Loneliness The Elderly Family Health And Social Care Essay

The purposes of the study was to find out more about the reasons and possible implementations to loneliness in the elderly family caregiver,it was also intended to find out various supports for the elderly familycaregiver.The study was done as a result of the authors’ practical training encounters with the elderly living with their spouse and their loneliness as a reslut of the burden they encounter.

The research questions used for the study were: how the elderly family caregiver’s loneliness was linked to social isloation;what are causes of loneliness in the elderly family caregiver;what are the symptoms associated with loneliness;what are the effects of loneliness; Are there any supports for the elderly caregiver?.The theoretical frame used for the study was Nicholas R. Nicholson Jnr’s theory of social isolation. The study also noted the institutional care approach to the elderly caregiver compared to being at home.

The method used for the study was a qualitative research method.A systematic literature review was used to answer the research question through content analysis.

The result of the study findings were that loneliness in the elderly caregiver resulted from social isolation,disengagemnets from social funtions,bereavemnet,loss of social contacts,and loss of jobs.The most commonly used scale in measuring loneliness was the University of Calofornia Los Angeles(UCLA) loneliness scale,to identify the level of lonelinss of the elderly family caregiver.

The study then identified types of supports that could help the elderly caregiver in coping and managing loneliness to enhance the quality of life.

The author therefore recommends the continuation of the study to sensitize and educate the elderly caregiver with major interest in socialization.

Keywords:

Loneliness,depression,family,caregiver,Elderly

Number of pages:

62

Language:

English

Date of acceptance:

OPINNÄYTE

Arcada

Koulutusohjelma:

Human Ageing and Elderly Service

Tunnistenumero:

9411

Tekijä:

Nana Yaa Essandor

Työn nimi:

Iäkkäiden omaishoitajien kokema yksinäisyys

Työn ohjaaja (Arcada):

Jari Savolainen

Toimeksiantaja:

Tiivistelmä:

Tutkielman tarkoituksena oli selvittää iäkkäiden omaishoitajien yksinäisyyden syitä ja mahdollisia täytäntöönpanoja.Tarkoituksena oli myös keksiä heille erilaisia tuen muotoja.

Tutkielma valmistui kirjoittajan käytännön harjoitteluissa tapahtuneiden kohtaamisten perusteella. Kohdatut omaishoitajat asuivat puolisoidensa kanssa ja he kokivat yksinäisyyttä taakkansa vuoksi.

Tutkimuksessa käytettiin seuraavia tutkimuskysymyksiä: kuinka iäkkään omaishoitajan yksinäisyys oli sidoksissa sosiaaliseen eristäytyneisyyteen; mitkä olivat syinä omaishoitajan kokemaan yksinäisyyteen; millaisia oireita yksinäisyyteen liitettiin; millaisia seurauksia yksinäisyydellä oli; oliko iäkkäille omaishoitajille olemassa tukea?

Tutkimuksessa käytettiin teoreettisena viitekehyksenä Nicholas R. Nicholson nuoremman tutkimusta sosiaalisen eristäytymisen teoriasta. Teoriassa huomioitiin myös laitoshoidollinen lähestymistapa verrattuna kotona pysymiseen.

Tutkimuksessa käytetty metodi oli luonteeltaan kvalitatiivinen. Systemaattista kirjallisuuskatsausta käytettiin tutkimuskysymyksiin vastattaessa sisällön analyysin avulla.

Tutkimustuloksena nähtiin omaishoitajien yksinäisyyden syiden johtuvan sosiaalisesta eristäytymisestä, sosiaalisista tapahtumista vetäytymisestä, surusta, sosiaalisten kontaktien puutteesta ja työpaikan menetyksestä.

Yleisimmin käytetty asteikko yksinäisyyden mittaamisessa oli Kalifornian yliopiston (UCLA) yksinäisyysasteikko, jonka avulla yksinäisyyden asteita omaishoitajien keskuudessa voitiin identifioida.

Sen jälkeen tutkimuksessa identifioitiin erilaisia tuen muotoja, jotka voisivat auttaa omaishoitajia selviytymään ja käsittelemään yksinäisyyttä, jotta heidän elämänlaatunsa paranisi.

Kirjoittaja suosittelee tutkimuksen jatkamista, jotta iäkkäät omaishoitajat tiedostaisivat ja oppisivat asioita paremmin pääpainon ollessa sosialisoinnissa.

Avainsanat:

yksinäisyys, depressio, perhe, omaishoitaja, vanhukset

Sivumäärä:

62

Kieli:

Englanti

Hyväksymispäivämäärä:

TABLE OF CONTENTS

Figures

Tables

FOREWORD

I will want to first of all thank the Almighty God for bringing me this far, this is a dream come true.

My sincere thanks to my dedicated supervisor Jari Savolainen, for your support guidance and encouragement that has led me to finish this project, I am very grateful.

I want to thank all HAGEL 07 teachers who helped me to be who I am today, uttermost thanks to Solveig Sundell and Åsa Rosengren.

My appreciation to all my family and friends who have contributed in diverse ways to help me accomplish this task for my future, may God bless you so much, my dear Flora Agalga now the victory is ours, I am grateful for your friendship and love.

I will want to say thank you to all my classmates of HAGEL 07 who contributed to my studies especially Roland Ngang and Yirgalem, and also my work colleague Maija Aapakari for helping me with the translation, I am grateful.

Again I will want to dedicate this work to my two lovely boys Nester and Daniel, I love you so much and will continue to go the extra mile to support you so you can even go higher than what I have and will achieve. To my dear one Nana Yaw Essien, I say a big thank you for your consistent encouragements for me to finish my course, I know you almost thought it was going to be impossible but today it is a reality and I know you are proud of it.

Lastly I will want to say I have fought the good fight and My God has rewarded me, though it has tarried it has come to pass, to him be all glory and honour.

Introduction

There are so many ways of a person feeling accepted or rejected, but feeling lonely can be described as the most unfortunate thing, it is an awful experience when a person feels left alone in life, that is when bad actions and ideas come to mind. In that situation, there is no one to confide in or talk to for example. For this reason, the author having been on three practical training working with elderly people chose to research more about loneliness and how best the elderly will be confident and feel belonged in the late cycle of their lives. It was the authors’ priority and concern to study further about the topic since the author was of the opinion that “feeling belonged grants the elderly person/people peace and comfortability.

