Suffering from loneliness indicates significant mortality risk of older people.

Abstract

Background. The harmful associates of suffering from loneliness are still in dispute. Objective. To examine the association of feelings of loneliness with all-cause mortality in a general aged population. Methods. A postal questionnaire was sent to randomly selected community-dwelling of elderly people (>74 years) from the Finnish National Population Register. The questionnaire included demographic characteristics, living conditions, functioning, health, and need for help. Suffering from loneliness was assessed with one question and participants were categorized as lonely or not lonely. Total mortality was retrieved from the National Population Information System. Results. Of 3687 respondents, 39% suffered from loneliness. Lonely people were more likely to be deceased during the 57-month follow-up (31%) than subjects not feeling lonely (23%, P < .001). Excess mortality (HR = 1.38, 95% CI = 1.21-1.57) of lonely people increased over time. After controlling for age and gender, the mortality risk of the lonely individuals was 1.33 (95% CI = 1.17-1.51) and after further controlling for subjective health 1.17 (CI = 1.02-1.33). The excess mortality was consistent in all major subgroups. Conclusion. Suffering from loneliness is common and indicates significant mortality risk in old age.

Full text

Page 1

SAGE-Hindawi Access to Research
Journal of Aging Research
Volume 2011, Article ID 534781, 5 pages
doi:10.4061/2011/534781
Research Article
Suffering fromLoneliness Indicates
SignificantMortalityRisk ofOlderPeople
ReijoS.Tilvis,1,2VenlaLaitalaV,1PirkkoE.Routasalo,2andKaisuH. Pitk¨ al¨ a2,3
1Clinics of Internal Medicine and Geriatrics, Helsinki University Central Hospital, BOX 340, 00290 HUS, Helsinki, Finland
2Central Union for the Welfare of the Aged, Malmin kauppatie 26, 00700 Helsinki, Finland
3Unit of General Practice, Helsinki University Central Hospital, BOX 20, 00014 University of Helsinki, Helsinki, Finland
Correspondence should be addressed to Reijo S. Tilvis, reijo.tilvis@helsinki.fi
Received 30 November 2010; Revised 5 January 2011; Accepted 13 January 2011
Academic Editor: James Lindesay
Copyright © 2011 Reijo S. Tilvis et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background.Theharmfulassociatesofsufferingfromlonelinessarestillindispute.Objective. Toexaminetheassociationoffeelings
of loneliness with all-cause mortality in a general aged population. Methods. A postal questionnaire was sent to randomly selected
community-dwelling of elderly people (>74 years) from the Finnish National Population Register. The questionnaire included
demographic characteristics, living conditions, functioning, health, and need for help. Suffering from loneliness was assessedwith
one question and participants were categorized as lonely or not lonely. Total mortalitywas retrieved from the National Population
Information System. Results. Of 3687 respondents, 39% suffered from loneliness. Lonely people were more likely to be deceased
during the 57-month follow-up (31%) than subjects not feeling lonely (23%, P < .001). Excess mortality (HR = 1.38, 95% CI =
1.21–1.57)oflonelypeopleincreasedovertime.After controllingforageandgender,themortalityriskofthelonelyindividualswas
1.33(95% CI = 1.17–1.51)andafter further controllingforsubjective health 1.17 (CI = 1.02–1.33).The excess mortalitywascon-
sistent in all majorsubgroups. Conclusion. Suffering from loneliness is commonand indicates significantmortality risk in old age.
1.Introduction
Loneliness is a distressing feeling which has been defined as
an individual’s subjective experience about lack of satisfying
human relationships [1]. The terms loneliness and social
isolation have often been used interchangeably but they
are distinct concepts [2]. Social isolation refers to the
numberofindividual’ssocialcontacts,and can beobjectively
measured. Loneliness can beevaluatedonlyby theindividual
experiencing it [2]. In Finland, about one third of older
people suffer from loneliness [3, 4]. Poor functional status,
widowhood, living alone, depression, feeling of being poorly
understood by close persons, and unfulfilled expectations
of contacts with friends have been the most powerful
explanations for suffering from loneliness [4, 5]. Thus, the
quality and satisfaction of relationships are more important
determinants of loneliness than the actual number of
contacts [6–9].
Several studies have addressed the harmful associates
of loneliness. Associations have been found with impaired
qualityoflife[10],poorsubjectivehealth[11]disability[12],
increased use of social and health services [13–16], and risk
of cognitive decline [16, 17]. Consequently, the deleterious
effects of loneliness on survival prognosis could be expected
but the results have been inconsistent, so far. Social isolation
has been proved to increase mortality independently of
feelings of loneliness [18, 19]. In middle-aged men the
increased postoperative mortality after coronary by-passing
has been associated with low quality of social relationships
and feelings of loneliness [20]. Fewer feelings of loneliness
have been associated with a reduced mortality risk among
older persons living in the Netherlands [21]. In this sample
excess mortality was neither explained by the chronic disease
status nor lack of social support suggesting that loneliness
influences mortality through another pathway than physical
health status. Nordid the person’s subjective health or health
behavior account for the interaction between loneliness and
mortality. On the contrary, social support and loneliness
have been found to affect indirectly on mortality of the
Japanese older people via chronic diseases, functional status,
and subjective health [19].

