Before the COVID-19 pandemic, loneliness had been very common among the elderly population and there were concerns regarding the increasing levels of loneliness in this population due to rapid population aging and other significant socio-demographic changes in recent decades worldwide, such as decreased family sizes and increased international and internal migration of young individuals (Newmyer et al., Reference Newmyer, Verdery, Wang and Margolis2022; Somes, Reference Somes2021; Zhang et al., Reference Zhang, Fan, Zhong and Chiu2023). To curb the transmission of COVID-19, various restriction measures were implemented, particularly during the initial outbreak phase, to minimize human-to-human contact. These measures included the closure of public gathering places, implementation of physical distancing protocols, quarantine measures, suspension of family visitations in nursing homes, and enforcement of stay-at-home orders. Given the high fatality rate of COVID-19 among the elderly population and their elevated risk of major medical conditions, older adults were strongly advised to remain at home and maintain social distancing from others (Chen et al., Reference Chen, Chen and Zhong2022). While necessary for minimizing the risk of COVID-19 infection, these public health measures unavoidably disrupted many daily routines and amplified social isolation among older adults, thereby intensifying the psychosocial problem of loneliness during the pandemic (Hwang et al., Reference Hwang, Rabheru, Peisah, Reichman and Ikeda2020).
To gauge the negative psychosocial impact of pandemic-related restrictions, Hughes and colleagues investigated the prevalence of “restriction-induced loneliness” and its associations with depressive and anxiety symptoms among community-residing older adults in a small-town region in Pennsylvania, United States. This study was conducted during the most restrictive period of the pandemic, the initial 120 days of the “stay-at-home” order imposed by Pennsylvania’s Governor in 2020 (Hughes et al., Reference Hughes2022). The authors hypothesized that the disruption of social connectedness, caused by the physical distancing measures, played an important role in the development of loneliness during this period. They specifically assessed changes in 11 common social activities, such as attending church and shopping, due to the restrictions and examined their associations with loneliness in this population.
The authors found that as high as 36.4% of the older adults reported experiencing loneliness caused by the restrictions to some degree or to a great extent. Loneliness was found to be independently and significantly associated with both depressive and anxiety symptoms. Among the survey participants, the risk of loneliness was greater in women than men, in unmarried individuals than married individuals, and in those living alone than those not living alone. Overall, the majority (92.4%) of the participants complied with the social distancing recommendations and made changes to or gave up social activities. Among them, 41–52% of the older adults had to give up nonessential shopping, visiting family in person, traveling, exercising, working outdoors, and working. The study also revealed that giving up in-person visits with family, changing the way of visiting friends in person, and giving up entertainment were significantly associated with loneliness.
Humans are social animals with natural needs for relational bonds. Loneliness occurs when these social interaction needs are not met either qualitatively or quantitatively (Perlman and Peplau, Reference Perlman, Peplau, Gilmour and Duck1981). Various relationship-related factors, such as being unmarried, experiencing the loss of a spouse or partner, living alone, limited social contact, infrequently meeting friends and trusted ones, and having a small social network, significantly contribute to feelings of loneliness in older adults (Awad et al., Reference Awad, Shamay-Tsoory and Palgi2023; Dahlberg et al., Reference Dahlberg, McKee, Frank and Naseer2022; Hutten et al., Reference Hutten, Jongen, Hajema, Ruiter, Hamers and Bos2022). The pandemic-related restrictions have directly impacted the social contacts of older adults, preventing them from participating in common social activities. For example, according to the empirical data from this study, 80.6% and 70.3% of older adults had to change or cancel their routine activities for in-person visits with family and friends, respectively. These changes created barriers to receiving timely support from close relationships and resulted in reduced social networks. Such circumstances are particularly detrimental to older adults who heavily rely on face-to-face interactions to maintain kinship and friendship (Wand et al., Reference Wand, Zhong, Chiu, Draper and De Leo2020). According to Choi et al., the COVID-19 pandemic has generated a disparity between an individual’s actual social relationships and their desired relationships due to its negative effects on three aspects of social connection: limited opportunities for social contact, decreased levels of necessary social support, and disrupted relationship quality (Choi et al., Reference Choi, Farina, Zhao and Ailshire2023). In the present study, forsaking in-person visits with family, altering the way of meeting friends, and giving up entertainment have the potential to decrease both the quantity and quality of social relationships and reduce levels of social support, which further exacerbate feelings of loneliness.
