Abstract
Older patients with loneliness are connected to others through their social network ties and are, therefore, more likely to be influenced by their family environment. We define collateral care as involving the family members of patients suffering from loneliness. This research letter determines what physicians and nurses should be aware of in the families of older patients to manage their health care. A cross-sectional study in Japan was conducted on patients aged 65 years or older together with their accompanying family members, aged 18 years or older. Patient loneliness was assessed using the 3-item version of the UCLA (University of California, Los Angeles) Loneliness Scale (Japanese). The sample comprised 50 pairs of patients and their families. Family income inadequacy was significantly associated with patient loneliness (P = .021). Our data reveal the family's financial instability contributes to patients’ loneliness. In addition to traditional forms of direct care, physicians and nurses need to be willing to manage the loneliness of older patients by attempting to provide collateral care, considering family circumstances.
Keywords
Introduction
Patients are connected to others through their social network ties. 1 As a result, patient outcomes are influenced by their family environment, which is especially relevant to the care of the patient suffering from loneliness. Few patients, however, seek medical care with loneliness as their chief complaint. Given mounting evidence of the serious detrimental health consequences of loneliness,2–4 healthcare providers should thus be screening for it. Yet evidence suggests that both physicians and nurses perform poorly at detecting loneliness in older patients. 5 One reason is because providers fail to accurately take into account the social circumstances of the patient's family during the clinical encounter. In turn, the diagnosis of loneliness presents a challenge when initiating solutions such as social prescribing. 5
Loneliness and social isolation share a number of similar risk factors. 4 One difference is that loneliness is a subjective feeling and not easily visible and therefore challenging for others to assess. 5 In this context, certain factors may be more crucial than social isolation in determining whether a person will likely experience loneliness. 5 For older individuals, family plays a significant role in providing social support, and the loss of family members tends to increase the risk of both loneliness and social isolation. 4 However, family factors influencing loneliness in older patients are not fully understood.
We define collateral care as the involvement of family members of patients who suffer from loneliness (Figure 1). The idea of including family members in the care of the patient is already recognized in medicine (eg, family-oriented primary care) 6 and in the nursing field (family systems theory in family nursing). 7 In this research letter, we determine what physicians and nurses should be aware of in the families of older patients to manage their health care. Focusing on the older patient's family can provide new insights for physicians and nurses when dealing with loneliness.
Collateral health effects of loneliness care. The conventional model, which is direct care, and the expanded model, which adds collateral care, are shown.
Methods
We conducted a cross-sectional survey of patients at Kashima Hospital, a facility affiliated with Fukushima Medical University School of Medicine, Department of Community and Family Medicine, from August to September 2023. The survey method was self-administered. We surveyed patients aged 65 years or older together with their accompanying family members, aged 18 years or older. For each patient, we interviewed one family member who was involved in the care of the patient. After the consultation, the family physician referred study subjects to the co-investigator, who explained the study in the waiting room and obtained their consent for data collection. Patient loneliness was evaluated using the 3-item short version of the UCLA (University of California, Los Angeles) Loneliness Scale (Japanese), with a score of 7/12 or higher indicating loneliness. 8 Other patient variables were “Basic characteristics,” “Living conditions and social network,” “Current medical conditions,” and “Comprehension of explanations.” We also measured family uncertainty using the 3-item short version of the MUIS-FM (Managing Uncertainty in Illness Scale-Family Member Form) (Japanese) 8 and the World Health Organization-Five Well-Being Index (WHO-5). The MUIS-FM was categorized into 2 groups based on a median split. Other family-related variables were “Age,” “Gender,” “Educational attainment,” “Relationship with the patient,” and “Economic circumstances.” Family income was self-assessed by the family member and rated on a 5-point scale: (1) comfortable, (2) somewhat comfortable, (3) normal, (4) somewhat distressed, (5) very distressed. We dichotomized the responses into sufficient income versus not by collapsing categories (1)-(3). Data were analyzed using Stata/SE version 16.1, with the Chi-square test and the Mann–Whitney U-test (Table 1), and then a multivariable logistic regression analysis was conducted. For multivariable analysis, because of the strong collinearity between family well-being and uncertainty, we ran a model including just family income and well-being and a separate model including just family income and uncertainty.
Univariable Analysis of Patient and Patients’ Family Factors Associated With the 3-Item Short Version of the UCLA Loneliness Scale (n = 50).
The Chi-squared test was adopted for the analysis of categorical variables.
Community activities: Activities within the community or neighborhood-led organized activities, etc.
The Mann–Whitney U-test was adopted for the analysis of continuous variables.
Results
The sample comprised 50 pairs of patients and their family members. Univariable analysis showed a significant association between patient loneliness and low family income (P = .021), low family well-being (WHO5) (P = .043), and high family uncertainty (P = .048). In a multivariable analysis, family income insufficiency continued to be associated with an increased odds ratio [OR] for patient loneliness, regardless of control for family income and well-being or family income and uncertainty (OR 3.20, 95% confidence interval [CI] 0.62-16.58; OR 4.45, 95% CI 0.97-20.28, respectively).
Discussion
Our results show that loneliness in older patients may be a consequence of family economic circumstances. In US data, household income insufficiency is associated with less time spent with household family members as well as companionship in general, increasing the risk of social isolation. 9 Financial insecurity might cause some people to keep a distance from family and friends. As a result, social connections—such as brief conversations—are reduced, resulting in the loneliness. 3
The study has several limitations. First, a cross-sectional study cannot establish causation between patient loneliness and family economic circumstances. Second, our study was exploratory in nature and a larger sample size is needed for more robust statistical analysis. Third, the family's economic circumstances (income sufficiency) were self-assessed. Last, this study did not measure social isolation, as the focus was solely on loneliness. Measuring social isolation could have allowed a comparison of loneliness and social isolation risk factors.
There is a critical distinction between social isolation and loneliness. The former refers to the objective condition of having few social relationships, social roles, group memberships, and infrequent social interaction.2,4 By contrast, loneliness refers to a subjective internal state, that is, the distressing experience that results from perceived isolation or unmet need between an individual's preferred and actual experience.2,4 Some patients are not objectively isolated, yet they may suffer from loneliness.
In contrast to objective social isolation (which is readily observable), physicians and nurses may be unaware of loneliness. Our data reveal that family circumstances (financial security) contribute to the loneliness of the patients. In addition to traditional forms of direct care, physicians and nurses need to be willing to manage the loneliness of older patients by attempting to provide collateral care, through taking family circumstances into consideration.
Footnotes
Acknowledgements
We are grateful to Kashima Hospital (Iwaki, Fukushima, Japan) for providing data.
Author's Note
Aya Goto is also affiliated with Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
This study was approved by the Ethics Committee. Institutional Review Board Name: General Ethics Committee of Fukushima Medical University IRB reference Number: REC2023-036.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Institute of Seizon and Life Sciences (ISLS) (grant number FY2023) and the Takemi Program in International Health.
Data Availability Statement
All data included in this manuscript can be accessed from the corresponding author upon request through the email address.