Page 2

2Journal of Aging Research
In a 10-year followup of 75-, 80-, and 85-year-old
citizens of Helsinki, both cognitive decline and mortality
were doubled among people feeling lonely [16, 22].
These results prompted us to conduct a nationwide ran-
domized controlled intervention trial aimed at empowering
elderly people, and promoting their peer support, and social
integration [23]. The intervention group showed a signif-
icant improvement in subjective health, better cognition,
and significantly lower health care costs during the two-year
followup. In addition, the intervention led to a surprisingly
clear mortality reduction within 2-year followup.
This surprising result prompted us to retest the asso-
ciation of loneliness with survival prognosis of the whole
population sample. The major target was to assess whether
and to what extent suffering from loneliness is an indicator
of mortality among home-dwelling elderly people.
2.Methods
In autumn 2002, a postal questionnaire was sent to random
sample of 6,786 Finnish aged (≥75 years) people gathered
from the Finnish National Population Register, and resent
after one month to those who had not yet responded [4,
5]. After removing people living in permanent institutional
care (10.5%), and people who had died before receiving
the questionnaire (5.1%), the number of the potential
community-dwelling respondents was 5722, of which 4113
returned the questionnaire. The response rate was thus 72%.
Approval to conduct the survey was obtained from the local
Ethics Committee.
The questionnaire included background information
such as age, gender, marital status, education, living condi-
tions, social contacts, physical functioning, subjective health,
and subjective need for help. Loneliness was assessed in
one question “Do you suffer from loneliness?” (1=seldom
or never, 2=sometimes, and 3=often or always). This
question has been used in prior surveys since 1989 and
has been found to be easily understandable for older
persons [16]. Loneliness was divided using two categories
(0 (not lonely)=those who reported feeling lonely seldom
or never, and 1 (lonely)=those who suffered from loneliness
sometimes and often or always).
Subjective health was asked with the question “What do
you consider your current health to be like?” (1=healthy,
2=quite healthy, 3=unhealthy and 4=very unhealthy).
Subjective health was categorized using two groups (0
(good)=those who considered them healthy and quite
healthy, 1 (poor)=those who considered them unhealthy
or very unhealthy). Poor vision indicated inability to read
normal text and poor hearing was defined as an inability to
follow normal discussion.
Total mortality up to 30 April, 2007 was retrieved from
the National Population Information System, which keeps
registry of all Finnish citizens. According to this Register,
assessment of vital status is very reliable for people having
their permanent residence in Finland (as in the present
cohort) irrespective whether they die in Finland or abroad.
The assessment of vital status was 100% complete.
3.StatisticalMethods
The data were analyzed with theSPSSforWindowsstatistical
program. Lonely respondents were compared to those not
feeling lonely with the X2-test for categorical variables and
with Mann-Whitney U testforage(continuousvariablewith
nonnormal distribution).Independentrisksofmortalityand
the role of feeling lonely in survival time were assessed using
the Cox survival analyses, in which age, gender, subjective
health and other variables concerning the status of the
respondents were forced in as covariates. The Kaplan-Meier
curvewasusedtoillustratethecumulativeeffectofloneliness
onmortalityinvarioussubgroups.Therespondentswhohad
answered the question about suffering from loneliness were
included to the primary analyses (n = 3687). The effects of
nonresponses (n = 171)were tested in sensitivity analyses, in
which the nonrespondents were alternatively allocated to the
lonely and not-lonely groups.
4.Results
4.1. Prevalence and Associates. Mean age of the respondents
was 81 and 69% of them were women. Of the respondents,
38.7% reported suffering from loneliness always, often, or
at least sometimes (Table 1). Loneliness was more common
in women than men and was associated significantly for
example, with old age, widowhood, lower education, poor
health, poor vision and hearing, living in residential care,
need for daily help, and inability to go outdoors daily. In the
oldest age group (>85 years), 47% reported suffering from
loneliness.
4.2. Predictive Value. Altogether, 967 respondents died
within 57-month followup. The all-cause mortality rate of
the lonely elderly subjects was 30.8%, whereas that of not-
lonely was significantly lower (23.4%, Hazard Ratio (HR) =
1.38, P < .001). Of the baseline characteristics differing
between the lonely and not lonely individuals, male gender
(HR 1.77, P < .001), age (HR 1.09/year, P < .001), need
for daily help (HR 1.87, P < .001), poor subjective health
(HR 1.51, P < .001), not having a physical exercise hobby
(HR 1.44, P < .001), and living in residential care (HR 1,26,
P < .001) were cumulatively forced into the Cox survival
analyses as covariates.
After controlling for age and gender, the mortality risk
of the lonely persons was significantly increased (HR 1.33,
95%CI = 1.17–1.51, P < .001) (Table 1). The adjusted life-
table analyses revealed that the difference in the surviving
rate increased over the follow-up period (Figure 1). The risk
(HR 1.17, P = .023) remained significantly elevated after
further controlling for subjective health (Table 2). Control-
ling for all associates of loneliness (Table 1) abolished the
statistical significance of the predictive value of loneliness.
4.3. Consistency of Observations. The subgroup analyses
showed that mortality was consistently increased in lonely
people of major subgroups (Table 2). The impact of loneli-
ness diminished with deteriorating the subjective health and

