Human health is a wonderfully dynamic area of medicine because it encompasses so many sub-specialisations, it is forever changing as patients move through various phases of health from poor to complete health in the space of days, weeks, months, years and one can even transition between different health states in just a matter of a single consultation with a doctor.
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There has been an evolution in the definition of health over the years. Early definitions in keeping with biomedical traditions of medicine focused on just the functionality of the body and how it is amenable to disturbances during disease states/illness. Then, in 1948 the WHO (World Health Organisation) radically altered the definition and stated that health is the complete physical, mental and social well-being and not merely the absence of disease or infirmity (a biopsychosocial model)1. This definition was initially heavily acclaimed and hailed as an innovative approach to defining the aim doctors should strive to achieve for their patients and although it seems complete and thorough, the inclusion criteria is seen to be somewhat broad, vague and immeasurable. In accordance with such a definition few people around the world would be regarded as completely healthy. Furthermore, adhering to such a definition could potentially incentivise the healthcare system2. Huber’s definition of health coined in 2011, went a long way to finding the appropriate conceptualisation of health and is still key in today’s healthcare practices. It involved a more dynamic approach with the fundamental theme being resilience, more specifically the capacity for a patient to absorb disturbance and re-organise, to maintain and restore one’s integrity and identity3.
Leading on from Huber’s definition, it has been understood that a crucial determinant of a positive health outcome and a patient attribute which favours resilience is social connectedness; the absence of which can cause destructive neurological and cardiovascular changes as well as having a damaging psychological impact4,5.
Maslow’s hierarchy of needs states that upon fulfilment of physiological and safety needs, the third level of human needs is interpersonal and involves feelings of belongingness (the need to be part of a community or social circle)6. This hierarchy holds true for patients, and their healthcare outcomes; deficiencies within this level of the hierarchy can detrimentally impact health-social anxiety and clinical depression being a chief example7. The foremost groups of patients that are likely to experience loneliness, neglect, and ostracism are the elderly, hospitalised patients, those with stigmatised conditions, and the disabled. In the USA a systematic study showed that in people over the age of 50 living with HIV/AIDS, positive changes in psychosocial factors such as loneliness and isolation resulted in a decreased transmission and improved health outcome, reducing the burden of disease as adherence to HIV medications increased8.
For the purpose of answering the question on the impact of loneliness on human health and well-being, the focus will be on the elderly population as they make up the majority of our population, the UK demographics is shifting more towards an ageing population. The elderly is more at risk of social isolation because of an increase in chronic debilitating conditions e.g. risk of heart disease, stroke, falls and fractures, patients experiencing chronic pain and fatigue. The elderly experience more losses than their younger counterparts, losses in relationships, independence (becoming reliant on family members and carers), mobility, work and income. Other life transitions afflict the older population which inherently involve a more sedentary and isolated lifestyle including retirement, potential loss of driving capabilities, functional losses e.g. rheumatoid arthritis affecting dexterity and manual handling, age related hearing loss etc. Research conducted by Age UK recently revealed that half a million people over the age of 60 in the UK usually spend each day alone9. And nearly half (49%) of people over the age of 75 are living alone10. Existing health conditions or impairments in the elderly can lead to a restricted level of independence resulting in feelings of loneliness which inevitably lead to social isolation11. A shocking statistic was revealed by a study conducted by Holt-Lunstad et al., 2010 which found that loneliness can be as harmful for our health as smoking 15 cigarettes per day12.
The impact of social isolation in the elderly is three-fold, the social impact is that those without a social network are more likely to participate in risk taking behaviours; studies have shown the use of alcohol to alleviate the depression, loneliness and anxiety experienced and patients are less likely to adhere to medical advice13. The psychological impact is the increased risk of cognitive decline due to a lack of social connections. Persistent/chronic loneliness and isolation is what impacts mental health the most. Impairment in sleep quality triggering memory dysfunction with adverse changes to hormonal and neural regulation; which in turn amplified the feelings of vulnerability, anxiety and depression14, 15. The risk of developing Alzheimer’s dementia doubles in those experiencing chronic self-perceived loneliness16. The English Longitudinal Study of Ageing has revealed that elderly people that have a social circle and are engaged with experience greater cognitive stimulation and have lower stress levels thus see less of a decline in cognition17 and have been shown to be less susceptible to developing dementia18. The physiological impact of being lonely is multi-faceted as it affects a number of normal functions including the increase in blood pressure, due to heightened sympathetic tone with increases in cortisol level (stress hormone) identified. A number of epidemiological studies have identified that those with a lack of social support are more predisposed to developing cardiovascular disease. Scarcity in social support and welfare has been linked to a faster development of atherosclerosis and a heightened risk of a myocardial infarction or stroke19,20,21.
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In the coming years we face a challenge to tackle the social isolation crisis not just because the life expectancy is increasing but also globally the number of elderly living with dementia is projected to escalate to 81 million by 2040, suffering from such a debilitating condition naturally lends itself towards becoming socially isolated22. The UK Kings Fund National Statistics Analysis has estimated that the number of people over the age of 85 living on their own is expected to grow from 573,000 to 1.4 million by 203223. A qualitative questionnaire study was conducted using the Manchester Short Assessment of Quality of life/Happiness Index, highlighted that mental health is negatively associated with day time activities24; having a daily occupation or even just being busy during the day vastly improves wellbeing and can be beneficial in providing meaning, improving social relations and boosting self-esteem25. Even offering adaptive coping strategies such as signposting them to social workers or focus groups can be significantly beneficial to patients suffering with social isolation and loneliness.
Social isolation should be seen as a diagnosis which needs be identified both in primary and secondary care by healthcare professionals. Appropriate training and education needs to be provided to be able to identify vulnerable patients. The NHS has made strides with the implementation of care packages for patients upon discharge from inpatient hospital stay with social care being endeavoured to be put into place. However, many patients go unnoticed, most times this is due to a lack of communication and understanding. More effort needs to be made to assess patients in primary care settings such as during home visits. A strategy needs to be implemented whereby when a patient arrives for a consultation, the patient is assessed holistically. Not to just focus on what is physiologically wrong but to always bear in mind the human dimension, to cultivate a climate of understanding with the patient and delve deeper into the different dimensions of patient care, the chief amongst them being social and psychological well-being; above and beyond anything else, patients always want to feel listened to26,27,28. A potential strategy for identifying patients most in need is by implementing a holistic assessment tool into everyday clinical practice, addressing the physiological, psychological, sociological, developmental, spiritual and cultural needs of a patient. Once high-risk patients are identified (for example patients that have experienced a recent bereavement or have health-limiting conditions) they need to be signposted to relevant psychological therapy services, support groups and they must be encouraged to help themselves by doing regular exercise and getting involved in activities they enjoy.
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