Loneliness and social support among nursing home residents without cognitive impairment: A questionnaire survey
Introduction
Loneliness is common among older people (Golden et al., 2009, Luanaigh et al., 2008, Routasalo et al., 2006). It is an unpleasant feeling (Hauge and Kirkevold, 2010) and is known to be strongly associated with adverse health effects, including depression (Luanaigh et al., 2008, Prince et al., 1997) physical impairment (Theeke, 2010), impaired quality of life (Jakobsson and Hallberg, 2005), poor subjective health (Holmen et al., 1992, Savikko et al., 2005, Theeke, 2010), increased risk of mortality (Lyyra and Heikkinen, 2006, Penninx et al., 1997, Stek et al., 2005), cognitive decline (Luanaigh et al., 2008) and life events (Cohen-Mansfield et al., 2009, Grenade and Boldy, 2008).
Loneliness has been documented among NH residents (Hicks, 2000, Scocco et al., 2006, Slettebø, 2008). However, little is known specifically about loneliness among NH residents without cognitive impairment.
NH residents without dementia represent a minority of NH residents (Linton and Lach, 2007, Nygaard et al., 2000, Selbaek et al., 2007) and concomitantly often have somatic and/or other mental conditions. The residents may also be exposed to stressful events such as loss of home, relational losses and loss of spouse, relatives and friends. All NH residents may have these experiences, but NH residents without dementia are of particular interest because they may provide insights that are relevant to all residents. Further, they may be particularly vulnerable because less attention may be directed to their particular psychosocial needs. It is therefore important that we understand loneliness among cognitively intact NH residents and whether all these conditions influence social interactions and contribute to loneliness. Learning more about what types of social relationships benefit lonely people without cognitive impairment is important in elaborating nursing regimens.
Loneliness is defined in various different ways, such as subjective experiences of a lack of satisfying human relationships (Andersson, 1998) or specific subjective feelings due to lack of belongingness (Nicholson, 2009). As described by Peplau and Perlman (1982), the definitions share the same concept: an unpleasant, subjective experience resulting from inadequate social relationships. The terms loneliness and social isolation are often used interchangeably, although they are distinct but interrelated concepts (Mullins and Dugan, 1991, Routasalo et al., 2006). Social isolation relates to the number of contacts and how an individual integrates into the surrounding social environment (Cattan et al., 2005).
Previous studies have been contradictory regarding the association between the frequency of contact with family and friends and loneliness. Several studies have not associated the frequency of children's or friends’ visits with loneliness (Dugan and Kivett, 1994, Routasalo et al., 2006). In contrast, some studies have found a low frequency of social contact with family (Bondevik and Skogstad, 1998, Drageset, 2002, Drageset, 2004), friends (Bondevik and Skogstad, 1998, Holmen et al., 1992) and neighbors (Bondevik and Skogstad, 1998) or lack of friends (Dugan and Kivett, 1994, Eshbaugh and Eshbaugh, 2009, Savikko et al., 2005) to be associated with loneliness. In some studies, childlessness has not been associated with loneliness (Holmen et al., 1992), whereas other studies have found an association (Mullins et al., 1996). Several studies have investigated social support and loneliness among older people using various social support instruments in different populations (Nicholson, 2009). Victor et al. (2005) found in a study among older people living at home in the United Kingdom that social support, defined as the presence of a confidant, contributes to reducing loneliness. Routasalo et al. (2006) found in a study among older people living at home in Finland that social support, defined as unfulfilled expectations of contact with friends, was associated with a lower level of loneliness. Tiikkainen and Heikkinen (2005) found in a 5-year follow-up study among people 80 years or older living in the community in Finland that people who lack high-quality social support (perceived togetherness) are frequently vulnerable to being lonely. Hicks (2000) reported that, among NH residents in the United Kingdom, the lack of intimate relationships is associated with increased loneliness. Slettebø (2008) found in a qualitative study among NH residents in Norway that lack of significant others was associated with a lower level of loneliness.To summarize, the qualitative and quantitative adequacy of the social network seems to be important for various needs. According to Andersson (1998), Cutrona and Russel (1987) and Weiss (1974), people need various kinds of social relationships that correspond to specific social needs. Weiss, 1973, Weiss, 1974 model of social provisions was originally conceived in the context of general loneliness but also covers social support. Weiss (1974) identified and described six categories of relational provisions: attachment (emotional closeness from which one drives a sense of security); social integration (relationships in which the person shares concerns and common interests); opportunities for nurturance (being responsible for the care of others); reassurance of worth (a sense of competence and esteem); reliable alliances (the person can count on assistance in times of need); guidance (having relationships with people who can provide knowledge and advice). Each provision is associated with a particular type of relationship. Cutrona and Russel (1987), who compared the six social provisions described by Weiss with dimensions of support that have been described by others, concluded that Weiss’ model includes all the main components of the most current conceptualizations of social support. The need for specific relational provisions may differ because of age, life stage and specific environmental circumstances (Andersson, 1998, Weiss, 1974). Several studies among older people have shown different needs for specific relational provisions based on Weiss’ concept of social support (Felton and Berry, 1992, Lyyra and Heikkinen, 2006, Tiikkainen and Heikkinen, 2005).