Page 3

Journal of Aging Research3
Table 1: Baseline characteristics and 57-month mortality by
suffering from loneliness.
Characteristic
Not lonely
N = 2260
63.1
80.8 (70–99)
40,5
Lonely
N = 1427
76.6
81.7 (72–98)
64,5
P-value1
Women, %
Age, years (range)
Widowed, %
Living in
residential care, %
High education, %
Poor health, %
Poor income, %
Poor functioning,
%
Goes outdoors
daily, %
Subjective need for
daily help, %
Poor vision, %
Poor hearing, %
Physical exercise
hobby weekly, %
Deceased within 57
months
Hazard ratios of loneliness (95% confidence intervals)
Unadjusted1.00
Age and gender1.00
Age, gender, and
subjective health
1Differences between the groups were tested with X2test for categorical
variables, and with Mann-Whitney U test for continuous variables.
<.001
<.001
<.001
5.610.4
<.001
39.2
26.4
1.5
30.0
46,3
4.8
<.001
<.001
<.001
13.9 29.7
<.001
85.072.9
<.001
19.636.7
<.001
5.1
9.8
10.4
16.3
<.001
<.001
67,6 55,0
<.001
23,430.8
<.001
1.38 (1.21–1.57)
1.33 (1.17–1.51)
<.001
<.001
1.001.17 (1.02–1.33).022
was greater in men (age-adjusted HR 1.68, CI = 1.37–2.07,
P < .001) than women (age-adjusted HR 1.15, CI = 0.98–
1.36, P = .083). The excess risk of death of the lonely people
was most obvious among individuals living in residential
care (HR 1.55), not being widowed (HR 1.41), and having a
physical exercise hobby (HR 1.37). No subgroup was found,
inwhichtheageandgenderadjustedhazard ratiowerebelow
1.0.
4.4. SensitivityAnalyses. Because 171 persons did not answer
the question about suffering from loneliness, the effects of
drop-outs were tested with two-type sensitivity analyses.
When the nonrespondents were allocated to the not lonely
group, the hazard ratio adjusted for age, gender, and
subjective health was 1.17 (CI = 1.03–1.34,P = .017). When
the nonresponders were allocated to lonely, the respective
figure was 1.13 (CI = 0.99–1.29, P = .059).
5.Discussion
Although there have been several longitudinal studies show-
ing the adverse effects of loneliness on health and use of
health services [13, 15–17, 21, 23, 24], this relatively large
Table 2: Age and gender adjusted 57-month mortality risks of
loneliness in selected subgroups.
Subgroup
Men
Women
<85 years
≥ 85 years
Good health
Poor health
Daily need for help
No daily need for help 2700
Widowed
Not widowed
Living at home
Living in residential
care
Goes outdoors daily
Does not go outdoors
daily
Physical exercise
hobby
No physical exercise
hobby
N
HR
1.80
1.30
1.31
1,23
1,31
1.07
1.18
1.13
1.32
1.41
1.22
95% CI
1.47–2.21
1.11–1,53
1,12–1.55
1.01–1,51
1.09–1.59
0.89–1.28
0.98–1.44
0.93–1.36
1,10–1.57
1,16–1.71
1.06–1,41
P-value
<.001
<.001
<.001
.043
.004
.471
.087
.217
.003
<.001
.006
1131
2556
2884
803
2381
1231
947
1826
1861
3319
3261.551.10–2.18.013
30531.180.99–1,39.057
7261.341.08–1.67.008
23321.371.13–1.67
<.001
13631.140.95–1.36.165
study confirms that one simple question unveils over 30-
percentage excess mortality risk of an aged population. Since
the increased mortality was not restricted to any particular
subgroup, the consistency of observation emphasizes the
importance and validity of the finding.
The cross-sectional association analyses do not indi-
cate any causal relationships between loneliness and other
prognostic significant conditions (Table 1). Widowhood,
accumulating losses in old age, poor health and functioning,
and living conditions may cause loneliness [4, 5]. Further-
more, both suffering from loneliness and its associates may
be caused by other factors not tested in this study. The
lack of in-depth interviews, clinical examinations including
assessments of comorbidity, and cross-sectional data except
mortality are the major weaknesses of the nationwide
survey handicapping the reliable evaluation of causes and
consequences of loneliness. It is possible that suffering from
loneliness is not a mere risk indicator but a real risk factor
in old age. In fact, psychosocial group intervention in our
study populationimprovedhealth, delayedcognitivedecline,
reducedall-cause mortality, and diminished theuse ofhealth
care services of the participants [23].
The associations of loneliness with mortality seemed
to diminish with deteriorating the subjective health sug-
gesting the emerging importance of diseases in old age.
The subjective health has been suggested to be sensitive
and comprehensive measure of general health status and
significant predictor of mortality [25]. Subjective health
has a biological basis showing a graded association, for
example, with laboratory values, and it covers a broad
spectrum ofhealthconditions[25].Althoughtheassociation

