Monday, May 9, 2011

Loneliness



2 recent articles have helped me prioritize addressing loneliness of patients.

An opinion piece in this week’s NEJM "The Loneliness of Visiting" emphasizes loneliness in the hospitalized patient during a prolonged hospital stay and how hospitalization is perceived by the family. After 3 months in the hospital, “The problem is the poor chap is lonely” the intern states. The team question why the family has quit coming to the hospital. The situation dramatically changes when the patient develops a stroke. In a delightful change of narrative, the patient changes from Mr. Wilson to Brad. The author, Dr. Ranjana Srivastava has known Brad since medical school and continues to visit daily not as a doctor but as a friend sitting by the bedside. From that perspective, Dr. Srivastava struggles with how to be present with the critically ill. Cell phone and newspapers have to be put aside when she recognizes they are keeping her from being with Brad. Then as a nurse asks what she is doing there, she ponders the question of whether our system keeps family away. She recognizes that being with the critically ill is often an introduction to mortality family members. Finally, she sympathizes with the Wilson family. Whereas, initially she viewed their lack of presence in the hospital as selfishness, she comes to see it as “self-insulation.”

I also highly recommend the Wakley Prize winning essay “An Epidemic of Loneliness” by Dr. Ishani Kar-Purkayasatha in December’s Lancet. Dr. Kar-Purkayasatha describes a patient on the wards named Doris who presented with palpitations. Despite a negative work-up, three weeks later (!!!) Doris is still in the hospital. On the planned day of discharge of December 24th, and after two previous attempts to discharge, Doris has more symptoms. Yet after another evaluation, the true problem reveals itself. “Doctor”, she asks, “can you give me a cure for loneliness?”

Among those over 85, 52% of women live alone compared to 29% for men. Many will have outlived not only spouses/partners but also their friends and children. And loneliness may impact patients physically. Loneliness may diminish the effectiveness of the cardiovascular, nervous and immune systems. The positive impact of exercise may even diminish in the lonely.

How can we deal with an epidemic of loneliness? While it would be nice if a simple antidepressant prescription would provide a cure, not all loneliness is depression. And, while we can involve social services, and make referrals to senior centers and counseling sites, the key to activating these resources is successfully identifying the loneliness.

I recently saw a delightful 93 year old who is the paragon of health. After some review of his perfectly controlled hypertension, it was clear he wanted more from our encounter. Screening for geriatric conditions was completely negative. He exercised two hours a day. He continued to publish in academic journals. He had normal cognition, and a geriatric depression screen was negative. Then, he began to tear as we discussed how he was coping with a few years of widowhood. “I am just so lonely.”

I often use the simple screening tool, “Are you sad or depressed?” in clinical practice. Now my follow-up question for the elder living alone will be, “Are you lonely?”

by: Paul Tatum

6 comments:

Ella Bowman said...

Paul, I read this over the weekend and share my sentiments with you. Loneliness seems to be a huge issue, quite understandably, for many of my elderly patients who have experienced cumulative losses. I just finished a consult on a lady with a new stroke who wants to stay in the hospital as long as possible because she is getting "so much more attention than back at the nursing home." Many of my homebound patients for whom I make house calls never want me to leave, and the conversation often continues long after I have completed the history, physical, medication reconciliation, and sometimes even played with their pets or talked with the family members. This is one of the toughest true dilemmas I believe we face in geriatrics, as there certainly is no easy answer for many of our patients who might not have the luxury of transportation to senior centers or families. I love your idea about screening for loneliness at every new encounter right along with depression and cognitive screening. My biggest fear, though, is that I'm going to get a lot of "yeses," and suspect I am ill prepared to adequately address them all! It is at least something with which we in health care can all strive for - our patients deserve it!

Suzana Makowski MD said...

Thanks for writing about this. I am curious about how social media might help decrease sense of isolation in patients with prolonged hospital stays. Using sites, not only like facebook, patientslikeme, carepages, but also some that allow stories to be told legacies collected: 1000memories for example.
Also, shared gaming experiences - such as those put forth by HopeLab might help.
Just some thoughts...

Anonymous said...

Wow, this really hits home as I see patients with frequent hospitalizations and wonder about their loneliness. Hospice patients who outlive their and their families expectations, heart failure patients that get lots of aggressive therapy on admission and need to return every 6 weeks or so for the same and see quite content to do so. We are fortunate to have a program of volunteer med students who 'visit' patients and families evenings and weekends and really help to provide..the caring presnce of another human being, without an agenda. But how to provide that at home???

Peny@uniforms scrubs said...

"I often use the simple screening tool, “Are you sad or depressed?” in clinical practice. Now my follow-up question for the elder living alone will be, “Are you lonely?”

Loneliness always creep the old ones for theirs is a long memory of many experiences and loved ones, ones with them and then gone. I don't know, but if you doc knows already that your elderly patient is lonely, then what could be the cure for that loneliness, eh?

Paul Tatum said...

I agree that in general it's not worth screening for things if you don't have a response. In this case, it might reframe how I proceed with somatic complaints and to what degree I work up. More importantly it would help me activate a Team to work to decrease isolation. SW is a big part of that, but community too.

I think social media is a great idea for helping here.

One of the best interventions we did in LTC was start a Wii bowling club. One of our "shut-in" leave-me alone types became one of the biggest participants.

Karen Hiensch said...

During a clinical rotation in a nursing home, I was struck by how many patients screened negative for depression on the GDS, but were tearful and admitted loneliness when asked how they'd been doing lately. So often I'd see 2 residents in similar situations just down the hall from each other. Of course, HIPAA prohibits me from saying, "Hey - Mr. X in room 301 is lonely too! Go stop by!" I settled on a generic "Many other people here might feel the same way. Ask someone you see at meals to take a walk with you and see how you get along."

But the experience definitely got me thinking about how nursing homes in general emphasize collective experiences with activities like concerts and bingo (things that look good in brochures), but do little to foster one-on-one friendships between residents. I noticed residents who attended many activities, but still felt lonely and longed for connection and conversation.