Designing a New Social Infrastructure to Combat Loneliness in Aging Adults

Abstract:

Loneliness in older adults is shaped by social context, which compounds personal vulnerabilities associated with aging. This article argues that while practitioners need to understand loneliness to better support those who are lonely now, because loneliness is a social issue, it cannot be solved one person at a time in a clinical context. This article demonstrates that some types of loneliness in older adults are socially constructed, a product of change in family structure and valuation of roles, ageism and age segregation, social norms, policies, and a social infrastructure created in the twentieth century that is not suited to twenty-first century realities.

Key Words:

loneliness, older adults, COVID-19, social context, ageism, age segregation, social infrastructure

Evidence indicates that conditions can be re-designed to ensure that loneliness is not the default in older age. Using a public health framework and population-level interventions for prevention, it is possible to “design out” loneliness through new approaches to social infrastructure and social institutions that support connection and cohesion. This framework can guide the evolution of age-friendly communities and policies in urban and rural contexts, designing out loneliness as a default option via the built environment; better using transportation and technology to connect people; and developing institutions that foster social capital and engagement within and across generations for the greater good. These approaches could create the twenty-first century bulwark to prevent loneliness in older adults.

Loneliness in Aging

Loneliness is an experience, indicating the subjective feeling of pain due to unmet human needs for meaningful, satisfying connection to other people. There are evolutionary reasons for desiring connection, as human survival depends upon people working together and sticking together (Cacioppo and Patrick, 2008). Feeling loneliness is so painful that it motivates pro-social behavior to acutely relieve it, analogous to the way hunger motivates eating.

A recent report distinguishes loneliness from social isolation, the latter defined as “the objective lack of (or limited) social contact with others” (National Academies of Sciences, Engineering, and Medicine, 2020). One can be lonely but not socially isolated, or the converse. Independently, they have substantial health consequences.

Notably, loneliness appears to be a highly prevalent issue for all age groups, starting in adolescence. There is a U-shape to the rates of loneliness, with 44 percent of 15- to 24-year-olds reporting being lonely, declining to 26 percent of those ages 25 to 44 reporting moderate to severe loneliness, and then increasing to peaks of 42 percent in those ages 80 and older (Dykstra, 2009). Initial reports indicate a rise in loneliness in middle-age and older adults in the United States; one study found 11 percent to 17 percent of older adults in 1970 were lonely, rising to 40 percent in 2010 (Cacioppo et al., 2015). Even if prevalence were not increasing, with the rise in numbers of older adults, the absolute number of older adults who are lonely is likely rising, making this is a twenty-first-century phenomenon of import.

Loneliness in Aging Is Situationally Induced

Why are rates of loneliness in older adults high? One set of reasons has to do with situational risks associated with getting older: being single, whether through widowhood, divorce, or never marrying; loss of family and friends; childlessness; retirement and loss of connections to peers the work role once provided; and living alone. Many of these are phenomena of recent decades.

In 2012, 30 percent of U.S. older adults lived alone, compared to in 1950 when 10 percent did; currently, 40 percent of those older than age 85 live alone (Luhmann and Hawkley, 2016). These age- and stage-related risks are exacerbated by lower income and assets, having poorer health and/or being mobility disabled (Ha, Hougham, and Meltzer et al., 2019). Geography also matters: older adults in rural areas experience greater declines in network size with aging than elders in urban settings (Huxhold and Fiori, 2019).

A distinct issue that compounds loneliness is “precariousness”: “the intrinsic sense of instability and insecurity stemming from a lack of, or difficulty to, access essential resources,” including financial and food insecurity, in contexts of unsafe neighborhoods and exposure to violence, compounded by lack of affordable housing and potential homelessness. All of these factors hinder maintaining and establishing relationships or social connections. The financial duress of living alone in old age falls particularly hard on women, renters, and ethnic and racial minorities, both those with low income and those in the middle class (Portacolone et al., 2019).

Loneliness in Aging Is Socially Constructed

The rise of the nuclear family and decreased family roles for older adults is one of the dominant factors in the increase of loneliness among older adults (Schirmer and Michailakis, 2016). Societal ageism, which makes older individuals invisible and devalued in society, and age segregation in housing and in work and volunteer roles have resulted in the United States being the most age-segregated society in the history of the world, with loss of intergenerational contact and solidarity. Schirmer and Michailakis argue that the systems operant in the late 20th and 21st centuries organize and value people by their functional roles in society, e.g., their individual performance roles and their achievements, rather than valuing the person as a whole or within a collective. For older people, retirement from work roles exacerbates the likelihood of loneliness because of loss of affiliation by performance role. In a culture that values independence and has frayed social institutions and social capital, it is left to the individual to find, on their own, satisfying relationships for their whole selves.