Loneliness researches tend to identify individual factors on either personality or absence of social contacts, Jylha & Jokela, (1990).Meanwhile loneliness is said to also be an individual’s relationship to society. It is also identified that differences in cultures and the manner of various peoples’ social relations results in a cross-cultural dimensions of the way people are able to cope with loneliness, Rokach and Brock (1997).

Since loneliness is pervasive and debilitating, it is of both theoretical and clinical necessity to identify the way different people cope with loneliness and how their coping skills are affected by the culture of a person, as coping with the stressful situations by individual and social resources Folkman & Moskowitz (2000).

Weil (1997), states that people are highly social, communal animals and are supposed to live in families, tribes and communities and once those connections do not exist, the human being suffers.

Previous studies on loneliness show it is a universal phenomenon that identifies it with mental health and wellbing.Cohen & Syme (1985); Ganster & Victor, (1988), Landis & Umberson, (1988).

Loneliness has many adverse effects on the human being and mind has been therefore linked to depression, anxiety and interpersonal hostility which can lead to bad health. Nursing Research (1999).

It has also been identified that, psychological variables which includes loneliness is associated with changes in the immune functioning and may thus weaken a person’s capacity to fight disease, journal of psychosocial oncology (1992).

Definitions of key words used for the study

Keywords are the words that were relevant and helped the author to focus on the selected topic study.

Loneliness

This term is described as the system of emotional and social isolation; loneliness could also be explained as a natural response of an individual’s response to certain situations and not as a form of weakness. Emotional and social isolation are two distinct forms of loneliness which can be listed as well as feeling of emptiness, anxiety, and restlessness Psycinfo Database Record (c) (2012).

Again according to Psycinfo Database Record (2012) APA, Real loneliness one of the least satisfactorily conceptualized psychological phenomena, plays an essential role in the genesis of mental disorder.

Nonconstructive loneliness has much in common with such states as panic and anxiety.

Descriptions of loneliness by poets, patients, and philosophers are reported and discussed. Different types of enforced and experimental isolation, physical loneliness, and the problems of psychotherapy with the lonely are considered.

Depression

Depression is generally a common type of psychiatric disorder in children, adolescents, adults, and the elderly. Depressed people have various bad feelings such as; sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms, Psychoinfo Data Base record (2012).

It is difficult to identify people with depression in a primary care because of lack of time but other depression screening measures helps to diagnose the disorder.

According to Am Fam Physician (2002), depression is the second most common chronic disorder seen by primary care physicians. On the average, 12 percent of patients seen in primary care settings have major depression. The degrees of suffering and disability associated with depression are comparable to those in most chronic medical conditions.

A study found out that lonely people showed more depressive symptoms such as wanting to isolate themselves from group or social gatherings. Again, people who are lonely and depressed tend to experience less togetherness in various social interactions.

Research has also found out that depression and loneliness cannot be interchanged since they always prolong each other’s disorder, since both work on an individual at a time, and may not be interchanged. Depression is often described as the emotional expression of the ego-helplessness to live up to certain strong aspirations. PsycInfo database (2012).

Caregiver

A person rendering services or assisting a person in a particular disability or giving support is basically termed a caregiver. Caregivers normally experience burden or stress related issues because of the process in giving care to the patient or person in question.

In another study, a caregiver refers to someone who provides unpaid support to a family member, partner. This could be because the person is ill, frail, disabled or has mental disability or substance misuse problems. GSA, (1991) (Gerontological Society of America).

In various examinations about this, studies that evaluated burden of care for a mentally ill relative using measurement instruments with established validity and reliability.

Mean age of respondents (69% female) of the studies reviewed was 52 years. Some review identifies aspects of caregiving as most burdensome to caregivers, and also seeks to describe the nature of the relationships between sociodemographic, illness-related, caregiver stress-related, and psychological resources variables and different dimensions of caregiver burden, it also identifies mixed findings that are theoretically relevant to caregiver burden.

In reading about a caregiver and the challenges associated with it, research findings in light of the methodological issues and research designs characterizing various literatures, briefly summarizes the effects of burden on the caregiver’s life. PsycINFO Database Record (2012).

Although it is assumed that the occurrence of depression in patients correlates strongly with the caregiver burden linked with depression, the vulnerability of caregivers to depression is linked to their own age, gender, physical ability, personality, and available social supports, JAMA (2002).

Elderly

In many researches and studies, “elderly” has been defined as a chronological age of 65 years old or older, while those from 65 through 74 years old are referred to as “early elderly” and those over 75 years old as “late elderly.”

However, the evidence on which this definition is based is unknown. Researchers have tried to review the definition of elderly by analyzing data collected from long-term longitudinal epidemiological studies, and clinical and pathological studies that have been accumulated at the Tokyo Metropolitan Geriatric Hospital and the Tokyo Metropolitan Institute of Gerontology.GGI, (2006).

In practice, most studies 13 out of 19, set the definition of elderly patients at 60 years. Median age of patients varies from 64 to 69 years from one study to another, which suggests, that, with regard to age, most studies are comparable, even if the definition of elderly people varies from 55 to 65 years, The Hematology Journal (2002).

Family

According to Alberto Alesina & Paola Giuliano (2007), family is an important socio-economic institution in every society. The nature of the links between family members varies across the globe. Depending on the environment, certain aspects must be taken into consideration in order to identify someone as a family relative. In this study, family is considered to comprise of husband, wife and children.

Motivation of Study

The research topic came into existence during the author’s practical training in a nursing home. In the course of the training, the author noticed most of the elderly patients were lonely and needed attention. One of the patient even made a comment “I wish my husband is here with me” in Finnish language. This drew attention and generated a scene of conversation between the patient and the author. The conversation yielded fruitful results and filled the author with a need to research on how it feels for elderly caregiver to care for their partners.

Previous Research

The author with the interest of the topic now tried to find previous information and articles about the subject, which different authors have discussed.

