons with cognitive impairment and environmental stimuli. Additionally, the study examines what factors are associated with interest and negative and positive feelings in engagement.

Life regrets and pride among low-income older adults: relationships with depressive symptoms, current life stressors and coping resources

We examined the contents and intensities of both life regrets and pride among a convenience sample of 213 low-income older adults and the associations between the contents and intensities of life regrets and pride, on the one hand, and the older adults' current life stressors, coping resources and depressive symptoms, on the other. Regrets about education, career and marriage were common, but intensities of regrets were higher for issues related to finance/money, family conflict and children's problems, loss and grief, and health. Common sources of pride were related to children and parenting, career, volunteering/informal caregiving, long/strong marriage and personal growth/self. Controlling for current life stressors of disability, money worries, loneliness and overdependence on others for management of daily life, and coping resources of social support and religiosity, the intensities of loss-and-grief related regrets and the pride in long/strong marriage were significant predictors of the Geriatric Depression Scale (GDS) scores. However, the regrets and pride explained a small amount of the variance in the GDS scores, while the current life stressors explained a large portion of the variance.

Social disconnectedness, perceived isolation, and health among older adults

Previous research has identified a wide range of indicators of social isolation that pose health risks, including living alone, having a small social network, infrequent participation in social activities, and feelings of loneliness. However multiple forms of isolation are rarely studied together making it difficult to determine which aspects of isolation are most deleterious for health. Using population-based data from the National Social Life, Health, and Aging Project, we combine multiple indicators of social isolation into scales assessing social disconnectedness (e.g., small social network, infrequent participation in social activities) and perceived isolation (e.g., loneliness, perceived lack of social support). We examine the extent to which social disconnectedness and perceived isolation have distinct associations with physical and mental health among older adults. Results indicate that social disconnectedness and perceived isolation are independently associated with lower levels of self-rated physical health. However, the association between disconnectedness and mental health may operate through the strong relationship between perceived isolation and mental health. We conclude that health researchers need to consider social disconnectedness and perceived isolation simultaneously.

The Relationship of Social Engagement to Psychological Well-Being of Older Adults in Assisted Living Facilities

The purpose of this study is to explore social engagement and its relationship to the psychological well-being of older adults residing in assisted living facilities (ALFs). Drawing on activity theory, the study focuses on the salience of social relationships on residents' life satisfaction and depressive symptoms. A total of 82 residents were interviewed face-to-face in eight ALFs in a southern state of the United States. The data were analyzed using hierarchical regression models in that demographic and health variables, site characteristics, and social engagement variables were entered into the model in successive steps. Results indicate that perceived friendliness of residents and staff was significantly associated with life satisfaction and depressive symptoms controlling for other variables, and enjoyment of mealtimes was related to low depressive symptoms. Findings suggest that ALFs could promote residents' psychological well-being by encouraging residents to develop meaningful relationships within the facility and by designing enjoyable mealtimes.

In the eye of the beholder: individual differences in perceived social isolation predict regional brain activation to social stimuli

Prior research has shown that perceived social isolation (loneliness) motivates people to attend to and connect with others but to do so in a self-protective and paradoxically self-defeating fashion. Although recent research has shed light on the neural correlates of social perception, cooperation, empathy, rejection, and love, little is known about how individual differences in loneliness relate to neural responses to social and emotional stimuli. Using functional magnetic resonance imaging, we show that there are at least two neural mechanisms differentiating social perception in lonely and nonlonely young adults. For pleasant depictions, lonely individuals appear to be less rewarded by social stimuli, as evidenced by weaker activation of the ventral striatum to pictures of people than of objects, whereas nonlonely individuals showed stronger activation of the ventral striatum to pictures of people than of objects. For unpleasant depictions, lonely individuals were characterized by greater activation of the visual cortex to pictures of people than of objects, suggesting that their attention is drawn more to the distress of others, whereas nonlonely individuals showed greater activation of the right and left temporo-parietal junction to pictures of people than of objects, consistent with the notion that they are more likely to reflect spontaneously on the perspective of distressed others.

Loneliness and the health of older people

BACKGROUND

The intense focus on major psychiatric disorders in both contemporary psychiatric research and clinical practice has resulted in the relative neglect of less definable constructs such as loneliness and how such entities might impact on health outcomes. The purpose of this review is to raise awareness among physicians and psychiatrists of the medical impact and biological effects of loneliness as well as making the argument that loneliness should be a legitimate therapeutic target.

