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Loneliness can be a precursor to depression in older people. NICKY DAVIES for her PhD thesis asked older people what they think loneliness actually is. FIONA CASSIE reports on the findings and the take-home messages for nurses working with older people who may be lonely… or just alone.

The best china was out, along with the lace doilies, and a plate of little rock-hard scones to go with the cup of tea that Nicky Davies was offered soon after stepping through the door.

Her gentleman host was one of 40 widows and widowers who took up an invitation to be interviewed about loneliness.

“I do this for the home help too,” explained the widower to Davies. “My wife would go mad if I didn’t.” He also told her that funders were talking about cutting back his home help’s hours. “So what I do now is run around with a Hoover before she [the home help] comes so she’s got some time to sit down and have a conversation.”

Loneliness can be a very real issue for older people. Davies says there is a lot of literature quantifying loneliness in older people and the mental health risks it poses. But she couldn’t find anybody who had actually gone out to talk to older people about what they thought loneliness was; and what strategies – like having a regular cuppa with the cleaner – they used to keep loneliness at bay. So she decided to fill the gap.

Davies has specialised in the mental health of older people since graduation and first explored the notion of loneliness for her master’s thesis – inspired by working with four older men who appeared bereft after retiring from high-flying careers. After shifting south to Christchurch, where she is now a nursing lecturer at the Ara Institute of Canterbury (formerly CPIT), she was persuaded to pursue her PhD and decided to have a conversation with older people about loneliness. She sought out widows and widowers in their 70s and beyond as the widowed were seen as a key group where loneliness occurs.

The 20 men and 20 women were recruited on her behalf by Canterbury practice nurses and a local marae; half lived in the country and half were aged over 85. All had been widowed for at least two years and were living on their own. She interviewed everybody in their own home using a series of prompt questions to get people to tell their stories of loneliness, which she analysed for her thesis.

“I think as nurses we forget how valuable we are as storykeepers. People tell us stories when they come in to see us with illness.”

One of the key findings of the stories she gathered in the interviews is never to make assumptions about how widowhood impacts on a person’s loneliness. Some people won’t be lonely at all, some will be just fleetingly lonely, and some people will be much lonelier than you
can imagine.

“I spoke to one lady who had been widowed for 40 years and she was as tearful as if it had happened last week. It never went away.

“Yet I spoke to somebody else who was widowed two years and they felt a release as they’d seen their partner suffering and they were very, very lonely during the caring phase. So when the spouse died they saw it as freeing their partner from suffering, as well as the regaining of freedom for themselves.”

Davies says she also interviewed elderly men who had never thought of themselves as lonely until the loss of their wives left a huge gap. One of the older men talked about the ‘quiet room’ getting to him – he said they weren’t great talkers as a couple but it was the sitting side by side and the little subtle noises he missed. Another widow was lonely as her husband had been the socialiser of the couple so she had lost not only him but also their social network.

The older the widowed person was when losing their spouse, the harder it was for them to adjust and “renegotiate their self-identity” as a solo person rather than one half of a couple,
says Davies.

Though not all missed being a couple.

“There was a lady who said she thought about remarrying as she didn’t have access to a car. Then she thought a bit more and added, ‘Oh no, I’d have to have a man to go with that’,” recalls Davies with a laugh.

Nurses’ role in helping to keep loneliness at bay

During her research it became clear to Davies the extent to which physical health can impact on loneliness and how important the nurse’s health promotion role is in helping to prevent or better manage some of the health issues associated with ageing – from hearing and sight to incontinence and mobility. This is particularly apparent when the newly widowed find themselves without a partner to prompt them about medications and appointments.

“Things you don’t think impact upon loneliness do – like, for instance, urinary incontinence – because people won’t go out of the house if they don’t think they can get to the toilet in time.”

Davies believe nursing also has an important role to play in identifying and helping the lonely – particularly practice nurses  – who she says should never assume that a longstanding patient will share that they are struggling with loneliness. “They don’t want to embarrass themselves …
and people don’t think it is a legitimate topic to talk about.”