Page 4

4Journal of Aging Research
Cumulative surviving
012345
Not lonely
Lonely
0.7
0.75
0.8
0.85
0.9
0.95
1
(years)
P < .001
Figure 1: Cumulative surviving adjusted for age and gender by
suffering from loneliness (P < .001).
between loneliness and mortality seemed to diminish with
deteriorating health, it remained significant after controlling
for subjective health suggesting that the excess mortality was
not explained by illnesses alone.
Most importantly, the excess mortality of lonely people
adjusted for age, gender, and subjective health increased
continually with the passing of time suggesting that suffering
from loneliness is not merely a consequenceof acute changes
in the health and living conditions but may aggravate
mechanisms leading to impaired long-term survival prog-
nosis. It is conceivable that controlling for all possible
associates, for example, need for daily help, dwelling, and
weekly physical exercise hobbies, gradually abolished the
statistical significance of the predictive value of loneliness.
These associates themselves were strong risk indicators in
the present population sample. Apart from age and gender,
subjective need for daily help appeared to be both the closest
associate of loneliness and most powerful confounder in the
survival analyses. To some extent, both issues may indicate
unfulfilled expectations to other people and society.
Earlier analyses of the present sample have shown that
feelings ofloneliness were notassociated with social isolation
or lesser quantities of contacts but were associated with
expectations of social contacts and experienced quality of
relationships [4, 5]. Consequently, the results support the
view that loneliness, a risk indicator independent of social
nets and contacts, is, at least partly, a reflection of inner
negativefeelingsandgeneralattitudestowardlife[24].Inthis
respect, theobservation aboutthe close relationship between
need for help and suffering from loneliness is of particular
interest. This result also helps to understand surprisingly
clear positive treatment effects of the psychosocial group
interventions on selected voluntary persons of this popula-
tion sample [23].
Interestingly, suffering from loneliness had a more
powerful effect on survival in men than women. Whilst
older men expressed suffering from loneliness less often
than women, they experienced more harmful associates
of loneliness. This observation supports the view that the
threshold for feeling lonely is lower in women than men or
that women admit easier their feelings of loneliness and may