METHODS

Using Pubmed we searched the literature for research and review papers looking at loneliness as a construct, how it is measured and its health effects. We reviewed the relevant papers and have summarized their main findings.

RESULTS

Loneliness has strong associations with depression and may in fact be an independent risk factor for depression. Furthermore loneliness appears to have a significant impact on physical health being linked detrimentally to higher blood pressure, worse sleep, immune stress responses and worse cognition over time in the elderly. There is a relative deficiency in adequate evidence based treatments for loneliness.

CONCLUSION

Loneliness is common in older people an is associated with adverse health consequences both from a mental and physical health point of view. There needs to be an increased focus on initiating intervention strategies targeting loneliness to determine if decreasing loneliness can improve quality of life and functioning in the elderly.

From social structural factors to perceptions of relationship quality and loneliness: the Chicago health, aging, and social relations study

OBJECTIVE

The objective of this study was to test a conceptual model of loneliness in which social structural factors are posited to operate through proximal factors to influence perceptions of relationship quality and loneliness.

METHODS

We used a population-based sample of 225 White, Black, and Hispanic men and women aged 50 through 68 from the Chicago Health, Aging, and Social Relations Study to examine the extent to which associations between sociodemographic factors and loneliness were explained by socioeconomic status, physical health, social roles, stress exposure, and, ultimately, by network size and subjective relationship quality.

RESULT

Education and income were negatively associated with loneliness and explained racial/ethnic differences in loneliness. Being married largely explained the association between income and loneliness, with positive marital relationships offering the greatest degree of protection against loneliness. Independent risk factors for loneliness included male gender, physical health symptoms, chronic work and/or social stress, small social network, lack of a spousal confidant, and poor-quality social relationships.

DISCUSSION

Longitudinal research is needed to evaluate the causal role of social structural and proximal factors in explaining changes in loneliness.

Enrichment Effects on Adult Cognitive Development: Can the Functional Capacity of Older Adults Be Preserved and Enhanced?