During the pre-pandemic era, a meta-analysis of 31 studies reported a 28.5% prevalence of loneliness among older adults in high-income countries (Chawla et al., Reference Chawla, Kunonga, Stow, Barker, Craig and Hanratty2021). A meta-analysis of 30 international studies conducted during the period of pandemic found a similar prevalence of loneliness among older adults at 28.6% (Su et al., Reference Su, Rao, Li, Caron, D'Arcy and Meng2023). In contrast, the present study identified a much higher prevalence of 36.4% for loneliness specifically attributed to pandemic-related restrictions. This increased risk in the current study may be due to the survey period coinciding with the initial COVID-19 outbreak and the implementation of strict containment measures in Pennsylvania. However, it is important to note that most studies included in the meta-analysis of studies during the pandemic were conducted outside the outbreak period, which could explain the lower risk of loneliness observed throughout the pandemic. Previous research on pandemic-related loneliness in older adults has seldom focused on the impact of restriction measures. Therefore, a significant contribution of this study is the presentation of epidemiological data on restriction-induced loneliness among the elderly population during the pandemic.
In the literature, loneliness is typically measured as a trait. For instance, commonly used loneliness scales like the UCLA Loneliness Scale and the De Jong Gierveld Loneliness Scale do not specify a timeframe when assessing the severity of loneliness symptoms. However, our understanding of loneliness within specific social contexts is still limited. According to the duration of loneliness, there are two basic types of loneliness: trait and state loneliness (Tang et al., Reference Tang2022). State loneliness is generally temporary, influenced by immediate situations, and does not persist for extended periods. Considering these perspectives, the observed prevalence of 36.4% loneliness during the period of strict physical distancing measures among older adults is likely a short-term phenomenon, indicating a temporary increase in psychosocial needs among this population. Additionally, the prevalence rate of 28.6% throughout the entire pandemic period (Su et al., Reference Su, Rao, Li, Caron, D'Arcy and Meng2023), which is similar to the pre-pandemic rate of 28.5% (Chawla et al., Reference Chawla, Kunonga, Stow, Barker, Craig and Hanratty2021), but lower than the 36.4% prevalence rate observed in the current study, further supports the situational and transient nature of restriction-induced loneliness.
Data from an empirical study in China have shown that the rate of perceived mental health service needs among lonely individuals is approximately four times higher than that among non-lonely individuals during the COVID-19 outbreak period (Bao et al., Reference Bao, Li and Zhong2021). However, due to barriers associated with the restriction measures, 84.7% of lonely individuals with mental health needs did not seek any mental health help (Bao et al., Reference Bao, Li and Zhong2021). These barriers included the suspension of mental health services in medical institutions, transportation restrictions, and concerns about COVID-19 infection when going outside (Zhong et al., Reference Zhong2020). Despite the lack of data on psychosocial service utilization and barriers to access for older adults in the study by Hughes et al. (Reference Hughes2022), it is likely that the provision and utilization of psychosocial services for lonely older adults in Pennsylvania, United States, would also be challenging during this crisis period.
A recently published systematic review of 12 studies found that psychological interventions aimed at improving social skills and reducing negativity had short-term effectiveness in alleviating loneliness in older adults during the pandemic, although their long-term effectiveness remains unknown (Li et al., Reference Li2023). While the COVID-19 pandemic is no longer considered a Public Health Emergency of International Concern and appears to be coming to an end, it is important to note that the possibility of a resurgence remains. Furthermore, it is essential to recognize that infectious diseases will never completely disappear from human history, and pandemics are likely to recur. Therefore, the findings from the current study and the lessons learned from the COVID-19 pandemic continue to hold public health implications for older adults in future medical pandemics. These insights can contribute to better preparation and response strategies for upcoming pandemics. Possible implications are provided below.
Given the stringent pandemic-related restrictions, a key consideration in tackling loneliness among older adults is the need for contactless delivery of psychosocial intervention services. Phone calls, video chats, and social media platforms offer safe and convenient channels for older adults to access these services. Those with limited digital literacy skills may benefit from the support of their adult children or caregivers who reside with them, helping them navigate online platforms and utilize the available services.