have more expectations for satisfying social contacts [6, 11].
The present new finding raises questions about whether the
intensity of loneliness orstress reactions caused by loneliness
is stronger in men than women.
References
[1] L.Andersson,“Lonelinessresearch andinterventions:areview
of the literature,” Aging and Mental Health, vol. 2, no. 4, pp.
264–274, 1998.
[2] G. C. Wenger, R. Davies, S. Shahtahmasebi, and A. Scott,
“Social isolation and loneliness in old age: review and model
refinement,” Ageing and Society, vol. 16, no. 3, pp. 333–358,
1996.
[3] M. Jylh¨ a and J. Jokela, “Individual experiences as cultural-a
cross-cultural study on loneliness,” Ageing Society, vol. 10, pp.
295–315, 1990.
[4] N. Savikko, P. Routasalo, R. S. Tilvis, T. E. Strandberg, and K.
H.Pitk¨ al¨ a,“Predictors andsubjective causesoflonelinessinan
aged population,” Archives of Gerontology and Geriatrics, vol.
41, no. 3, pp. 223–233, 2005.
[5] P. E. Routasalo, N. Savikko, R. S. Tilvis, T. E. Strandberg,
and K. H. Pitk¨ al¨ a, “Social contacts and their relationship to
loneliness among aged people—a population-based study,”
Gerontology, vol. 52, no. 3, pp. 181–187, 2006.
[6] S. Berg, D. Mellstrom, G. Persson, and A. Svanborg, “Loneli-
ness in the Swedish aged,” Journals of Gerontology, vol. 36, no.
3, pp. 342–349, 1981.
[7] R. F.Creecy, W.E. Berg, andR. Wright,“Lonelinessamongthe
elderly: acausalapproach,”Journals of Gerontology,vol.40,no.
4, pp. 487–493, 1985.
[8] L. C. Mullins and E. Dugan, “The influence of depression,
and familyand friendship relations, on residents’ lonelinessin
congregate housing,”Gerontologist, vol.30, no. 3, pp. 377–384,
1990.
[9] O. Kim, “Predictors of loneliness in elderly Korean immigrant
women living in the United States of America,” Journal of
Advanced Nursing, vol. 29, no. 5, pp. 1082–1088, 1999.
[10] U. Jakobssonand I. R. Hallberg, “Loneliness, fear, and quality
oflifeamongelderlyinSweden:agenderperspective,” Aging—
Clinical andExperimental Research,vol.17,no.6,pp. 494–501,
2005.
[11] M. A. R. Tijhuis, J. De Jong-Gierveld, E. J. M. Feskens, and
D. Kromhout, “Changes in and factors related to loneliness in
older men. The Zutphen Elderly Study,” Age and Ageing, vol.
28, no. 5, pp. 491–495, 1999.
[12] M. I. Bisschop, D. M. W. Kriegsman, T. G. van Tilburg, B.
W. J. H. Penninx, J. TH. M. van Eijk, and D. J. H. Deeg,
“The influence of differing social ties on decline in physical
functioning among older people with and without chronic
diseases: the longitudinal aging study Amsterdam,” Aging—
Clinical andExperimental Research,vol.15,no.2,pp. 164–173,
2003.