In this monograph, we ask whether various kinds of intellectual, physical, and social activities produce cognitive enrichment effects-that is, whether they improve cognitive performance at different points of the adult life span, with a particular emphasis on old age. We begin with a theoretical framework that emphasizes the potential of behavior to influence levels of cognitive functioning. According to this framework, the undeniable presence of age-related decline in cognition does not invalidate the view that behavior can enhance cognitive functioning. Instead, the course of normal aging shapes a zone of possible functioning, which reflects person-specific endowments and age-related constraints. Individuals influence whether they function in the higher or lower ranges of this zone by engaging in or refraining from beneficial intellectual, physical, and social activities. From this point of view, the potential for positive change, or plasticity, is maintained in adult cognition. It is an argument that is supported by newer research in neuroscience showing neural plasticity in various aspects of central nervous system functioning, neurochemistry, and architecture. This view of human potential contrasts with static conceptions of cognition in old age, according to which decline in abilities is fixed and individuals cannot slow its course. Furthermore, any understanding of cognition as it occurs in everyday life must make a distinction between basic cognitive mechanisms and skills (such as working-memory capacity) and the functional use of cognition to achieve goals in specific situations. In practice, knowledge and expertise are critical for effective functioning, and the available evidence suggests that older adults effectively employ specific knowledge and expertise and can gain new knowledge when it is required. We conclude that, on balance, the available evidence favors the hypothesis that maintaining an intellectually engaged and physically active lifestyle promotes successful cognitive aging. First, cognitive-training studies have demonstrated that older adults can improve cognitive functioning when provided with intensive training in strategies that promote thinking and remembering. The early training literature suggested little transfer of function from specifically trained skills to new cognitive tasks; learning was highly specific to the cognitive processes targeted by training. Recently, however, a new generation of studies suggests that providing structured experience in situations demanding executive coordination of skills-such as complex video games, task-switching paradigms, and divided attention tasks-train strategic control over cognition that does show transfer to different task environments. These studies suggest that there is considerable reserve potential in older adults' cognition that can be enhanced through training. Second, a considerable number of studies indicate that maintaining a lifestyle that is intellectually stimulating predicts better maintenance of cognitive skills and is associated with a reduced risk of developing Alzheimer's disease in late life. Our review focuses on longitudinal evidence of a connection between an active lifestyle and enhanced cognition, because such evidence admits fewer rival explanations of observed effects (or lack of effects) than does cross-sectional evidence. The longitudinal evidence consistently shows that engaging in intellectually stimulating activities is associated with better cognitive functioning at later points in time. Other studies show that meaningful social engagement is also predictive of better maintenance of cognitive functioning in old age. These longitudinal findings are also open to important rival explanations, but overall, the available evidence suggests that activities can postpone decline, attenuate decline, or provide prosthetic benefit in the face of normative cognitive decline, while at the same time indicating that late-life cognitive changes can result in curtailment of activities. Given the complexity of the dynamic reciprocal relationships between stimulating activities and cognitive function in old age, additional research will be needed to address the extent to which observed effects validate a causal influence of an intellectually engaged lifestyle on cognition. Nevertheless, the hypothesis that an active lifestyle that requires cognitive effort has long-term benefits for older adults' cognition is at least consistent with the available data. Furthermore, new intervention research that involves multimodal interventions focusing on goal-directed action requiring cognition (such as reading to children) and social interaction will help to address whether an active lifestyle enhances cognitive function. Third, there is a parallel literature suggesting that physical activity, and aerobic exercise in particular, enhances older adults' cognitive function. Unlike the literature on an active lifestyle, there is already an impressive array of work with humans and animal populations showing that exercise interventions have substantial benefits for cognitive function, particularly for aspects of fluid intelligence and executive function. Recent neuroscience research on this topic indicates that exercise has substantial effects on brain morphology and function, representing a plausible brain substrate for the observed effects of aerobic exercise and other activities on cognition. Our review identifies a number of areas where additional research is needed to address critical questions. For example, there is considerable epidemiological evidence that stress and chronic psychological distress are negatively associated with changes in cognition. In contrast, less is known about how positive attributes, such as self-efficacy, a sense of control, and a sense of meaning in life, might contribute to preservation of cognitive function in old age. It is well known that certain personality characteristics such as conscientiousness predict adherence to an exercise regimen, but we do not know whether these attributes are also relevant to predicting maintenance of cognitive function or effective compensation for cognitive decline when it occurs. Likewise, more information is needed on the factors that encourage maintenance of an active lifestyle in old age in the face of elevated risk for physiological decline, mechanical wear and tear on the body, and incidence of diseases with disabling consequences, and whether efforts to maintain an active lifestyle are associated with successful aging, both in terms of cognitive function and psychological and emotional well-being. We also discuss briefly some interesting issues for society and public policy regarding cognitive-enrichment effects. For example, should efforts to enhance cognitive function be included as part of a general prevention model for enhancing health and vitality in old age? We also comment on the recent trend of business marketing interventions claimed to build brain power and prevent age-related cognitive decline, and the desirability of direct research evidence to back claims of effectiveness for specific products.

Depression prevalence: is it really increasing?

OBJECTIVE

There is conflicting evidence as to whether depression prevalence is increasing or is stable. Although birth cohort analysis studies show increasing prevalence, longitudinal studies do not. To date there are no published Australian studies providing long-term estimates of depression prevalence. The aim of the present study was to examine the increasing depression prevalence hypothesis in an Australian context.

METHOD

Data from the 1998 and 2004 South Australian Health Omnibus Surveys were re-analysed. In each survey there were >3000 participants who were interviewed. The data were weighted to achieve representativeness prior to analysis. Depression status was classified by the Primary Care Evaluation of Mental Disorders scale (the PRIME-MD) into major, other and no depressions. Both univariate and multivariable analyses were used to examine depression trends over time and to adjust the data for significant background variables.

RESULTS

There was no significant increase in the cases of patients classified with major depression between 1998 and 2004; there was, however, a significant decrease in other depression. The overall unadjusted prevalence of major depression was 7.4% (6.8% in 1998 and 8.0% in 2004) and for other depression it was 9.5% (10.6% in 1998 and 8.4% in 2004). The highest levels of depression, both major and other, were observed among females aged 15-29 years, and the lowest levels among those aged > or =50 years. The strongest predictor of depression was poor overall health status.

CONCLUSION

It is time for the conventional wisdom that depression is increasing to be reconsidered, and for a more realistic perspective, developed from evidence-based analyses, to be accepted.

Addressing loneliness in later life

OBJECTIVES

Social and solitary pastimes with the potential to ameliorate the experience of loneliness among older individuals were investigated for the purpose of informing future interventions designed to reduce the negative consequences of social isolation.