The second challenge lies in the insufficient availability of mental health service resources to meet the sudden surge in psychosocial needs in older adults during the outbreak. For instance, the current study revealed that 36.4% of older adults reported feeling lonely following the implementation of restriction strategies. To ensure the cost-effective provision of services, it is important to assess the severity of loneliness in older adults before the intervention and allocate the resources according to the level of risk of loneliness within specific subpopulations. For example, priority should be given to severely lonely older adults who may require online counseling services, crisis-hotline interventions, or online training in social skills. Conversely, those with a milder level of loneliness may primarily benefit from encouragement to stay connected with family, friends, and community members through digital technologies. The present study identified several high-risk subgroups for loneliness, including older adult women, those who were unmarried, and individuals living alone, warranting the allocation of additional service resources to address their specific needs.
Third, the significant associations between loneliness and symptoms of depression and anxiety highlight the necessity for comprehensive psychosocial services for older adults during the pandemic. Once again, priority should be given to individuals experiencing two or more mental health problems, including loneliness, depression, and anxiety, when accessing these services.
Last but not least, it is crucial to underscore the importance of establishing and maintaining an age-friendly society, even during the pandemic; raising public awareness through campaigns, media, and community programs about the significance of addressing psychosocial problems in older adults during this time; implementing inclusive policies to combat ageism and other forms of discrimination (Zhong and Chiu, Reference Zhong and Chiu2023); fostering intergenerational connections by promoting interactions between young adults and their elderly parents; and encouraging acquaintances, friends, neighbors, social workers, and community volunteers to regularly connect with older adults who are confined to their homes using various communication channels, helping them maintain social connections. By implementing these social prescribing strategies (The Lancet, 2023), societies can collectively work toward reducing loneliness and other mental health problems, promoting social connections, and improving the mental well-being of older adults during the pandemic.
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Before the COVID-19 pandemic, loneliness had been very common among the elderly population and there were concerns regarding the increasing levels of loneliness in this population due to rapid population aging and other significant socio-demographic changes in recent decades worldwide, such as decreased family sizes and increased international and internal migration of young individuals (Newmyer et al., Reference Newmyer, Verdery, Wang and Margolis2022; Somes, Reference Somes2021; Zhang et al., Reference Zhang, Fan, Zhong and Chiu2023). To curb the transmission of COVID-19, various restriction measures were implemented, particularly during the initial outbreak phase, to minimize human-to-human contact. These measures included the closure of public gathering places, implementation of physical distancing protocols, quarantine measures, suspension of family visitations in nursing homes, and enforcement of stay-at-home orders. Given the high fatality rate of COVID-19 among the elderly population and their elevated risk of major medical conditions, older adults were strongly advised to remain at home and maintain social distancing from others (Chen et al., Reference Chen, Chen and Zhong2022). While necessary for minimizing the risk of COVID-19 infection, these public health measures unavoidably disrupted many daily routines and amplified social isolation among older adults, thereby intensifying the psychosocial problem of loneliness during the pandemic (Hwang et al., Reference Hwang, Rabheru, Peisah, Reichman and Ikeda2020).
To gauge the negative psychosocial impact of pandemic-related restrictions, Hughes and colleagues investigated the prevalence of “restriction-induced loneliness” and its associations with depressive and anxiety symptoms among community-residing older adults in a small-town region in Pennsylvania, United States. This study was conducted during the most restrictive period of the pandemic, the initial 120 days of the “stay-at-home” order imposed by Pennsylvania’s Governor in 2020 (Hughes et al., Reference Hughes2022). The authors hypothesized that the disruption of social connectedness, caused by the physical distancing measures, played an important role in the development of loneliness during this period. They specifically assessed changes in 11 common social activities, such as attending church and shopping, due to the restrictions and examined their associations with loneliness in this population.