Social context is also shaped by our built environment, which has increasingly segregated people in the United States by age and wealth, and zoned senior housing to the margins of communities. The creation of suburban communities, without sidewalks or grocery stores or pharmacies that one can walk to, limits personal interaction within a neighborhood. Further, housing has, in recent decades, been built for independence, not connection; witness apartment buildings with no space allocated for community activities.

Finally, the decline in institutions of social capital formation—from bowling leagues to town councils to voluntary organizations), particularly those that are intergenerational, diminishes opportunities to prevent loneliness and precariousness during normal times, much less in emergency situations. This contributes to low neighborhood social cohesion and collective efficacy, which creates a vicious cycle of not investing in the institutions that foster social capital.

The COVID-19 pandemic has substantially increased the risk and the reality of loneliness for everyone, and particularly for older adults. The high rates of loneliness among older adults who are secluded in “lockdown” to prevent contracting COVID-19 can be seen as an exacerbation of preexisting risks of loneliness for older people. Ageist stereotypes and narratives suggesting that protecting older people from infection is causing everyone else to suffer from the economic consequences of lockdown further exacerbates the sense older adults have of being worthless to society (Ayalon et al., 2020).

Loneliness in the Twenty-First Century Is a Social Determinant of Health

The evidence that much of loneliness in older age is socially constructed, and that the resulting loneliness has serious adverse effects on health and well-being, lays the basis for considering loneliness to be a twenty-first-century social determinant of health. This is defined as “conditions in the environments—social, economic, and physical—in which people are born, live, work, play, worship, and age, which affect a wide range of health, functioning, and quality-of-life outcomes and risks” (United States Office of Disease Prevention and Health Promotion, n.d.). Understanding loneliness as socially determined suggests that a public health framework focused on changing default societal conditions could prevent the condition. Interventions that address social determinants of health have the highest population benefit with the greatest return on investment for prevention. Such approaches likely require a mixture of policy and infrastructure changes as well as direct programmatic interventions at a community level (Frieden, 2010).

Different Types of Loneliness May Require Different Types of Solutions

Broadly, loneliness can be conceived of as a perceived discrepancy between desired and actual social relationships. Cacioppo and colleagues have identified three major types of loneliness (Cacioppo, Cacioppo, and Boomsma, 2014):

1. Intimate or emotional loneliness from significant others;
2. Social, relational loneliness (lacking quality friendships or family connections);
3. Public or collective loneliness (the absence of meaningful connection to societal or community institutions and organizations—in which one derives meaning, purpose, and value, and sense of connection to a collective identity greater than the individual).

It is possible that there are other types of loneliness, including that which could result from a dearth of meaningful intergenerational connections—which could be salved by new societal approaches. Frailty and end-of-life issues also likely carry risk for several types of loneliness. An “existential loneliness” associated with this life stage also is connected with one’s awareness of being vulnerable and mortal, while wrestling with basic questions of the meaning of life (Edberg and Bolmsjö, 2019). While existential loneliness is primarily described in the context of death and dying, this sense is amplified when a person is left on their own in a threatening situation, such as during severe illness, like COVID-19.

Overall, solutions for loneliness need to be matched with the particular type of loneliness they are meant to ameliorate. To that end, the remainder of this article will emphasize opportunities at the population level to prevent the second and third types of loneliness, above, and intergenerational loneliness.

Designing Out Societally Constructed Loneliness with a Twenty-First-Century Social Infrastructure

This article suggests three major frameworks in which society can design out the twenty-first-century conditions that create loneliness. They are: building connectors—physical transportation and technological approaches that bring people together and foster engagement in society, regardless of functional abilities; designing the built environment as social infrastructure that fosters connection and cohesion and enables older adults to be located in the action, rather than at the margins; and creating the social infrastructure for social capital and engagement for the twenty-first century—with meaning, purpose, and impact toward a stronger future.

This latticework of social infrastructure in tech, transport, the built environment, and societal institutions would overcome the structural determinants of loneliness, and promote intergenerational and community cohesion and resilience. And it would be the basis for designing out loneliness as the default option when people grow old. This approach would amplify the goals of age-friendly cities and communities, by embedding loneliness alleviation into each age-friendly component (transportation, housing, volunteering, and employment, among others) via an interconnected social and physical environment (Steels, 2015).

What follows are examples of how each of these dimensions can be used to create the conditions that design out loneliness.

Connectors: transportation and technology

Transportation is essential to meet daily needs, and reliable, timely, and affordable alternatives to driving are needed that match the needs and the functional abilities of different subsets of older adults.