In one development, it was identified that by the year 2050,family members will be providing most of the homecare needed by the 11-16 million people in the United States proposed to have dementia, Alzheimer’s Association(2009);Herbert, Scherr, Bienias, Bennett & Evans(2003).

The author again identified that the burden of providing care at home for an elderly person with dementia gradually increases the risk for depreciating health effects for the person providing that care, Pinquart & Sorensen, (2003); Vitaliano et al, (2005).Schulz and Beach(1999) also reported that caregivers stress experiences was a high increasing risk of 63% mortality rate compared to noncaregivers.Again, it was reported that caregivers for spouses with dementia had developed high levels of emotional stress,depression,loneliness and other health related problems, Adams,(2008);Mills et al,(2009).

The caregiving process has generally been identified that spouse caregivers are at greater risk of stress related mental and physical problems than the adult children caregivers for the elderly, Pinquart & Sorensen (2003); Vitaliano et al (2005) specifically because the spouses are older and have more chronic conditions which needs assistance to their own health conditions, Kolanowski, Fick, Waller & Shea, (2004); Schubert, (2008).

The depreciating health of the caregiver has been attributed to living with the elderly burden of constant caregiving, Schulz & Martire (1999) and not having the usual life for healthy living, for example caregivers have reported less participation in healthy behaviours, disabling physical conditions and poor attention to personal health, Bruce (2005); Pinquart & Sorensen (2003); Schubert, (2008).

It was thereby recognized that caregiver burden or difficulties attributed to the greater incidence of caregiver psychological effects, primary anxiety and depression as a result of loneliness, Cooper, (2008); Pinquart& Sorensen, (2003).

The diagram below shows the relationship of the factors affecting the caregiver.

BACKGROUND AND CONTEXUAL FACTORS

CAREGIVER BURDEN

(PREDICTOR)

FINDING MEANING THROUGH CAREGIVING

(MEDIATOR)

CAREGIVER PHYSICAL HEALTH

CAREGIVER MENTAL HEALTH

(OUTCOMES)

Research design by, (Farran, Miller, Kaufman&Davis, 1997; Hilgeman, Allen, DeCoster, &Burgio, 2007).

Figure .The caregiver burden

Once again, the author identified that since the population in Finland and everywhere else in the world continues to age and growing effort to develop better outpatient services for the elderly people was a necessity, the idea was to help support the elderly people to cope and live independently in the community as long as possible to promote wellbeing, Krach, (1996) and also less expensive option compared to the institutional care, Chiu, (2000).

The policy in Finland is therefore to facilitate family care for elderly people at home and support family caregivers in their demanding jobs, Ministry of social affairs and Health, (1999).

It was then realized that coping demands aroused from distress, which was a s a result of stimulus that is perceived as a threat, harm or challenge that exceeds the individual (caregiver) ability to cope, Nolan & Lundh (1999).

The coping demands are always great when the caregivers only get limited support or no support at all from the immediate government,environment,family and friends, Robinson & Steele,(1995);Coen (2002);Rawlings and Spenser (2002) and again if the interaction and encouragement for the elderly person does not work, Pyykko (2001).

Former researchers also found out that family caregivers have less interaction with other people due to the evolvement of their life’s around the home and coping with their caring responsibilities, Jykyla & AStedt-Kurki, (1998); Pyykko et al (2001).It was with that reason that the elderly family caregivers often have negative experiences such as loneliness, isolation, boredom and frustration, Chambers (2001); Samuelsson (2001); Rawlings& Spenser (2002).

According to Wright (1999);Chambers et al (2001);Pyykko et al (2001);Samuelsson et al (2001),various emotional reactions exhibited by family caregivers includes feelings of guilt, anger, anxiety and depression which are difficult to cope with except by getting professional assistance.

Finally, in another research about the subject, the author came across studies which showed that emotional and physical strains were so much imposed on family caregivers in connection with the responsibility of caring for the elderly with mental illness,Hoenig & Hamilton (1966); Martyns-Yellowe (1992).

In a survey of five European family associations about psychiatric services, the respondents stressed on the need for interventions at creating stability and social functioning,Haan et al (2002).

The research done by the author on the articles above therefore authenticate the many challenges experienced by the elderly family caregiver which loneliness is a part of.

AIM OF STUDY AND RESEARCH QUESTIONS

The author realized during her practical training in the various home care centers, how the older people experience rejection and left alone to face their last life’s by themselves, and the situation was even sad with the one’s living with their spouses(husband or wife),they rather felt lonely at most times because although they are also going through the stages of their lives and suffering various sicknesses and diseases, they will always have to abandon themselves and take care of the other spouse because the situation might be worse than his/hers, therefore making them have too much stress and pain. In such an instance, it is then possible that the other spouse taking care of the one supposed to be worse rather experiences various forms of neglect and even lead to psychological malfunction, then instead of being together, they are rather split apart from each other so that each one can take care of him/herself and not harm or maltreat the other.

This study was to find out more about reasons and possible implementations and guidelines which might support the elderly person’s caregiver.

The author of this study used content analysis and literature review, to ascertain the ongoing facts and findings further about the topic, since we all get or are lonely at some point in our lives, it must not dominate the human nature to bring up difficulties in coping especially in the last days of the human cycle (life).

Furthermore, the study aimed at getting inventions and interventions’ about this concept of loneliness and depression. Within the context of the study, two research questions were derived as seen below;

1. How is loneliness in the elderly family caregiver, linked to social isolation?

1. A. What is/are the causes of loneliness in the elderly family caregiver?

1. b. What are the symptoms associated with loneliness?

1. c. What are the effects of loneliness?

2. Is there any form of support for the elderly care giver?

A. What are the supports for the family caregiver?

BACKGROUND STUDY

Loneliness is defined as the time of feeling neglected and left alone, it is a condition of being lonely; solitude. Loneliness is also described as a personal feeling of depression resulting from being alone. Hsu, Hailey, Range (2001)

Basically, every person experiences loneliness from time to time, for example on valentines’ day when everyone has a dear one around and during some cases or encountering some stress, that is the time a person feels very lonely when there’s no one around.

