Loneliness and Boredom: A Psychiatric Disorder or Late-Life Challenge?
Mrs. L is a 78-year-old widowed woman, who is a retired school principal. She presents to her primary care physician, Dr. D, complaining again that he has prescribed too much medication for her. Dr. D has only known Mrs. L for the past 6 months, following her discharge from a lengthy hospital and rehabilitation stay due to a total hip replacement with multiple complications. Mrs. L was getting off of a public bus when it was hit by a speeding car, throwing her to the ground. She suffered multiple fractures of her right scapula, radius, and hip. Mrs. L required several orthopedic procedures, including the total hip replacement. She also sustained multiple rib fractures and lacerations. Despite these serious injuries, Mrs. L recovered well initially. Unfortunately, after a period of fever, an infection in her joint replacement was found that required removal of the hardware and a lengthy period of immobility. She spent more than 5 months in the hospital and a rehabilitation center, later returning to have her right hip repaired following completion of extended antibiotic therapy. Mrs. L is now ambulatory with a walker, but due to the complications from the joint infection, she can only walk for short periods of time.
Mrs. L has been widowed for 25 years, and has two sons who live in very distant states. They visit her frequently, and both have offered to have her live with them and their families. Mrs. L has declined, stating that she has lived in the same house for almost 60 years and plans on dying there. Mrs. L has been a challenging patient for Dr. D. She appears very strong-willed and determined to remain independent, but presents with a multitude of complaints that have become overwhelming. Mrs. L suffers from chronic hip pain, which is often aggravated by her refusal to use a walker when she leaves her home. Dr. D has prescribed many different pain medications, but typically Mrs. L will not even fill the prescriptions. She has a history of hypothyroidism that is well controlled on thyroxine 88 g once daily
. There are many stairs in her home, and although her sons have installed ramps for her, Mrs. L is restricted to the main floor and her upstairs bedroom. She complains of feeling “useless,” as she can no longer travel to the after-school program where she was a very popular tutor for children living in foster care. She used to spend a great deal of time volunteering at voter registration drives, local political committees, and a professional association of teachers. Mrs. L complains that since her lengthy hospitalization, and because of her need to use a wheelchair when going long distances, she receives very few offers to join events. She describes feeling lonely in her house, bored with television, and tired of reading books all day. Mrs. L has started going to bed earlier each night, out of boredom, but she now wakes up at 4:00 or 5:00 am. Mrs. L is angry with Dr. D for prescribing an antidepressant medication for her at her last visit, and gives him back the unfilled prescription. She tells Dr. D that pills will not make people stop feeling sorry for her, or give her something to do with her time. When Dr. D offers her a prescription for a new hypnotic medication and suggests that she go to a local senior center, Mrs. L calls him “useless” and leaves the office. Dr. D reviews what happened and is concerned that his patient may be depressed, but it appears that her symptoms are primarily related to frustration, loneliness, and boredom. He consults with a hospital social worker, Ms. G, to see if there are other options for Mrs. L.
This case illustrates a common challenge facing older adults. How does an elderly person manage to find new meaning in her life when physical activity and independence become restricted?1 It is certainly appropriate for Dr. D to be concerned about depression, to ask the patient about feeling sad and hopeless, and for him to screen for suicidal thoughts. However, it appears that Mrs. L is coping with adjustment issues related to her injuries, prolonged illness, and physical dependence.2 With the majority of our older population living in the community, coping with physical decline is a significant issue. In this case, it appears that the patient’s major source of social support was her volunteer work, and the loss of the ability to continue in this role is a major factor in her loneliness and boredom.3 Many physicians have identified loneliness as a clinical problem that is too often misidentified as a disease.4
Erikson5 described the greatest challenge facing the older adult as one of integrity versus despair. The resolution of this challenge comes through identifying and utilizing the wisdom that is acquired throughout the lifespan. Wisdom is a major coping skill and the means through which older adults may share the knowledge that is accumulated through life experience.5,6 Older adults who face the loss of physical functioning must deal with their sense of grief and bereavement that accompanies this stress.1,3 An older adult who becomes more physically dependent must deal with the changes in roles and interpersonal relationships that accompany increasing needs. Changes in social status are common among older adults who need assistance and among elderly persons who serve as caregivers.1 These are additional stressors that often lead to a sense of not only loss, but demoralization.
Older adults frequently encounter a number of new roles as they age. This often begins with retirement, and the change from having a full-time job to having leisure time. As acute and chronic illness increase with age, the role of the patient becomes more time consuming and stressful.6 In addition, as one older adult becomes ill, typically a spouse or other family member may need to take on the role of caregiver. The ability to transition to another role while continuing to utilize life skills is vital to maintaining social and emotional well-being.5 Social networks, supports, and positive interpersonal relationships have been associated with improved health outcomes in late life. Older adults who are able to utilize existing social supports to maintain life roles despite changes in physical functioning adjust far better to stressors.1,6
Those who are unable to adapt to changes in function or roles due to lack of social support display significant negative changes in health outcomes. Fortunately, social supports can be provided through formal and informal networks. Senior centers, religious groups, and volunteer agencies offer social programs that range from activities to visiting the homebound elderly.7 Another major feature associated with the ability to cope with the stressors of aging is the concept of self-efficacy, originally defined by Bandura in1982 as the personal capacity to effect change and control events.8 Older adults who maintain a sense of being able to take control of their environment and make desired changes are far more likely to maintain a sense of well-being.3 They are more likely to live longer and have better health status.6,7 The use of social supports and the promotion of self-efficacy have been associated not only with healthy aging, but with better outcomes following illness and improved morale in older adults who suffer from chronic illness.6,7 It is important that the clinician focus on the promotion of these psychosocial aspects of aging, as their effect on health status is powerful (Table1,3,6-8).
OUTCOME OF THE CASE PATIENT
Dr. D consulted with the social worker, Ms. G, who knew Mrs. L during her stay on the rehabilitation unit. Ms. G remembers Mrs. L as a “natural leader” who organized a group on the unit that met with the hospital administrator regarding issues of food being served late and the need for more nurses during the night shift. The social worker knows of a number of community programs that would love to have Mrs. L assist with their needs. She arranges to meet with Mrs. L and reviews her interests. Ms. G tells Mrs. L about an advocacy program for high school students who are at risk of not graduating, but who have no access to special services. Mrs. L relates to this immediately, saying, “These are the kids that the board of education tries to throw under the bus and forget about, just like what happened to me.” She joins the advocacy program and starts providing tutoring services to students. She also joins a task force to improve high school graduation rates. Within a few weeks, Mrs. L is quite busy. She attends meetings in her wheelchair, and advocates to improve the access to public transportation. Loneliness and boredom are no longer problems for Mrs. L, who was able to successfully transition into new roles by utilizing her background as an educator. Like many older adults, she went through a period of adjustment and bereavement over her physical losses. She still sees Dr. D, and has accepted some pain medication to help with the days when she overexerts herself.