Page 5

Journal of Aging Research5
[13] D. W. Russell, C. E. Cutrona, A. De la Mora,andR. B. Wallace,
“Loneliness and nursing home admission among rural older
adults,”PsychologyandAging, vol.12,no.4,pp.574–589,1997.
[14] A. Ellaway, S. Wood, and S. Macintyre, “Someone to talk
to? The role of loneliness as a factor in the frequency of GP
consultations,” British Journal of General Practice, vol. 49, no.
442, pp. 363–367, 1999.
[15] J. Geller, P. Janson, E. McGovern, and A. Valdini, “Loneliness
as a predictor of hospital emergency department use,” Journal
of Family Practice, vol. 48, no. 10, pp. 801–804, 1999.
[16] R. S. Tilvis, K. H. Pitkala, J. Jolkkonen, and T. E. Strandberg,
“Socialnetworksanddementia,”Lancet,vol.356,no.9223,pp.
77–78, 2000.
[17] L.Fratiglioni,S. Paillard-Borg, andB. Winblad, “An active and
socially integrated lifestyle in late life might protect against
dementia,” Lancet Neurology, vol. 3, no. 6, pp. 343–353, 2004.
[18] L. F. Berkman and S. L. Syme, “Social networks, host
resistance, and mortality: a nine-year follow-up study of
AlamedaCountyresidents,”American JournalofEpidemiology,
vol. 109, no. 2, pp. 186–204, 1979.
[19] H. Sugisawa, J. Liang, and X. Liu, “Social networks, social
support, andmortalityamongolder people in Japan,”Journals
of Gerontology, vol. 49, no. 1, pp. S3–S13, 1994.
[20] G. A. Kaplan, T. W. Wilson,R. D. Cohen, J. Kauhanen, M. Wu,
and J. T. Salonen, “Social functioning and overall mortality:
prospective evidence from the Kuopio Ischemic Heart Disease
Risk Factor Study,” Epidemiology, vol. 5, no. 5, pp. 495–500,
1994.
[21] B. W. J. H. Penninx, T. Van Tilburg, D. M. W. Kriegsman, D.
J. H. Deeg, A. J. P. Boeke, and J. TH. M. Van Eijk, “Effects of
social support and personal coping resources on mortality in
older age: the longitudinal agingstudy Amsterdam,” American
Journal of Epidemiology, vol. 146, no. 6, pp. 510–519, 1997.
[22] R. S. Tilvis, M. H. K¨ ah¨ onen-V¨ are, J. Jolkkonen, J. Valvanne,
K. H. Pitkala, and T. E. Strandberg, “Predictors of Cognitive
Decline and Mortality of Aged People over a 10-Year Period,”
Journals of Gerontology—Series A Biological Sciences and
Medical Sciences, vol. 59, no. 3, pp. 268–274, 2004.
[23] K. H. Pitkala, P. Routasalo, H. Kautiainen, and R. S. Tilvis,
“Effects of psychosocial group rehabilitation on health, use of
health care services, and mortality of older persons suffering
from loneliness: a randomized, controlled trial,” Journals of
Gerontology—Series A Biological Sciences and Medical Sciences,
vol. 64, no. 7, pp. 792–800, 2009.
[24] M. Jylh¨ a, S. Volpato, and J. M. Guralnik, “Self-rated health
showed a graded association with frequently used biomarkers
inalargepopulationsample,”Journal of ClinicalEpidemiology,
vol. 59, no. 5, pp. 465–471, 2006.
[25] K. H. Pitkala, M. L. Laakkonen, T. E. Strandberg, and R.
S. Tilvis, “Positive life orientation as a predictor of 10-
year outcome in an aged population,” Journal of Clinical
Epidemiology, vol. 57, no. 4, pp. 409–414, 2004.