There are a quite number of people who experience loneliness more, it is because people do not talk about their feelings of being lonely, and even if they do feel lonely, they don’t know what to do or how to react at these times of experiencing such feeling of loneliness. There are so many ways that loneliness may or can affect a person’s life such as emotional, physical pain and depression.

Physical Pain

Research has identified the area of the brain that deals with social exclusion as the same that processes physical pain, thus a scientific explanation to the often romanticized experience of a “broken heart”

Physical Health

In reading about physical health it was realized that studies have been linked to emotional stress and depression. Other researches link loneliness and depression with poor health and wellbeing. This means that people who are experiencing loneliness are susceptible to a variety of health issues and problems.

Loneliness in later life remains a serious problem despite extensive research across life span. Studies of loneliness includes elderly people who are lonely, other studies recommend interventions depending on the external factors such as socialization and functional activities.

Some interventions are not always suitable for elderly people who might have experienced social and functional losses. Nurses and healthcare professionals must therefore adopt a new way of examining loneliness in later life. This new perspective must include a better positive approach that focuses on elderly people who are not lonely eventhough they may have experienced decreased socialization or physical function. Identifying some of those strategies by the elderly people in question can be used to help other elderly people avoid loneliness and help others to cope with the related losses.

The findings from biological psychiatry cannot be ignored somehow because the empirical evidence is mounting that many elderly people are biologically vulnerable to the onset of depression, Alexopoulos (2000); Krishnan, (2002).Epidemiological studies document that depression is less frequent among the elderly until they reach the oldest old, Blazer, (2002).

When the issue is analyzed, it would mean that elderly people are biologically vulnerable to depression, meanwhile, psychological and social factors are more protective in late life compared to mid-life when cognitive dysfunction and physical illness are held constant, Blazer,(2002).

UCLA Loneliness Scale

The UCLA loneliness scale is a method that was devised to assess the subjective feelings of loneliness or social isolation.

The original version was based on statements used by lonely individuals to describe how they feel, Russell, Peplau, & Refuson, (1978).

Questions were all worded in a negative or “lonely” direction, with the various individuals indicating how often they felt, this was therefore described on a four point scale which ranged from “never” to “often”.

This scale is represented below as follows;

Table 1.A loneliness scale

O

“I often feel this way”

S

“I sometimes feel this way”

R

“I rarely feel this way” and the last letter

N

“I never feel this way”.

How often do you feel unhappy doing so many things alone? OSRN

How often do you feel you have nobody to talk to? OSRN

How often do you feel you cannot tolerate being so alone? OSRN

How often do you feel as if nobody really understands you? OSRN

How often do you find yourself waiting for people to call or write? OSRN

How often do you feel complete alone? OSRN

How often do you feel you are unable to walk out and communicate with those around you? OSRN

How often do you feel starved for company? OSRN

How often do you feel shut out and excluded by others? OSRN

After these questions were asked, then a score was added up ranging between 1 and 4, 4 for each O, 3 for each S, 2 for each R and 1 for N.

Scores between 15 and 20 were considered a normal experience of loneliness, and scores that were above 30 identified a person was experiencing severe loneliness.

This scale has therefore become the most widely measure of loneliness. Scores of this loneliness scale has predicted a wide variety of mental (for example depression) and physical (nursing home admission, mortality), Russell, (1996).

THEORETICAL FRAME AND PHENOMENA OF LONELINESS

Feeling lonely is something common and is a universal experience that is significant to health and quality of life. However, loneliness was described earlier on in fictional works, poetry and painting, Munch; Hertervig (1998).

In the Nordic countries and the USA, research groups and individual researchers emerged in the late 1970s and studied loneliness first as subthemes and subsequently as the subject for independent studies.

It appears that the influence of modern research had asserted itself. In a contextual perspective, western industrialized society is termed a ‘Narcissistic Age’, but it is also referred to as ‘The Age of Loneliness’, in which the phenomenon of loneliness, regardless of victims’ age, has become almost epidemic. Loneliness as a dysfunction in modern times is revealed partially in surveys concerning society’s technological advancement in the use of internet and its relation to loneliness. Cultural background also plays a significant role in studies of loneliness.

Loneliness is further regarded as an important factor in the development of medical dysfunctions, such as psychosomatic disorders, breast cancer, and cardiovascular dysfunctions among others.

However, the author decided to use Nicholas R. Nicholson Jr (2008) theory of social isolation as the main theoretical frame of the study. The essence of this theory is to highlight to the reader the possible impact/s that may evolve as a result of isolation most especially with elderly caregiver.

Theory of Social Isolation

Following the work of the aforementioned writer, it exhibits that one of the cause of loneliness among elderly people is due to social isolation. It has long run adverse health consequences which if not well taken care of might affect a great number of elderly people in the future. The United States census Bureau (2004) predicted that the situation might double by 2025. Another recent US census bureau report that older adults (65 years and over) represent 12% of the total US population, Gist & Hetzel (2004). With the continual aging of America, it is expected that the older adult population will double within 25 years, Fowles & Greenberg (2003).

Similarly, in Europe, a fifth to a quarter of the population in many countries will consist of older adults over the next two decades, Grundy et al. (2006). Grundy et al. (2006) note that there are changing family and household patterns in Europe, which may weaken family bonds and have a negative impact on social aspects of older adults health, particularly support.

Elderly people are more concerned with social isolation because of their diminished vitality and health, Bondevik & Skogstad (1998). Some researchers report rates of social isolation as high as 35% in this population, Tremethick (2001). Elderly people who live alone or have difficulty leaving home are at increased risk of being socially isolated, Lien-Gieschen (1993).

The importance of social isolation is emphasized in many research publications internationally. Another Australian-based research group found that “social isolation is a significant factor affecting the health status of the ageing Australian population” Howat, (2004). International interest in this topic extends well beyond Australia and the US. For example, researchers in Spain, Zunzunegui, (2003), Sweden, Fratiglioni, (2000) and England, Cattan, (2005) have all examined social isolation.

It was then identified that elderly people with lesser social interactions and associations with people had increased risk for mortality, Berkman (1995) compared to the elderly people with consistent and social interactions with families, friends and the society as a whole.

