By: Graham Teaford, OTD, OTR/L, SCLV

There has long been concern among occupational therapy practitioners about the risk and potential harm of social isolation and loneliness among older adults. There are good reasons for this emphasis. The issue is widespread, with some estimates suggesting that nearly a quarter of older adults living in the community experience social isolation (Pomeroy et al., 2023). Furthermore, social isolation is associated with increased risk of institutionalization, depression, functional declines, and mortality (Golden et al., 2009; Hoogendijk et al., 2020; Leigh-Hunt, et al., 2017; Pomeroy et al, 2023). The effects of social isolation appear to increase the perception of loneliness among older adults (Taylor, 2020). That is, the more socially isolated a person is, the more likely they are to also experience loneliness. This is particularly concerning as there is a higher risk of mortality among older adults with the combined presence of frailty, and loneliness or social isolation (Hoogendijk et al., 2020). It is understandable why these continue to be areas of great concern for occupational therapy practitioners.

Fortunately, occupational therapy has long demonstrated the ability to promote health and quality of life through occupational engagement (Jackson et al., 1998; Clark et al., 2012). These interventions can improve social connection and address social isolation as a hazardous but potentially modifiable risk factor (Cudjoe et al., 2020). It is appropriate that OT has focused on the many complex factors that contribute to social isolation, including geography, family living situations, life stage changes, and a range of sociodemographic factors. As an OT clinician working most of my career, I would certainly not advocate reducing the emphasis on addressing social isolation. However, it is a fair question to ask how one might address an individual who spends much of their time engaged in solitary occupations without apparent distress.

Who is the Person Who is Alone?

To borrow from Bilbo Baggins via J.R.R. Tolkien: “Not all who wander are lost.”  Similarly, it is fair to wonder: are all who are alone socially isolated or depressed? To unpack this a bit, it may be helpful to review the terms. Social isolation refers to the objective lack of access to tangible established social networks and connections. Loneliness is the subjective experience of a discrepancy between an older adult’s desired level of social engagement and support and their lived reality (Veazie et al., 2019). Both are concerns for those of us working with older adults because they can affect mood. In addition, loneliness is related to social isolation, such that greater social isolation is associated with greater loneliness (Taylor, 2020). However, it does appear that there are some older adults who might spend more time alone by choice without the process necessarily being attributed to social isolation or loneliness.

Being Alone vs. Being Lonely

Lay et al. (2020) noted that although humans are social beings who need social contact to thrive, it does not necessarily follow that we want such contact all of the time. They researched people who chose to seek out solitude and noted that older adults might be more likely than those in middle adulthood to spend their time alone. The researchers found that older adults were more likely than the middle-aged participants to maintain a positive affect while seeking solitude. The reasons for this are likely complex and may include differences in work demand, more time spent at home, greater emotional stability, stronger emotional regulation, and greater control over social contacts (that is, not having to engage in as much forced fun or obligatory social participation).

There is also scholarship suggesting that a distinction should be made between solitude, which may carry connotations of being remote, alone, socially isolated, or lonely, and positive solitude (Ost Mor et al., 2021). The consensus definition and distinction between these terms remains a work in progress. There are likely many factors that influence whether solitude is perceived as desirable or instead experienced as something closer to social isolation. Certainly, the ability to spend time in a more favorable surrounding or the ability to enjoy solitude is shaped by a variety of social, economic, and contextual factors. However, one intriguing possibility is that the difference might be framed based on the approach one takes toward being alone at times. That is, some people may experience time alone to be meaningful, calming, and volitional. OT literature is replete with examples of solitary occupations that people may find rewarding. Pierce (2001) provides examples such as listening to music, being in nature, and “quiet-focus” occupations such as needlework or woodworking.  