So Davies believes that, when listening to their patients’ stories, nurses need to be skilled in picking up the nuances of whether a person is struggling to manage their loneliness. The onus is on the nurse to normalise talking about loneliness in a conversation without being too overt. “Don’t put [loneliness] into some tick list or point scoring system like ‘have you felt lonely today – two points, did you feel lonely last week – three points’. You just need to have a conversation.”

This conversation can be squeezed into an appointment looking at somebody’s ingrown toenail or changing their dressing, believes Davies. She says the temptation when nurses are stressed or busy is to refer patients with social or mental health issues on. This might sometimes be the right call, but she reminds nurses that the practice nurse, district nurse or other nurse they see regularly is probably the key person they trust.

Widows and widowers are not the only ones who are sometimes lonely and Davies believes that people who are alone aren’t necessarily lonely all the time. For some, solitude is a choice, particularly people who have never been keen socialisers. It is also important to remember when suggesting social activities to the lonely that not all older people share the same interests – Mick Jagger is 72 and it’s hard to imagine anybody suggesting he take up lawn bowls now he’s a septuagenarian.

And moving into a rest home or in with family might not always be the instant cure for loneliness it appears.

“For some people it is the right answer, but for other people they can be just as lonely with people around them as they are living on their own.

“I think it’s really important not to medicalise loneliness. At any age through our lives it is part of who we are – it is just when loneliness starts to take over and consume people … that is when red flags should pop up.

“It’s like when you’ve got an ulcer on your tongue or have got a sore and you pick at it;  the more you become aware of it the more it is there with you. That’s what loneliness can be like.” 

So being mindful of when lonely thoughts start dominating too much of the day, and learning how to manage and curtail those thoughts, she believes, is an important coping mechanism. She is currently working with a Canterbury psychologist on developing a form of mindfulness intervention for loneliness in older people.

Coping strategies

Davies’ resilient widows and widowers all already had their own strategies for managing loneliness “because the people I spoke to were all survivors”. One common strategy was to always consider others who were worse off than themselves. “That seemed to give them buoyancy to carry on.”

Not all strategies were equal, however – Davies divided them loosely into adaptive or maladaptive coping mechanisms for loneliness.

“By maladaptive, I mean like people who go to bed early. As they get lonely in the evening, instead of looking at a way of managing that loneliness, they go to bed at 7 o’clock at night and then they start waking up in the middle of the night and before you know it they are on a slippery slope of not sleeping and sleeping pills may be prescribed.” Another example of a maladaptive strategy was a lady who began playing the pokies regularly.

Davies was also intrigued that when she asked those who said they were not lonely what they did to prevent loneliness, they’d say, “I read or I go out and chat to people on the bus and I make the most of any little conversations that I can have.”

Then when she asked the group who admitted being lonely how they managed their loneliness, they listed almost identical strategies. The difference was all in their perceptions. (A list of the loneliness strategies used by Davies’ interviewees can be viewed in the online version of this article at www.nursingreview.co.nz.)

Soapbox

One other common coping mechanism that people used to allay loneliness were rituals around the visits of their home help.

The international trend to encourage people to stay longer in their own homes has seen the development of home care support for older people to help make this possible.

But funding for caregivers and cleaners is always pressured and Davies says it makes her want to “get on her soapbox” when she hears of cutbacks to home care hours. She believes cutting back hours isn’t just a matter of letting dust and grime accumulate but cuts into a special relationship that is important to the mental health of many older people.

There has been some talk about replacing home help with ‘befrienders’ to provide social support, but the older people Davies spoke to were horrified at the idea saying “there is nothing more insulting than having somebody paid to be your friend”.

The nuance between having a ‘paid friend’ and having a cuppa with the cleaner may be lost on funders and planners but it was very important to the people concerned, who saw offering the home help a cup of tea and having a chat after the chores as an act of mutual reciprocity.

Davies argues that it is false economy to cut back home help hours as the loss could see more older people deteriorate through loneliness and move into residential care earlier.

No instant cure

Unfortunately, there is no instant cure for loneliness. Davies says nurses are attracted to the caring profession because they care but not everything can be fixed easily and there is no pill for loneliness. It may also take time for an older person to decide what steps they would like to take to better manage their loneliness.

But the first step is to be ready to start the conversation and see where it leads. “You can have a five-minute conversation that can make all the difference.”

And if you have time for a cup of tea, all the better.