On another account it was realized that elderly people with suffering from social isolation suffered from various negative health consequences, such as poor nutrition, Locher, (2005), rehospitalization,Mistry, (2001), cognitive decline,Bassuk, (1999) and heavy alcohol consumption, Hanson (1994).

Is Loneliness a Meaningful Dimension in the Existence?

Through this study, the author gradually realized the positive dimension of loneliness, an aspect that does not appear in the earlier mentioned synthesized definitions.

The question that comes to mind is about whether ‘lonely’ is a description of what one is or rather what one becomes? Philosopher B. Mijuskovic maintains that “there is a possibility to consider loneliness as a modern phenomenon”.

Mijuskovic has the view that loneliness is a misconception, since people have suffered from acutely pervasive feelings of loneliness.

Human beings are described according to Mijuskovic as thoroughly lonely creatures that want to desperately find an escape from its loneliness, Ben Lazare Mijuskovic, (1987). Loneliness, according to Mijuskovic, is a construct of the consciousness, both as a concept and emotion. In the authors understanding of Mijuskovic, the human being is metaphysically and psychologically alone in the world, and that loneliness is one basic structure in the human mind.

Therefore, since loneliness thus far is considered by Mijuskovic as a basic structure in the human mind, what exactly arouses the wild experience of loneliness in human kind is yet to be known. Mijuskovic then identifies and talks about the human mind in the western culture and to what extent a person can be aware of the feeling lonely.

Loneliness is considered by Cacioppo & Patrick (2008) as a consistent social phenomenon and also seen as a painful experience because the society seems to encourage it by allowing a growing number of people to go through emotional disorders which disturbs the environment, Mijuskovic (1992).

Rokach describes the subjective dimension of loneliness as related to life cycles, noting that it is ineffective to distance oneself from one’s loneliness, which may or can be disregarded only temporarily. Interesting articles illustrated the tension between the meaningfulness of loneliness and loneliness as a dysfunction, Rokach (2000).

It was finally disclosed that loneliness was regarded in the Nordic and European countries as a category of existence and not a psychological dysfunction, Nordic College of Caring Science (2006).

Interrelationship between Depression and Loneliness

There is recurring evidence that loneliness and depressiveness correlate with each other in elderly people. However, in spite of this correlation, loneliness and depression are discrete phenomena, both of which involve various negative emotions and adverse experiences of social interaction. For purposes of developing effective social interventions, it is important to learn about how these phenomena are related to each other and what kind of social interaction is beneficial to lonely and depressive elderly people.

Although elderly people do not suffer from loneliness and depressive symptoms any more than the adult population in general, the continuing growth of the elderly population and rising life expectancy are bound to throw up new challenges most particularly in the case of the oldest-old. The prevalence of loneliness in elderly people ranges from a few percent to almost 50%. It is estimated that loneliness is a source of some difficulty for around one-third of the elderly population, but for 10% it is a serious, health-endangering problem.

Clinical symptoms of depression are seen in 8-16% of the elderly population (Blazer, 2003). Evidence on the associations of ageing with loneliness and depressiveness is contradictory, partly because of the scarcity of longitudinal research. In a 10-year longitudinal study on Dutch men born in 1910-1920, the number of those reporting experiences of loneliness increased in the oldest age group,Tijhuis, De Jong-Gierveld, Feskens, & Kromhout, (2000), but studies among Swedish people over 75, for instance, have reported opposite results, Holmen & Furukawa, (2002).

Longitudinal studies indicate that depressiveness does not necessarily increase with advancing age, nor is it a problem for the large majority of elderly people,Haynie, Berg, Johansson, Gatz, & Zarit, (2001), but women over 80 in particular and the oldest men may be at increased risk,Heikkinen & Kauppinen, (2004). However, the increase in loneliness or depression is not explained by age itself, instead there is a complex web of underlying factors that have to do with changes and losses in health, functional capacity and social networks, Blazer, (2003); Heikkinen &Kauppinen, (2004).

Loneliness is defined in various different ways, but all definitions share the same concept that identifies it as unpleasant, anxiety-inducing and subjective.

The size of social network, number of contacts, availability of support, and marital status are very important aspects in describing the social relationships of elderly people, but yet do not provide an exhaustive explanation.

Loneliness and depression are not direct responses to external circumstances, but mental well-being is best described by the individual’s subjective assessment of the quality of life. Subjective assessments of social interaction are particularly relevant in studies with elderly people, for several reasons.

Institutional Care Approaches to Loneliness in Elderly Caregiver

About 10-15% of elderly people meet the clinical criteria for a diagnosis of depression, and major depression is a recurring disorder with older patients having a recurrence within three years. Some groups are more at risk of depression: 40% of people living in care homes are depressed and there is prevalence also in the community.

According to the National Confidential Inquiry into Suicides and Homicides, elderly people have the highest suicide rate for women and the second highest for men, and it is the only age group in which rates have not declined. In contrast with young people, self-harm in elderly people usually signifies mental illness, mostly depression, with a high risk of completed suicide.

Therefore the emotional and physical health problems of elderly people are entwined and manifest in complex co-morbidity. Those with a physical disability have fivefold rates of depression. Although there is variation between studies, it has been estimated that up to 26% of people with diabetes also suffer from depression and comparable figures have been reported for coronary heart disease (CHD).Primary care is on the front line of dealing with older people’s mental health, supporting families and managing people with complex co-morbidities.

Elderly people consult almost twice as often as other age groups. Depression is undertreated in elderly people, with about five out of six elderly people with depression receiving no treatment at all. Only one-third of elderly people with depression discuss their symptoms with their general providers and less than one-half of these will receive adequate treatment.

Most people with mental health problems are managed in primary care, with only 6% of elderly people with depression receiving specialist mental healthcare. The diagnosis for depression is mentioned as the most difficulties of depression in later life and it occurs largely in four areas follows;

Table 2.Institutional Approaches to Loneliness

Patient factors

Healthcare Professional factors

Organizational factors

Societal factors

Patient Factors

Elderly people can present with non-specific symptoms, such as malaise, tiredness or insomnia, rather than disclosing symptoms of depression. In addition, physical symptoms, in particular pain, are common and healthcare professionals may feel that these represent organic disease.