The authors found that as high as 36.4% of the older adults reported experiencing loneliness caused by the restrictions to some degree or to a great extent. Loneliness was found to be independently and significantly associated with both depressive and anxiety symptoms. Among the survey participants, the risk of loneliness was greater in women than men, in unmarried individuals than married individuals, and in those living alone than those not living alone. Overall, the majority (92.4%) of the participants complied with the social distancing recommendations and made changes to or gave up social activities. Among them, 41–52% of the older adults had to give up nonessential shopping, visiting family in person, traveling, exercising, working outdoors, and working. The study also revealed that giving up in-person visits with family, changing the way of visiting friends in person, and giving up entertainment were significantly associated with loneliness.
Humans are social animals with natural needs for relational bonds. Loneliness occurs when these social interaction needs are not met either qualitatively or quantitatively (Perlman and Peplau, Reference Perlman, Peplau, Gilmour and Duck1981). Various relationship-related factors, such as being unmarried, experiencing the loss of a spouse or partner, living alone, limited social contact, infrequently meeting friends and trusted ones, and having a small social network, significantly contribute to feelings of loneliness in older adults (Awad et al., Reference Awad, Shamay-Tsoory and Palgi2023; Dahlberg et al., Reference Dahlberg, McKee, Frank and Naseer2022; Hutten et al., Reference Hutten, Jongen, Hajema, Ruiter, Hamers and Bos2022). The pandemic-related restrictions have directly impacted the social contacts of older adults, preventing them from participating in common social activities. For example, according to the empirical data from this study, 80.6% and 70.3% of older adults had to change or cancel their routine activities for in-person visits with family and friends, respectively. These changes created barriers to receiving timely support from close relationships and resulted in reduced social networks. Such circumstances are particularly detrimental to older adults who heavily rely on face-to-face interactions to maintain kinship and friendship (Wand et al., Reference Wand, Zhong, Chiu, Draper and De Leo2020). According to Choi et al., the COVID-19 pandemic has generated a disparity between an individual’s actual social relationships and their desired relationships due to its negative effects on three aspects of social connection: limited opportunities for social contact, decreased levels of necessary social support, and disrupted relationship quality (Choi et al., Reference Choi, Farina, Zhao and Ailshire2023). In the present study, forsaking in-person visits with family, altering the way of meeting friends, and giving up entertainment have the potential to decrease both the quantity and quality of social relationships and reduce levels of social support, which further exacerbate feelings of loneliness.
During the pre-pandemic era, a meta-analysis of 31 studies reported a 28.5% prevalence of loneliness among older adults in high-income countries (Chawla et al., Reference Chawla, Kunonga, Stow, Barker, Craig and Hanratty2021). A meta-analysis of 30 international studies conducted during the period of pandemic found a similar prevalence of loneliness among older adults at 28.6% (Su et al., Reference Su, Rao, Li, Caron, D'Arcy and Meng2023). In contrast, the present study identified a much higher prevalence of 36.4% for loneliness specifically attributed to pandemic-related restrictions. This increased risk in the current study may be due to the survey period coinciding with the initial COVID-19 outbreak and the implementation of strict containment measures in Pennsylvania. However, it is important to note that most studies included in the meta-analysis of studies during the pandemic were conducted outside the outbreak period, which could explain the lower risk of loneliness observed throughout the pandemic. Previous research on pandemic-related loneliness in older adults has seldom focused on the impact of restriction measures. Therefore, a significant contribution of this study is the presentation of epidemiological data on restriction-induced loneliness among the elderly population during the pandemic.
In the literature, loneliness is typically measured as a trait. For instance, commonly used loneliness scales like the UCLA Loneliness Scale and the De Jong Gierveld Loneliness Scale do not specify a timeframe when assessing the severity of loneliness symptoms. However, our understanding of loneliness within specific social contexts is still limited. According to the duration of loneliness, there are two basic types of loneliness: trait and state loneliness (Tang et al., Reference Tang2022). State loneliness is generally temporary, influenced by immediate situations, and does not persist for extended periods. Considering these perspectives, the observed prevalence of 36.4% loneliness during the period of strict physical distancing measures among older adults is likely a short-term phenomenon, indicating a temporary increase in psychosocial needs among this population. Additionally, the prevalence rate of 28.6% throughout the entire pandemic period (Su et al., Reference Su, Rao, Li, Caron, D'Arcy and Meng2023), which is similar to the pre-pandemic rate of 28.5% (Chawla et al., Reference Chawla, Kunonga, Stow, Barker, Craig and Hanratty2021), but lower than the 36.4% prevalence rate observed in the current study, further supports the situational and transient nature of restriction-induced loneliness.