The subscales “reliable alliance” and “guidance” are highly correlated with the other subscales (Cutrona and Russel, 1987). Mancini and Blieszner (1992) and Andersson and Stevens (1993) therefore omitted these subscales. Studies that have used the four subscales attachment, nurturance, reassurance of worth and social integration include studies among NH residents in Norway (Bondevik and Skogstad, 1996, Bondevik and Skogstad, 1998, Drageset et al., 2009). Based on this, the desire was to investigate how these four subscales (attachment, nurturance, reassurance of worth and social integration) are associated with loneliness.
In summary, studies have examined loneliness and quantitative versus qualitative support among older people living at home (Routasalo et al., 2006), but such research has been limited among NH residents. Studying loneliness among older people requires taking into account both objective and subjective factors of social support (Andersson, 1998, Nicholson, 2009). This study therefore aimed to examine the frequency of contact and loneliness among NH residents without cognitive impairment and, more in depth, the association between the loneliness dimensions attachment, nurturance, reassurance of worth and social integration and social support.
The research questions were as follows.
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What are the relationships between the social support dimensions attachment, social integration, reassurance of worth, nurturance and loneliness?
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What are the relationships between the frequency of contact with family and friends and loneliness?
Section snippets
Design and setting
A cross-sectional, descriptive, correlation design was used. All long-term care residents (n = 2042) from the 30 NH in Bergen, Norway were potential participants. The study was carried out between 15 January 2004 and 31 May 2005. All participants included provided informed consent. The Western Norway Regional Committee for Medical Research Ethics and the Norwegian Social Science Data Services approved the study.
Subjects
All cognitively intact NH residents aged 65 years and older who were capable of
Participants
Table 1 presents the demographic characteristics and comorbidity (FCI) of the 227 respondents, of whom 72% were women. The mean age was 85.4 years (range: 65–102). The FCI was 1.9 (median 2.0, standard deviation 1.2, range: 0–6). The most common diagnoses were stroke (including transient ischemic attack) (30%), depression (18%), congestive heart failure (or heart disease) (17%) and diabetes types 1 and 2 (17%). Generally, the residents had lower or middle education, most were widowed and three
Discussion
This study among NH residents without cognitive impairment found that 56% experienced loneliness.
This finding is in accordance with other studies among NH residents reporting that loneliness is common in long-term care institutions (Golden et al., 2009, Hicks, 2000, Slettebø, 2008). Most residents in this study were widowed and quite frail, which may affect their ability to participate in social activities. In addition, people moving into NH may experience some form of loss: for example,
Conclusion and implications
This study had three important findings. First, more than half the NH residents without cognitive impairment were lonely. Second, the frequency of contact with family and friends did not explain loneliness, but lack of social support was associated with loneliness. Third, the social support dimension of emotional attachment from significant others from which one derive a sense of security was strongly related to loneliness.
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