Similarly symptoms of forgetfulness may lead to concern that a patient has cognitive impairment and early dementia. It is not unusual for older adults to hold beliefs that prevent them from seeking help for depression, such as a fear of stigmatization or that antidepressant medication is addictive, or they may misattribute symptoms of major depression to ‘old age’, ill health or grief. Ethnic elders, in particular, do not perceive psychiatric services to be appropriate for them and believe them to be primarily for psychosis and violence.

People across cultures often present with culturally specific idioms of distress. South Asian people often describe their distress as a ‘sinking heart’ or ‘gas in their abdomen’ (gola). This often misguides clinicians, who tend to overlook the psychological distress and focus solely on physical aspects of the presentation

Healthcare Professional Factors

Primary healthcare professionals may lack the necessary consultation skills or confidence to diagnose late-life depression correctly. They may be wary of opening a ‘Pandora’s box’ in time-limited consultations and instead collude with the patient in what has been called ‘therapeutic nihilism’, and feel unsupported because of poor availability of psychological interventions.

Organizational Factors

The trend in the UK for mental health services to be ‘carved out’ of mainstream medical services may disadvantage older depressed people who may find it difficult to attend different sites for mental and physical disorders. New contractual arrangements for primary care provide no new incentives to offer reconfigured services for elderly people with depression

Societal Factors

The barriers described previously are likely to be compounded for economically poor and minority populations, who tend to have more ill health and disability. Nursing and caring science studies on loneliness relates to serious psychological dysfunctions.

Loneliness is described in nursing and caring scientific research articles related to psychological dysfunction? The theme of loneliness, which is treated by a number of nursing and caring scholars both inside and outside of the Nordic countries are related to: general health, illness, the relationship of loneliness and well-being, stress and age.

Hagerty and Williams (1992) demonstrate, among other things, that a low degree of belonging is associated to a higher level of depression and loneliness. Peplau’s article is also interesting, since she focuses on an understanding of the development of loneliness from a social perspective. These two perspectives, the individual and the social aspect, are the basis for the nurse’s approach to the patient.

In Norway, Bondevik has in her PhD made a study of loneliness related to the oldest old, where among other things, their relationships between loneliness and social contacts were investigated. The results show that the elderly are not as lonely as we think they are.

In Thorsten’s study, the primary theme is loneliness among the elderly, in conjunction with contact and health conditions.

In Finland, Lindstrom’s qualitative study of loneliness and the patient’s perception of the qualitative environment, as well as the latter’s relation with patients, is important and interesting. Different descriptions of psychiatric patients’ loneliness are expounded here, as well as descriptions in particular of schizophrenic patients’ loneliness.

Likewise, loneliness appears as a partial implication in Eriksson, in connection with perception of suffering. Loneliness also emerges as a theme in Lindholm.In Lindholm et al.’s study, the heuristic value is found in the discovery of the fact that loneliness in young people is related to both suffering and desire. The sample groups for the study comprised two groups of young people, and the study itself has a nursing science application in its hermeneutical approach. Likewise, Lindstrom and Lindholm’s study shows that loneliness is one category of existence Furthermore, the same authors demonstrate the existential meaningfulness of loneliness and write: It belongs to the mystery of love that one attempts to uphold another’s loneliness and create a free space in which existential loneliness can be transformed into a mutually shared loneliness.

Erdner et al. describe in their article the disadvantages that long-term psychiatric patients experience in the Swedish community where they live. The study is ethnographic and the sample group comprises four patients. In the content analysis of 12 interviews, loneliness emerges as one of three primary themes. Moreover, Nystrom’s study of the daily existence of persons with serious psychological dysfunctions shows that loneliness is one of the categories of experience.

In psychiatric nursing, there are serious psychological dysfunctions and loneliness; two findings were the psychiatric patients’ experience of loneliness in hospital, and in being lonely alone. De Niro’s, article describes the alienation of schizophrenic patients, where loneliness is one implied aspect. Three articles were of used indirectly, through an examination of the first authors study’s empirical focus: ‘loneliness in persons living alone with serious psychological dysfunctions’. One of the articles concludes that it is positive for the psychiatric patient to live in his own home.

The second article may be seen contextually in relation with the first and concerned what may be predicted about the welfare of elderly long-term psychiatric patients in their home community and how patients’ welfare is improved if varied types of assistance are provided.

The third article concerned a 3-year comparative study on the treatment of schizophrenic patients living alone as opposed to living with the family; the study concludes that treatment is most effective in cases where the patient resides with a family. In this study, psychiatric patients in local community healthcare facilities and their professional caregivers were surveyed to determine the presence of stigmatization, seen from both the caregivers’ and the patients’ point of view. In the studies as a conclusion, the lack of and need for an examination of the term stigmatization was emphasized. For patients in local community healthcare facilities, a self-stigmatizing tendency arises through the use of medical psychiatric terms, and anxiety and loneliness follows in the wake of stigmatization. Borge et al. in their study of quality of life, investigated persons with serious psychological dysfunctions who were released to live on their own in the care of their local community psychiatric facility after having been institutionalized for a period of 6 years. The result showed that health personnel became the single most important network for the patients, confirming Kristoffersen’s findings. Patients outside the institution were the most socially active and had the most satisfactory contact with their own families.

MATERIAL AND METHODS

Systematic Literature review was selected for this study as the main data-gathering method. Through this method, it was easier to evaluate previous research papers in a retrospective and comprehensive manner so as to minimize systematic bias.

M.Kangasniemi (2010), proposed this method as a good one because it covers the research protocol, the quanti¬cation of the research question, the retrieval and selection of original scienti¬c articles and the estimation of their quality as well as their analysis and presentation.

Again the author used systematic literature review for the purpose of assisting readers to understand the whole body of the study topic, thereby informing readers on the strengths and weaknesses of the studies, De Los Reyes & Kazdin, (2008), since systematic literature review is understood by its guiding concept and topical focus, that is giving an account of previously published literature on a specific topic. This method chosen by the author also prevents reliance on one research study that is not in accordance to the results from other studies, Dunst, Trivette&Cutspec, (2002).