METHOD

Nineteen individual interviews with Australians aged 65 years and older.

RESULTS

Several pastimes were described by interviewees as instrumental in determining whether the increasing social isolation they experience in older age results in feelings of emotional isolation and thus of loneliness.

CONCLUSION

The specific behaviours that were found to ameliorate loneliness included utilizing friends and family as an emotional resource, engaging in eating and drinking rituals as a means of maintaining social contacts, and spending time constructively by reading and gardening. Specific recommendations are provided for interventions designed to prevent and treat loneliness among older people.

Genetic and environmental contributions to stability in loneliness throughout childhood

Heritability estimates based on two small cross-sectional studies in children indicate that the genetic contribution to individual differences in loneliness is approximately 50%. A recent study estimated the genetic contribution to variation in loneliness in adults to be 48%. The current study aims to replicate and expand these findings by conducting longitudinal analyses in order to study causes of individual differences in stability of loneliness throughout childhood. Univariate and multivariate longitudinal analyses are conducted in a large sample of young Dutch twins. Information on loneliness comes from maternal ratings on the Child Behavior Checklist. Using an average score of loneliness over ages 7, 10, and 12, results from the two previous studies are replicated and a heritability estimate of 45% is found. The remaining variance is accounted for by shared environmental influences (12%), and nonshared environmental influences (43%). The longitudinal analyses, however, show that heritability is 58% at age 7, 56% at age 10, but drops to 26% at age 12. A parallel increase in influences of shared family environment is observed, explaining 6% of the variance at age 7, 8% at age 10 and 35% at age 12. The remaining variance is explained by relatively stable influences of nonshared environmental factors. Stability in loneliness is high, with phenotypic correlations in the range of 0.51-0.69. This phenotypic stability is mainly caused by genetic and nonshared environmental influences. The results indicate the importance of both innate as well as nonshared environmental factors for individual differences in loneliness. Further, different results between causes of individual differences for the average score of loneliness and results for age 12 from the longitudinal analyses, indicate the importance of longitudinal analyses with data at well-defined ages.

Spirituality and autonomic cardiac control

BACKGROUND

Spirituality has been suggested to be associated with positive health, but potential biological mediators have not been well characterized.

PURPOSE AND METHODS

The present study examined, in a population-based sample of middle-aged and older adults, the potential relationship between spirituality and patterns of cardiac autonomic control, which may have health significance. Measures of parasympathetic (high-frequency heart rate variability) and sympathetic (pre-ejection period) cardiac control were obtained from a representative sample of 229 participants. Participants completed questionnaires to assess spirituality (closeness to and satisfactory relationship with God). Personality, demographic, anthropometric, health behavior, and health status information was also obtained. A series of hierarchical regression models was used to examine the relations between spirituality, the autonomic measures, and two derived indexes--cardiac autonomic balance (CAB, reflecting parasympathetic to sympathetic balance) and cardiac autonomic regulation (CAR, reflecting total autonomic control).

RESULTS

Spirituality, net of demographics, or other variables were found to be associated with enhanced parasympathetic as well as sympathetic cardiac control (yielding a higher CAR) but was not associated with CAB. Although the number of cases was small (N = 11), both spirituality and CAR were significant negative predictors of the prior occurrence of a myocardial infarction.

CONCLUSIONS

In a population-based sample, spirituality appears to be associated with a specific pattern of CAR, characterized by a high level of cardiac autonomic control, irrespective of the relative contribution of the two autonomic branches. This pattern of autonomic control may have health significance.

Cardiac autonomic balance versus cardiac regulatory capacity

The concept of autonomic balance views autonomic states along a bipolar continuum from sympathetic (S) to parasympathetic (P) dominance, whereas regulatory capacity models emphasize overall autonomic flexibility as a marker of the capacity for regulation. These two concepts were evaluated for their utility in characterizing patterns of autonomic control. Measures of P (high frequency heart rate variability, HF) and S (preejection period, PEP) cardiac control were obtained. A measure of cardiac autonomic balance (CAB) was derived as the difference in the normalized P index minus the S index, and a measure of cardiac autonomic regulation (CAR) was derived as the normalized P index plus the S index. Results reveal that CAR, but not CAB, was a significant predictor of the prior occurrence of a myocardial infarction, net of demographic and other variables, whereas CAB, but not CAR, was a significant predictor of concurrent diabetes.