Summary 

As OT practitioners, we are unlikely to stop attending to the issues raised by persons who spend much of their time alone. I would not advocate for doing so. We routinely ask individuals about their degree of social participation and occupational engagement, and we will continue to provide services to promote occupational engagement opportunities. We continue to have tools to screen for this risk, including the UCLA Loneliness Scale and the Lubben Social Network Scale (Lubben, 1988; Russell, 1996). However, it is worth exploring how individual older adults perceive the time that they spend alone. While continuing to address the need to expand social opportunities, we may also be able to support a positive sense of solitude through occupational engagement. In this way, the time that is spent alone might be perceived more positively.

References

Clark, F., Jackson, J., Carlson, M., Chou, C.-P., Cherry, B. J., Jordan-Marsh, M., Knight, B. G., Mandel, D., Blanchard, J., Granger, D. A., Wilcox, R. R., Lai, M. Y., White, B., Hay, J., Lam, C., Marterella, A., & Azen, S. P. (2012). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the well elderly 2 randomised controlled trial. Journal of Epidemiology and Community Health, 66(9), 782–790. https://doi.org/10.1136/jech.2009.099754

Cudjoe, T. K. M., Roth, D. L., Szanton, S. L., Wolff, J. L., Boyd, C. M., & Thorpe, R. J. (2020). The epidemiology of social isolation: National Health and Aging Trends Study. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 75(1), 107–113. https://doi.org/10.1093/geronb/gby037

Golden, J., Conroy, R. M., Bruce, I., Denihan, A., Greene, E., Kirby, M., & Lawlor, B. A. (2009). Loneliness, social support networks, mood and wellbeing in community-dwelling elderly. International Journal of Geriatric Psychiatry, 24(7), 694–700. https://doi.org/10.1002/gps.2181

Hoogendijk, E. O., Smit, A. P., van Dam, C., Schuster, N. A., de Breij, S., Holwerda, T. J., Huisman, M., Dent, E., & Andrew, M. K. (2020). Frailty combined with loneliness or social isolation: An elevated risk for mortality in later life. Journal of the American Geriatrics Society, 68(11),  2587-2593. https://doi.org/10.1111/jgs.16716 

Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: the Well Elderly Study Occupational Therapy Program. American Journal of Occupational Therapy, 52(5), 326–336. https://doi.org/10.5014/ajot.52.5.326

Lay, J. C., Pauly, T., Graf, P., Mahmood, A., & Hoppmann, C. A. (2020). Choosing solitude: Age differences in situational and affective correlates of solitude-seeking in midlife and older adulthood. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 75(3), 483–493. https://doi.org/10.1093/geronb/gby044

Leigh-Hunt, N., Bagguley, D., Bash, K., Turner, V., Turnbull, S., Valtorta, N., & Caan, W. (2017). An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health, 152, 157–171. https://doi.org/10.1016/j.puhe.2017.07.035

Lubben, J. E. (1988). Assessing social networks among elderly populations. Family & Community Health: The Journal of Health Promotion & Maintenance, 11(3), 42–52. https://doi.org/10.1097/00003727-198811000-00008 

Pierce, D. (2001). Occupation by design: Dimensions, therapeutic power, and creative process. American Journal of Occupational Therapy, 55(3), 249–259. https://doi.org/10.5014/ajot.55.3.249 

Pomeroy, M. L., Cudjoe, T. K. M., Cuellar, A. E., Ihara, E. S., Ornstein, K. A., Bollens-Lund, E., Kotwal, A. A., & Gimm, G. W. (2023). Association of social isolation with hospitalization and nursing home entry among community-dwelling older adults. JAMA Internal Medicine, 183(9), 955–962. https://doi.org/10.1001/jamainternmed.2023.3064

Russell, D. W. (1996). UCLA Loneliness Scale (Version 3): Reliability, validity, and factor structure. Journal of Personality Assessment, 66(1), 20–40. https://doi.org/10.1207/s15327752jpa6601_2 

Taylor, H. O. (2020). Social isolation’s influence on loneliness among older adults. Clinical Social Work Journal, 48(1), 140–151. https://doi.org/10.1007/s10615-019-00737-9

Veazie, S., Gilbert, J., Winchell, K., Paynter, R., & Guise, J. M. (2019). Addressing social isolation to improve the health of older adults: A rapid review. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK537897/