In another development, the author chose to do a systematic literature review because of sharing the same opinion as that of Sebastian K.Boell and Dubravka Cecez-kecmanomc which allows the author to help the reader with a better understanding of the complexity and uncertainty of various articles chosen because literature review also forms an integral part of a research which can also constitute a research publication on its own. The author used this method because it helped the study to be done in a structured way to lead to unbiased, complete and reproducible researches, Kitchenham & Charters, (2007).

Lastly, the author chose literature review since it provides an essential component of the study and also since systematic literature review of primary research studies helps the transforming of study into clinical practices, Lau & Magarey (2006).

A systematic literature review is a summary of the research literature related to particular topic; it also involves identifying, selecting, appraising and synthesizing all high quality research evidence relevant to the topic in question, Torgerson (2003).

Selecting Literature

Literature review was done with all the selected articles and journals found out about the authors’ topic.

According to Rowley, Jennifer; Slack, Frances; (2004),a literature review is used to draw on and evaluate a range of professional journals, articles, books and web-based resources and it is also a summary of a subject field that supports the identification of specific research questions.

Search engines are therefore used to search web resources and bibliographical databases.

Literature review for the study involved stages of scanning, making notes, structuring the literature, writing the literature review and then finally building a concrete research, Management research review (2004).

The author used literature review in the study by considering the following points of;

Table 3.A literature review process

Supporting the identification of the study topic, research question/s or hypothesis;

Identifying the literature to which the study made a contribution to, and contextualized the study within the found literature

Building an understanding of the theoretical concepts and terminology

Facilitating the list of sources used

Suggesting research method that was helpful

Analyzing and interpreting the results found and lastly

Evaluating information resources

Article List

Table 4.Articles Selected

NAME OF ARTICLE

AUTHOR/S

YEAR OF PUBLICATION

DETAILS OF ARTICLE

LONELINESS AS A PREDICTOR OF QUALITY OF LIFE AMONG ELDERLY CAREGIVERS

Anna K. Ekwall,bengtSivberg,Ingalill R. Hallberg

2004

The article focuses on the quality of life related to loneliness in the caregiver of the elderly.

SUCCESSFUL AGING FROM THE CAREGIVERS PERSPECTIVE

Jeanne M. Hilton,KarenKopera-frye,AnneKrave

2003

The article talks about the factors of successful aging and the caregiver

SCHOOL OF HEALTH AND SOCIAL CARE

PROFESSOR CHRISTINA R VICTOR

2004

The article discusses about the origin of gerontology and loneliness linked to social isolation, risk factors for loneliness

JOURNAL OF AGING AND HEALTH

Joe Tomaka,Sharon Thompson, Rebecca Palacios

2006

The article describes the relation of loneliness, social isolation to the elderly

LONELINESS AND DEPRESSION IN SPOUSAL CAREGIVERS

Rose A. Beeson

2003

The article outlines the mental health and depression in the family caregiving process in especially spouses

CULTURAL AND EMOTIONAL COMPONENTS OF LONELINESS AND DEPRESSION

Lorie R.HSU,B.JoHailey,LillianM.Range

2001

The article identifies the relation between loneliness and depression

THE EFFECTS OF GENDER AND MARITAL STATUS ON LONELINESS OF THE AGED

Ami Rokach,RaanMatalon,BenRokach,ArtemSafarov

2007

The article explored to know whether marital status affected the experience of loneliness

ADVERSE EFFECTS OF CAREGIVING LINGER AFTER SPOUSE’S DEATH

Larkin Marilyn

2001

The article focuses on the effects on loneliness in the caregiving for an elderly whose spouse is dead

LONELINESS AND DEPRESSION IN CAREGIVERS OF PERSONS WITH ALZHEIMERS DISEASE OR RELATED DISORDERS

Rose Beeson,Sara Horton-Deutsch,CarolFarran,MarciaNeundorfer

2000

The article describes the loneliness and depression felt by caregivers of elderly with Alzheimer’s disease

PSYCHOSOCIAL EFFECTS EXPERIENCED BY GRANDMOTHERS AS PRIMARY CAREGIVER

G.Tshweneagae-Thupayagale

2008

The article studies the psychosocial effects of family caregiver (grandmother) as primary caregiver.

MENTAL HEALTH PRACTICE

NOTICE BOARD

2010

The article talks about mental health practices and caregiver support

VULNERABILITY TO HEALTH PROBLEMS IN FEMALE INFORMAL CAREGIVERS OF PERSONS WITH HIV/AIDS AND AGE-RELATED DEMENTIAS.

Flaskerud Jacquelyn H,Lee Patricia

2001

The article outlines the physical and mental health problems experienced by informal caregivers (family).

INFORMAL CARE AND VOLUNTARY ASSISTANCE

Anita Karp,RoyaEbrahimi,AlessandraMarengoni,LauraFratiglioni

2010

The article discusses informal care in Sweden,Italy,United Kingdom and Canada

FAMILY CAREGIVERS’ SUBJECTIVE EXPERIENCES OF SATISFACTION IN DEMENTIA CARE

Andren S,&Elmståhl S.

2005

The article talks about the family caregivers burden and experiences

Search Engines Used

The following search engines and journals were used during the study,

EBSCO, CINAHL, JOURNAL OF ADVANCED NURSING.

Data Extraction

Firstly, the author used EBSCO database to search for information on articles about the topic loneliness, the initial hit of the subject term loneliness gave 953articles, the author then wanting to have full text articles hit that and it resulted in 485 articles.

Again the author restricted the articles selecting based on the criteria chosen to limit search for only the recent published articles, which was from years 2000-2012 respectively. This thereby produced 376 articles. The author then restricted the search to caregiver which produced 9 articles. Out of these 9 articles, 3 were selected since the author was interested in the articles with a social perspective; the chosen 3 articles matched the criteria for analysis.

Secondly, the author also used the search engine CINAHL to gather articles and information on the topic loneliness. First when loneliness was typed for articles in the exact subject heading, 1122 results were found, now the author restricted the search again to full text and gathered 251articles. The author wanted to have recent articles for the study restricted the years from 2000 to 2012 and got 213 articles. After this the author again restricted the search to only the caregiver and this resulted in 9articles, the author finally chose 2 articles.