Technology enables many older adults to bridge the limitations of distance and decrease loneliness. From phones to programs like Whatsapp or Skype, older adults are staying in touch with family and friends in new ways. Via social technologies, older adults are expanding social networks and making new friends, contributing to society and the greater good, or finding education, information, online services, commercial services, health information, recreation and cultural opportunities, and work. Online dating is gaining increasing popularity among older adults, with 24 percent of people older than age 65 in the United States knowing someone who uses online dating (Pew Research Center, 2013). Training programs designed to teach older adults online skills, such as the Older Americans Technology Services, report great success—even participating in the training relieves loneliness.

AARP’s new Connect2Affect initiative is designed to help older adults assess their risks of loneliness and find practical solutions to reconnect to their communities. Socially isolated older adults who are living alone in an independent community setting may benefit from the new Personal Reminder Information & Social Management System (PRISM) software application developed by CREATE, a consortium of five universities dedicated to ensuring that older adults benefit from technology. PRISM is designed to support social connectivity and engagement with new people, as well as leisure activities and access to resources (Czaja et al., 2018).

Assisted and independent living organizations have found that the more often older adults go online the better their connection to family and friends; usage was inversely associated with loneliness, although it did not change social isolation (Cotten, Anderson, and McCullough, 2013). There is expanding research to develop new applications and evaluate them for the second type of loneliness, of social connections with family and friends. For the third type of loneliness, there is large potential to develop online approaches to enable societal engagement for the public good; one example would be to organize the opportunity for older adults to read to children online during this COVID-19 pandemic, or serve as a communication network to help people at risk in an emergency. However, this arena remains to be developed.

Neighborhood built environment

In addition to transportation, three dimensions of age-friendly communities and cities (housing, neighborhood, environment) could be intentionally designed for connection and cohesion. Basic urbanist principles of density, walkability, and mixed-use support connections between people (Duany and Plater-Zyberk, 2009). However, the age-friendly housing goals of accessibility, affordability, and housing options need to be amplified to create interpersonal connection through design.

One dimension of this is location: is social isolation zoned in by zoning senior housing out of the center of the life of a city and necessary services, and away from public transport? Are streets and crossings safe and walkable? Is there lighting and benches, and are there parks—and do they have bathrooms? Further, is standard housing designed with common spaces for gatherings and activities, to facilitate people connecting? (MetLife Foundation et al., 2007) Models like Naturally Occurring Retirement Communities (NORCs) are being created to provide services to support aging-in-place and building social support networks within apartment buildings, which can be of great value during emergencies (such as the pandemic) that isolate people and create precariousness.

New housing models for connection and cohesion are emerging. Co-generational housing for friends or single older adults, and multigenerational home-sharing services are being developed by Generations United and Nesterly. Housing developers also are now building homes for multigenerational families. Finally, highly innovative approaches are exemplified by the Communities of Nurturance for Three Generations being created by Generations of Hope Development Corporation. This initiative has created several intentional communities of multiple generations with goals of young, middle age and old people together to support, for example, the nurturing of foster children, or of wounded warriors, and each other. In each model, all age groups gain.

Societal Institutions Build Social Capital and Shared Action, Decreasing Collective Loneliness

The forerunners of community-based approaches for easing loneliness were focused on functionally compromised older adults, including nutrition and activities programs with group meals and activities. Beyond these targeted programs, there are new models to support making new friends, and build the “weak ties” of trust and reciprocity that are the foundation of a community’s social capital—and thus decrease loneliness.

One model of twelve structured group sessions is a friendship enrichment program organized in the Netherlands that stresses self-esteem and goals related to friendship. It attracted lonely older women and was found to be effective in decreasing loneliness in the short term, and over the following year (Stevens, 2001).

Another model in New York City is LILY (Lifeforce in Later Years), which pairs homebound and lonely older adults with members of their neighborhood who visit weekly; both sides of the dyad benefit from the reciprocal relationships, which are sustained over years, and it creates a network of connection within a neighborhood that protects against precariousness in the face of crisis, as well as in daily life.

One profound observation is that “lonely people have been found to benefit more from groups designed to meet some other need, such as housing, rather than loneliness” (Stevens, 2001). Building on this perception, the United Kingdom has initiated a wide array of loneliness-prevention programs, many of which offer activities that attract people who share an interest, such as Men’s Sheds, which provides shared resources of tools to build things and serve as a basis for men meeting each other and leads to engaging in other shared activities.