Data from an empirical study in China have shown that the rate of perceived mental health service needs among lonely individuals is approximately four times higher than that among non-lonely individuals during the COVID-19 outbreak period (Bao et al., Reference Bao, Li and Zhong2021). However, due to barriers associated with the restriction measures, 84.7% of lonely individuals with mental health needs did not seek any mental health help (Bao et al., Reference Bao, Li and Zhong2021). These barriers included the suspension of mental health services in medical institutions, transportation restrictions, and concerns about COVID-19 infection when going outside (Zhong et al., Reference Zhong2020). Despite the lack of data on psychosocial service utilization and barriers to access for older adults in the study by Hughes et al. (Reference Hughes2022), it is likely that the provision and utilization of psychosocial services for lonely older adults in Pennsylvania, United States, would also be challenging during this crisis period.
A recently published systematic review of 12 studies found that psychological interventions aimed at improving social skills and reducing negativity had short-term effectiveness in alleviating loneliness in older adults during the pandemic, although their long-term effectiveness remains unknown (Li et al., Reference Li2023). While the COVID-19 pandemic is no longer considered a Public Health Emergency of International Concern and appears to be coming to an end, it is important to note that the possibility of a resurgence remains. Furthermore, it is essential to recognize that infectious diseases will never completely disappear from human history, and pandemics are likely to recur. Therefore, the findings from the current study and the lessons learned from the COVID-19 pandemic continue to hold public health implications for older adults in future medical pandemics. These insights can contribute to better preparation and response strategies for upcoming pandemics. Possible implications are provided below.
Given the stringent pandemic-related restrictions, a key consideration in tackling loneliness among older adults is the need for contactless delivery of psychosocial intervention services. Phone calls, video chats, and social media platforms offer safe and convenient channels for older adults to access these services. Those with limited digital literacy skills may benefit from the support of their adult children or caregivers who reside with them, helping them navigate online platforms and utilize the available services.
The second challenge lies in the insufficient availability of mental health service resources to meet the sudden surge in psychosocial needs in older adults during the outbreak. For instance, the current study revealed that 36.4% of older adults reported feeling lonely following the implementation of restriction strategies. To ensure the cost-effective provision of services, it is important to assess the severity of loneliness in older adults before the intervention and allocate the resources according to the level of risk of loneliness within specific subpopulations. For example, priority should be given to severely lonely older adults who may require online counseling services, crisis-hotline interventions, or online training in social skills. Conversely, those with a milder level of loneliness may primarily benefit from encouragement to stay connected with family, friends, and community members through digital technologies. The present study identified several high-risk subgroups for loneliness, including older adult women, those who were unmarried, and individuals living alone, warranting the allocation of additional service resources to address their specific needs.
Third, the significant associations between loneliness and symptoms of depression and anxiety highlight the necessity for comprehensive psychosocial services for older adults during the pandemic. Once again, priority should be given to individuals experiencing two or more mental health problems, including loneliness, depression, and anxiety, when accessing these services.
Last but not least, it is crucial to underscore the importance of establishing and maintaining an age-friendly society, even during the pandemic; raising public awareness through campaigns, media, and community programs about the significance of addressing psychosocial problems in older adults during this time; implementing inclusive policies to combat ageism and other forms of discrimination (Zhong and Chiu, Reference Zhong and Chiu2023); fostering intergenerational connections by promoting interactions between young adults and their elderly parents; and encouraging acquaintances, friends, neighbors, social workers, and community volunteers to regularly connect with older adults who are confined to their homes using various communication channels, helping them maintain social connections. By implementing these social prescribing strategies (The Lancet, 2023), societies can collectively work toward reducing loneliness and other mental health problems, promoting social connections, and improving the mental well-being of older adults during the pandemic.
Conflict of interest
None.
Description of authors’ roles
Hong-Guang Zhang and Bao-Liang Zhong drafted the manuscript, Helen Fung-Kum Chiu revised it critically for important intellectual content, and all authors revised, read, and approved the submitted version.