Again the author used the e-journal journal of advanced nursing and the initial hit for the journals’ loneliness gave 19 articles which the author now selected full text and still got 19 articles after which the author then restricted the years to 2000-2009 respectively and got 11, out of which the author then restricted the search to caregivers and got 2 articles and those was used.

The author during the study also used the Google scholar to get some information about the topic which came out as follows; the initial hit with the advanced search with words loneliness and elderly caregiver 9,160 results. The author then restricted the search to the current years of 2000-2010 and got 14 results; the author then considered 1 of the final results which was relevant to the topic.

Finally the author also considered the compilation of various articles through Anhörga which had 126 articles but since the authors focus was on English text, 4 of the information met the selection criteria and made use of all of them.

Inclusion and Exclusion Criteria

The inclusion and exclusion criteria was used for this study, the author used this method to be able to state out clearly information and researches that corresponds to the subject area and also to be more concise and specific.

The author selected articles, and journals from the years 2000 and 2012 which were written in English.

The author also selected articles and journals which were directly related to the topic and subject to prevent broad opinions that could be contrary to the authors’ topic and ideas.

The author identified also that, in large reviews, the inclusion and exclusion criteria is used to all searches retrieved by the title or topic and then those titles that were relevant to the topic were selected using the laid down aims of selecting and gathering research.

Content Analysis

This was used to analyze and review the literature chosen.

According to Dr. Farooq Joubish (2002), it is a scholarly method of study in humanities and authenticities by which texts are studied.

Also according to Dr Klaus Krippendorff (2004), in the qualitative sense, content analysis can involve all kinds of communication content (speech, written text, interviews, images) is/are differentiated.

Finally the author found out that content analysis was suitable for the study as it is described as a method that may be used either quantitatively or qualitatively as an inductive or deductive way of study and research, Journal of advanced nursing (2007).

Two approaches of content analysis were considered but the deductive content analysis was used as it is based on earlier theory or model and thereby makes it specific instead of general, Burns & Grove (2005).

This involved; preparation, organizing and reporting, whereby the preparation stage starts with the selection of the topic for analysis, Guthrie (2004) which could be a theme or a word Polit & Beck (2004).

According to Polit & Beck (2004), Hsieh & Shannon (2005), deductive content analysis generally based on earlier theories, models and literature reviews. Therefore a categorization matrix is developed and as mentioned earlier on divided into various subsection of main category to the others Polit & Beck (2004).

The author after considering all the content analysis contents, choose to use the method according to Satu Elo and Helvi Kyngäs,they state that using content analysis meant the systematic grouping of articles into main category, generic category and sub-category.

Grouping of Articles into Categories

Causes of loneliness in the Family Caregiver?

QUESTION 1: What is/are the causes of loneliness in the elderly family caregiver?

In trying to identify the dominance of loneliness in the elderly caregiver and what causes it, it was identified that, the caregiver might loose a special person who provides his or her need. A study found out that, wives as caregivers had a greater portion of loneliness than that of husband as caregivers, Dirken (2008).

It was again noticed that another cause of loneliness in the caregiver was with the constant and progressive care because caregivers become mentally and physically exhausted because of the extra demanding responsibilities of providing care, Dirken et al (2008).

Another cause of loneliness in the caregiver of the elderly was social isolation linked with stress, fatigue and depression, Cheever (2008).Therefore the causes of loneliness in the family caregiver has been outlined in the table below;

Table 5.Causes of Loneliness

MAIN CATEGORY

GENERIC CATEGORY

SUB-CATEGORY

Causes of loneliness in the family caregiver

Personal loss

Loss of family member, loved one or friend, loss of self esteem

Constant and progressive care

Poor quality of relationship with friends, stress related or demanding tasks

Social isolation

Inability to socialize, frustration

Common Symptoms and Signs of Loneliness

QUESTION 2: What are the symptoms associated with loneliness?

It is identified that, elderly people who are withdrawn from the society, abandoned or isolated remain connected to informal social networks and thereby loose their social relationships, Hooyman & Kiyak (2002).

Loneliness is very difficult to identify since being alone cannot be determined as loneliness but there are various symptoms of it which are grouped into categories a; mental problem, personal issues, social problems and medical problems.

Table 6.Symptoms of Loneliness

MAIN CATEGORY

GENERIC CATEGORY

SUB-CATEGORY

Symptoms associated with loneliness

Mental problems

Depression, loss of identity, withdrawal from family and society

Personal issues

Eating disorders, talking to oneself, changes in temperament, mild aggressive behavior

Social problems

Disengagement from social networks and activities, reduction in contribution to societal performance and activity of daily living

Medical problems

chronic headache, mild migraine, verbally agitated behavior

Effects of Loneliness in the Family Caregiver

QUESTION 3 What are the effects of loneliness in the caregiver?

Loneliness can be very severe if not taken care of and help granted because it makes the caregiver in this case live in solitude.

The effects of loneliness in the family caregiver are grouped in the following categories below as follows; social effects, psychological effects, personal effects.

Table 7.Loneliness effects

MAIN CATEGORY

GENERIC CATEGORY

SUB-CATEGORY

Effects of loneliness

Social effects

Loss of close relations, abstaining from social gatherings, loss of networks

Psychological effects

sleep disorder, depresion,hallucinations,mental disorder

Personal effects

Loss of job, alcohol abuse, drug abuse, decreased social involvement, loss of education

Supporting the Family Caregiver

QUESTION 4 What are the supports for the family caregiver?

The caregivers have some support to help them through the administration of their duties especially in the family setting.

These supports are categorized as follows; support groups, educational help.

Table 8.The Family Caregiver supports

MAIN CATEGORY

GENERIC CATEGORY

SUB-CATEGORY

Supports for the caregiver

Support groups

Identification of cohort groups giving care and sharing ideas and objectives

Educational help

Organization of training for the caregiver, recreational activities, explanation of care related occurrences

Ethical Considerations

The author read and understood the Helsinki declaration regarding ethics (Declaration of Helsinki,” (2004) and Hertzen Von et al., (2009), Arcada Thesis Guide with the aim of avoiding plagiarism and with the intention of doing academically wel