In the United States, models like The Villages are membership-driven grassroots organizations run by volunteers, which provide a set of services for an annual fee; these services are designed to assist older adults to remain in their homes, aging in place. They also connect to community services and promote social connection through a range of activities. Bloomingdale Aging in Place, in New York City, is a volunteer-led, community-based program for older adults with an array of activities to meet interests, from book clubs to arts and culture. Located in a small geographic area, it builds a latticework of connection between neighbors. Another model is university-located programs in United States, such as the Institute for Retired Professionals in New York City, which is a voluntary program organized by retired professionals who teach courses for one another. A diversity of opportunities enables older adults to find others of like interests, and to decrease loneliness by building meaningful connections and new friendships. When these create communities of shared purpose and sometimes aspirations, they can address the second and third types of loneliness.

Recognizing that individuals and society benefit from intergenerational connection and cohesion, which can both resolve loneliness and strengthen solidarity between generations, many programs have been developed that create cross-generational benefit (Butts, 2020). During the COVID-19 pandemic, intergenerational digital engagement has benefited many. However, generally, connections need to be sustained for meaning and impact. On the shorter end of sustained connection, for example, one home-visiting program of college and social work graduate students visited homebound patients every two weeks for six months; outcomes included improved perceptions of aging by the graduate students, and less reported loneliness among 80 percent of the patients, along with significant decreases in patient hospitalizations and emergency department visits (Ng et al., 2020).

The above examples are about fostering one-on-one bonds between older adults and others to resolve loneliness, and the secondary impact this could have in building a stronger network of weak ties across a community. Last, but not least, is the need to create and build out societal institutions and community organizations that enable older adults to meet age-related generative needs and to leave the world better for future generations. A secondary outcome is connections to a new social network with shared goals.

National volunteer programs can provide community benefit and social connection, such as Foster Grandparents, through which 25,190 volunteers have provided 21 million hours of service serving 189,100 children; the Senior Companion program, in which 12,190 older volunteers, serving fifteen to forty hours a week, have provided more than 7 million hours of service supporting 43,000 frail elders and other adults to maintain independence; and RSVP, in which 232,000 older volunteers have provided more than 46 million hours of service to tutor children, renovate homes, teach English to immigrants, and make many other contributions in their communities.

Many such U.S. programs for older adult volunteers have long waiting lists and need to be expanded to accommodate the increasing older population. There is strong evidence that older volunteers experience less loneliness and positive changes in their life satisfaction and perceived health through volunteering (Greenfield and Marks, 2004).

New social institutions harness the talents and energy of older adults to address complex social problems. A prime example is Experience Corps, designed to create an evidence-based public health model for elder volunteering that supports the academic success of children in public elementary schools, while resolving loneliness, promoting health and function, and meeting older volunteers’ generative goals (Fried et al., 2004; Fried, 2016). Experience Corps is a social model for health promotion. First implemented under the auspices of the Corporation for Community and National Service to assess feasibility and proof of principle, it was then expanded nationally (Fried, 2004). Now the program is run by AARP, and operates in more than twenty U.S. cities.

Numerous reports support the positive impact of the program on multiple dimensions for children (school success and behavior) and older adults (generative fulfillment, loneliness amelioration, and cognitive and physical health and well-being) (Fried, 2004; Rebok, 2004), while strengthening schools and communities. The Experience Corps design places older adults in teams for problem-solving and social support, and volunteers report a significant increase in the number of people they could depend upon and turn to if sick, compared to controls, as well as decreased loneliness. Experience Corps creates sustained social engagement and loneliness alleviation through achieving generative goals to contribute to future generations in a shared enterprise, organizing the human capital of older adults into social capital with collective efficacy (Fried, 2004).

Our world only recently included older people, and we have not yet built a society that is inclusive or values the assets, generative desires, and meaning of living longer (Carstensen and Fried, 2012). Communities that promote successful aging have to include, at their center, meaningful human connection, and the potential for shared goals, activities, and generative impact that enables older adults to deploy the assets of older age for meaning, purpose, and lasting effect (Fried, 2016).

Solving loneliness for older people can be a gateway to solving loneliness of the young and building new models of inclusive, intergenerational connections that support the well-being of all. The eminent epidemiologist, Geoffrey Rose, laid out the principles of prevention by the population strategy, which pertain as much to loneliness as preventing cardiovascular or other diseases: population strategies enable removing the underlying causes that make the problem common, and have great potential for diminishing the problem for the whole population by altering society’s behavior norms and making the preferred alternative the easy one. Prevention by the population strategy enables individual success in solving loneliness (Rose, 1985).

Linda P. Fried, MD, MPH, is dean and DeLamar Professor of Public Health in the Mailman School of Public Health at Columbia University in New York.

Acknowledgment: The author thanks Maria Andriella O’Brien for significant contributions in editing this document.

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